Hidden Hunger in Aging Bodies: Malnutrition and Sarcopenia Strike Even Those With Excess Weight

Older adults carrying cardiometabolic disease are far more likely to be malnourished, sarcopenic, or both than their body weight alone would ever suggest, according to a new cross-sectional study from Northern Italy. In a cohort of 303 adults aged 65 and older recruited from a General Medicine ward and an Endocrinology and Metabolic Diseases outpatient clinic, researchers found that malnutrition affected 39.9% of participants, sarcopenia 30.9%, and sarcopenic obesity 9.4%. Probable sarcopenia, identified by low muscle strength alone, reached 42.6%, while metabolic syndrome was present in 60.1% of the sample. The findings, published in Frontiers in Nutrition as part of the SENIOR study, paint a picture of aging bodies in which excess fat, depleted muscle, and disturbed metabolism frequently coexist in the same person.

The study, conducted at three hospitals in Northern Italy—the ICS Maugeri IRCCS in Pavia, the IRCCS Policlinico San Matteo Foundation, and the IRCCS San Gerardo dei Tintori Foundation in Monza—recruited participants consecutively between November 2023 and December 2025, maintaining a three-to-one ratio of inpatients to outpatients. Of the 303 Caucasian participants, 233 were hospitalized patients and 70 were outpatients. The cohort had a mean age of 76.6 years with an almost perfectly balanced sex distribution at 49.8% female. Most participants were retired, and the group carried a substantial clinical burden: the mean comorbidity index stood at 6.6, and 76.6% of participants were taking five or more chronic medications.

Diagnoses followed internationally recognized consensus criteria. Malnutrition was identified using the Global Leadership Initiative on Malnutrition (GLIM) framework, with screening performed through the Malnutrition Universal Screening Tool. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) algorithm, which moves stepwise from low muscle strength through reduced muscle quantity to impaired physical performance. Sarcopenic obesity was classified under the ESPEN/EASO consensus, and metabolic syndrome was diagnosed using International Diabetes Federation criteria based on central obesity plus at least two metabolic abnormalities. Body composition was assessed through bioelectrical impedance analysis, muscle strength through handgrip dynamometry, and physical performance through a four-meter gait speed test.

The numbers revealed a heavy and overlapping burden. Malnutrition coexisted with overweight or obesity in 13.2% of enrolled participants, a striking illustration that elevated body weight does not rule out nutritional impairment. Among those diagnosed with malnutrition by GLIM criteria, 56.2% actually had a normal weight, 33.0% were overweight or obese, and only 10.7% were underweight. Malnutrition and sarcopenia overlapped in 29.2% of the sample, and the combination of malnutrition, sarcopenia, and probable sarcopenic obesity affected 20.2% of the total population. The simultaneous presence of all three confirmed conditions was rare, at 2.0% overall.

Setting made a dramatic difference. Hospitalized patients showed substantially higher prevalence across nearly every measure: malnutrition affected 47.2% of inpatients versus 15.7% of outpatients, and sarcopenic obesity was found exclusively among hospitalized patients, at 12.2%, all classified as Stage II severity. No confirmed cases appeared among outpatients, though the authors note this may reflect the smaller outpatient sample, their younger age, lower disease burden, and missing body composition data. Probable sarcopenic obesity, however, was frequent in both settings, affecting 55% of inpatients and 44.9% of outpatients. Metabolic syndrome was present in 67% of inpatients compared with 37.1% of outpatients.

Multivariable logistic regression identified distinct risk profiles for each condition. For malnutrition, participants aged 75 to 84 years had more than double the odds of diagnosis compared with younger participants (odds ratio 2.20), while the oldest-old, aged 85 to 99, showed an odds ratio of 8.53. Poor physical health-related quality of life, measured by the physical component summary of the SF-12, tripled the odds of malnutrition (OR 3.17). For sarcopenia, functional dependence in activities of daily living, defined as a Barthel Index score of 70 or below, carried an odds ratio of 5.39, and poor physical health-related quality of life again raised the odds (OR 3.90). Notably, overweight and obesity were associated with significantly lower odds of confirmed sarcopenia—odds ratios of 0.18 and 0.02 respectively—a pattern the authors suggest may reflect limitations of current diagnostic criteria in people with excess adiposity.

Sarcopenic obesity followed its own pattern. It was independently associated with being aged 75 to 84 years (OR 2.00) and with low physical activity levels, defined as a Physical Activity Scale for the Elderly score below 76 (OR 1.80). Metabolic syndrome was significantly associated with malnutrition, sarcopenia, and sarcopenic obesity alike, reinforcing the close interplay between metabolic and geriatric syndromes. An exploratory analysis also examined sarcopenic diabetes—the coexistence of sarcopenia and type 2 diabetes—which was observed in 9.6% of patients, exclusively among inpatients. Participants with a Cumulative Illness Rating Scale severity index of 2.5 or higher had substantially increased odds of this combination, with an odds ratio of 10.55.

