Abstract
Background
Sarcopenia is a clinically relevant syndrome with health, social, and economic implications. The Mediterranean dietary pattern is considered a healthy diet; however, its association with sarcopenia has been controversial and has not been fully investigated in the Chinese population. The current study aimed to assess the relationship between the Mediterranean dietary pattern and sarcopenia, or its elements, among Chinese in Henan Province.
Methods
A cross-sectional study was conducted to collect data on nutrition and health in Henan province, northeast central China. A total of 639 individuals were studied. Sarcopenia was defined according to the 2019 Asian Working Group for Sarcopenia (AWGS) criteria. Adherence to the Mediterranean dietary pattern was evaluated using the Alternative Mediterranean Diet (aMed) score, and the population was categorized into groups based on the aMed score. Binary logistic regression analysis with odds ratios (OR) and 95% confidence intervals (CI) after multiple adjustments was used to assess the association between sarcopenia and Mediterranean dietary patterns.
Results
Individuals with a higher aMed score were more likely to live in urban areas and have a higher level of education. After adjusting for age, gender, smoking index, sleep quality, and literacy, we found that the group with the highest aMed score (≥ 6) was more likely to have high muscle mass (OR: 0.368; 95% CI: 0.148–0.912) or low risk of sarcopenia (OR: 0.319; 95% CI: 0.124–0.819) compared to the group with a low aMed score (< 4). However, we did not find a relationship between the aMed score and muscle strength or gait speed.
Conclusion
Among the Henan population, A higher aMed score reflects greater adherence to the Mediterranean diet, indicating that the Mediterranean dietary pattern is a protective factor against sarcopenia and low muscle mass.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28610-8.
Keywords: Mediterranean dietary pattern, aMed, Sarcopenia, Association
Introduction
As our society experiences a progressive demographic transition towards an aging population, considerable emphasis has been placed on the study of age-related diseases that significantly impact the health of the elderly. Among these diseases, sarcopenia has emerged as a prominent focus of investigation. Sarcopenia is an age-related degenerative condition characterized by a generalized decline of skeletal muscle mass and its function [1]. Sarcopenia refers to the progressive loss of skeletal muscle mass and strength, which, despite being typically associated with advanced age, declines of 1–2% per year after age 50, coincides with a decline in strength of 1.5% per year, which accelerates to 3% per year after age 60 [2].Therefore, the adverse effects of sarcopenia can affect both middle-aged and older adults [3]. The prevalence of sarcopenia varies worldwide as a result of varying diagnostic criteria. According to studies adopting the European diagnostic criteria for sarcopenia, the prevalence in Oceania and Europe ranges from 8% to 36% in people aged < 60 and 10%-27% in people aged ≥ 60 [4]. In China, the prevalence of sarcopenia in the population aged 60 or older ranged from 10.7% to 15.1% in females and 8.9% to 13.4% in males [5], which is higher than the average prevalence in Asia. The cause of sarcopenia has not yet been precisely determined. Sarcopenia is influenced by many factors, including genetics, chronic diseases, medication, exercise, and dietary factors; The latter are closely related to nutritional status and play an important role in the development of sarcopenia. Therefore, exploring dietary factors may be an effective approach for the prevention and treatment of sarcopenia.
The Mediterranean dietary pattern is characterized by a high consumption of whole grains, fruits, vegetables, legumes and olive oil; moderate consumption of dairy products and alcohol; and low meat consumption [6]. In 2003, Trichopoulou et al. developed a scale to evaluate adherence to the traditional Mediterranean Diet (MED) [7]. Following that, Fung et al. created the Alternative Mediterranean Diet (aMed) score to assess Mediterranean diet adherence in a non-Mediterranean populations [8]. The aMed score is mainly composed of nine components, including vegetables (excluding potatoes), fruits, nuts, whole grains, legumes, fish, the ratio of monounsaturated fatty acids (MUFA) to saturated fatty acids (SFA), red meat and processed meat products, and wine, respectively.
