Preamble

Association Between the Chinese Healthy Eating Index and Sarcopenia in Patients with Colorectal Cancer

Authors: Li Xuebo, Liu Xuan, Li Shuxing

Abstract

Background: Sarcopenia is a common complication in patients with colorectal cancer (CRC) and is closely associated with poor prognosis. While dietary patterns are known to influence muscle mass and function, the specific relationship between the Chinese Healthy Eating Index (CHEI) and sarcopenia in CRC patients remains to be fully elucidated.

Objective: To investigate the correlation between the Chinese Healthy Eating Index (CHEI) and the occurrence of sarcopenia in patients with colorectal cancer.

Methods: A cross-sectional study was conducted among patients diagnosed with colorectal cancer. Dietary intake was assessed using a validated Food Frequency Questionnaire (FFQ), and CHEI scores were calculated to evaluate adherence to the Chinese Dietary Guidelines. Sarcopenia was diagnosed based on the criteria established by the Asian Working Group for Sarcopenia (AWGS), which includes assessments of muscle mass, muscle strength, and physical performance. Logistic regression analysis was employed to analyze the association between CHEI scores and the risk of sarcopenia, adjusting for potential confounders such as age, gender, body mass index (BMI), and clinical stage.

Results: A total of [N] patients were included in the final analysis. The prevalence of sarcopenia in the study population was [X%]. Patients in the highest tertile of CHEI scores exhibited a significantly lower risk of sarcopenia compared to those in the lowest tertile (OR = [Value], 95% CI: [Lower-Upper], $P < 0.05$). Specifically, higher consumption of whole grains, vegetables, fruits, and dairy products was negatively correlated with the incidence of sarcopenia.

Conclusion: Higher adherence to the Chinese Healthy Eating Index is associated with a reduced risk of sarcopenia in patients with colorectal cancer. Promoting healthy dietary patterns based on national guidelines may serve as a vital strategy for the prevention and management of sarcopenia in this population.

Introduction

Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide, posing a significant burden on public health systems. In recent years, sarcopenia—characterized by the progressive and generalized loss of skeletal muscle mass and strength—has gained increasing attention as a critical prognostic factor for CRC patients. Sarcopenia is not only associated with increased chemotherapy toxicity and postoperative complications but also leads to decreased quality of life and shorter overall survival.

背景

Sarcopenia has a significant impact on the treatment and prognosis of patients with colorectal cancer, and a strong correlation exists between dietary patterns and the development of this condition. Clarifying the relationship between the Chinese Healthy Eating Index (CHEI) and sarcopenia is of great significance for implementing dietary interventions based on Chinese nutritional standards.

This study utilizes the Chinese Healthy Eating Index (CHEI) to investigate the correlation between Chinese healthy dietary patterns and sarcopenia in patients with colorectal cancer.

方法

From July 2024 to May 2025, a total of 326 patients with colorectal cancer admitted to Tangshan People's Hospital, the Affiliated Hospital of North China University of Science and Technology, and Kailuan General Hospital were selected as the research subjects. Data regarding the Chinese Healthy Eating Index (CHEI) and various diagnostic indicators for sarcopenia were collected. Binary logistic regression analysis and restricted cubic spline (RCS) models were employed to analyze the correlations between the total CHEI score, individual dietary components, and the occurrence of reduced muscle mass, declined physical function, and sarcopenia in patients with colorectal cancer.

结果

Among the 326 patients included in the study, 195 were male (59.82%) and 131 were female (40.18%), with a mean age of $64.0 \pm 8.8$ years. Regarding sarcopenia-related indicators, 49 cases (15.03%) exhibited reduced muscle mass, with a median Chinese Healthy Eating Index (CHEI) score of 50 (40, 55); 220 cases (67.48%) showed diminished muscle strength, with a CHEI score of 55 (45, 60); and 217 cases (66.56%) demonstrated declined physical function, with a CHEI score of 55 (45, 60). Sarcopenia was diagnosed in 46 patients (14.11%), who had a median CHEI score of 47.5 (40, 55). Binary logistic regression analysis revealed that CHEI scores were negatively correlated with the risk of reduced muscle mass ($OR = 0.934$, 95% $CI = 0.891\text{--}0.979$, $P = 0.004$), declined physical function ($OR = 0.968$, 95% $CI = 0.942\text{--}0.995$, $P = 0.020$), and the overall incidence of sarcopenia ($OR = 0.931$, 95% $CI = 0.889\text{--}0.975$, $P = 0.003$).

Results from the restricted cubic spline (RCS) model indicated a linear dose-response relationship between CHEI scores and the risk of reduced muscle mass ($P_{overall} = 0.019$, $P_{non-linear} = 0.216$, $P_{trend} = 0.004$), declined physical function ($P_{overall} = 0.095$, $P_{non-linear} = 0.617$, $P_{trend} = 0.020$), and sarcopenia ($P_{overall} = 0.038$, $P_{non-linear} = 0.467$, $P_{trend} = 0.002$). Correlation analyses between individual dietary components and these outcomes showed that higher scores for fruit ($OR = 0.880$, 95% $CI = 0.786\text{--}0.985$, $P = 0.026$), legumes ($OR = 0.480$, 95% $CI = 0.290\text{--}0.794$, $P = 0.004$), poultry ($OR = 0.799$, 95% $CI = 0.644\text{--}0.991$, $P = 0.041$), and sodium ($OR = 0.897$, 95% $CI = 0.805\text{--}1.000$, $P = 0.049$) were negatively associated with the risk of reduced muscle mass. For physical function, scores for fruit ($OR = 0.839$, 95% $CI = 0.714\text{--}0.986$, $P = 0.033$) and seafood ($OR = 0.848$, 95% $CI = 0.730\text{--}0.985$, $P = 0.031$) were negatively correlated with risk, while red meat intake ($OR = 1.256$, 95% $CI = 1.048\text{--}1.506$, $P = 0.014$) showed a positive correlation with functional decline. Regarding sarcopenia, cereal intake ($OR = 1.608$, 95% $CI = 1.115\text{--}2.317$, $P = 0.011$) was significantly positively correlated with risk, whereas higher scores for fruit ($OR = 0.886$, 95% $CI = 0.788\text{--}0.996$, $P = 0.043$), legumes ($OR = 0.409$, 95% $CI = 0.238\text{--}0.703$, $P = 0.001$), and poultry ($OR = 0.731$, 95% $CI = 0.584\text{--}0.916$, $P = 0.007$) were negatively associated with the risk of sarcopenia.

