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Association of hematological parameters and inflammatory indices with sarcopenia in the United States and China: a cross-sectional study

European Journal of Medical Research volume 30, Article number: 289 (2025) Cite this article

Abstract

Background

In this study, we examined the association between hematological parameters and inflammatory indices and sarcopenia in the general population of the United States and China.

Methods

The cross-sectional study was conducted using data from the National Health and Nutrition Examination Survey (NHANES) (2011–2014) and the Affiliated Hospital of Anhui Medical University (2022–2024). We employed weighted restricted cubic spline (RCS) plots and multivariable logistic regression analyses to explore the association of hematological parameters and inflammatory indices with the prevalence of sarcopenia in American and Chinese populations.

Results

A total of 8805 participants from NHANES, and 2598 individuals from the First Affiliated Hospital of Anhui Medical University were included in our analysis. In American and Chinese populations, the roughly J-shaped curve was detected in the RCS plots for mean platelet volume and platelet-to-lymphocyte ratio with the risk of sarcopenia. Additionally, the risk of sarcopenia was positively and linearly associated with white blood cells, lymphocytes and platelet, while it was inversely and linearly associated with mean cell volume.

Conclusions

We demonstrated a nonlinear association between some hematological parameters, inflammatory indices and sarcopenia in American and Chinese populations. The need to focus more on hematological parameters and inflammatory indices in the body could provide better prevention strategies for sarcopenia.

Introduction

Sarcopenia is emerging as a pressing public health issue, especially among aging populations, with profound implications for both individual well-being and global healthcare systems [1, 2]. The global prevalence of sarcopenia demonstrates considerable variation across diverse demographics and environmental settings [2,3,4]. The prevalence of this condition spans a range of approximately 3–24%, followed by a subsequent escalation to affect approximately 11–50% of adults aged 80 years and older [2, 3]. Moreover, there is a notably higher prevalence observed among institutionalized elderly populations compared to those living within community settings [5]. The consequential loss of muscle strength and functional capacity attributable to sarcopenia is well-established to elevate the risk of falls, fractures, loss of autonomy, and overall mortality, thereby significantly impairing individuals'ability to carry out daily activities [2, 6, 7].

A multitude of well-established risk factors contribute to the development of sarcopenia, including advancing age, sedentary behavior, inadequate nutritional intake, the presence of chronic diseases, and age-related hormonal alterations [2, 8]. Various biological pathways have been proposed to elucidate the intricate interplay between hematological parameters and inflammatory indices and sarcopenia, thereby offering potential avenues for early detection through the evaluation of hematological parameters and inflammatory indices [2, 3, 6, 8]. For example, an elevated white blood cell (WBC) count can indicate underlying inflammation, which is a risk factor for conditions like diabetes, cardiovascular disease, and metabolic syndrome [9]. Neutrophils (Neu), lymphocytes (Lymph), mean cell volume (MCV), and red blood cell distribution width (RDW) are also key blood components involved in subclinical inflammation. Neu serve as vital markers of innate immunity, while Lymph offers valuable insights into adaptive immunity [10]. Furthermore, the systemic immune-inflammation (SII) index and systemic inflammation response index (SIRI) are excellent and reliable indicators of both local immune responses and overall inflammation in the body [11, 12]. Previous research has shown WBC, platelet, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), RDW, SII index, and SIRI have been implicated in the pathogenesis of sarcopenia, contributing to muscle wasting and functional decline [13,14,15,16]. These markers are routinely assessed in blood or urine specimens and offer valuable insights into the inflammatory status of individuals afflicted with sarcopenia [17]. While it is imperative to recognize that no individual marker comprehensively encapsulates the complexity of these processes, a thorough understanding of the association of each marker with sarcopenia is essential for establishing a robust foundation for the utilization of a combination of markers to augment risk assessment and facilitate disease progression monitoring [1, 6]. Therefore, this study aimed to offer a novel contribution by systematically investigating the association between hematological parameters, inflammatory indices, and sarcopenia. In addition, while previous studies have explored individual biomarkers in relation to sarcopenia, our study is among the first to apply a cross-national comparative approach using data from both the United States (U.S.) and China. The differing epidemiological profiles, healthcare systems, and demographic structures between the U.S. and China may provide a valuable opportunity to assess whether the observed associations are consistent across diverse populations. For example, the U.S. represents a high-income country with a predominantly Western diet and healthcare system, while China, as an upper-middle-income country, exhibits unique dietary, lifestyle, and aging-related characteristics that may present different sarcopenia risk. Therefore, in this study, we utilized the National Health and Nutrition Examination Survey (NHANES) and the Affiliated Hospital of Anhui Medical University data to explore associations between hematological parameters and inflammatory indices and the risk of sarcopenia. By examining data from these two countries, our study enhanced the generalizability of findings and contributed to a deeper understanding of the role of hematological and inflammatory markers in sarcopenia in a U.S. and China-based context.