The Mediterranean dietary pattern, a globally recognized healthy dietary pattern, has been shown to reduce the risk of developing several chronic diseases [9]. Recent studies suggest that adhering to a Mediterranean dietary pattern may help to minimize the loss of skeletal muscle mass and muscle function, although the findings regarding the effect on grip strength are inconsistent, and there is no direct evidence of the beneficial effect of the Mediterranean dietary pattern on sarcopenia [10–14]. However, the association between the Mediterranean dietary pattern and the risk of sarcopenia has not been fully investigated, specifically in the Chinese population, and to the best of our knowledge, only one study has elaborated the association between the Mediterranean diet and sarcopenia [14]. Hence, it is necessary to investigate the association between the Mediterranean dietary pattern and sarcopenia in the Chinese population. Therefore, we conducted a cross-sectional study to investigate the association between the Mediterranean dietary pattern and the risk of sarcopenia in the Chinese populace.
Materials and methods
Study design and population
We conducted a cross-sectional study During 2020 in Henan Province, China. Our study population consisted of residents from Henan Province. We excluded individuals with a history of cancer because cancer diagnoses may result in dietary and physical condition changes. We then obtained informed consent from the participating population. Finally, we excluded individuals with missing information (n = 27). A total of 639 individuals were finally included in the study.
This study was approved by the Ethical Review Committee, and written informed consent was obtained from all participants (Protocol 2020–KY-066).
Sarcopenia assessment
Sarcopenia was assessed by the 2019 recommended revised diagnostic criteria of AWGS [15]. Lean muscle mass was measured by bioelectrical impedance analysis (Inbody 570, BioSpace, Seoul, Korea). Individuals were asked to remove jewelry and other personal items that could interfere with the examination. Low muscle mass was defined by appendicular skeletal muscle mass(ASM), and appendicular skeletal muscle mass index (ASMI) was calculated by the following formula: lean mass of arms and legs (kg)/height (m2). Physical performance was measured by the walking speed test. In this test, an individual walks 6 m theiraverage daily walking pace, and the time taken is recorded accordingly. The test is repeated twice, and the average time an individual completes 6 m of walking then counts. Reduced muscle mass was diagnosed when appendicular skeletal muscle mass index (SMI) is less than 5.7 kg/m2 for females and less than 7.0 kg/m2 for males. Low muscle strength was diagnosed when grip strength was ≤ 26 kg for males and ≤ 18 kg for females. Walking speed of more than 1 m/s was considered normal for both males and females, otherwise it was considered low physical performance. Sarcopenia was identified by low muscle mass plus muscle strength or physical performance, while severe sarcopenia was diagnosed when all three criteria of the definition were met [15]. Because of the small sample size of this study, the sarcopenia stage (including severe sarcopenia) and its elements (low muscle mass, muscle strength, and physical performance) were also analyzed.
Dietary assessment
After incomplete data and implausible energy intake were eliminated, according to the dietary habits of local residents, modify the validated Food Frequency Questionnaire (FFQ) to collecte the dietary intake of the participants over the last year [16, 17]. A set of food containers was used to measure quantities. The resulting dietary data were converted uniformly to a daily intake (g or mL) for each food entry.
Adherence to the Mediterranean diet in non-Mediterranean populations was assessed using the Alternative Mediterranean diet (aMed) score, which was adapted by Fung et al. from a scale developed by Trichopoulou et al. to assess adherence to the traditional MED. The aMed score consists of nine main components: vegetables (excluding potatoes), fruits, nuts, whole grains, legumes, fish, the ratio of monounsaturated fatty acids to saturated fatty acids (MUFA/SFA), red and processed meat products, and wine. The scoring criteria were as follows: the average daily intake for the first 7 components was scored as 1 if the average daily intake of the population was > the median daily intake level of the population, 0 otherwise; 1 if the consumption of red and processed meat products was < the median level of the population, 0 otherwise; and 1 for moderate alcohol consumption (5–15 g of alcohol per day), 0 otherwise. The aMed score ranged from 0 to 9, with the higher score indicating a greater resemblance to the Mediterranean diet.