结论

Abstract

The Chinese Healthy Dietary Pattern is positively correlated with reduced loss of muscle mass, improved physical function, and a lower risk of sarcopenia in patients with colorectal cancer, exhibiting a linear dose-response relationship. Adequate intake of fruits, legumes, poultry, whole grains, and seafood—combined with moderate relaxation of restrictions on red meat intake and controlled consumption of sodium and refined grains—contributes to reducing the risk of sarcopenia in this patient population.

Keywords: Colorectal cancer; Chinese healthy dietary pattern; Muscle strength; Physical function; Muscle mass; Sarcopenia; Restricted cubic spline model

Study on the Correlation Between Chinese Healthy Dietary Pattern and Sarcopenia in Colorectal Cancer Patients

Xuebo Shuxing
Department of Nursing and Rehabilitation
North China University of Science and Technology
Tangshan 063210, China

LI Shuxing
Professor

Introduction

Colorectal cancer (CRC) remains a significant global health challenge, often accompanied by metabolic changes that lead to the deterioration of musculoskeletal health. Sarcopenia, characterized by the progressive loss of skeletal muscle mass, strength, and physical function, is a common complication in CRC patients that adversely affects clinical outcomes, treatment tolerance, and quality of life. Nutrition plays a pivotal role in the management of sarcopenia; however, the specific impact of the Chinese Healthy Dietary Pattern on these musculoskeletal parameters in the context of CRC requires rigorous investigation.

Methodology

This study evaluates the correlation between adherence to the Chinese Healthy Dietary Pattern and the prevalence of sarcopenia among patients diagnosed with colorectal cancer. Utilizing a cross-sectional design, researchers assessed muscle mass, muscle strength, and physical function using standardized clinical metrics. To further explore the nature of these associations, restricted cubic spline (RCS) models were employed to characterize the dose-response relationship between dietary scores and sarcopenia risk.

Results and Discussion

The findings indicate that higher adherence to the Chinese Healthy Dietary Pattern is significantly associated with better preservation of muscle mass and superior physical performance. Specifically, the data revealed a linear dose-response relationship, suggesting that incremental improvements in dietary quality correspond to proportional decreases in the risk of developing sarcopenia.

Key dietary components identified as protective factors include:
- High Intake: Fruits, legumes, poultry, whole grains, and seafood provide essential micronutrients and high-quality proteins necessary for muscle protein synthesis.
- Moderate Intake: While traditional guidelines often emphasize strict limits on red meat, this study suggests that moderate consumption may be beneficial for maintaining muscle mass in CRC patients, provided it is balanced within a healthy framework.
- Controlled Intake: Reducing the overconsumption of sodium and refined grains is critical to mitigating systemic inflammation and metabolic imbalances that contribute to muscle wasting.

Conclusion

Adherence to the Chinese Healthy Dietary Pattern serves as a protective factor against sarcopenia in colorectal cancer patients. By emphasizing a diverse intake of nutrient-dense foods and maintaining balanced consumption of proteins and grains, patients can significantly reduce the risk of muscle mass loss and functional decline. These results provide a theoretical basis for clinical nutritional interventions aimed at improving the long-term

Chinese General Practice

Background

Sarcopenia significantly influences the treatment outcomes and prognosis of colorectal cancer patients，and dietary patterns show a notable correlation with sarcopenia. Elucidating the characteristics of Chinese healthy dietary patterns and their association with sarcopenia is crucial for developing targeted nutritional interventions based on traditional Chinese dietary practices.

Objective To explore the correlation between Chinese healthy dietary pattern and sarcopenia in colorectal cancer patients，utilizing the Chinese Healthy Eating Index（CHEI）.

Methods

From July 2024 to May 2025，a total of 326 colorectal cancer patients from Tangshan People's Hospital，North China University of Science and Technology Affiliated Hospital，and Kailuan General Hospital were enrolled as study subjects. The Chinese Healthy Eating Index （CHEI） and various diagnostic indicators of sarcopenia were collected. After adjusting for covariates，binary Logistic regression analysis and restricted cubic spline models were employed to examine the associations between the total CHEI score and its dietary components with low muscle mass，decreased muscle strength，impaired physical function and sarcopenia in colorectal cancer patients.

Results

Among the 326 patients，195 were male（59.82%） and 131 were female（40.18%），with an average age of（64.0±8.8） years. Among them，there were 49 cases（15.03%） with reduced muscle mass，and the CHEI score was 50 （40，55）. Muscle strength was reduced in 220 cases（67.48%），and the CHEI score was 55（45，60）. Physical function declined in 217 cases（66.56%），with CHEI scores of 55（45，60）. There were 46 patients（14.11%） with sarcopenia， with a CHEI score of 47.5（40，55）. Binary Logistic regression analysis results indicated that CHEI scores were negatively associated with the risk of low muscle mass（ 0.934，95% =0.891-0.979， =0.004），impaired physical function（ 0.968， =0.942-0.995， =0.020），and sarcopenia（ 0.931，95% =0.889-0.975， =0.003）. Rstricted cubic spline model showed a linear dose-response relationship between CHEI and the occurrence of low muscle mass（ overall trend =0.019， linear =0.216， linear =0.004），impaired physical function（ overall trend =0.095， non-linear =0.617， linear =0.020），and sarcopenia overall trend =0.038， non-linear =0.467， linear =0.002）. Analysis of the correlation between various dietary components and low muscle mass，impaired physical function，and sarcopenia revealed that scores for fruits（ 0.880，95% =0.786-0.985， =0.026），legumes（ 0.480，95% =0.290-0.794， =0.004），poultry intake（ 0.799，95% =0.644-0.991， =0.041），and sodium（ 0.897，95% =0.805-1.000， =0.049） were negatively correlated with the risk of low muscle mass. Scores for whole grains（ 0.839，95% =0.714-0.986， =0.033） and seafood（ 0.848，95% =0.730-0.985， =0.031） were negatively correlated with the risk of impaired physical function，while red meat（ 1.256，95% =1.048- 1.506， =0.014） was positively correlated with the risk of impaired physical function. Grains（ 1.608，95% =1.115- 2.317， =0.011） showed a significant positive correlation with the risk of sarcopenia. Scores for fruits（ 0.886， =0.788-0.996， =0.043），legumes（ 0.409，95% =0.238-0.703， =0.001），and poultry（ 0.731， =0.584-0.916， =0.007） were negatively correlated with the risk of sarcopenia.

Conclusion

The Chinese Healthy Eating Index (CHEI) is positively associated with a reduced risk of low muscle mass, impaired physical function, and sarcopenia in colorectal cancer (CRC) patients, demonstrating a linear dose-response relationship. Adequate intake of fruits, legumes, poultry, whole grains, and seafood, combined with moderate red meat consumption and controlled intake of sodium and grains, may help lower the risk of sarcopenia in CRC patients.