Material and methods

Study population

The NHANES program is a series of cross-sectional surveys that examine health topics for the general American public of all ages. Instead of taking a simple random sample from the U.S. population, data are collected and analyzed using a multistage, complex clustered probability design [18]. Our study initially included 19,931 participants, but 8858 were excluded due to missing sarcopenia data. In addition, 2268 patients were excluded due to missing data on hematological parameters and inflammatory indices. The final secondary data analysis included 8805 participants (Fig. 1). The National Center for Health Statistics (NCHS) Research Ethics Review Board approved the study. All participants provided written informed consent when recruited [19]. More information about the data can be found at https://www.cdc.gov/nchs/nhanes/index.htm. In addition, a total of 2598 individuals obtained by the First Affiliated Hospital of Anhui Medical University between 2022 and 2024 were also included and analyzed to explore the link between hematological parameters and inflammatory indices and risk of sarcopenia in China population. Supplementary Fig. 1 provided more information about detailed inclusion and exclusion criteria for the individuals obtained from the First Affiliated Hospital of Anhui Medical University.

Fig. 1
figure 1

Study flowchart. NHANES, National Health and Nutrition Examination Surveys

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Covariates

The following covariates were included in the present study: demographic data (age, family poverty income ratio (PIR), race/ethnicity, marital status, sex, and education level), examined data (body mass index (BMI) and waist circumference), questionnaire results (smoking status, drinking status), dietary data (mean energy intake), and lab results (WBC, Lymph, monocyte, RDW, estimated glomerular filtration rate (eGFR), MCV, platelet, mean platelet volume (MPV), fast glucose (FBG), Neu, triglyceride (TG), alkaline phosphatase (ALP), total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), serum uric acid (sUA), serum creatinine (Scr), and blood urea nitrogen (BUN)).

Measurement of the hematological parameters and inflammatory indices

An in-depth description of how to collect and process instructions was provided in the NHANES Laboratory/Medical Technologists Procedures Manual. In this study, we calculated the NLR, PLR, SII index, and SIRI for each participant as follows [11]: NLR = neutrophil count (× 109/L)/lymphocyte count (× 109/L); PLR = platelet count (× 109/L)/lymphocyte count (× 109/L); SII index (× 109/L) = neutrophil count (× 109/L)/lymphocyte count (× 109/L) × platelet count (× 109/L); SIRI (× 109/L) = neutrophil count (× 109/L) × monocyte(× 109/L)/lymphocyte count (× 109/L).

The sarcopenia measurement

Sarcopenia was diagnosed using the dual-energy X-ray absorptiometry (DXA) scan. The DXA scan provides a precise measurement of muscle mass and strength, making it an accurate method for diagnosing sarcopenia. Appendicular lean mass (ALM) was defined as the sum of the fat-free masses of all four extremities (arms and legs). For this study, Foundation for the National Institutes of Health criteria were used for ALM-defined sarcopenia (< 19.75 kg in males, < 15.02 kg in females) and ALM adjusted for body mass index (BMI) (< 0.789 kg for males, < 0.512 kg for females) [20, 21].

Statistical analysis

The study used R version 4.4.0 and SPSS version 22.0 for all statistical analyses. The P-value < 0.05 was considered statistically significant. The calculation results of the sample size in this study met the requirements and were obtained through PASS software. Continuous variables were expressed as mean ± standard deviation, while categorical variables are expressed as a number (%). The weighted Student's t-tests and weighted Chi-square tests were employed to compare continuous variables and constituent ratios between each group, respectively. Such weighted tests were also able to minimize selection bias and improve the reliability of our findings due to the complex NHANES survey design and potential confounders such as demographic characteristics, health conditions, and lifestyle factors. To explore the potential nonlinearity of the association of hematological parameters and inflammatory indices with sarcopenia risk, the weighted restricted cubic spline (RCS) plot and multivariate logistic regression analysis were used. Models 1, 2, and 3 were constructed to evaluate the independent associations of hematological parameters and inflammatory indices with sarcopenia while progressively reducing residual confounding. Firstly, model 1 was adjusted for age and sex, as these are fundamental demographic variables that significantly influence sarcopenia risk. Second, model 2 was further adjusted for marital status, smoking status, education level, family PIR, race/ethnicity, the complications of hypertension and DM, and drinking status. These factors were included to capture lifestyle and socioeconomic influences on sarcopenia. Finally, model 3 was further adjusted for TG, mean energy intake, FBG, UA, TC, waist circumference, Scr, HDL-C, BUN, and eGFR. These variables were incorporated to account for metabolic health and nutritional status, both of which have been implicated in sarcopenia pathophysiology.

