Endocrinol Metab.  2021 Dec;36(6):1161-1174. 10.3803/EnM.2021.1348.

Quality Matters as Much as Quantity of Skeletal Muscle: Clinical Implications of Myosteatosis in Cardiometabolic Health

Affiliations
  • 1Subdivision of Endocrinology and Metabolism, Health Screening and Promotion Center, Asan Medical Center, Seoul, Korea
  • 2Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea

Abstract

Although age-related changes in skeletal muscles are closely associated with decreases in muscle strength and functional decline, their associations with cardiometabolic diseases in the literature are inconsistent. Such inconsistency could be explained by the fact that muscle quality—which is closely associated with fatty infiltration of the muscle (i.e., myosteatosis)—is as important as muscle quantity in cardiometabolic health. However, muscle quality has been less explored compared with muscle mass. Moreover, the standard definition of myosteatosis and its assessment methods have not been established yet. Recently, some techniques using single axial computed tomography (CT) images have been introduced and utilized in many studies, as the mass and quality of abdominal muscles could be measured opportunistically on abdominal CT scans obtained during routine clinical care. Yet, the mechanisms by which myosteatosis affect metabolic and cardiovascular health remain largely unknown. In this review, we explore the recent advances in the assessment of myosteatosis and its changes associated with aging. We also review the recent literature on the clinical implication of myosteatosis by focusing on metabolic and cardiovascular diseases. Finally, we discuss the challenges and unanswered questions that need addressing to set myosteatosis as a therapeutic target for the prevention or treatment of cardiometabolic diseases.

Keyword

Muscle, skeletal; Myosteatosis; Cardiometabolic health

Figure

  • Fig. 1. Three different adipose depots in skeletal muscle. (A) Skeletal muscle is made up of intramyocellular myofibrils, muscle fibers, and fascicles bound together by successively thicker connective tissue layers (i.e., endomysium, perimysium, and epimysium). (B) Skeletal muscle fat may be classified into intramyocellular (lipid droplets filling the cytoplasm between the myofibrils of elongated myocytes) and extramyocellular components. Adipocytes may infiltrate between muscle fibers (intramuscular fat) and fascicles (intermuscular fat) or exist around the epimysium as extramuscular fat depots of adipose tissue. Reprinted from Altajar et al. [5].

  • Fig. 2. Muscle quality map derived from abdominal computed tomography (CT) using an automated artificial intelligence software. The total abdominal muscle area (TAMA) includes all muscles on the selected axial images (i.e., psoas, paraspinal, transversus abdominis, rectus abdominis, quadratus lumborum, and internal and external obliques). The TAMA is segmented into three areas according to the CT density [16]: (1) inter and intramuscular adipose tissue area (IMAT; −190 to −30 Hounsfield unit [HU], yellow), (2) normal attenuation muscle area (NAMA; 30 to 150 HU, red), and (3) low attenuation muscle area (LAMA; −29 to 29 HU, sky blue). The skeletal muscle area (SMA, −29 to 150) refers to the combined area of NAMA and LAMA. Reprinted from Kim et al. [22], with permission from Elsevier.

  • Fig. 3. Histogram of computed tomography measurements in a Korean population of general health check-up participants (n=12,697 men and 7,967 women, age 20 to 88 years). TAMA, total abdominal muscle area; SMA, skeletal muscle area; NAMA, normal attenuation muscle area; IMAT, inter and intramuscular adipose tissue area; LAMA, low attenuation muscle area.

  • Fig. 4. Distribution of computed tomography measurements according to sex and age group in a Korean population of general health check-up participants (n=12,697 men and 7,967 women, age 20 to 88 years) [22]. TAMA, total abdominal muscle area; SMA, skeletal muscle area; NAMA, normal attenuation muscle area; IMAT, inter and intramuscular adipose tissue area; LAMA, low attenuation muscle area.

  • Fig. 5. Box-plot distribution of the normal attenuation muscle area (NAMA)/total abdominal muscle area (TAMA) index according to age group in men (blue) and women (red). NAMA/TAMA index=(NAMA/TAMA)×100. Reprinted from Kim et al. [22], with permission from Elsevier.

  • Fig. 6. Prevalence of myosteatosis defined by T-scores (<–2) of normal attenuation muscle area (NAMA)/total abdominal muscle area (TAMA) index according to sex and age group in a Korean population of general health check-up participants (n=12,697 men and 7,967 women, age 20 to 88 years). NAMA/TAMA index=(NAMA/TAMA)×100.

  • Fig. 7. Representative cases of similar age with different degrees of myosteatosis. Axial computed tomography scan images on L3 vertebral level from (A) a 58-year-old metabolically healthy man shows higher normal attenuation muscle area (NAMA; red)/total abdominal muscle area (TAMA) index and good quality muscles without myosteatosis, (B) a 60-year-old man with prediabetes shows lower NAMA/TAMA index and some fat infiltration of skeletal muscles, and (C) a 60-year-old man with coronary artery disease (CAD) having coronary stent shows lowest NAMA/TAMA index and more severe fat infiltration of skeletal muscles. ASM, appendicular skeletal muscle; SMA, skeletal muscle area; NAMA/TAMA index=(NAMA/TAMA)×100; LAMA, low attenuation muscle area (sky blue); IMAT, inter and intramuscular adipose tissue area (yellow).


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