Patients with colorectal cancer often experience changes in dietary intake following diagnosis, such as restricting animal proteins and dairy products, which can negatively impact muscle health. Furthermore, the coexistence of intestinal malabsorption, gut microbiota dysbiosis, and chronic inflammation in these patients leads to an imbalance between catabolism and anabolism, thereby increasing the risk of sarcopenia \cite{2-3}. Numerous studies have confirmed that sarcopenia not only affects the incidence of perioperative complications in CRC patients but also exacerbates the toxic side effects of chemotherapy and adversely affects long-term survival and prognosis \cite{4-5}. While nutritional intervention is one of the most effective strategies for managing sarcopenia, existing interventions often focus on supplementing single nutrients, such as protein or energy, while ignoring the role of the overall daily dietary structure. Dietary patterns fully account for the interactions and cumulative effects of various foods, compensating for the limitations of single-nutrient approaches. This perspective helps clarify the role of dietary guidelines in daily nutritional supplementation and is essential for improving sarcopenia outcomes. While the Mediterranean diet and ketogenic diet have been identified as significant factors influencing sarcopenia in CRC patients \cite{7-8}, the Chinese healthy dietary pattern is characterized by a foundation of cereals, rice, and flour, supplemented by plant-based foods such as tubers, legumes, vegetables, and fruits. It includes moderate intake of animal-based foods such as fish, poultry, eggs, and dairy, featuring diverse food types, reasonable combinations, and balanced nutrition \cite{9-10}. This pattern aligns with the Dietary Guidelines for Chinese Residents (DGC). Although several studies suggest that this pattern has a positive effect on muscle strength and frailty status \cite{11-12}, there is currently no direct evidence confirming the association between this dietary pattern and sarcopenia.

One method for evaluating dietary patterns is to use diet quality as an orientation, assessing the degree of alignment between dietary intake and recommended levels based on dietary guidelines.

Key words: Colorectal cancer; Chinese healthy dietary pattern; Muscle strength; Muscle mass; Physical function; Sarcopenia; Restricted cubic spline.

In 2017, Yuan developed the Chinese Healthy Eating Index (CHEI) based on the 2016 version of the Dietary Guidelines for Chinese Residents (DGC-2016). Since the recommended intake ranges in the 2022 version (DGC-2022) are essentially the same as those in DGC-2016, the CHEI remains a reliable tool for evaluating the degree of alignment between an individual's dietary intake and DGC-2022, as well as for assessing adherence to the Chinese healthy dietary pattern. Given that sociodemographic factors, treatment modalities, tumor progression, comorbid chronic diseases, pharmacological treatments, and physical activity \cite{17-19} are associated with the risk of sarcopenia in CRC patients, it is necessary to adjust for these confounders to accurately assess the independent role of the traditional Chinese healthy dietary pattern. This study utilizes the CHEI as an assessment tool and employs binary logistic regression analysis and restricted cubic spline models to explore the correlation and dose-response relationship between the Chinese healthy dietary pattern (including individual food components) and sarcopenia in CRC patients. The objective is to provide a theoretical basis for interventions targeting sarcopenia in CRC patients based on the Chinese healthy dietary pattern.

1.1 调查对象

Patients newly diagnosed with colorectal cancer (CRC) at Tangshan People's Hospital, the Affiliated Hospital of North China University of Science and Technology, and Kailuan General Hospital between July 2024 and May 2025 were selected as the research subjects. The inclusion criteria were: (1) age $\ge 18$ years; (2) pathologically confirmed Stage II–IV CRC; (3) no prior history of chemotherapy or radiotherapy; (4) resumption of a normal diet; and (5) an expected survival period of more than 6 months. The exclusion criteria were: (1) presence of other digestive system diseases, requirement of special diets such as liquid or semi-liquid diets, or inability to tolerate oral intake; (2) presence of motor system diseases such as primary myasthenia gravis; (3) comorbid severe organ dysfunction; (4) impaired consciousness or inability to understand and express themselves normally; and (5) physical deformities preventing muscle strength or physical fitness testing. This study was approved by the Ethics Committee of North China University of Science and Technology (Approval No.: 2024212).

Based on the cross-sectional sample size calculation formula, with $\alpha = 0.05$ and $\beta = 0.1$,

the incidence of sarcopenia in CRC patients was estimated at 18.2%. Accounting for a 20% loss-to-follow-up rate, the required sample size was calculated to be 275 cases. In practice, a total of 332 questionnaires were distributed. After individual inspection and the exclusion of unqualified responses, 326 valid questionnaires were recovered, resulting in an effective recovery rate of 98.19%.

1.2.1 一般资料调查表

A general information questionnaire was designed by the researchers, primarily covering demographic and disease-related data. The demographic data consisted of 5 items: age, gender, educational level, average monthly household income per capita, and primary caregiver.

The disease-related data comprised 11 items: time since surgery, stoma status, tumor location, tumor stage, number of metastatic lymph nodes, degree of differentiation, types of chronic diseases, types of medications used, body mass index (BMI), smoking status, and alcohol consumption.

Smoking status was categorized into three groups: non-smokers (those who have never smoked or have smoked fewer than 100 cigarettes in total and do not smoke at the time of the survey), former smokers (those who have smoked 100 or more cigarettes in total but have been abstinent for $\ge 2$ months), and current smokers (those who have not quit and smoke at least one cigarette daily). Alcohol consumption was categorized into two groups: non-drinkers (those who have never consumed alcohol) and former drinkers (those with a history of alcohol consumption who have been completely abstinent for $\ge 2$ months).

1.2.2 CHEI

The Chinese Healthy Eating Index (CHEI) comprises 12 components for adequate intake (total grains, whole grains and mixed beans, tubers, total vegetables, dark vegetables, fruits, dairy, soybeans, fish and seafood, poultry, eggs, and seeds and nuts) and 5 components for limited intake (red meat, cooking oils, sodium, added sugars, and alcohol).

Dietary data were collected using the 3-day 24-hour dietary recall method. In accordance with the "Standard Food Portions" defined in the Dietary Guidelines for Chinese Residents 2016 (DGC-2016), researchers utilized physical models—such as standard measuring tools, reference hand gestures, and visual aids—to record the type and quantity of food consumed by patients during every meal over a 3-day period. Intake levels for cooking oil and sodium were calculated based on the number of individuals sharing meals and the duration over which the supplies were depleted.

The intake of each food category was converted into standard portions, and scores were calculated proportionally across 17 items, with maximum scores for individual items set at either 5 or 10 points. The total possible score is 100 points; a higher score indicates a higher degree of compliance between an individual's dietary pattern and the Chinese healthy eating model.

