Metabolic sarcopenia in the era of incretin-based therapy: a narrative review of mitochondrial determinants of muscle quality and emerging therapeutic strategies.

Glucagon-like peptide-1 (GLP-1) receptor agonists and related incretin-based therapies have transformed obesity and type 2 diabetes mellitus care by producing clinically meaningful weight reductions, improving glycemic control, and modifying cardiometabolic risks. Their success has also exposed a new clinical question: Should weight loss be evaluated not only by magnitude but also by quality? In older adults and patients with obesity, diabetes, physical inactivity, chronic inflammation, or low nutritional reserve, lean mass loss during pharmacological weight reduction may contribute to or exacerbate vulnerability to metabolic sarcopenia, frailty, dysmobility, and fracture risk. Skeletal muscle is a major determinant of glucose disposal and whole-body metabolic flexibility, and mitochondrial dysfunction is increasingly recognized as a convergent mechanism linking insulin resistance, obesity, aging, and sarcopenia. Altered mitochondrial biogenesis, dynamics, mitophagy, oxidative phosphorylation, redox balance, calcium handling, and substrate selection may reinforce metabolic inflexibility and impaired muscle adaptation. Pyruvate oxidation via the pyruvate dehydrogenase complex and its regulatory kinases represents an illustrative pathway within this broader mitochondrial network. This review integrates GLP-1-based metabolic disease management, muscle health, and mitochondrial quality control. We propose a therapeutic framework that combines incretin pharmacotherapy with resistance exercise, protein and micronutrient support, monitoring of body composition and function, and investigational mitochondria-targeted strategies.