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Cited by 35Nutrition and Health in AgingBody Composition Measurement TechniquesMuscle Physiology and Disorders

Effects of nutrition and exercise interventions on persons with sarcopenic obesity: an umbrella review of meta-analyses of randomised controlled trials

Open access
Reiter, Lea, Bauer, Silvia, Traxler, Mariella, Schoufour, Josje D., Weijs, Peter J. M., Cruz-Jentoft, Alfonso, Topinková, Eva, Eglseer, Doris·2023·Current Obesity Reports
DOI 10.1007/s13679-023-00509-0PMC PMC10482763
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Abstract

Background: Sarcopenic obesity (SO) is an increasing phenomenon and has been linked to several negative health consequences. The aim of this umbrella review is the assessment of effectiveness and certainty of evidence of nutrition and exercise interventions in persons with SO. Method: We searched for meta-analyses of RCTs in PubMed, EMBASE and CENTRAL that had been conducted in the last five years, focusing on studies on the treatment and prevention of SO. The primary endpoints were parameters for SO, such as body fat in %, skeletal muscle mass index (SMMI), gait speed, leg strength and grip strength. The methodological quality was evaluated using AMSTAR and the certainty of evidence was assessed using GRADE. Results: Four systematic reviews with between 30 to 225 participants were included in the umbrella review. These examined four exercise interventions, two nutrition interventions and four interventions that combined nutrition and exercise. Resistance training was the most frequently studied intervention and was found to improve gait speed by 0.14 m/s to 0.17 m/s and lower leg strength by 9.97 kg. Resistance, aerobic, mixed exercise and hypocaloric diet combined with protein supplementation is not significantly effective on selected outcomes for persons with SO compared to no intervention. The low number of primary studies included in the reviews resulted in moderate to very low certainty of evidence. Conclusion: Despite the lack in certainty of evidence, resistance training may be a suitable intervention for persons with SO, in particular for improving muscle function. Nevertheless, further research is necessary to strengthen the evidence.

AI snapshot

Written from the paper’s full text.

TL;DR

This umbrella review of four meta-analyses of RCTs found resistance training was the most studied intervention and improved gait speed and lower-leg strength in persons with sarcopenic obesity, but certainty of evidence was moderate to very low. Nutrition interventions, including protein supplementation, showed little consistent effectiveness.

Key findings

  • Four systematic reviews with meta-analyses were included, each including between 30 and 225 participants per outcome. Resistance training was the most frequently studied intervention and improved gait speed by 0.14 to 0.17 m/s and lower/leg extremity strength by 9.97 kg (95% CI 4.43–15.51), with low certainty of evidence.
  • Mixed training significantly improved gait speed across all reviews that measured it, by 0.12 to 0.15 m/s (certainty very low to moderate). WB-EMS improved SMMI by 1.25 to 1.29 (certainty low) and gait speed by 0.11 m/s (certainty low). WB-EMS plus protein supplementation improved total body fat mass by −2.01 kg, ASMM by 0.44 to 0.46 kg, SMMI by 0.72 to 1.18, grip strength by 1.10 to 1.31 kg, and gait speed by 0.04 m/s (certainty low to moderate).
  • Protein supplementation alone showed no significant improvement in any studied outcome (certainty very low to moderate). A low-calorie plus high-protein diet significantly reduced total body fat mass by 0.82 kg (95% CI −1.34 to −0.30; certainty very low).
  • Overall certainty of evidence ranged from moderate to very low, largely due to the low number of primary studies, small sample sizes, wide confidence intervals, and imprecision.

Methods

  • Umbrella review conducted according to PRISMA and registered at PROSPERO (CRD42022342822). Searches were run in PubMed/Medline, EMBASE, and the Cochrane Library via OVID for meta-analyses of RCTs from the last five years, plus Google Scholar and reference-list screening; an update search was conducted in August 2022.
  • Eligible studies were meta-analyses of RCTs comparing any exercise or nutrition intervention with a control group in adults with diagnosed sarcopenic obesity. Outcomes included body fat %, total body fat mass, total muscle mass, ASMM, SMMI, lower/leg extremity strength, grip strength, and gait speed.
  • Methodological quality was assessed with AMSTAR 2, and certainty of evidence with GRADE. When data were not stratified by intervention type, primary studies measuring the same intervention and outcome were pooled in RevMan 5.4 using a random-effects model, 95% confidence intervals, p < 0.05, and I².