1.2.3 国际体力活动量表－中文版短卷（International

The International Physical Activity Questionnaire-Short Form (IPAQ-SF) was developed by the International Physical Activity Questionnaire Working Group and adapted into Chinese by Wang et al. This instrument measures an individual's total physical activity over the past week across several domains: vigorous-intensity activity (activities causing significant increases in breathing and heart rate that preclude normal conversation, such as running, fast cycling, or climbing stairs), moderate-intensity activity (activities causing slight increases in breathing and heart rate where normal conversation is possible but singing is not, such as sweeping, brisk walking, or ballroom dancing), and walking (episodes lasting at least 10 minutes). The questionnaire records the number of days and the daily duration spent on these activities, as well as daily sedentary time (including reading, using a mobile phone, listening to music or radio, watching television or videos, daydreaming, napping, using public transportation, socializing, or engaging in hobbies). Physical activity is converted into Metabolic Equivalent of Task (MET) values, with vigorous activity assigned 8 METs, moderate activity 4 METs, and walking 3.3 METs. An individual's weekly physical activity level for a specific category is calculated as: $\text{MET value} \times \text{duration (min/bout)} \times \text{frequency (days/week)}$. The total weekly energy expenditure is the sum of the energy expenditure across all activity categories.

Physical activity levels are classified according to the following criteria: (1) High level: meeting either (a) vigorous-intensity activity on at least 3 days with a total weekly physical activity level of $\ge 1500$ MET-min/week, or (b) any combination of the three activity types for 7 days with a total weekly physical activity level of $\ge 3000$ MET-min/week. (2) Moderate level: meeting any of the following three criteria: (a) at least 20 minutes of vigorous-intensity activity per day for $\ge 3$ days; (b) at least 30 minutes of moderate-intensity activity or walking per day for $\ge 5$ days; or (c) any combination of the three activity types for $\ge 5$ days with a total weekly physical activity level of $\ge 600$ MET-min/week. (3) Low level: meeting either (a) no physical activity reported, or (b) activity levels that do not meet the criteria for the moderate or high categories.

1.2.4 肌肉减少症诊断

According to the diagnostic criteria established by the Asian Working Group for Sarcopenia 2019 (AWGS 2019), sarcopenia is diagnosed when a patient exhibits low muscle mass accompanied by either reduced muscle strength or diminished physical performance. In this study, the appendicular skeletal muscle mass index (ASMI) was used to evaluate muscle mass, maximum handgrip strength was used to assess muscle strength, and a 6-meter gait speed test was used to evaluate physical performance.

(1) ASMI Calculation: AWGS 2019 defines ASMI as the appendicular skeletal muscle mass (ASM) divided by the square of the height ($m^2$). An anthropometric equation was utilized to estimate the ASM of the sample, incorporating the participants' body mass, height, sex, and age: $ASM = 0.193 \times \text{body mass (kg)} + 0.107 \times \text{height (cm)} - 4.157 \times \text{sex (male=1, female=2)} - 0.037 \times \text{age (years)} - 2.631$. The ASM calculated using this equation shows good agreement with results obtained via dual-energy X-ray absorptiometry (DXA). The diagnostic thresholds for low muscle mass (ASMI) were $<7.0 \text{ kg/m}^2$ for men and $<5.4 \text{ kg/m}^2$ for women. Height and weight measurements were conducted according to the WS/T 424—2013 "Anthropometric Methods for Health Surveillance of Populations," with height recorded to two decimal places and weight to one decimal place.

(2) Handgrip Strength Measurement: Maximum handgrip strength was used to represent muscle strength. Patients were instructed to stand with feet shoulder-width apart and arms hanging naturally at their sides. Using their dominant hand, patients squeezed the dynamometer handle with maximum force as quickly as possible. During the exertion, the dynamometer remained stationary and did not touch the body; the arm remained straight without swinging, and no additional force was generated by jerking, stomping, or bending. Two measurements were taken with the dominant hand, with an interval of more than 15 seconds between trials. The highest value was recorded as the final handgrip strength in kilograms (kg), accurate to one decimal place. For participants uncertain of their dominant hand, both hands were measured twice, and the highest value was recorded. The diagnostic thresholds for reduced muscle strength were $<28 \text{ kg}$ for men and $<18 \text{ kg}$ for women.

(3) 6-meter Gait Speed Test: The 6-meter gait speed was used to represent physical performance. A 6-meter distance was marked on an unobstructed, level floor in a hospital corridor. Patients were instructed to walk the 6-meter distance at a normal pace without accelerating or decelerating. A stopwatch was used to record the time taken to pass between the two markers, accurate to two decimal places. The average of at least two trials was used to calculate the speed: $6 \text{ (m)} / \text{walking time (s)}$. A gait speed of $<1 \text{ m/s}$ indicated a decline in physical performance.

Quality Control Methods: All questionnaire data were collected personally by the researcher. Uniform instructions were used to explain the questionnaire content and precautions to the patients. Any questions raised by patients during the process were answered using standardized responses.

After the questionnaires were completed, they were checked for missing items, and patients were contacted promptly to provide any necessary supplements.

Statistical Methods: Statistical analysis was performed using SPSS 22.0. Categorical data were expressed as relative numbers, and comparisons between groups were conducted using the $\chi^2$ test. Measurement data following a normal distribution were expressed as mean $\pm$ standard deviation ($\bar{x} \pm s$), and comparisons between two groups were performed using independent samples t-tests. As the Chinese Healthy Eating Index (CHEI) and its individual component scores followed a skewed distribution, they were expressed as medians and interquartile ranges $[M(Q_1, Q_3)]$. Binary logistic regression analysis was employed to explore the correlation between CHEI scores (including individual dietary components) and low muscle mass, reduced muscle strength, declined physical performance, and sarcopenia. Restricted cubic spline (RCS) curves were used to investigate the linear dose-response relationship between CHEI scores and low muscle mass, declined physical performance, and sarcopenia. A $P$-value $<0.05$ was considered statistically significant.

2.1 一般资料比较

In this study, a total of 332 questionnaires were distributed, and 326 valid responses were recovered, yielding an effective recovery rate of 98.19%. The participant pool consisted of 195 males (59.82%) and 131 females (40.18%), with a mean age of $(64.0 \pm 8.8)$ years. Among the patients with colorectal cancer (CRC), 49 cases (15.03%) exhibited low muscle mass, while 277 cases (84.97%) were within the normal range. Statistically significant differences were observed between these two groups regarding per capita monthly household income, Body Mass Index (BMI), and alcohol consumption ($P < 0.05$). Furthermore, 220 cases (67.48%) showed decreased muscle strength compared to 106 cases (32.52%) with normal strength. Significant differences were found between these groups in terms of educational level, per capita monthly household income, and the number of medications used ($P < 0.05$), as detailed in [TABLE:1].

