Our study demonstrated that sarcopenic obesity (SO) is associated with significant impairments in functional measures, as well as increased frailty and mortality. Logistic regression analysis showed that female gender, advanced age, hypertension, diabetes mellitus, low Mini-Nutritional Assessment (MNA-SF) scores, and reduced handgrip strength were significantly associated with SO. Importantly, our findings suggest that geriatric factors, particularly malnutrition and muscle weakness, are more strongly associated with SO than metabolic risk factors alone.
Functional and cognitive impairment in SO
SO was associated with poorer ADL and IADL scores, reflecting greater physical dependence. However, logistic regression analysis did not significantly associate ADL and IADL with SO. This may be due to the more decisive influence of other geriatric factors, such as muscle weakness (handgrip strength) and nutritional deficits (MNA-SF), which have been significantly associated with SO. Previous studies have reported a strong association between SO and functional decline, as SO exacerbates mobility limitations due to combined muscle weakness and excess fat mass [5, 7, 17]. However, our findings suggest that ADL and IADL impairments may be mediated by other factors such as frailty, underlying comorbidities, and hospitalization status rather than being directly associated with SO. Additionally, ADL and IADL are subjective measures, and psychological, environmental, and social factors can influence their assessment. Hospitalized individuals, such as those included in our study, may already exhibit lower functional scores due to acute illness or overall frailty, which might have attenuated the strength of association between these variables and the presence of SO. Furthermore, IADL impairment has also been linked to cognitive dysfunction, which was not significantly associated with SO in our model, possibly contributing to the lack of an independent relationship between SO and IADL [18,19,20]. These findings suggest that while SO negatively impacts physical function, its effects may be more strongly reflected through muscle strength and nutritional status rather than self-reported functional scores. Future studies should explore whether objective functional measures, such as gait speed or balance testing, provide a stronger link between SO and functional decline.
Although cognitive impairment has been linked to SO in some studies [18, 21, 22], our logistic regression analysis did not identify Mini-Mental State Examination (MMSE) scores as independently associated with SO. This discrepancy may stem from multiple factors. First, cognitive impairment is a multifactorial condition influenced by vascular, metabolic, and neurodegenerative mechanisms. It SO alone may not be sufficient to drive cognitive decline without additional risk factors such as neuroinflammation. Second, MMSE may not be sensitive enough to detect subtle cognitive impairments, particularly those related to executive function and processing speed, which have been suggested as key domains affected in SO populations. Third, the relatively homogeneous nature of our hospitalized older adult cohort, with many patients already exhibiting baseline cognitive decline, may have resulted in an underestimation of SO’s independent contribution to cognitive dysfunction. Future studies using more detailed neuropsychological assessments and including community-dwelling older adults may provide a clearer understanding of the relationship between SO and cognitive impairment.
Frailty and mortality in SO
Frailty is a key concern in SO, with affected individuals showing significantly higher frailty scores than those with sarcopenia or obesity alone [23, 24]. The increased mortality risk observed in the SO group further underscores the compounded burden of these two conditions [3, 4, 25, 26]. The mechanisms underlying this association may include chronic inflammation, hormonal dysregulation, and increased oxidative stress, all contributing to both frailty and mortality [27,28,29]. Given these risks, targeted interventions such as resistance exercise, nutritional optimization, cognitive monitoring, and metabolic management are essential to delay or mitigate frailty progression in SO patients. Implementing structured exercise programs, ensuring adequate protein intake, and controlling metabolic risk factors may help maintain functional independence and reduce adverse outcomes.
The dominant role of geriatric factors in SO risk
Our study found that geriatric factors, particularly low Mini Nutritional Assessment (MNA-SF) scores and reduced handgrip strength, are more strongly associated with sarcopenic obesity (SO) than metabolic risk factors such as hypertension and diabetes mellitüs. This finding suggests that geriatric syndromes play a more significant role in SO development than metabolic syndromes, highlighting the importance of addressing malnutrition and muscle weakness in preventive and therapeutic strategies. Previous studies have shown that SO is associated with both metabolic and geriatric factors; for instance, a study reported that the coexistence of obesity and sarcopenia increases frailty and disability risk, while another study linked sarcopenia and obesity to cardiovascular diseases and mortality [30]. However, these studies did not differentiate whether metabolic or geriatric factors had a stronger association with SO. Our study adds to the literature by demonstrating that nutritional status and muscle function are more direct determinants of SO than metabolic disturbances alone. Malnutrition contributes to muscle wasting and functional decline, accelerating SO progression, while decreased muscle strength directly impairs physical function and increases dependency. Although metabolic factors such as hypertension and diabetes mellitüs may not be the primary drivers of SO, they could contribute indirectly by exacerbating inflammation, insulin resistance, and energy metabolism imbalances, which may accelerate sarcopenia and malnutrition [8]. This interaction suggests that metabolic and geriatric factors are not isolated but rather interconnected in the pathogenesis of SO. Given these findings, a comprehensive approach addressing metabolic and geriatric factors is crucial for effective SO prevention and management, focusing on early nutritional support, resistance training, and metabolic control to mitigate the adverse outcomes associated with SO.
