Objective  To explore the association between dietary quality and sarcopenic obesity (SO).

Methods  Based on data from the National Health and Nutrition Examination Survey (NHANES) in the United States from 2011 to 2018, participants in four survey cycles were selected as the study subjects. Weighted multivariate Logistic regression analysis was used to explore the association and interaction between Healthy Eating Index 2020(HEI-2020) and SO, and the mediating effects of inflammation, metabolism, and nutritional status on the relationship between HEI-2020 and SO were analyzed.

Results  A total of 8,602 participants were included, of whom 504 had SO, with a weighted prevalence of approximately 5.33%, The SO group had lower HEI-2020 scores. Multivariate Logistic regression analysis showed that, after adjusting for age, sex, lifestyle, related comorbidities, and energy intake, compared with low HEI-2020 scores, medium HEI-2020 scores [OR=0.73, 95%CI (0.54, 0.99)] and high HEI-2020 scores [OR=0.50, 95%CI (0.35, 0.72)] were negatively correlated with SO. Subgroup analysis showed that, except for low-income groups and those with sedentary time ≥8 hours, high HEI-2020 scores were negatively correlated with SO. No interaction was found between age, sex, education level, income level, or sedentary time on the association between HEI-2020 and SO. Mediation analysis showed that systemic inflammatory response index (SIRI), glycated hemoglobin, non-HDL cholesterol to HDL cholesterol ratio (NHHR), albumin, and plasma vitamin D negatively mediated the relationship between HEI-2020 and SO.

Conclusion  Dietary quality is negatively correlated with SO. HEI-2020 can affect SO through the mediating effects of SIRI, glycated hemoglobin, NHHR, albumin, and plasma vitamin D. We should strengthen dietary health education, improve the dietary quality of residents, and promote healthy aging.

1.Donini LM, Busetto L, Bischoff SC, et al. Definition and diagnostic criteria for sarcopenic obesity: ESPEN and EASO consensus statement[J]. Obes Facts, 2022, 15(3): 321-335. DOI: 10.1159/000521241.

2.Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies[J]. Nat Rev Endocrinol, 2018, 14(9): 513-537. DOI: 10.1038/s41574-018-0062-9.

3.Kong HH, Won CW, Kim W. Effect of sarcopenic obesity on deterioration of physical function in the elderly[J]. Arch Gerontol Geriatr, 2020, 89: 104065. DOI: 10.1016/j.archger.2020.104065.

4.Veronese N, Ragusa FS, Pegreffi F, et al. Sarcopenic obesity and health outcomes: an umbrella review of systematic reviews with Meta-analysis[J]. J Cachexia Sarcopenia Muscle, 2024, 15(4): 1264-1274. DOI: 10.1002/jcsm.13502.

5.陈长, 刘辉, 蔺阳刚, 等. 肌少症在老年动脉粥样硬化性心血管疾病发病中的作用研究进展[J]. 解放军医学杂志, 2021, 46(5): 512-517. [Chen Z, Liu H, Lin YG, et al. Research progress on the role of sarcopenia in the pathogenesis of atherosclerotic cardio-cerebrovascular disease in the elderly[J]. Medical Journal of Chinese People's Liberation Army, 2021, 46(5): 512-517.] DOI: 10.11855/j.issn.0577-7402.2021.05.14.

6.Jia S, Zhao W, Hu F, et al. Sex differences in the association of physical activity levels and vitamin D with obesity, sarcopenia, and sarcopenic obesity: a cross-sectional study[J]. BMC Geriatr, 2022, 22(1): 898. DOI: 10.1186/s12877-022-03577-4.

7.Cheah KJ, Cheah LJ. Benefits and side effects of protein supplementation and exercise in sarcopenic obesity: a scoping review[J]. Nutr J, 2023, 22(1): 52. DOI: 10.1186/s12937-023-00880-7.

8.Shams-White MM, Pannucci TE, Lerman JL, et al. Healthy eating index-2020: review and update process to reflect the dietary guidelines for americans, 2020-2025[J]. J Acad Nutr Diet, 2023, 123(9): 1280-1288. DOI: 10.1016/j.jand.2023.05.015.