Among CRC patients, 217 cases (66.56%) exhibited decreased physical function, while 109 cases (33.44%) remained normal. Statistically significant differences were observed between these groups regarding the primary caregiver, presence of a stoma, number of metastatic lymph nodes, physical activity level, and BMI ($P < 0.05$). Sarcopenia was identified in 46 cases (14.11%), while 280 cases (85.89%) did not meet the criteria for sarcopenia. Significant differences between the sarcopenia and non-sarcopenia groups were noted in per capita monthly household income, BMI, and alcohol consumption ($P < 0.05$). Regarding dietary quality, the total Chinese Healthy Eating Index (CHEI) scores for CRC patients ranged from 30 to 80, with a median score of 55 (45, 60). Specifically, the median CHEI score was 50 (40, 55) for patients with low muscle mass, 55 (45, 60) for those with decreased muscle strength, 55 (45, 60) for those with decreased physical function, and 47.5 (40, 55) for patients with sarcopenia. Component scores were as follows: cereals (0), whole grains 5 (5, 5), tubers (0), vegetables 0 (0, 5), dark vegetables 5 (0, 5), fruits 0 (0, 10), dairy 5 (0, 5), legumes (0), seafood (0), poultry 0 (0, 5), eggs 5 (5, 5), nuts (0), red meat 5 (5, 5), oils 10 (10, 10), sodium 10 (0, 10), added sugars 5 (5, 5), and alcohol 5 (5, 5).

To investigate the relationship between dietary quality and sarcopenia in CRC patients, binary logistic regression analyses were conducted. Low muscle mass, decreased muscle strength, decreased physical function, and sarcopenia were utilized as dependent variables, while the CHEI score (assigned as the measured value) served as the independent variable.

In Model 1, which did not adjust for confounding factors, the results indicated that the CHEI score was significantly associated with low muscle mass in CRC patients ($OR = 0.930$, $95\% CI = 0.900\text{--}0.962$, $P < 0.001$), as well as with physical function.

Chinese General Practice: Univariate analysis of low muscle mass and decreased muscle strength in colorectal cancer patients. Low muscle mass: $64.9 \pm 9.7$ vs. $63.8 \pm 8.7$; Decreased muscle strength: $64.2 \pm 8.5$ vs. $63.4 \pm 9.5$. Case distributions: 7 (14.3%) vs. 52 (18.8%) for muscle mass, and 36 (16.4%) vs. 23 (21.7%) for muscle strength.

0 种

24（49.0） 105（37.9） 78（35.5） 51（48.1）

1 种

16（32.7） 97（35.0） 81（36.8） 32（30.2）

0 种

19（38.8） 94（33.9） 68（30.9） 45（42.5）

1 种

14（28.6） 70（25.3） 53（24.1） 31（29.2）

Chinese General Practice (Continued from Table 1): Univariate analysis of impaired physical function and sarcopenia in colorectal cancer patients. The variables analyzed include reduced muscle mass, decreased muscle strength, impaired physical function, and sarcopenia. The mean ages for these groups were $63.9 \pm 9.0$, $64.1 \pm 8.5$, $64.7 \pm 9.9$, and $63.9 \pm 8.7$ years, respectively.

Chinese General Practice (Continued from Table 2 [TABLE:2]): There was a significant negative correlation between the Chinese Healthy Eating Index (CHEI) scores and the risk of both impaired physical function ($OR = 0.959$, $95\% CI = 0.937\text{--}0.982$, $P < 0.001$) and sarcopenia ($OR = 0.927$, $95\% CI = 0.895\text{--}0.960$, $P < 0.001$). In Model 2, after further adjusting for potential confounding factors—including age, sex, educational level, average monthly household income, primary caregiver, operation time, stoma status, tumor location, number of metastatic lymph nodes, tumor stage, degree of differentiation, number of chronic diseases, types of medication, physical activity level, BMI, smoking status, and alcohol consumption—the results remained consistent.

The results indicated that CHEI scores remained negatively correlated with the risk of reduced muscle mass ($OR = 0.934$, $95\% CI = 0.891\text{--}0.979$, $P = 0.004$), impaired physical function ($OR = 0.968$, $95\% CI = 0.942\text{--}0.995$, $P = 0.020$), and sarcopenia ($OR = 0.931$, $95\% CI = 0.889\text{--}0.975$, $P = 0.003$) in patients with colorectal cancer (CRC). However, results from both Model 1 and Model 2 showed that the correlation between CHEI scores and decreased muscle strength in CRC patients was not statistically significant ($P > 0.05$), as shown in Table 3 [TABLE:3].

The prevalence of impaired physical function and sarcopenia across the study groups was recorded as follows: 40 (18.4%), 19 (17.4%), 7 (15.2%), and 52 (18.6%).

0 种

85（39.2） 44（40.4） 21（45.7） 108（38.6）

1 种

74（34.1） 39（35.8） 16（34.8） 97（34.6）

0 种

74（34.1） 39（35.8） 18（39.1） 95（33.9）

1 种

55（25.3） 29（26.6） 13（28.3） 71（25.4）

Logistic Regression Analysis of the Association Between Chinese Healthy Dietary Patterns and Sarcopenia in Colorectal Cancer Patients

[TABLE:1]

Note: Model 1 is unadjusted for confounding factors. Model 2 is adjusted for age, gender, educational level, average monthly household income per capita, primary caregiver, duration of surgery, presence of a stoma, tumor location, number of metastatic lymph nodes, tumor stage, degree of differentiation, number of chronic diseases, number of medications, physical activity level, BMI, smoking status, and alcohol consumption.

2.3 CHEI

To analyze the linear dose-response relationship between Chinese Healthy Eating Index (CHEI) scores and the reduction of muscle mass, decline in physical function, and sarcopenia in patients, restricted cubic spline (RCS) models were employed. The 5th, 25th, 75th, and 95th percentiles of the CHEI scores were set as the four knots. After adjusting for potential confounding factors, the results indicated a linear dose-response relationship between CHEI scores and the reduction of muscle mass in patients with colorectal cancer (CRC) ($P_{non-linear} = 0.216$, $P_{overall} = 0.004$). The linear results showed no significant thresholds or inflection points; as CHEI scores increased, the risk of muscle mass reduction decreased ($OR = 0.933$, $95\% CI = 0.890\text{--}0.978$), as shown in [FIGURE:1]A. Furthermore, a linear dose-response relationship was observed between CHEI scores and the decline in physical function ($P_{non-linear} = 0.095$,

$P_{non-linear} = 0.617$, $P_{overall} = 0.020$). No significant thresholds or inflection points were found, and the risk of physical function decline decreased as CHEI scores increased ($OR = 0.968$, $95\% CI = 0.942\text{--}0.995$), as shown in Figure 1B. Additionally, a linear dose-response relationship was identified between CHEI scores and sarcopenia ($P_{non-linear} = 0.038$,

$P_{non-linear} = 0.467$, $P_{overall} = 0.002$). With no obvious thresholds or inflection points, the risk of sarcopenia decreased as CHEI scores increased ($OR = 0.930$, $95\% CI = 0.888\text{--}0.974$), as shown in Figure 1C.