Results

Characteristics of participants

As shown in Table 1, the study population had the following characteristics. The total number of participants in this study was 8805. There were 145 individuals with sarcopenia, or 1.6% of the population. Sex, education level, the complication of hypertension and DM, drinking status, waist circumference, WBC, UA, Neu, monocyte, HDL, MCV, RDW, SII index, platelet, SIRI, ALP, Lymph, FBG, TG, and eGFR had significant differences among the non-sarcopenia and sarcopenia groups. Additionally, the basic characteristics of the 2598 individuals from the Affiliated Hospital of Anhui Medical University are shown in Supplementary Table 1.

Table 1 Demographic characteristics of the study participants
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Associations of hematological parameters and inflammatory indices with sarcopenia in American population

In the general American population, the RCS plot represented a roughly J-shaped curve association of MPV (P for nonlinearity = 0.013), NLR (P for nonlinearity = 0.028), PLR (P for nonlinearity = 0.195), SII index (P for nonlinearity = 0.488) and SIRI (P for nonlinearity = 0.237) with the prevalence of sarcopenia (Fig. 3A, B, C, D and E). Additionally, the prevalence of sarcopenia had a positive and linear correlation with WBC, Neu, Lymph, RDW, platelet and ALP (Figs. 2A, B, C, E, F and 3F) and was inversely and linearly associated with MCV (Fig. 2D). The hematological parameters and inflammatory indices were all divided into quartiles in American population (Supplementary Table 2). Finally, the results of the multivariate logistic regression analysis of hematological parameters and inflammatory indices with sarcopenia risk are presented in Tables 2 and 3.

Fig. 2
figure 2

The restricted cubic spline plot of the association of A white blood cells, B lymphocyte, C neutrophils, D mean cell volume, E red cell distribution width, and F platelet with risk of sarcopenia

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Fig. 3
figure 3

The restricted cubic spline plot of the association of A mean platelet volume, B neutrophil-to-lymphocyte ratio, C platelet-to-lymphocyte ratio, D systemic immune inflammation index, E system inflammation response index, and F alkaline phosphatase with risk of sarcopenia

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Table 2 Associations of WBC, Lymph, Neu, MCV, RDW and platelet with sarcopenia risk
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Table 3 Associations of MPV, NLR, PLR, SII index, SIRI and ALP with sarcopenia risk
Full size table

Associations of hematological parameters and inflammatory indices with sarcopenia in Chinese population

In the general Chinese population, the RCS plot represented a roughly J-shaped curve association of Neu, MPV and PLR with sarcopenia risk (Supplementary Fig. 2B, 3 A and 3 C). Additionally, the risk of sarcopenia had a positive and linear correlation with WBC, Lymph, platelet, NLR, SII index, SIRI and ALP (Supplementary Fig. 2 A, 2 C, 2 F, 3B, 3D, 3E and 3 F) and was inversely and linearly associated with MCV (Supplementary Fig. 2D). However, RDW was associated with sarcopenia risk in an N-shaped curve (Supplementary Fig. 2E). The hematological parameters and inflammatory indices were all divided into quartiles in China population (Supplementary Table 3). Finally, the results of the multivariate logistic regression analysis, which involved the correlation between hematological parameters and inflammatory indices with sarcopenia risk, are presented in Supplementary Tables 4 and 5.

Discussion

Our research findings contribute to the body of knowledge by elucidating J-shaped relationships between various hematological parameters and the risk of sarcopenia, offering novel insights compared to prior studies. Firstly, in the U.S. general population, this study firstly revealed a roughly J-shaped curve association of MPV, NLR, PLR, SII index and SIRI with the prevalence of sarcopenia. It highlights that both excessively high and abnormally low levels of these biomarkers may be associated with increased sarcopenia risk. This finding suggests that clinical interventions should focus on balanced regulation rather than solely reducing inflammatory or hematological markers, which could inadvertently introduce other health risks. Additionally, sarcopenia risk demonstrated a positive and linear correlation with WBC, Neu, Lymph, RDW, platelet and ALP and was inversely and linearly associated with MCV. It could indicate that individuals with a higher level of WBC, Neu, Lymph, RDW, platelet and ALP or lower MCV could be considered to have a higher risk of developing sarcopenia. These results underscore the nuanced nature of the relationship between these parameters and sarcopenia, potentially acknowledging potential inconsistencies across diverse population groups.