Assessment of other variables
The average daily food intakes were analyzed by a nutrition calculator (NCCW software) based on the China food composition tables [21]. Height was measured by experienced investigators. The general questionnaire was used to collect information about age, gender, literacy, place of residence, marital status, sleep quality, smoking status, chronic diseases and so on. Physical activity data was collected using the Chinese version of the International Physical Activity Questionnaire (IPAQ) [18], which divides physical activity into three main categories: light, moderate, and vigorous physical activity. The corresponding metabolic equivalents (MET) were calculated based on the coefficients; in this study, we calculate the metabolic equivalents for moderate and vigorous physical activity. The moderate-vigorous physical activity (Met-h/day, MET, metabolic equivalent of task) was calculated for each individual according to Chinese Guidelines for Chinese Residents [19].
Statistical analysis
All data were analyzed using SPSS statistical software, version 21 and a P value < 0.05 was considered statistically significant. Categorical variables were expressed as numbers and percentages (%). A chi-square test was used to determine if there were statistical differences between groups of categorical variables groups respectively. Continuous variables were first tested for normality, expressed as mean ± standard deviation and a one-way ANOVA was used to determine whether there was a statistical difference between the groups.
Based on the quartiles of the aMed score of the study population, the respondents were equally divided into four groups (Quartile 1, Q1 < 4; Quartile 2, Q2; Quartile 3, Q3; Quartile 4, Q4). The likelihood of sarcopenia being associated with the alternative Mediterranean dietary pattern was assessed using binomial Logistic Regression analyses with odds ratios (OR) and 95% confidence intervals (CI) (Q1 was used as a reference group). In the analyses, model 1 was a crude model, unadjusted for confounders; model 2 was adjusted for age, gender, smoking index, sleep quality, and literacy; and model 3 was adjusted for age, gender, place of residence, smoking index, underlying disease, sleep quality, literacy, and moderate to high-intensity physical activity.
Results
Data from 639 participants was analyzed using the AWGS algorithm, updated in 2019. Among them, 48 patients were diagnosed with sarcopenia, representing a prevalence rate of 7.51%. The aMed score of the study population was in the range of 1–8. Based on the quartiles of the aMed score, the respondents were equally divided into four groups.
Table 1 shows the characteristics of the study participants according to the aMed score. Participants who have higher aMed scores have higher literacy levels(P < 0.05). Individuals with a higher aMed score were likelier to live in urban areas (P < 0.05). sarcopenia, muscle mass and Gait speed differed between groups(P < 0.05, Table 1).No statistical differences were observed between the four groups regarding moderate to vigorous physical activity, smoking index, gender, sleep quality, underlying diseases, and Grip strength ((P > 0.05, Table 1).
Table 1.
