What causes muscle loss in aging men?

Marc Darrow, MD, JD.

What causes muscle loss in men? If you have obesity and diabetes, you have known risk factors for the development of physical disability. This includes loss of muscle.

A major problem we see in our practice in aging men in is sarcopenia, the progressive loss of muscle mass and strength. Researchers have put together a good amount of evidence to link obesity and diabetes as factors that will accelerate  the progression of sarcopenia, and subsequently functional muscle decline in older adults. In other research not only was obesity and diabetes cited as culprits of muscle loss but back pain as well as it prevented exercise necessary to maintain and build muscle. Worse is the connection that obesity and low back pain can also lead to problems of bone mineral density.

These are the many factors effecting the aging male patient who wishes to maintain a muscular figure.

A February 2024 study (1) offers us a brief summary of the treatments of sarcopenia: “it is well known that sarcopenia is a complex disorder caused by multiple factors, e.g., imbalance in protein turnover (the ability to eat enough protein and the ability to turn that protein into muscle), satellite cell (the cells responsible for muscle generation) and mitochondrial dysfunction (you don’t produce or have the energy biologically to produce muscle), hormonal changes, low-grade inflammation, senescence the breakdown of aging), anorexia of aging (older people not eating enough), and behavioral factors such as low physical activity. Therefore, pharmaceuticals, either alone or combined, that exhibit multiple actions on these factors simultaneously will likely be the drug of choice to manage sarcopenia. Among various drug options explored throughout the years, testosterone still has the most cumulated evidence regarding its effects on muscle health and its safety.”


Let’s explore testosterone a little further. A January 2023 study (2) notes that low levels of free testosterone have been shown to be a factor in mobility limitations. Men with low free testosterone were 68% more likely to experience mobility limitation than men with normal free testosterone levels. One reason the paper discusses is that testosterone has been shown to have many anti-inflammatory and protective effects. Low testosterone can reduce the immune system’s anti-inflammatory properties. Chronic inflammation is linked to muscle loss.

An October 2023 paper (3) writes testosterone supplementation has been shown to increase maximal voluntary contraction (the maximum force a muscle can generate), inhibit adipogenesis (the development of fat) and reduce inflammation.


Cognitive decline and muscle loss

Continuing further on this line. An October 2023 study (4) writes: “Declining muscle function accelerates cognitive impairment, and cognitive impairment in turn affects muscle strength.” The authors highlight a connection  between declining muscle function and cognitive impairment and shared problems of  chronic inflammation, mitochondrial dysfunction and oxidative stress, and gut microbiota disorder. Additionally, neuroendocrine connections including testosterone, insulin, and growth factors have important effects on muscle and brain function.”


An April 2022 study (5) looked at finding risk factors of declining physical performance in older men. In this study of 821 men aged 60-87, physical performance was assessed by four tests (five chair stands, standing with closed eyes, forward and backward tandem walk (walking a line on the floor)) at baseline, four and eight years. The authors found being older, with higher fat mass index, low physical activity, prior stroke and fracture were associated with poor physical performance at baseline. Being older, low physical activity, low calcium intake, prior non-vertebral fractures, low apparent free testosterone concentration and poor health status were associated with higher risk of loss to follow-up (patients dropped out of the study).

Obesity and Chronic Inflammation

A February 2024 paper (6) examined the body’s natural anti-inflammatory workings in dealing with muscle loss and chronic low-level inflammation. The objective of this study was to examine the association between muscle mass and circulating adiponectin levels among obese patients with metabolic syndrome who are older than 60 years of age. As noted by the authors: “Adiponectin is one of the most important adipokines in human beings. Obesity and sarcopenia are associated with a low-level chronic inflammatory status, and adiponectin plays an anti-inflammatory role.”

In addition to acting as an anti-inflammatory, Adiponectin, is involved in monitoring and maintaining glucose levels and fatty acid breakdown. Adiponectin is secreted by the fat tissue.

In essence, obesity and muscle loss occur as contributors or the result of chronic low-level chronic inflammatory status. Low levels of serum adiponectin levels are negatively associated with low skeletal muscle mass among obese people with metabolic syndrome who are older than 60 years of age. A February 2023 paper (7) wrote: “In terms of dietary components, high fiber content, fish-rich diet, legume-rich diet, low-glycemic index diet, and low-calorie diet are some of the dietary patterns that have been shown to enhance adiponectin levels.”

Sarcopenic obesity

Sarcopenic obesity is a term to describe loss of muscle combined with obesity. A January 2021 study revealed (8) salivary testosterone values in men with sarcopenia and sarcopenic obesity were significantly lower which suggests a potential use of the biomarker for diagnostic purposes. What the researchers suggest is that salivary biomarkers can play an important role in the diagnosis and prevention of sarcopenic . The relationship between testosterone levels in saliva and sex as well as the relationship between this hormone at the salivary level and age in men make it an effective, inexpensive, and easy-to-use parameter. Salivary testosterone is reduced in men with sarcopenic  and sarcopenic obesity.

A September 2023 study (9) writes: “Various treatments have been suggested for sarcopenic obesity. The most important factors are increased skeletal muscle mass (more muscle) and decreased body fat mass (less fat). Therefore, exercise has been proposed as a fundamental treatment. However, implementing an optimal diet is also important for maximizing recovery from sarcopenic obesity . . . several dietary methods can have positive effects, such as calcium supplementation, vitamins D and K, a ketogenic diet, and a high-protein diet.  . . ”


A June 2021 study (10) suggests that lack of sleep and the chemical imbalances it creates, i.ie, weight gain, muscle loss, hormone disturbance can contribute to metabolic damage caused by lower testosterone and higher cortisol levels. These imbalances may lead to systemic inflammation, insulin resistance, and suppress pathways involved in muscle protein synthesis. These changes may lead to dysregulated energy balance and skeletal muscle metabolism, increasing the risk of sarcopenic obesity.

