Comparative effectiveness of exercise modalities and nutritional supplementation for sarcopenic obesity in older adults: a network meta-analysis based on randomized controlled trials.

INTRODUCTION

Sarcopenic obesity is highly prevalent among older adults and is associated with adverse clinical outcomes. However, direct comparative evidence on the relative efficacy and safety of different exercise-based rehabilitation strategies, with or without nutritional supplementation or high-protein intake, remains limited. This study aimed to compare and rank the effects of diverse rehabilitation interventions using a systematic review and network meta-analysis.

METHODS

PubMed, Embase, the Cochrane Library, and Web of Science were systematically searched from database inception to November 1, 2025, without language restrictions. Both Medical Subject Headings and free-text terms were used. Primary outcomes included body mass index (BMI), handgrip strength (GRIP), fat mass (FM), percentage body fat (PBF), and skeletal muscle index (SMI). A systematic review and network meta-analysis were conducted. Risk of bias was assessed using the Cochrane Risk of Bias 2 (ROB 2) tool, and the certainty of evidence was evaluated using the CINeMA framework. The study protocol was prospectively registered in PROSPERO (CRD420251270452).

RESULTS

Twenty-four randomized controlled trials involving 1,298 participants and nine distinct exercise- and nutrition-related rehabilitation strategies were included. For BMI, only multicomponent training (MC) significantly reduced BMI compared with usual care (UC) (MD = -1.08, 95% CI -1.86 to -0.29) and ranked highest (SUCRA 85.1%). For handgrip strength, both resistance training (RT) (MD = 3.96, 95% CI 2.15-5.77) and MC (MD = 2.13, 95% CI 0.25-4.01) were superior to UC, with RT ranking first (SUCRA 90.9%). For fat mass, only RT significantly reduced FM compared with UC (MD = -2.30, 95% CI -3.63 to -0.98) and achieved the highest ranking (SUCRA 79.0%). For PBF, both MC (MD = -3.53, 95% CI -5.70 to -1.36) and RT (MD = -2.30, 95% CI -3.98 to -0.62) were effective, with MC ranking highest (SUCRA 77.1%). No intervention demonstrated a statistically significant advantage over UC for SMI; however, MC combined with nutritional supplementation ranked relatively favorably (SUCRA 74.1%). Global consistency testing supported overall network coherence. Sensitivity analyses confirmed the robustness of the findings, and comparison-adjusted funnel plots indicated no clear evidence of publication bias.

CONCLUSION

In older adults with sarcopenic obesity, exercise-centered interventions yield clinically meaningful benefits across several key rehabilitation outcomes. Overall, resistance training appears particularly effective for improving muscle strength and reducing adiposity-related measures, whereas multicomponent training shows greater advantages in reducing BMI and PBF. Evidence for improvements in SMI remains limited and uncertain, highlighting the need for larger, well-designed randomized trials with longer follow-up and direct head-to-head comparisons to clarify long-term benefits and identify optimal intervention combinations.

SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251270452, PROSPERO: CRD420251270452.