Baseline characteristics according to quartiles of aMed score
| Q1<4 N = 117 |
4 ≤ Q2<5 N = 136 |
5 ≤ Q3<6 N = 153 |
Q4 ≥ 6 N = 233 |
χ 2 /F | P | |
|---|---|---|---|---|---|---|
| age | 57.99 ± 9.39 | 60.31 ± 8.45 | 57.79 ± 9.52 | 59.33 ± 8.53 | 2.519 | 0.057 |
| Metmh1 | 8.38 ± 8.06 | 7.42 ± 6.16 | 8.07 ± 6.67 | 8.31 ± 6.23 | 0.614 | 0.606 |
| somking index | 294.55 ± 398.23 | 326.60 ± 473.91 | 319.95 ± 416.81 | 295.67 ± 439.75 | 0.221 | 0.882 |
| gender | 1.756 | 0.624 | ||||
| male | 78(66.7%) | 81(59.6%) | 93(60.8%) | 140(60.1%) | ||
| female | 39(33.3%) | 55(40.4%) | 60(39.2%) | 93(39.9%) | ||
| literacy | 32.418 | <0.001 | ||||
| illiterate | 7(6.0%) | 5(3.7%) | 5(3.3%) | 1(0.4%) | ||
| Primary education | 14(12.0%) | 19(14.0%) | 20(13.1%) | 14(6.0%) | ||
| Secondary school | 83(70.9%) | 91(66.9%) | 94(61.4%) | 149(63.9%) | ||
| University | 13(11.1%) | 21(15.4%) | 34(22.2%) | 68(29.2%) | ||
| sleep quality | 0.343 | 0.952 | ||||
| good | 63(53.8%) | 77(56.6%) | 87(57.2%) | 128(54.9%) | ||
| worse | 54(46.2%) | 59(43.4%) | 66(42.8%) | 105(45.1%) | ||
| resident | 20.945 | <0.001 | ||||
| urban | 88(75.2%) | 112(82.4%) | 131 (85.6%) | 216(92.7%) | ||
| township | 29(24.8%) | 24 (17.6%) | 22(14.4%) | 17(7.3%) | ||
| disease | 1.856 | 0.603 | ||||
| no | 64(54.7%) | 75(55.1%) | 92(60.1%) | 124(53.2%) | ||
| yes | 53(45.3%) | 61(44.9%) | 61(39.9%) | 109(46.8%) | ||
| Sarcopenia | 61.576 | <0.001 | ||||
| no | 106(90.6%) | 124(91.2%) | 137(89.5%) | 223(95.7%) | ||
| yes | 11(9.4%) | 12(8.8%) | 16(10.5%) | 10(4.3%) | ||
| SMI2 | 10.973 | 0.012 | ||||
| no | 106(90.6%) | 117 (86.0%) | 134(87.6%) | 222(95.3%) | ||
| yes | 11(9.4%) | 19 (14.0%) | 19(12.4%) | 11(4.7%) | ||
| Grip strength | 7.580 | 0.056 | ||||
| no | 104(88.9%) | 110(80.9%) | 133(86.9%) | 211(90.6%) | ||
| yes | 13(11.1%) | 26(19.1%) | 20(13.1%) | 22(9.4%) | ||
| Gait speed | 9.006 | 0.029 | ||||
| no | 25(21.4%) | 43(31.6%) | 32(20.9%) | 43(18.5%) | ||
| yes | 92(78.6%) | 93(68.4%) | 121(79.1%) | 190(81.5%) |
1 metmh(moderate-vigorous physical activity)
2 SMI (skeletal muscle mass index)
Table 2 shows the association between the quartiles of the aMed score and the risk of sarcopenia. We did not observe a relationship between the aMed score and the risk of sarcopenia; however, after adjustment for age, gender, smoking index, education level, and sleep quality, a significant negative relationship was observed between the aMed score and the risk of sarcopenia and muscle mass. The group with the highest aMed score (≥ 6) had a 63.2% lower risk of developing low muscle mass (OR: 0.368; 95% CI: 0.148–0.912), and the risk of sarcopenia was 31.9%(OR:0.319; 95% CI: 0.124–0.819)compared to the low aMed score (< 4) group (Model 2). The association between sarcopenia and the aMed score was more prominent in participants after adjustment for age, gender, metmh, smoking index, education level, disease, place of residence, and sleep quality. The risk of sarcopenia in the highest aMed score group (≥ 6) was 0.305 (OR: 0.305,95% CI: 0.117–0.791), and the risk of muscle mass was 0.363 (0R:0.363,95% CI: 0.162–0.982) (Model 3). However, we did not find a relationship between the aMed score and muscle strength or gait speed.
Table 2.