9.Wang K, Wu J, Deng M, et al. Associations of healthy eating index-2015 with osteoporosis and low bone mass density in postmenopausal women: a population-based study from NHANES 2007-2018[J]. Front Nutr, 2024, 11: 1388647. DOI: 10.3389/fnut.2024.1388647.

10.He T, Yan Y, Wang D, et al. Association of dietary health indices with frailty[J]. BMC Public Health, 2025, 25(1): 1068. DOI: 10.1186/s12889-025-22245-x.

11.Hao X, Li D. The healthy eating index-2015 and all-cause/cause-specific mortality: a systematic review and dose-response Meta-analysis[J]. Adv Nutr, 2024, 15(3): 100166. DOI: 10.1016/j.advnut.2023.100166.

12.Guo B, Liu X, Si Q, et al. Associations of CBC-derived inflammatory indicators with sarcopenia and mortality in adults: evidence from NHANES 1999~2006[J]. BMC Geriatr, 2024, 24(1): 432. DOI: 10.1186/s12877-024-05012-2.

13.Lou Y, Xie Y, Jiang Q, et al. The effect of sarcopenic obesity on glycaemic status based on fasting plasma glucose and glycated haemoglobin: a prospective cohort study[J]. Diabetes Obes Metab, 2025, 27(1): 291-299. DOI: 10.1111/dom.16016.

14.Picca A, Coelho-Junior HJ, Calvani R, et al. Biomarkers shared by frailty and sarcopenia in older adults: a systematic review and Meta-analysis[J]. Ageing Res Rev, 2022, 73: 101530. DOI: 10.1016/j.arr.2021.101530.

15.卢姝妤, 陈国婷, 毛志锦, 等. 老年住院患者握力和骨骼肌量与营养状况的相关性研究[J]. 数理医药学杂志, 2023, 36(1): 30-35. [Lu SY, Chen GT, Mao ZJ, et al. A study of the correlation between handgrip strength and skeletal muscle mass and nutritional status in elderly hospitalized patients[J]. Journal of Mathematical Medicine, 2023, 36(1): 30-35.] DOI: 10.12173/j.issn.1004-4337.202211012.

16.Studenski SA, Peters KW, Alley DE, et al. The FNIH sarcopenia project: rationale, study description, conference recommendations, and final estimates[J]. J Gerontol A Biol Sci Med Sci, 2014, 69(5): 547-558. DOI: 10.1093/gerona/glu010.

17.Wang ZZ, Xu Q, Zhang YH, et al. Oxidative balance score is associated with increased risk of sarcopenia and sarcopenic obesity in non-elderly adults: results from NHANES 2011-2018[J]. Nutr Metab (Lond), 2025, 22(1): 23. DOI: 10.1186/s12986-025-00914-3.

18.Kong F, Huang J, Xu C, et al. System inflammation response index: a novel inflammatory indicator to predict all-cause and cardiovascular disease mortality in the obese population[J]. Diabetol Metab Syndr, 2023, 15(1): 195. DOI: 10.1186/s13098-023-01178-8.

19.Zhang L, Lai Y, Yan L, et al. The joint and interactive effects of the non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) and body mass index on the risk of depression, as well as the mediating role of NHHR: results from NHANES 2005-2023[J]. Lipids Health Dis, 2025, 24(1): 77. DOI: 10.1186/s12944-025-02493-x.

20.Howarth NC, Murphy SP, Wilkens LR, et al. Dietary energy density is associated with overweight status among 5 ethnic groups in the multiethnic cohort study12[J]. J Nutr, 2006, 136(8): 2243-2248. DOI: 10.1093/jn/136.8.2243.