Binary logistic regression was used to analyze the relationship between individual dietary component scores within the CHEI and muscle mass reduction, physical function decline, and sarcopenia. The scores of each dietary component in the CHEI were treated as independent variables (using measured values). The analysis controlled for confounding factors including age, sex, education level, average monthly household income, primary caregiver, duration of surgery, stoma status, tumor location, number of metastatic lymph nodes, tumor stage, degree of differentiation, types of chronic diseases, types of medications, physical activity level, BMI, smoking status, and alcohol consumption. With muscle mass reduction as the dependent variable (assigned as: Yes=1, No=0), the results showed that scores for fruits ($OR = 0.880$, $95\% CI = 0.786\text{--}0.985$, $P = 0.026$), legumes ($OR = 0.480$, $95\% CI = 0.290\text{--}0.794$, $P = 0.004$), poultry intake ($OR = 0.799$, $95\% CI = 0.644\text{--}0.991$, $P = 0.041$), and sodium ($OR = 0.897$, $95\% CI = 0.805\text{--}1.000$, $P = 0.049$) were negatively correlated with the risk of muscle mass reduction. Fitting indices showed a Cox & Snell $R^2 = 0.369$ and a Nagelkerke $R^2 = 0.646$. The Omnibus test indicated overall model validity ($\chi^2 = 150.175$, $P < 0.001$), and the Hosmer-Lemeshow test indicated good model fit ($\chi^2 = 4.077$, $P = 0.850$).

Using physical function decline as the dependent variable (assigned as: Yes=1, No=0), binary logistic regression analysis revealed that whole grains ($OR = 0.839$, $95\% CI = 0.714\text{--}0.986$, $P = 0.033$) and seafood ($OR = 0.848$, $95\% CI = 0.730\text{--}0.985$, $P = 0.031$) were negatively correlated with the risk of physical function decline, while red meat ($OR = 1.256$, $95\% CI = 1.048\text{--}1.506$, $P = 0.014$) was positively correlated with the risk. Fitting indices showed a Cox & Snell $R^2 = 0.230$ and a Nagelkerke $R^2 = 0.319$. The Omnibus test indicated good overall validity ($\chi^2 = 85.276$, $P < 0.001$), and the Hosmer-Lemeshow test showed good model fit ($\chi^2 = 11.196$, $P = 0.191$). When sarcopenia was used as the dependent variable (assigned as: Yes=1, No=0), the results showed that grains ($OR = 1.608$, $95\% CI = 1.115\text{--}2.317$, $P = 0.011$) were significantly positively correlated with the risk of sarcopenia. Conversely, scores for fruits ($OR = 0.886$, $95\% CI = 0.788\text{--}0.996$, $P = 0.043$), legumes ($OR = 0.409$, $95\% CI = 0.238\text{--}0.703$, $P = 0.001$), and poultry ($OR = 0.731$, $95\% CI = 0.584\text{--}0.916$, $P = 0.007$) were negatively correlated with the risk of sarcopenia. Fitting indices showed a Cox & Snell $R^2 = 0.351$ and a Nagelkerke $R^2 = 0.630$. The Omnibus test indicated overall validity ($\chi^2 = 140.885$, $P < 0.001$), and the Hosmer-Lemeshow test confirmed good model fit ($\chi^2 = 3.984$, $P = 0.859$).

3 讨论

Sarcopenia negatively impacts both the short-term and long-term prognosis of patients with colorectal cancer (CRC). Dietary patterns represent one of the most effective intervention strategies for managing sarcopenia in this population. While existing research has confirmed the association between Western dietary patterns—such as the Mediterranean diet and the ketogenic diet—and sarcopenia in CRC patients \cite{7-8}, the relationship between sarcopenia and a Chinese healthy dietary pattern based on the Dietary Guidelines for Chinese Residents remains to be established.

In this study, we employed binary logistic regression to adjust for confounding factors and utilized restricted cubic splines (RCS) to further explore the dose-response relationship between a Chinese healthy dietary pattern and sarcopenia in CRC patients. By focusing on the specific characteristics of Chinese healthy eating habits, this study aims to reveal the association between nutrition and sarcopenia from a holistic dietary pattern perspective. Ultimately, these findings seek to provide an evidence-based foundation for developing routine nutritional intervention strategies that align with Chinese dietary habits for patients with CRC.

The study found that the detection rate of sarcopenia in patients with Colorectal Cancer (CRC) was 14.11%. This figure is lower than the results reported by Zhang Xuejing et al., which may be attributed to the fact that the average age of the patients included in this study was lower than that of their study population. Furthermore, the per capita monthly household income...

Income can indirectly interfere with muscle protein synthesis and contraction by influencing a patient's nutritional intake and physical activity, thereby affecting the occurrence of sarcopenia. Patients with a BMI < 23.9 kg/m² face a significantly higher risk of developing sarcopenia compared to those with a BMI ≥ 23.9 kg/m². This finding is consistent with the cohort study results of Xie et al. \cite{...}, likely because cancer patients often experience the simultaneous consumption of adipose and muscle tissue; furthermore, the decrease in BMI caused by weight loss frequently precedes a noticeable reduction in muscle mass.

Among patients with a BMI < 23.9 kg/m², those with a BMI between 18.5 kg/m² and 23.9 kg/m² exhibited a higher risk of sarcopenia than those with a BMI < 18.5 kg/m². This aligns with the research findings of Kiss et al. \cite{...}, suggesting that BMI may not accurately reflect the distribution of fat mass versus muscle mass. Patients with a normal BMI are more likely to have masked reductions in muscle quality and physical function. Additionally, our results indicate that alcohol consumption primarily influences the occurrence of sarcopenia by affecting muscle mass, which is consistent with the findings of Coelho et al. \cite{...}. It is hypothesized that a long-term history of alcohol consumption leads to a chronic imbalance between protein synthesis and degradation, inducing a chronic inflammatory response \cite{30-31}. This manifests as a decrease in muscle mass and a reduction in the cross-sectional area of fiber-rich muscle. Although all patients in this study had ceased alcohol intake prior to receiving treatment, a history of alcohol consumption may still exert a persistent negative impact on muscle status.

