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.