Relative risks of sarcopenia and its elements by quartiles of aMed score
| Q1<4 N = 117 |
4 ≤ Q2<5 N = 136 |
5 ≤ Q3<6 N = 153 |
Q4 ≥ 6 N = 233 |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Model 12 | Model 23 | Model 34 | Model 1 | Model 2 | Model 3 | Model 1 | Model 2 | Model 3 | ||
| Odds ratio | Odds ratio | Odds ratio | Odds ratio | Odds ratio | Odds ratio | Odds ratio | Odds ratio | Odds ratio | ||
| Sarcopenia | 1 | 0.933(0.395,2.200) | 0.794(0.331, 1.906) | 0.766(0.316,1.856) | 1.125(0.501,2.526) | 1.047(0.459, 2.387) | 1.028(0.448,2.357) | 0.432(0.178,1.049) | 0.319(0.124, 0.819) | 0.305(0.117,0.791) |
| SMI1 | 1 | 1.565(0.712,3.440) | 1.385(0.621, 3.087) | 1.362(0.607,3.053) | 1.366(0.623,2.996) | 1.287(0.581, 2.583) | 1.281(0.575,2.853) | 0.477(0.201,1.136) | 0.368(0.148, 0.917) | 0.363(0.145,0.909) |
| Grip strength | 1 | 1.891(0.923,3.876) | 1.662(0.780, 3.542) | 1.762(0.824,3.768) | 1.203(0.572,2.531) | 1.208(0.550, 2.653) | 1.252(0.564,2.781) | 0.834(0.404,1.722) | 0.914(0.419, 1.997) | 0.821(0.397,1.698) |
| Gait speed | 1 | 0.588(0.332,1.040) | 0.648(0.359, 1.170) | 0.635(0.350,1.153) | 1.028(0.570,1.852) | 1.043(0.569, 1.913) | 0.976(0.529,1.798) | 1.201(0.691,2.086) | 1.165(0.651, 2.083) | 1.132(0.629,2.039) |
1SMI (skeletal muscle mass index)
2Model 1: Crude model
3Model 2: Adjusted for age, sex, smoking index, sleep quality, and literacy
4model 3 : Adjusted for age, sex, place of residence, smoking index, underlying disease, sleep quality, literacy, and moderate to high intensity physical activity
Discussions
In this cross-sectional study, we investigated the association between the Mediterranean dietary pattern and the prevalence risk of sarcopenia among Henan province residents. Higher adherence to the Mediterranean dietary pattern was associated with a lower risk of low muscle mass and sarcopenia after multiple adjustments; however, no association was found between adherence to the Mediterranean diet and grip strength or gait speed.
The Mediterranean dietary pattern, a healthy eating pattern, has been proven in many studies to play a positive role in the development of several chronic diseases [20]. Although the association between the Mediterranean diet and sarcopenia has been reported in human studies, the number of studies is limited, and their results are still controversial [10–14]. Before adjustment for confounding factors, our findings showed no relation between the Mediterranean dietary pattern and sarcopenia, or mass muscle. However, we found that the Mediterranean dietary pattern was positively associated with high mass muscle and a low prevalence risk of sarcopenia after multiple adjustments.This inconsistency may be attributable to the relatively small sample size; A larger sample should be verified in future studies. In addition, gender, age, BMI, chronic diseases, and smoking status have been identified as factors related to MD adherence [21], which may influence the risk of developing sarcopenia, thus presenting meaningful results after adjusting for confounders.Our findings are in line with previous studies indicating that adherence to Mediterranean diet scores is negatively associated with the risk of developing sarcopenia [22] and positively associated with muscle mass [23]. It may be related to the healthy food components included in the Mediterranean dietary pattern. The pathogenesis of sarcopenia mainly consists of oxidative stress, inflammatory load, decreased protein synthesis, and increased catabolism [24]. The Mediterranean dietary pattern can influence the development of sarcopenia through multiple pathways. For example, whole-grain components can enhance muscle metabolic function by promoting myogenesis, influencing muscle fiber-type transformation, reducing muscle protein loss, and improving muscle metabolism [25]. Fruits and vegetables contain carotenoids, antioxidants, vitamins, and phytochemicals that reduce oxidative stress and inflammatory load in the body. Fish are rich in omega-3 fatty acids, lean proteins, selenium, and vitamin D, which have some anti-inflammatory, anti-oxidative, and stress reduction potential [26], associated with sarcopenia pathology. Olive oil in the Mediterranean diet has anti-inflammatory properties [27]. Studies suggest that extra virgin olive oil stimulates protein synthesis and may play a role in sarcopenia treatment [28]. Excessive alcohol intake can lead to long-term imbalances in protein homeostasis, defects in insulin signaling pathways, and consequent loss of muscle strength [29]. Unsaturated fatty acids may contribute to their anti-inflammatory properties. Another study reported that higher MUFA intake and adherence to a Mediterranean diet have been related to fewer falls in community-dwelling older men [30]. Dairy products, nuts and legumes are rich in proteins that provide sufficient amino acids for protein synthesis and are associated with a reduced risk of sarcopenia [31]. Excessive saturated fat in red and processed meat may contribute to inflammation and oxidative stress, adversely affecting body functions and frailty [32]. The Mediterranean dietary pattern may be one of the approaches to preventing sarcopenia due its high intake of dietary fiber, low-fatty acid and high-quality proteins [33, 34]. Our study showed the positive effects of the Mediterranean dietary pattern on sarcopenia and muscle mass, suggesting that a higher aMed score may reduce the risk of sarcopenia and prevent loss of muscle mass. Therefore, increasing adherence to the Mediterranean diet may serve as a strategy for preventing sarcopenia and low muscle mass.
