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It also calls for uniform diagnosis, mechanistic analysis, and longitudinal follow-up using repeated measures to strengthen future research and clinical 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is the main purpose of this letter?","Question",{"text":63,"@type":64},"It addresses methodological limitations in an article about the association between diabetic peripheral neuropathy (DPN) and lower-limb muscle strength in type 2 diabetes, and explains how those issues could affect the results.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Why are the diagnostic criteria used in included studies considered a problem?",{"text":68,"@type":64},"The studies use vastly different DPN diagnostic criteria, such as NCS versus mixed techniques, which complicates comparisons and may introduce misclassification bias.",{"name":70,"@type":61,"acceptedAnswer":71},"What additional evidence do the authors suggest would improve the research?",{"text":72,"@type":64},"They recommend standard diagnostic criteria, a stronger discussion of underlying mechanisms, and longitudinal cohort data with repeated measures to clarify whether neuropathy progression leads to muscle 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diabetic peripheral neuropathy and lower limb muscle strength inpatients with type 2 diabetes mellitus: A systematic review and meta-analysis’  \nTo the Editor,  \nWe read with great interest the article by Ito et al.1 on the relationship between diabetic peripheral neuropathy (DPN) and muscle strength in patients with type 2 diabetes. The meta-analysis greatly improves our understanding of the association between DPN and lower limb strength by analyzing previous research and adding to it. Although the article provides great insight into the topic, we have found certain limitations that may have affected the results of this study.  \nFirstly, the studies included in the article have vastly different diagnostic criteria for diagnosing DPN. Some have opted for NCS while others have used a mix of techniques. This approach complicates comparisons as there is a chance of misclassification bias. Recent studies suggest that methods like Quantitative Sensory Testing (QST) can be used to assess the sensory loss that occurs before any of the muscular symptoms, and Nerve Conduction Studies serve as a standard tool to assess peripheral nerve function2. Thereis no mention of a uniform criteria applied to assess and diagnose DPN. Hence, a standard criteria for diagnosis would have improved reproducibility and accuracy.  \nSecondly, there is no discussion about the underlying mechanisms that  \nCorrespondence Huzaifah Ahmed Tel: +92 331 1219998  \nE-mail address: [huzaifahahmed23@gmail.com](huzaifahahmed23@gmail.com)  \nReceived 15 October 2025; revised 15 October 2025; accepted 18 October 2025  \ncontribute to this association. The study reports strength outcomes but does not address potential mediators such as reduced muscle mass (detectable via MRI or DEXA), motor unit loss, or neuromuscular junction dysfunction. Chronic high blood sugar and oxidative stress damage nerves and blood vessels, disrupting nerve–muscle communication and reducing muscle function; all of these may contribute to the outcome3. Therefore, a detailed discussion about these underlying mechanisms would greatly strengthen the study’s interpretation. Integrating the use of imaging and other tools may help with the clinical aspect of future research.  \nThird, the absence of longitudinal cohort data restricts the ability to draw logical conclusions. Cross-sectional studies cannot differentiate whether worsening of neuropathy leads to muscle decline or if it is related to poor glycemic control. Studies with repeated measures of DPN severity and muscle strength would allow us to follow its effects overtime and improve our understanding of its progression. DPN clearly reduces LEMS in older type 2 diabetic patients within 4 years. It also results in loss of LEMS and decrease in mobility due to DPN. For that reason, DPN examination should be considered, with glycemic control and LEMS maintained at a high level to ensure quality of life in type 2 diabetic patients4.  \nIn conclusion, indeed the article highlights an important link between DPNand muscular weakness; addressing these  \nmethodological issues—uniform diagnostic criteria, mechanistic analysis, and longitudinal follow-up—would considerably strengthen future research. Such approaches are essential for the development of targeted strategies to preserve muscle function in patients with type 2 diabetes.  \nACKNOWLEDGMENTS None.  \nDISCLOSURE  \nThe authors declare no conflict of interest.  \nApproval of the research protocol: None.  \nInformed consent: None.  \nRegistry and the registration no. of the study/trial: None.  \nAnimal studies: None.  \nDATA AVAILABILITY STATEMENT The data that support the findings of this study are openly available in Diabetes of investigation and journal at [https://](https://)[ ](https://)[onlinelibrary.wiley.com/share/3DUXXNC](onlinelibrary.wiley.com/share/3DUXXNC)[R6ERTSGY4PI9X?target](R6ERTSGY4PI9X?target=10.1111/jdi.)","cbCaiktGlxzg54Hs","https://ap.wps.com/l/cbCaiktGlxzg54Hs","pdf",213550,"English","# Response to the Editor\n## Diagnostic criteria limitations for DPN\n## Need for mechanistic discussion\n## Importance of longitudinal cohort data\n## Conclusion and future research directions","[{\"question\":\"What is the main purpose of this letter?\",\"answer\":\"It addresses methodological limitations in an article about the association between diabetic peripheral neuropathy (DPN) and lower-limb muscle strength in type 2 diabetes, and explains how those issues could affect the results.\"},{\"question\":\"Why are the diagnostic criteria used in included studies considered a problem?\",\"answer\":\"The studies use vastly different DPN diagnostic criteria, such as NCS versus mixed techniques, which complicates comparisons and may introduce misclassification bias.\"},{\"question\":\"What additional evidence do the authors suggest would improve the research?\",\"answer\":\"They recommend standard diagnostic criteria, a stronger discussion of underlying mechanisms, and longitudinal cohort data with repeated measures to clarify whether neuropathy progression leads to muscle decline.\"}]","Letter to the Editor - Response to Association between Diabetic Peripheral Neuropathy and Lower Limb Muscle Strength | PDF",1790604125]