21.钟文, 方传明, 杨燕, 等. 增龄性脂代谢异常与肌少症[J]. 中国老年学杂志, 2022, 42(13): 3340-3344. [Zhong W, Fang CM, Yang Y, et al. Age-increasing lipid metabolism abnormalities and sarcopenia[J]. Chinese Journal of Gerontology, 2022, 42(13): 3340-3344.] DOI: 10.3969/j.issn.1005-9202.2022.13.061.

22.Kalinkovich A, Livshits G. Sarcopenic obesity or obese sarcopenia: a cross talk between age-associated adipose tissue and skeletal muscle inflammation as a main mechanism of the pathogenesis[J]. Ageing Res Rev, 2017, 35: 200-221. DOI: 10.1016/j.arr.2016.09.008.

23.Park MJ, Choi KM. Interplay of skeletal muscle and adipose tissue: sarcopenic obesity[J]. Metabolism, 2023, 144: 155577. DOI: 10.1016/j.metabol.2023.155577.

24.Hong SH, Choi KM. Sarcopenic obesity, insulin resistance, and their implications in cardiovascular and metabolic consequences[J]. Int J Mol Sci, 2020, 21(2): 494. DOI: 10.3390/ijms21020494.

25.Abete I, Konieczna J, Zulet MA, et al. Association of lifestyle factors and inflammation with sarcopenic obesity: data from the PREDIMED-Plus trial[J]. J Cachexia Sarcopenia Muscle, 2019, 10(5): 974-984. DOI: 10.1002/jcsm.12442.

26.Li P, Zhang X, Tian L, et al. Vitamin C promotes muscle development mediated by the interaction of CSRP3 with MyoD and MyoG[J]. J Agric Food Chem, 2022, 70(23): 7158-7169. DOI: 10.1021/acs.jafc.2c02432.

27.Ellulu MS. Obesity, cardiovascular disease, and role of vitamin C on inflammation: a review of facts and underlying mechanisms[J]. Inflammopharmacology, 2017, 25(3): 313-328. DOI: 10.1007/s10787-017-0314-7.

28.Wang K, Zhou Q, Jiang Z, et al. The inverse associations between composite-dietary-antioxidant-index and sarcopenia risk in US adults[J]. Front Endocrinol (Lausanne), 2024, 15: 1442586. DOI: 10.3389/fendo.2024.1442586.

29.Softic S, Stanhope KL, Boucher J, et al. Fructose and hepatic insulin resistance[J]. Crit Rev Clin Lab Sci, 2020, 57(5): 308-322. DOI: 10.1080/10408363.2019.1711360.

30.Taskinen RE, Hantunen S, Tuomainen TP, et al. The associations between whole grain and refined grain intakes and serum C-reactive protein[J]. Eur J Clin Nutr, 2022, 76(4): 544-550. DOI: 10.1038/s41430-021-00996-1.

31.Li Q, Chen H, Zhang M, et al. Altered short chain fatty acid profiles induced by dietary fiber intervention regulate AMPK levels and intestinal homeostasis[J]. Food Funct, 2019, 10(11): 7174-7187. DOI: 10.1039/c9fo01465a.

32.Nani A, Murtaza B, Sayed KA, et al. Antioxidant and anti-inflammatory potential of polyphenols contained in mediterranean diet in obesity: molecular mechanisms[J]. Molecules, 2021, 26(4): 985. DOI: 10.3390/molecules26040985.

33.Adeva-Andany MM, Fernández-Fernández C, López-Pereiro Y, et al. The effects of glucagon and the target of rapamycin (TOR) on skeletal muscle protein synthesis and age-dependent sarcopenia in humans[J]. Clin Nutr ESPEN, 2021, 44: 15-25. DOI: 10.1016/j.clnesp.2021.06.025.

34.Chang MC, Choo YJ. Effects of whey protein, leucine, and vitamin D supplementation in patients with sarcopenia: a systematic review and Meta-analysis[J]. Nutrients, 2023, 15(3): 521. DOI: 10.3390/nu15030521.

35.Agoncillo M, Yu J, Gunton JE. The role of vitamin D in skeletal muscle repair and regeneration in animal models and humans: a systematic review[J]. Nutrients, 2023, 15(20): 4377. DOI: 10.3390/nu15204377.

