Re: Commentary on “Impact of diabetes mellitus and grip strength on postoperative outcomes in older patients undergoing cancer surgery: A single‐center retrospective cohort study”

Dear Editor‐in‐Chief,

We read with great interest the study by Fujimoto et al. [1], published in the Journal of Diabetes Investigation (2025, DOI: https://doi.org/10.1111/jdi.70224), examining the impact of diabetes mellitus and grip strength on postoperative outcomes in older patients undergoing gastrointestinal cancer surgery. This work makes a valuable contribution to geriatric oncology by emphasizing that reduced physical function, particularly weakened grip strength, emerges as a more significant independent predictor of adverse postoperative outcomes than current diabetes mellitus status in elderly surgical patients.

While the authors' comprehensive geriatric assessment methodology and robust statistical analysis are commendable, we offer the following methodological and analytical suggestions to strengthen the clinical applicability and generalizability of their findings:

1. Temporal dynamics of grip strength deterioration: The current analysis treats grip strength as a static preoperative measure. Future research should incorporate longitudinal grip strength assessments across multiple preoperative timepoints and postoperative intervals to characterize trajectories of muscle strength decline and identify critical thresholds associated with poor outcomes. Recent evidence suggests that the rate of grip strength deterioration, rather than absolute values alone, may better predict postoperative complications and mortality [2]. Time‐series analyses or latent growth curve modeling could elucidate whether accelerated muscle loss in the months preceding surgery independently predicts adverse events beyond baseline grip strength values, thereby enabling more precise patient stratification and targeted prehabilitation interventions.

2. Phenotypic heterogeneity within sarcopenia classification: The multicategorical sarcopenic score approach, while innovative, may obscure distinct phenotypes with different pathophysiological mechanisms and prognostic implications. Cluster analysis or latent class modeling could identify subgroups characterized by specific combinations of weak grip strength, slow gait speed, and low muscle mass—each potentially requiring different perioperative management strategies [3]. Additionally, stratified analyses by antidiabetic medication class (particularly dipeptidyl peptidase‐4 [DPP‐4] inhibitors, sodium‐glucose cotransporter‐2 [SGLT2] inhibitors, and glucagon‐like peptide‐1 [GLP‐1] receptor agonists, which have been increasingly recognized as important modifiers of muscle metabolism in recent years) would elucidate whether certain diabetes pharmacotherapies attenuate or exacerbate the skeletal muscle complications in this cohort. Given the evolving evidence on newer agents' effects on lean mass preservation, medication‐specific analyses would substantially enhance clinical decision‐making.

3. Integration of inflammatory and nutritional biomarkers: While the study captures estimated glomerular filtration rate (eGFR) and hemoglobin A1c, incorporation of systemic inflammatory markers (C‐reactive protein and interleukin‐6 [IL‐6]) and nutritional parameters (prealbumin and total lymphocyte count) would strengthen mechanistic understanding of the diabetes mellitus (DM) sarcopenia surgery axis. Recent meta‐analyses have demonstrated that elevated inflammatory cytokines mediate the bidirectional relationship between type 2 diabetes and sarcopenia and that nutritional insufficiency independently predicts postoperative complications [4]. Multivariate models including these biomarkers could delineate whether diabetes influences postoperative outcomes primarily through physical deconditioning or through systemic inflammatory/nutritional dysregulation. Additionally, analysis stratified by baseline nutritional status would identify whether preoperative nutritional interventions might differentially benefit sarcopenic patients with or without diabetes—an actionable finding for clinical practice.

We commend the authors' finding that current diabetes mellitus status does not independently predict postoperative survival when physical function is accounted for, a clinically reassuring result that challenges the traditional assumption of diabetes as a major independent surgical risk factor. This observation underscores the paramount importance of comprehensive geriatric assessment and targeted optimization of physical function in all older patients undergoing cancer surgery, regardless of glycemic status.

FUNDING

This work was supported by the Yunnan Provincial Department of Education Science Research Fund (Grant No. 2024J2133) and the Yunnan Medical Health College University‐level Research Project Fund (Grant No. 2024Y010).

ETHICS STATEMENT

This manuscript is a commentary on a previously published article and does not involve any original research with human participants or animals. Therefore, ethical approval was not required for this work.

DISCLOSURE

Approval of the research protocol: Not applicable. This manuscript is a commentary on a previously published article and does not involve any original research with human participants.

Informed consent: Not applicable. No human participants were involved in this work.

Registry and the registration no. of the study/trial: Not applicable. This is a letter to the editor/commentary, not a clinical trial or registered study.

Animal studies: Not applicable. No animal studies were conducted.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.