As reported previously, the Mediterranean diet plays a positive role in muscle and physical function [10, 35, 36]; however, this is inconsistent with our results. The reason may be due to the different age and ethnic composition of the groups. In addition, probably due to our small sample size, no relationship between aMed scores and muscle strength or gait speed was found for the time being. Further investigations are needed for whether there is an association between the Mediterranean diet and muscle strength and physical function. Thus, we plan to continue the current investigation to expand the sample size and conduct a follow-up investigation to form a cohort study.
We observed that individuals with high adherence to the Mediterranean diet are well-educated and more likely to live in cities. This is consistent with previous studies [37, 38] indicating that individuals with a high-quality diet are more likely to have higher levels of education and live in cities than those with a lower-quality diet. It may be due to the fact that people who live in cities and have higher levels of education are likely to be more conscious of their health and have better dietary behaviors.
Studies have shown [39] that metabolism, endurance contraction speed and muscle strength begin to decline with age, with a sharp decline (about 10% per year) occurring after the age of 60, leading to a loss of function and independence. Concerned that sarcopenia in the elderly is a hot topic in national research. The Mediterranean diet is characterized by food variety, lightness, simple processing, nutrient richness, and high intake of monounsaturated fatty acids (olive oil) and dietary fiber (whole grains), whereas the Chinese diet has an excessive intake of sodium and carbohydrates, while the intake of whole grains, fruits, and vegetables is far from optimal, which is associated with an increase in a variety of chronic diseases [40], so improving the adherence to the Mediterranean diet among Chinese residents will help to improve the physical fitness of the population.
The current study has some strengths. First, this is the first study to explore the association between the aMed score and sarcopenia in Chinese general populations. Second, sarcopenia was defined according to the 2019 updated standard criteria. In addition, to the best of our knowledge, this study adds to the limited evidence on the relationship between the Mediterranean diet and sarcopenia in the Chinese pupulation.
Our study has some limitations. First, our dietary data was derived from the self-reported Food Frequency Questionnaire (FFQ) for the past year, so there may be recall and social desirability biases. Second, the sample size was small. Due to the cross-sectional study design, we cannot predict the causal relationship between the Mediterranean diet and sarcopenia with this dataset. Further prospective studies are warranted to investigate the causal associations between the Mediterranean diet and sarcopenia. Finally, our study measures were measured by multiple members of the group, and although they were professionally trained, there were still some measurement errors and some potential bias.
Conclusions
Our study showed that the Mediterranean diet reduces the risk of low muscle mass and is associated with a lower risk of sarcopenia among Henan residents. More longitudinal studies are needed to understand the relationship between a Mediterranean diet and sarcopenia.
Supplementary Information
Acknowledgements
We thank all volunteers and staff involved in this research.
Authors' contributions
All authors had full access to all the data and take responsibility for the integrity of the data and the accuracy of the data analysis. J.Z., M.X., and X.R. collected the data. Q.L., A.U. and M.X. analyzed and interpreted the data. M.X., X.R. and J.Z. drafted the manuscript, which was critically revised for important intellectual content by all authors. M.X., J.Z. and Q.L. were responsible for the statistical analysis and revised the manuscript. Q.L. and J.Z. supervised the study and was a guarantor of this study.
Funding
This research received no external funding.
Data availability
The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
All procedures involving research study participants were approved by the first affiliated hospital of Zhengzhou University approved the study design (Protocol 2020–KY-066).Informed consent was obtained from all participants prior to their inclusion in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Quanjun Lyu, Email: lqjnutr@zzu.edu.cn.
Junya Zhai, Email: zhaijunya1229@126.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.