Limitations

  • Paper-stated limitations: the literature search was restricted to the last five years; the umbrella review did not consider primary-study data and trusted the included reviews’ data extraction and pooling, with indications that errors had been made (e.g., Hita-Contreras et al. and Yin et al. reported slightly different results for mixed exercise plus protein supplementation despite the same number of primary studies and participants); included reviews used different definitions of sarcopenic obesity, reducing comparability; and only reviews that performed meta-analyses were included.
  • Evident from the text: the number of included primary studies and participants was very low across interventions and outcomes, many outcomes were based on a single primary study, and this led to very serious imprecision and moderate to very low certainty. AMSTAR 2 quality ranged from moderate to critically low, and none of the included reviews reported adverse events or injuries.

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Integrity signals

Registry

Crossref · 10.1007/s13679-023-00509-0

Cites

34 of 34 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 101 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Resistance training was the most frequently studied intervention.

    “Resistance training was the most frequently studied intervention”
    • Also stated in: § Discussion · plain
      “Resistance training was the most frequently studied intervention.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Four systematic reviews with between 30 and 225 participants were included in the umbrella review.

    “Four systematic reviews with between 30 to 225 participants were included in the umbrella review.”
    Quote in the paperNot a substantial claim
  • Findingreasoning

    The low number of primary studies included in the reviews resulted in moderate to very low certainty of evidence.

    “The low number of primary studies included in the reviews resulted in moderate to very low certainty of evidence.”
    Quote in the paperSubstantial claim
  • Findingcitation

    All four included studies were systematic reviews focusing on people with diagnosed sarcopenic obesity.

    “All four of the included studies were systematic reviews focussing on people with diagnosed sarcopenic obesity [21, 22, 26, 27••].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [21] Hita-Contreras F, et al. Effect of exercise alone or combined with dietary supplements on anthropometric and physical performance measures in community-dwelling elderly people with sarcopenic obesity: A meta-analysis of randomized controlled trials. Maturitas. 2018;116:24–35. source

      Not checked in the free run.

    • cites [22] Yin YH, Liu JYW, Välimäki M. Effectiveness of non-pharmacological interventions on the management of sarcopenic obesity: A systematic review and meta-analysis. Exp Gerontol. 2020;135: 110937. source

      Not checked in the free run.

    • cites 26, 27••

      Not checked in the free run.

  • Findingown data

    A total of ten interventions were identified in the included reviews.

    “A total of ten interventions were identified in these reviews, representing either exercise or nutrition interventions or a combination of these.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 48
  • Classified as probably not a substantial claim. 20
  • The quote only partly states this claim. 3

  • May combine two claims.

    Findingown data

    The included reviews examined four exercise interventions, two nutrition interventions and four interventions that combined nutrition and exercise.

    “These examined four exercise interventions, two nutrition interventions and four interventions that combined nutrition and exercise.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingown data

    The search identified 51 systematic reviews and meta-analyses; after removing duplicates, 47 articles were screened, 18 full texts were assessed, two reviews were included for data extraction, and a manual search identified two further eligible studies.

    “As shown in Fig. 1, the search enabled us to identify 51 systematic reviews and meta-analyses. After removing duplicates (n = 4), 47 articles were included in the title and abstract screening. Following, 18 full texts were assessed for their eligibility, resulting in the inclusion of two reviews for data extraction [21, 26]. A manual search resulted in the identification of two further studies”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [21] Hita-Contreras F, et al. Effect of exercise alone or combined with dietary supplements on anthropometric and physical performance measures in community-dwelling elderly people with sarcopenic obesity: A meta-analysis of randomized controlled trials. Maturitas. 2018;116:24–35. source

      Not checked in the free run.

    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Three of the seven critical AMSTAR items were rated yes or partial yes for all studies, while critical items 2, 13 and 15 contributed to flaws in quality.

    “While three of the seven critical items were rated with “yes” (criterion met) or “partial yes” for all studies, the critical items no. 2 (methodology in protocol), 13 (discussing risk of bias) and 15 (publication bias) apparently contributed to the flaws in quality.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    The combinations of nutrition and exercise interventions were WB-EMS and protein supplementation, mixed training and protein supplementation, and resistance training and protein supplementation.

    “The combinations of nutrition and exercise interventions were WB-EMS and protein supplementation, mixed training and protein supplementation, resistance training and protein supplementation.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Resistance training improves lower/leg extremity strength by 9.97 kg.

    “Resistance training was the most frequently studied intervention and was found to improve gait speed by 0.14 m/s to 0.17 m/s and lower leg strength by 9.97 kg.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Exercise interventions included resistance training, aerobic training, WB-EMS and mixed training.