Inflammation-based scores such as NLR and PLR, derived from peripheral blood cell counts, have been linked to systemic inflammation and adverse health outcomes [22, 23]. While some studies suggested associations between elevated NLR or PLR values and increased sarcopenia risk, inconclusive results were reported [22,23,24,25]. For example, a study by Liaw et al. based on NHANES (1988–1994) found that among older adults aged 60 and older, PLR was suggested to be an inflammatory biomarker for sarcopenia [26]. In our study, the J-shaped association highlights that either a lower or higher PLR level is associated with a greater risk of sarcopenia in geriatric populations. Moreover, SIRI, an innovative inflammation-based score integrating peripheral blood neutrophil, monocyte, and lymphocyte counts, offers a quantitative assessment of systemic inflammation [27]. Studies exploring the associations of SIRI with the risk of sarcopenia remain relatively scarce, as these markers are emerging in the field [15]. Recent investigations in China have reported a positive correlation between elevated SIRI levels and sarcopenia, indicating a potential association between systemic inflammation and muscle loss [15, 22]. Our findings, indicating an optimal value may exist in the association between SIRI and sarcopenia risk, do not completely align with prior research in this area [28, 29]. Overall, future studies are warranted to elucidate the precise role of such biomarkers for sarcopenia and their potential utility in clinical practice. Lymphocytes, pivotal in immune function and inflammation regulation, have been posited to correlate with sarcopenia, potentially reflecting immune dysregulation or chronic inflammation [30]. Studies have shown that higher levels of lymphocytes may be associated with an increased risk of sarcopenia due to their role in modulating inflammation and immune function [22, 31]. As cost-effective clinical indicators, WBC and platelet counts have emerged as independently associated factors with the risk of sarcopenia, attributable to chronic low-grade inflammation, as evidenced by studies conducted within Iran and Korean cohorts [14, 32]. Elevated RDW levels are often indicative of impaired erythropoiesis and can be a marker of systemic inflammation and poor health status [29, 33]. Some studies have suggested that higher RDW levels may be associated with an increased risk of sarcopenia, possibly due to the inflammatory processes involved [22, 34]. Additionally, while ALP levels have been associated with various health conditions, their direct correlation with sarcopenia prevalence may be less clear compared to other markers such as inflammation and nutritional status [35, 36]. In addition, a nationwide cross-sectional study in South Korea found that serum ALP levels were positively associated with low skeletal muscle mass index in both men and women [37]. Future studies should investigate its potential involvement in bone metabolism, inflammation, and muscle function to determine whether it serves as a biomarker or contributes mechanistically to sarcopenia pathogenesis. Secondly, we found that in the Chinese population, the roughly J-shaped curve was detected for MPV and PLR with sarcopenia risk. The risk of sarcopenia was positively and linearly associated with WBC, Lymph and platelet, while it was inversely and linearly associated with MCV. This is consistent with what we found above in the American population. Therefore, the maintenance of optimal levels of hematological parameters and inflammatory indices within the body is critical to reducing the risk of sarcopenia in the general population, whether in the U.S. or China. Additionally, the prevalence of sarcopenia exhibits significant differences between males and females. During aging, men lose skeletal muscle mass and strength twice as fast as women [38]. However, some studies have suggested that sarcopenia and sarcopenic obesity are more prevalent among female patients, along with a lower percentage of lean mass, making them more vulnerable compared to males [39]. The potential reason might be that there may be some sex-related differences among some specific subtypes of sarcopenia. For example, spinal muscular atrophy (SMA) is a common subtype of sarcopenia that primarily affects infants and children and it has been found that male patients may be more affected by SMA than female patients in which male patients generally show more severe symptoms [40]. Therefore, future research on exploring sex differences in subtypes of sarcopenia is warranted to support clinical intervention in various population groups.