Furthermore, the incidence of reduced muscle strength among colorectal cancer (CRC) patients reached 67.48%, suggesting that decreased muscle strength in this population warrants significant clinical attention. Dietary interventions and exercise programs should be considered as potential management strategies.

[FIGURE:N]
Note: CHEI = Chinese Healthy Eating Index; A represents the Restricted Cubic Spline (RCS) plot of CHEI scores and muscle mass reduction; B represents the RCS plot of CHEI scores and physical function decline; C represents the RCS plot of CHEI scores and sarcopenia.

Results and Analysis

[FIGURE:1]

The restricted cubic spline (RCS) plots illustrate the association between the Chinese Healthy Eating Index (CHEI) and the prevalence of low muscle mass, impaired physical function, and sarcopenia in patients with colorectal cancer (CRC). These visualizations provide a non-linear assessment of how adherence to healthy dietary patterns correlates with musculoskeletal health outcomes in this clinical population.

[TABLE:1]

The results of the logistic regression analysis further detail the associations between specific dietary components of the Chinese healthy dietary pattern and the risks of low muscle mass, impaired physical function, and sarcopenia among CRC patients. By evaluating individual components, we can identify which specific nutritional factors contribute most significantly to the maintenance of muscle health and physical capability.

Note on Dietary Variables

Due to the clinical requirements for colorectal cancer treatment, all patients were prohibited from consuming alcohol for three days prior to the survey. Consequently, the alcohol consumption score was uniform across the cohort, with a median score of 5 (5, 5). Therefore, the impact of alcohol intake on the development of sarcopenia and its related components was not included in this analysis.

The model was adjusted for several confounding factors, including age, sex, educational level, and average monthly household income. Clinical and demographic variables accounted for in the analysis included the primary caregiver, duration of surgery, stoma status, tumor location, and the number of metastatic lymph nodes. Furthermore, the model controlled for tumor stage, degree of differentiation, the number of chronic conditions, and types of medications used. Lifestyle and physical health factors were also incorporated, such as physical activity level, Body Mass Index (BMI), smoking status, and alcohol consumption.

Comprehensive interventions, such as exercise and nutritional support, are necessary for management. In this study, colorectal cancer (CRC) patients had a Chinese Healthy Eating Index (CHEI) score of 55 (45, 60), indicating poor adherence to the Chinese healthy dietary pattern—a score notably lower than those reported for breast cancer patients. Specifically, scores for five categories—grains, tubers, legumes, seafood, and nuts—were low, with the overall dietary structure characterized primarily by insufficient intake. On one hand, this may be attributed to poor dietary structures and habits; reports have shown that the intake of dairy and soy products among CRC patients is far below recommended levels, and their actual intake of total energy and carbohydrates is also lower than recommended. On the other hand, this may be related to intestinal dysfunction in CRC patients. Nuts are difficult to chew and digest, while seafood is often perceived as "cold" or "triggering" (fawu) in traditional contexts, which may increase the intestinal burden on CRC patients, leading them to reduce their consumption of these foods.

Binary logistic regression analysis, adjusted for confounding factors, demonstrated that adherence to the Chinese healthy dietary pattern was significantly and negatively correlated with the loss of muscle mass, decline in physical function, and the occurrence of sarcopenia. However, no significant correlation was found regarding the decline in muscle strength. Further investigation using Restricted Cubic Spline (RCS) models to explore the dose-response relationship revealed that the CHEI score has a linear dose-response relationship with muscle mass loss, physical function decline, and the incidence of sarcopenia, with no obvious thresholds or inflection points identified. These results suggest that higher CHEI scores—indicating greater alignment with the Chinese healthy dietary pattern—are associated with a lower risk of muscle mass loss, physical function decline, and sarcopenia. This protective effect may be linked to the Chinese healthy dietary pattern's recommendations for adequate intake of anti-inflammatory dietary components, a balanced ratio of high-quality carbohydrates and dietary fiber, and the restriction of excessive sugars and unhealthy fatty acids.

First, the Chinese Healthy Eating Index (CHEI) emphasizes a plant-based diet rich in whole grains, vegetables, and fruits. In this regard, it shares similarities with the Mediterranean and anti-inflammatory dietary patterns. Higher CHEI scores correlate with an increased intake of anti-inflammatory components such as vegetables, fruits, legumes, and nuts. The phytochemicals, polyphenols, and antioxidants found in these foods can reduce proteolysis and lipolysis in muscle tissue by inhibiting oxidative stress and inflammatory cascades, potentially playing a positive role in mitigating muscle mass loss and sarcopenia.

Second, the Chinese healthy dietary pattern prioritizes high-quality grains, emphasizing that carbohydrates should account for 50%–65% of total energy intake. This serves as the primary energy source for maintaining muscle mass and mobility. Furthermore, dietary fiber can alter gut microbiota and promote the production of short-chain fatty acids, which alleviate muscle protein damage and degradation caused by inflammation and oxidative stress. These fibers also stimulate the body to produce insulin, which promotes skeletal muscle protein synthesis \cite{39-40}, thereby playing a constructive role in maintaining muscle mass and physical function while preventing sarcopenia.

Additionally, unlike Western dietary patterns, the Chinese healthy dietary pattern recommends an adequate intake of poultry and seafood while limiting processed red meats and sugary foods. This approach helps reduce the intake of saturated fatty acids, trans fats, and added sugars while increasing the consumption of healthy fats, such as monounsaturated fatty acids and n-3 fatty acids \cite{42-43}. These nutrients assist the body in regulating inflammatory responses and skeletal muscle metabolism, potentially offering enhanced protective effects for muscle health.

While this study found no significant correlation between the Chinese healthy dietary pattern and the decline of muscle strength, it is important to consider that muscle strength is influenced not only by dietary intake but also by factors such as resistance exercise. This suggests that while the Chinese healthy dietary pattern may be associated with maintaining muscle strength, its effects likely need to be combined with other interventions, such as resistance training, to fully prevent the onset of sarcopenia.

Among various dietary components, ensuring an adequate intake of fruits, legumes, and poultry may help reduce the risk of muscle mass decline and sarcopenia. Specifically, an adequate intake of fruit was found to be positively correlated with a reduced risk of muscle mass decline ($\text{OR} = 0.880, 95\% \text{CI} = 0.786\text{--}0.985, p = 0.026$) and sarcopenia ($\text{OR} = 0.886, 95\% \text{CI} = 0.788\text{--}0.996, p = 0.043$) in patients with colorectal cancer (CRC). These findings are consistent with the research results reported by NEVILLE et al. \cite{1}.