    “Exercise interventions included resistance training, aerobic training, WB-EMS (whole-body electromyostimulation) and mixed training (resistance training and aerobic training).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Resistance training improves gait speed by 0.14 m/s to 0.17 m/s.

    “Resistance training was the most frequently studied intervention and was found to improve gait speed by 0.14 m/s to 0.17 m/s and lower leg strength by 9.97 kg.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    According to AMSTAR 2, only one review was rated as moderate quality, two were low quality, and one was critically low quality.

    “According to the AMSTAR 2 assessment results regarding the quality of the reviews, only one was rated as being of moderate quality [27••], two systematic reviews were of low quality [21, 22] and one was rated as being critically low [26].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites 27••

      Not checked in the free run.

    • cites [21] Hita-Contreras F, et al. Effect of exercise alone or combined with dietary supplements on anthropometric and physical performance measures in community-dwelling elderly people with sarcopenic obesity: A meta-analysis of randomized controlled trials. Maturitas. 2018;116:24–35. source

      Not checked in the free run.

    • cites [22] Yin YH, Liu JYW, Välimäki M. Effectiveness of non-pharmacological interventions on the management of sarcopenic obesity: A systematic review and meta-analysis. Exp Gerontol. 2020;135: 110937. source

      Not checked in the free run.

    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

  • The quote only partly states this claim.

    Findingown data

    Aerobic training is not significantly effective on selected outcomes for persons with sarcopenic obesity compared to no intervention.

    “Resistance, aerobic, mixed exercise and hypocaloric diet combined with protein supplementation is not significantly effective on selected outcomes for persons with SO compared to no intervention.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

    Findingown data

    Resistance training is not significantly effective on selected outcomes for persons with sarcopenic obesity compared to no intervention.

    “Resistance, aerobic, mixed exercise and hypocaloric diet combined with protein supplementation is not significantly effective on selected outcomes for persons with SO compared to no intervention.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The effect of resistance training on gait speed was studied in three reviews, with two reviews revealing significant improvements ranging from 0.14 (95% CI 0.05; 0.23) to 0.17 (95% CI 0.01; 0.34) (CoE low).

    “The effect of resistance training on gait speed was studied in three reviews, with two reviews revealing significant improvements ranging from 0.14 (95% CI, 0.05; 0.23) to 0.17 (95% CI, 0.01; 0.34) (CoE low) [22, 26, 27••].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [22] Yin YH, Liu JYW, Välimäki M. Effectiveness of non-pharmacological interventions on the management of sarcopenic obesity: A systematic review and meta-analysis. Exp Gerontol. 2020;135: 110937. source

      Not checked in the free run.

    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

    • cites 27••

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Resistance training significantly improved grip strength in two of four reviews, with average improvements ranging from 3.73 kg to 4.52 kg (CoE moderate and very low).

    “A significant effect regarding grip strength was reported in two of four reviews, with average improvements ranging from 3.73 kg (95% CI, 2.60; 4.85) [27••] to 4.52 kg (95% CI, 1.88, 7.17) (CoE moderate and very low) [26].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [27••]

      Not checked in the free run.

    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingown data

    Resistance training was not significantly effective for SMMI (CoE low and moderate) or total muscle mass (CoE very low).

    “Resistance training did not prove to be significantly effective for the outcome SMMI (CoE low and moderate) and total muscle mass (CoE very low).”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingcitation

    In the two other reviews, resistance training effects on body fat percentage were not significant but showed a tendency in favour of resistance training (CoE moderate and low).

    “Although the effects reported in the two other reviews were not significant, both showed a tendency in favour of resistance training (CoE moderate and low) [21, 22].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [21] Hita-Contreras F, et al. Effect of exercise alone or combined with dietary supplements on anthropometric and physical performance measures in community-dwelling elderly people with sarcopenic obesity: A meta-analysis of randomized controlled trials. Maturitas. 2018;116:24–35. source

      Not checked in the free run.

    • cites [22] Yin YH, Liu JYW, Välimäki M. Effectiveness of non-pharmacological interventions on the management of sarcopenic obesity: A systematic review and meta-analysis. Exp Gerontol. 2020;135: 110937. source

      Not checked in the free run.

    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingown data

    Hita-Contreras et al. and Hsu et al. had not preliminarily defined the methodology in a protocol and failed to take risk of bias into consideration when interpreting results, resulting in AMSTAR items 2 and 13 being rated no.