The inflammatory profile of the cohort added a biological dimension to these findings. Inpatients showed markedly higher levels of C-reactive protein (4.7 versus 0.3 mg/dL), interleukin-6 (14.6 versus 5.9 pg/mL), interleukin-10, white blood cell counts, and uric acid than outpatients, along with significantly lower prealbumin, a marker at the interface of nutrition and inflammation. Age correlated positively with interleukin-6, interleukin-10, and tumor necrosis factor-alpha, consistent with the concept of inflammaging—the chronic low-grade inflammation that accompanies aging. Among all the biomarkers evaluated, interleukin-6 showed the most consistent associations: concentrations were higher in older participants, in those with sarcopenic obesity (18.1 versus 10.1 pg/mL), and in those with metabolic syndrome (13.2 versus 9.8 pg/mL).

Dietary patterns showed only limited links to the measured biomarkers. Participants with high adherence to the Mediterranean diet, assessed by the MEDI-LITE score, had significantly lower white blood cell counts than those with lower adherence (7.6 versus 9.3 × 10⁹/L), but no significant differences appeared for C-reactive protein, cytokines, or other markers. Low adherence to the MIND diet was associated with higher serum uric acid concentrations. The authors caution that, given the cross-sectional design, no conclusions can be drawn about the direction or causality of these associations, and uric acid may simply reflect a greater metabolic-inflammatory burden rather than a direct dietary effect.

The study’s limitations frame how these results should be read. The cross-sectional design precludes causal inference, and the participants—recruited from a single ward and outpatient clinic in Northern Italy and predominantly Caucasian—should not be extrapolated to the general community-dwelling older population. Exclusion of patients with severe cognitive impairment, cancer, dysphagia, or severe illness may have led to underestimation of malnutrition and sarcopenia in frailer populations. Gait speed could not be assessed in 27.4% of inpatients because they were bedridden, had unstable gait, or faced a high risk of falls, which may have affected estimates of severe sarcopenia. Bioelectrical impedance could not be performed in 62 participants, and because current sarcopenic obesity definitions do not allow calf circumference as a substitute, diagnosis could not be confirmed in 42 participants with probable sarcopenic obesity—though a subanalysis of the 237 participants with complete data showed a similar prevalence. Biomarker data were incomplete, partly because serum collection for cytokine measurements was incorporated into the protocol only after recruitment had begun.

Despite these constraints, the central message stands firm: excess body weight does not exclude nutritional or muscle impairment in older adults with cardiometabolic disease. With overweight affecting 30.7% of the sample, obesity 33.3%, and mean waist circumference at 103.9 cm, a substantial share of these older adults carried both abundant fat and hidden deficits in muscle and nutrition. The authors argue that integrated assessment—combining nutritional, functional, body-composition, and cardiometabolic evaluation—is needed to identify vulnerable older adults and guide targeted interventions, particularly in hospital settings where the burden is greatest. Larger multicenter and longitudinal studies, they conclude, are needed to confirm these observations and clarify the temporal and causal relationships among these overlapping geriatric syndromes.

Subject of Research: Prevalence and overlap of malnutrition, sarcopenia, sarcopenic obesity and metabolic syndrome in older adults with cardiometabolic diseases

Article Title: Prevalence and clinical characterization of malnutrition, sarcopenia and sarcopenic obesity in older adults with cardiometabolic diseases: SENIOR cross-sectional study

Article References: Santero, S., Bolpagni, F., Boussetta, S., Coperchini, F., Biino, G., Madini, N., Rizzo, C. R., Magri, F., Rotondi, M., Vincenti, A., Beretta, A., Viroli, G., Manuelli, M., Fonte, M. L., Di Napoli, I., Corvino, D., De Cata, P., Di Sabatino, A., Falchi, A. G., … Cena, H. (2026). Prevalence and clinical characterization of malnutrition, sarcopenia and sarcopenic obesity in older adults with cardiometabolic diseases: SENIOR cross-sectional study. Frontiers in Nutrition, 13, 1927628. https://doi.org/10.3389/fnut.2026.1927628

Image Credits: AI Generated

DOI: 10.3389/fnut.2026.1927628

Keywords: malnutrition, sarcopenia, sarcopenic obesity, metabolic syndrome, older adults, cardiometabolic disease, inflammaging, interleukin-6, GLIM criteria, EWGSOP2, body composition, cross-sectional study