36.Silva-Fhon JR, Rojas-Huayta VM, Aparco-Balboa JP, et al. Sarcopenia and blood albumin: a systematic review with Meta-analysis[J]. Biomedica, 2021, 41(3): 590-603. DOI: 10.7705/biomedica.5765.

37.Liu X, Hao Q, Yue J, et al. Sarcopenia, obesity and sarcopenia obesity in comparison: prevalence, metabolic profile, and key differences: results from WCHAT study[J]. J Nutr Health Aging, 2020, 24(4): 429-437. DOI: 10.1007/s12603-020-1332-5.

38.Erdoğan K, Kara M, Şener FE, et al. Serum albumin as a biomarker of (nutritional status in) sarcopenia[J]. J Bone Miner Metab, 2025, 43(2): 108-113. DOI: 10.1007/s00774-024-01557-9.

39.Bollen SE, Bass JJ, Fujita S, et al. The vitamin D/vitamin D receptor (VDR) axis in muscle atrophy and sarcopenia[J]. Cell Signal, 2022, 96: 110355. DOI: 10.1016/j.cellsig.2022.110355.

40.Garbossa SG, Folli F. Vitamin D, sub-inflammation and insulin resistance. A window on a potential role for the interaction between bone and glucose metabolism[J]. Rev Endocr Metab Disord, 2017, 18(2): 243-258. DOI: 10.1007/s11154-017-9423-2.

41.桑德春. 老年肌少症研究进展[J]. 华西医学, 2018, 33(10): 1219-1223. [Sang DC. Progress in the study of elderly sarcopenia[J]. West China Medical Journal, 2018, 33(10): 1219-1223.] DOI: 10.7507/1002-0179.201805182.

42.Lee H, Park S. Regional differences in the associations of diet quality, obesity, and possible sarcopenia using the seventh Korea National Health and Nutrition Examination Survey (2016-2018) [J]. Epidemiol Health, 2023, 45: e2023059. DOI: 10.4178/epih.e2023059.

43.Banerjee S. Determinants of rural-urban differential in healthcare utilization among the elderly population in India[J]. BMC Public Health, 2021, 21(1): 939. DOI: 10.1186/s12889-021-10773-1.

44.Shim JE, Hwang JY, Kim K. Objective and perceived food environment and household economic resources related to food insecurity in older adults living alone in rural areas[J]. BMC Geriatr, 2019, 19(1): 234. DOI: 10.1186/s12877-019-1231-y.

45.Hamilton MT, Hamilton DG, Zderic TW. Role of low energy expenditure and sitting in obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease[J]. Diabetes, 2007, 56(11): 2655-2667. DOI: 10.2337/db07-0882.

46.Owen N, Healy GN, Matthews CE, et al. Too much sitting: the population health science of sedentary behavior[J]. Exerc Sport Sci Rev, 2010, 38(3): 105-113. DOI: 10.1097/JES.0b013e3181e373a2.

47.Eglseer D, Traxler M, Embacher S, et al. Nutrition and exercise interventions to improve body composition for persons with overweight or obesity near retirement age: a systematic review and network Meta-analysis of randomized controlled trials[J]. Adv Nutr, 2023, 14(3): 516-538. DOI: 10.1016/j.advnut.2023.04.001.

48.徐磊, 李春艳, 陈宁, 等. 老年人肌少性肥胖的机制与运动营养调控研究进展[J]. 食品科学, 2017, 38(21): 279-286. [Xu L, Li CY, Chen N, et al. Exercise and nutrition interventions of sarcopenic obesity and underlying mechanisms[J]. Food Science, 2017, 38(21): 279-286.] DOI: 10.7506/spkx1002-6630-201721044.

49.Rhodes DG, Murayi T, Clemens JC, et al. The USDA automated multiple-pass method accurately assesses population sodium intakes[J]. Am J Clin Nutr, 2013, 97(5): 958-964. DOI: 10.3945/ajcn.112.044982.