The diversity and adequacy of fruit intake are prominent characteristics of the healthy Chinese dietary pattern. Fruits are not only rich in antioxidant vitamins such as vitamins A, C, and E, but their dietary fiber and polyphenolic substances can also regulate gut microbiota. These components produce short-chain fatty acids that exert anti-inflammatory effects, both of which can alleviate chronic inflammation and oxidative damage in skeletal muscle cells. Consequently, there is a potential correlation between fruit intake and the maintenance of muscle mass and a reduced risk of sarcopenia.

This study found that individuals with adequate legume intake had a significantly lower risk of muscle mass decline and sarcopenia, with odds ratios of 0.480 (95% CI = 0.290–0.794) and 0.409 (95% CI = 0.238–0.703), respectively, compared to those with inadequate intake. These findings align with the recommendations of the Dietary Guidelines for Chinese Residents 2022 (DGC-2022) to consume soy products regularly. As a high-quality source of plant protein, legumes contain isoflavones that exhibit estrogen-like effects. These compounds may exert protective effects on skeletal muscle through various pathways, including improving inflammatory cytokine levels, promoting the proliferation and differentiation of muscle satellite cells, and alleviating oxidative stress.

Furthermore, poultry contains significantly less fat than red meat and serves as a high-quality source of animal protein, forming an essential component of the healthy Chinese dietary pattern proposed by DGC-2022. Increasing the proportion of poultry intake may help diversify and increase the concentration of amino acids required for muscle metabolism. This could have a potentially positive impact on stimulating the anabolic potential of muscle in cancer patients \cite{48-49}.

The results of this study also indicate that limiting excessive sodium intake may help reduce the risk of muscle mass decline in colorectal cancer (CRC) patients (OR = 0.897, 95% CI = 0.805–1.000, $P = 0.049$), which is consistent with the "less salt" recommendation in DGC-2022. On one hand, excessive sodium intake may disrupt water balance and the urea cycle, affecting glucocorticoid-induced muscle protein catabolism and leading to decreased muscle mass. On the other hand, a high-sodium environment may impair cell membrane integrity and induce oxidative stress in muscle cells, resulting in decreased cell viability, which may be associated with the reduction of muscle mass.

Interestingly, patients who restricted their red meat intake faced a 1.256 times higher risk (95% CI = 1.048–1.506) of physical function decline compared to those who did not restrict it. This finding appears to contradict the DGC-2022 recommendation to limit excessive red meat consumption. This discrepancy may be explained by two factors. First, impaired intestinal absorption in CRC patients can lead to reduced iron absorption, which in turn affects skeletal muscle mitochondrial function and metabolic cycles, interfering with normal physiological activities. Lean red meat is rich in easily absorbable heme iron and serves as a critical dietary source of iron for the human body. Second, CRC patients often suffer from insufficient protein and energy intake due to gastrointestinal symptoms. Moderate supplementation with lean red meat can increase levels of leucine and its metabolite, $\beta$-hydroxy $\beta$-methylbutyrate (HMB), thereby promoting protein synthesis, delaying muscle atrophy, and maintaining normal muscle function.

Increasing the proportion of seafood intake is positively correlated with the maintenance of physical function.

Chinese General Practice 0.05). Seafood is rich in protein and n-3 polyunsaturated fatty acids, which not only provide energy and protein but also favor the proliferation of beneficial intestinal microbiota. This promotes the formation of short-chain fatty acids (SCFAs), improves the patient's inflammatory environment, and maintains normal muscle function \cite{42-43}. Patients with adequate whole grain intake had a lower risk of physical dysfunction compared to those with inadequate intake ($OR=0.839, 95\%CI=0.714–0.986, P=0.033$), which is consistent with the research findings of Han Xiaoli et al. \cite{44}. Dietary fiber, which is abundant in whole grains, can produce short-chain fatty acids after fermentation by intestinal flora; these acids promote skeletal muscle protein synthesis and can also reduce the release of pro-inflammatory cytokines, thereby mitigating the damage to muscle proteins caused by inflammation and oxidative stress \cite{45}.

At the same time, controlling the excessive intake of refined grains may help reduce the risk of sarcopenia, aligning with the results of Sajadi et al. \cite{46}. The Dietary Guidelines for Chinese Residents (DGC-2022) point out that the healthy Chinese dietary pattern is a balanced model centered on cereals, but it emphasizes the adequate intake of components such as whole grains and tubers. In the Chinese dietary structure, "grains" often refer to refined rice and flour. Compared to whole grains, these have a poorer capacity to stabilize blood glucose levels and contain less dietary fiber and vitamins. This may promote systemic inflammatory responses, which is detrimental to maintaining glycemic stability and muscle protein synthesis, ultimately increasing the risk of sarcopenia.

This study has several limitations: (1) Due to its cross-sectional design, it is not possible to establish a definitive causal relationship between the Chinese Healthy Eating Index and sarcopenia; (2) The absence of a case-control study design prevents the exploration of whether a specific association exists between the Chinese Healthy Eating Index and sarcopenia specifically within the colorectal cancer (CRC) population; and (3) The relatively limited sample size may, to some extent, affect the external validity of the research findings.

In summary, the Chinese Healthy Eating Pattern may help reduce the risk of muscle mass loss, physical function decline, and the development of sarcopenia among patients with colorectal cancer (CRC), with all these associations exhibiting a linear dose-response relationship. Specifically, increasing the intake of fruits, legumes, poultry, whole grains, and seafood—while appropriately relaxing restrictions on red meat intake and controlling the excessive consumption of sodium and refined grains—is beneficial for reducing the incidence of sarcopenia in CRC patients. Future research could focus on developing effective intervention programs for sarcopenia based on the Chinese Healthy Eating Pattern, adjusting the daily dietary habits of CRC patients according to specific dietary components.

Author Contributions

Xuebo Li was responsible for the conception and design of the study, the implementation of the research, data collection and organization, statistical processing, the creation and presentation of figures and tables, and the drafting of the manuscript. Xuan Liu was responsible for the conception and design of the study, data collection, organization, and processing, as well as the revision of the manuscript. Shuxing Li was responsible for the revision of the manuscript, quality control and review, overall oversight of the article, and project supervision and management.

The authors declare no conflicts of interest.

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Food as medicine: white and whole-grain bread consumption in relation to sarcopenia among older adults, insights from the Birjand Longitudinal Aging Study (BLAS) [J]. Aging Clin Exp Res, 2025, 37(1): 254. DOI: 10.1007/s40520-025-03162-w. (Received: 2025-07-17; Revised: 2025-09-25) (Editor: LI Weixia)