Clinical implications: screening and management of SO
Due to SO’s multifactorial nature, a multidisciplinary approach is required for effective management. To identify at-risk individuals early, routine screening using MNA-SF, MMSE, and handgrip strength should be incorporated into clinical practice [6, 31]. These tools comprehensively evaluate nutritional deficits, cognitive impairment, and muscle strength, crucial components in SO management. Once SO is identified, an individualized treatment plan should be developed to address each patient’s needs. Management strategies should include structured resistance exercise programs to enhance muscle strength, functional capacity, and mobility [23, 24]. Exercise interventions, particularly progressive resistance training, have mitigated muscle loss and improved overall functional performance in SO patients. In addition to exercise, nutritional optimization is fundamental, emphasizing adequate protein intake and caloric balance to prevent further muscle wasting and promote anabolic processes [8]. The recommended dietary approach should focus on high-quality protein sources, leucine-enriched supplementation, and adequate caloric intake to counteract the catabolic effects of SO. Nutritional interventions should be individualized, considering comorbid conditions such as renal function and metabolic disorders. Furthermore, cognitive and functional monitoring should be regularly conducted to detect and manage cognitive decline and physical impairment at early stages [18, 19].
Lastly, comprehensive metabolic control is essential, particularly for individuals with diabetes mellitüs and hypertension, as these conditions can contribute to the inflammatory and metabolic dysfunction underlying SO progression [31, 32]. Optimizing glycemic control, blood pressure regulation, and lipid profile management through pharmacological and lifestyle interventions may help mitigate the systemic effects contributing to SO. A multidisciplinary team approach, including geriatricians, dietitians, physiotherapists, and endocrinologists, is recommended to implement a holistic, patient-centered management plan that effectively addresses SO and its complications.
Future research directions
Prospective cohort studies are needed to establish causality between SO and adverse health outcomes. Additionally, randomized controlled trials should investigate the efficacy of exercise and nutrition-based interventions in reducing SO prevalence and mitigating its complications. Future research should also explore the biological mechanisms linking SO with frailty, cognitive decline, and mortality, particularly the role of inflammatory and hormonal pathways [32,33,34].
Limitations and strengths
This study has several limitations that should be acknowledged to provide a comprehensive understanding of the findings. The retrospective cross-sectional design of our study limits the ability to infer causal relationships between sarcopenic obesity (SO) and the clinical outcomes observed. While associations are evident, the lack of temporal data prevents establishing whether SO is a direct cause or a consequence of these outcomes. Future longitudinal studies are necessary to confirm causality and explore the progression of SO over time.
Although multivariate analyses were conducted to adjust for some variables, such as hypertension and diabetes mellitüs, this study did not account for other potential confounding factors. Systemic syndromes, other comorbidities (e.g., chronic kidney disease, cardiovascular diseases), and lifestyle factors (e.g., physical activity levels, dietary habits) could have influenced the results. The inability to fully control for these factors is a limitation that may have introduced bias into our findings.
Another potential limitation of this study is the extended duration of data collection for a cross-sectional design. We performed a time-segmented analysis to address potential sampling and measurement bias concerns, dividing the dataset into different collection periods. Although the study spans multiple years, we did not observe any major institutional or procedural changes that would be expected to introduce systematic bias over time. Therefore, we assume the data to be temporally consistent. Furthermore, to minimize variability, all data collection procedures followed standardized protocols across the study duration, ensuring uniformity in measurements and assessments. While this approach mitigates the impact of long-term data collection on study findings, we acknowledge that residual biases may still exist.
Our sample was from hospitalized patients, which may not represent the general geriatric population. Hospitalized individuals often exhibit more severe health conditions and frailty compared to community-dwelling older adults. This selection bias limits the external validity of our findings and may overestimate the prevalence and impact of SO in the broader population. However, it is also important to note that sarcopenic obesity and its associated negative health consequences may be more prominently observed in hospitalized older adults, making this population particularly relevant for studying the condition’s clinical significance. Future research involving community-based samples could provide more generalizable insights. Furthermore, while detailed nutritional intake records were unavailable, we ensured all participants underwent the Mini Nutritional Assessment (MNA-SF), a validated and reliable tool widely used in geriatric populations. This provides an objective measure of nutritional status, helping to account for variations in dietary intake.
We acknowledge that specific inflammatory biomarkers were not comprehensively assessed regarding inflammatory status. However, key laboratory parameters such as C-reactive protein (CRP), leukocyte count, erythrocyte sedimentation rate (ESR), and albumin levels were available and analyzed. This study has several strengths that contribute significantly to understanding sarcopenic obesity (SO) in older adults. First, the comprehensive use of geriatric assessment tools, including ADL, IADL, MMSE, MNA-SF, GDS, and handgrip strength, allows for a multidimensional evaluation of physical, cognitive, and psychosocial health. Additionally, the study provides a detailed analysis of SO, highlighting its distinct impacts compared to obesity or sarcopenia alone. By utilizing logistic regression, the study identifies independent risk factors for SO, such as diabetes mellitüs, hypertension, and poor nutritional and cognitive status, offering valuable insights for targeted interventions. Furthermore, the association of SO with frailty and mortality underscores its clinical importance and emphasizes the need for early detection and management. The hospital-based real-world data strengthen the study’s relevance while including diverse functional, cognitive, and biochemical parameters to enrich its findings. Overall, the study addresses an underexplored area in the literature, providing a robust foundation for future research and clinical applications. Importantly, this study is among the first to apply the ESPEN–EASO consensus criteria for diagnosing SO in a hospitalized older adult population. The use of these standardized criteria enhances the comparability of findings across studies and supports a unified diagnostic framework. Notably, our analysis demonstrated that geriatric parameters—particularly handgrip strength, nutritional status, and frailty—offered greater discriminatory power for SO than traditional metabolic indicators. These findings underscore the importance of integrating geriatric assessments into SO screening and highlight the clinical value of ESPEN–EASO-based diagnostic approaches in routine geriatric care.
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