Insulin Resistance

When we eat, our bodies release insulin into our blood stream so that we can process glucose (sugars) from our foods to make energy, especially in our muscles. Glucose belongs in our cells and not in our blood. When it remains in our blood we produce more insulin. Increased insulin, according to many researchers, is the number one factor for accelerated aging. Aging is associated with a decrease in muscle mass.

A November 2023 paper (11) writes: “Insulin resistance and hyperglycemia accelerate muscle loss, leading to a deterioration in strength, muscle mass, and physical capacity in older adults.  . . .Poor glycemic control is associated with the presence of sarcopenia and low muscle mass, which highlights the need to implement better (insulin resistance) treatment strategies in order to reduce the loss of muscle mass.” Also noted in this paper was that  between 30% and 40% of a person’s muscle mass can decrease by the time they reach an age of 80 years. It is reasonable to think that this loss is related to the development of glucose intolerance and subsequently to the increased risk of developing type 2 diabetes mellitus.  “People with prediabetes and high HbA1c levels experience a loss of muscle mass, muscle strength, and physical performance, particularly in the lower extremities among older ages, and worsening when untreated.”

Type 2 diabetes mellitus a modifiable risk factor for muscle loss

An August 2023 paper in the Journal of Clinical Medicine (12) writes: “Sarcopenia is associated with type 2 diabetes mellitus and vice versa. In a study of 159 diabetics (cases) and 79 non-diabetics (controls) aged over the age of 50, the prevalence of sarcopenia was significantly higher among the type 2 diabetes mellitus cases than the controls (22.5% vs. 8.86%).

  • The authors note: Body mass index, physical activity, serum calcium levels, hypertension, and neuropathy were significantly associated with sarcopenia following data  analysis. By modifying these risk factors among the elderly Type 2 diabetes mellitus, sarcopenia can be prevented.

Gut Bacteria

In this article we are discussing inflammation as a factor in developing muscle loss. Chronic inflammation can be the result of too much bad bacteria in the bowel. Research suggests that diet can reduce bad inflammation and promote the growth of good bacteria like those listed below.

A March 2024 study (13) discusses gut bacteria as a significant player in controlling sarcopenia. This study focused on the association of gut microbiota on muscle health.

“Nutritional supplements containing proteins, vitamin D, omega-3 fatty acids, creatine, curcumin, kefir, and ursolic acid positively impact the gut microbiome. Dietary fibers foster a conducive environment for the growth of beneficial microbes such as Bifidobacterium, Faecalibacterium, Ruminococcus, and Lactobacillus.

Probiotics and prebiotics act (as anti-inflammatories) by protecting against reactive oxygen species (ROS) and inflammatory cytokines (these are the mechanisms that the body creates “oxidants” to which you would want to take “anti-oxidants.” They also increase the production of gut microbiota metabolites like short-chain fatty acids (SCFAs), which aid in improving muscle health. Foods rich in polyphenols are anti-inflammatory and have an antioxidant effect, contributing to a healthier gut. “

Inadequate diet

A January 2021 study (14) cites research that describes the protective effect of dietary protein for sarcopenia and positive associations between protein intake and muscle mass. The study notes among many factors that it has been well documented that older individuals with high protein intake lose less muscle. Poor diet promotes cognitive decline, including Alzheimer’s disease. Poorer diet was associated with reduced attention and cognitive flexibility, visuospatial ability and perceptual speed.

A February 2023 study (15) suggests that diet should be customized to the individual and that “the effects of protein and supplements on muscle mass and function differed between adults and the elderly. Although the positive effects of protein and supplements were found in adults and athletes, they may not be the same in the elderly. Therefore, further studies on various protein, supplement and pharmaceuticals in sarcopenia should be performed.”

Thyroid disorders

Subclinical hypothyroidism occurs in people with thyroid levels within normal range but serum thyroid-stimulating hormone (TSH) levels are elevated. This is where the body seemingly have enough thyroid hormones, but thinks it needs more. A December 2023 paper (16) explains how this may cross over into muscle loss: “Subclinical hypothyroidism is a risk factor for sarcopenia in the older adults and correlated with low muscle strength and low muscle mass, but not with low physical performance. Triiodothyronine (T3), Free thyroxine (FT4)  and TSH levels are associated with sarcopenia components, but not with sarcopenia.” In other words, no direct correlation but the researchers noted that the presence of subclinical hypothyroidism was significantly correlated with low muscle strength and low muscle mass, but not with low physical performance (men were functioning.)

Muscle loss and erectile dysfunction

A December 2023 paper (17) affirms that “implementing testosterone replacement therapy (TRT) can effectively enhance erectile function among elderly individuals.” They also not that testosterone replacement therapy  has potential adverse effects (which should be discussed with your doctor. Further testosterone replacement therapy may not help everyone). In this study the researchers demonstrated a significant association of frailty (muscle loss and weakness) in advancing age, with the occurrence of erectile dysfunction.

In returning to a discussion on testosterone, a March 2024 study (18) writes of the connection between low testosterone, muscle loss and erectile dysfunction, that men suffer from symptoms of  sexual dysfunction, including low sexual desire, reduced nocturnal erections, and ejaculate volume along with loss of bone density and muscle mass. The problem of low testosterone and  skeletal muscle mass/strength is widely recognized.

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