Overall, our data from NHANES and the First Affiliated Hospital of Anhui Medical University provided a valuable data resource to explore the associations between hematological parameters, inflammatory indices, and sarcopenia. However, there are some limitations to our study. Firstly, this study was based on secondary data analysis and NHANES and the First Affiliated Hospital of Anhui Medical University data are both cross-sectional studies. Therefore, the relationship between dynamic changes in hematological parameters, inflammatory indices, and sarcopenia in participants were unable to be explored. And, since only 32% of the NHAHES population was included in the study from 2011 to 2014, this could lead to selection bias in the findings. Additionally, there are differences between Chinese and American populations. Secondly, NHANES relies on self-reported data on health status and dietary and behavioral habits. This dependence may be affected by subjective memory and self-report bias, thereby reducing the accuracy and reliability of the data. Thirdly, it is noted that the oncological conditions such as cancers may influence the risk of sarcopenia; however, due to the cross-sectional design of the two datasets, it was not possible to capture comprehensive confounding factors in this study. Fourthly, due to the limitations of the NHAENS database, we can only evaluate the prevalence of low muscle mass not of sarcopenia. Therefore, we were also unable to present the functional evaluation by dynamometry or by physical performance test. Finally, in the study, the association between hematological parameters, inflammatory indices, and sarcopenia is well discussed; however, further research is needed to elucidate the underlying mechanisms driving these relationships. Additionally, future studies should focus on longitudinal investigations to determine causal pathways and assess whether interventions targeting inflammation and hematological markers can mitigate the risk of sarcopenia.

Conclusion

In the U.S. and China general population, WBC, Lymph and platelet were positively correlated with the risk of sarcopenia, while MCV was inversely associated with the risk of sarcopenia. Individuals with higher levels of WBC, Lymph, and platelet or a lower level of MCV may be at a higher risk of developing sarcopenia. Additionally, we also found a roughly J-curve association of MPV, and PLR with sarcopenia risk. Maintaining the levels of hematological parameters and inflammatory indices in the body is crucial to the prevention of sarcopenia. These findings provide a foundational framework for future investigations exploring the dynamics of hematological parameters and inflammatory indices and their underlying mechanistic implications for the onset and progression of sarcopenia.

Data availability

The NHANES datasets for this study can be found at www.cdc.gov/nchs/nhanes/. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

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Acknowledgements

The authors thank the staff and the participants of the NHANES study for their valuable contributions.

Funding

This work was supported by the Health Research Program of Anhui (AHWJ2023 A20394).

Author information

Author notes

  1. Ying Cheng and Chen Kuang contributed equally to this work.

Authors and Affiliations

  1. Department of Rehabilitation Medicine, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, 230022, Anhui, China

    Ying Cheng

  2. Department of Joint Orthopedics, Kunshan Hospital of Traditional Chinese Medicine, No. 388 Zuchongzhi Road, Kunshan, 215300, Jiangsu, China

    Chen Kuang

  3. Department of Rehabilitation, Anhui Public Health Clinical Center, The First Affiliated Hospital of Anhui Medical University, 100 Huaihai Dadao, Xinzhan District, Hefei, 230011, Anhui, China

    Gang Zhang & Zhongzheng Zhang

  4. Department of Orthopaedics, Anhui Public Health Clinical Center, The First Affiliated Hospital of Anhui Medical University, 100 Huaihai Dadao, Xinzhan District, Hefei, 230011, Anhui, China

    Kunpeng Qin

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  3. Gang Zhang
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  4. Zhongzheng Zhang
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  5. Kunpeng Qin
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Contributions

Ying Cheng and Chen Kuang contributed to hypothesis development and manuscript preparation. Ying Cheng and Gang Zhang contributed to study design. Chen Kuang and Zhongzheng Zhang undertook data analyses. Kunpeng Qin and Ying Cheng drafted and revised the manuscript. All authors approved the final draft of the manuscript for publication.

Corresponding author

Correspondence to Kunpeng Qin.

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Ethics approval and consent to participate

The NHANES 2003–2016 was approved by the NCHS Research Ethics Review Board (Continuation of Protocol #2003–2016), and each participant signed the written informed consent. The study was conducted in accordance with the Declaration of Helsinki and was approved by the ethics committee for medical research at the First Affiliated Hospital of Anhui Medical University (PJ2023 - 01 - 31).

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Not applicable.

Competing interests

The authors declare no competing interests.

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Cheng, Y., Kuang, C., Zhang, G. et al. Association of hematological parameters and inflammatory indices with sarcopenia in the United States and China: a cross-sectional study. Eur J Med Res 30, 289 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40001-025-02551-1

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40001-025-02551-1

Keywords

European Journal of Medical Research

ISSN: 2047-783X

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