    “Both Hita-Contreras et al. [21] and Hsu et al. [26] had not preliminarily defined the methodology used for their reviews in a protocol (item no. 2) and also failed to take the risk of bias into consideration when interpreting the results, (item no. 13) resulting in items no. 2 and no. 13 being rated with “no” (criterion not met).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [21] Hita-Contreras F, et al. Effect of exercise alone or combined with dietary supplements on anthropometric and physical performance measures in community-dwelling elderly people with sarcopenic obesity: A meta-analysis of randomized controlled trials. Maturitas. 2018;116:24–35. source

      Not checked in the free run.

    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Eglseer et al. was the only review with moderate quality and the only review to take risk of bias into consideration when interpreting results.

    “Eglseer et al. [27••] which was the only review with moderate quality, was also the only review to take the risk of bias into consideration when interpreting results of the meta-analyses.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 27••

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Aerobic training significantly improved total body fat mass in one of two reviews, with an average decrease of 5.2 kg (95% CI -9.47 to -0.93) (CoE Very Low).

    “However, this significant effect was only measured in one out of the two reviews on total body fat mass with an average decrease of 5.2 kg (95% CI, -9.47 to -0.93) (CoE Very Low) [26].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingcitation

    WB-EMS significantly improved SMMI in both reviews that measured it, with improvements ranging from 1.25 to 1.29 kg (CoE low).

    “Regarding SMMI, both reviews reported significant improvements that ranged from 1.25 (95% CI, 0.64; 1.86) [21] to 1.29 kg (95% CI, 0.68; 1.90) [22] (CoE low)”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [21] Hita-Contreras F, et al. Effect of exercise alone or combined with dietary supplements on anthropometric and physical performance measures in community-dwelling elderly people with sarcopenic obesity: A meta-analysis of randomized controlled trials. Maturitas. 2018;116:24–35. source

      Not checked in the free run.

    • cites [22] Yin YH, Liu JYW, Välimäki M. Effectiveness of non-pharmacological interventions on the management of sarcopenic obesity: A systematic review and meta-analysis. Exp Gerontol. 2020;135: 110937. source

      Not checked in the free run.

    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingcitation

    Lower/leg extremity strength was analysed only by Eglseer et al. and showed a significant improvement of 9.97 kg (95% CI 4.43; 15.51) (CoE low).

    “Lower/leg extremity strength was analysed only by Eglseer et al. [27••] and showed a significant improvement of 9.97 kg (95% CI, 4.43; 15.51) (CoE low) (see Table 3).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 27••

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    WB-EMS was not reported as showing significant improvement in any review for body fat percentage (CoE low) or grip strength (CoE low).

    “WB-EMS was not reported as showing a significant improvement in any review of measurements of outcomes on body fat in percent (CoE low) or grip strength (CoE low).”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingcitation

    Resistance training significantly decreased body fat percentage in two of four reviews, with decreases ranging from 1.53% to 2.67% (CoE moderate and very low).

    “Two out of the four reviews reported a significant decrease in the proportion of body fat, ranging from 1.53% (95% CI, -2.91; -0.15) [27••] to 2.67% (95% CI, -4.03; -1.32) [26] (CoE moderate and very low).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [27••]

      Not checked in the free run.

    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingcitation

    Resistance training combined with protein supplementation did not significantly improve total body fat mass or total muscle mass compared to resistance training alone (CoE low).

    “Both body fat mass in kg and muscle mass in kg did not significantly improve (CoE low) [27••].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27••]

      Not checked in the free run.

    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingown data

    Neither Hsu et al. nor Yin et al. performed statistical or graphical analyses to detect publication bias.

    “Regarding a possible publication bias (item no. 15), neither Hsu et al. [26] nor Yin et al. [22] performed any statistical or graphical analyses to detect a publication bias.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

    • cites [22] Yin YH, Liu JYW, Välimäki M. Effectiveness of non-pharmacological interventions on the management of sarcopenic obesity: A systematic review and meta-analysis. Exp Gerontol. 2020;135: 110937. source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Mixed training significantly improved gait speed across all reviews that measured it, with improvements ranging from 0.12 to 0.15 m/s (CoE very low to moderate).

    “Measurements of the effect of mixed training on gait speed were reported in three reviews, and this was the only outcome for which a significant improvement was seen across all reviews with improvements ranging from 0.12 to 0.15 m/s (CoE very low to moderate) [21, 22, 26] see Table 3.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [21] Hita-Contreras F, et al. Effect of exercise alone or combined with dietary supplements on anthropometric and physical performance measures in community-dwelling elderly people with sarcopenic obesity: A meta-analysis of randomized controlled trials. Maturitas. 2018;116:24–35. source

      Not checked in the free run.

    • cites [22] Yin YH, Liu JYW, Välimäki M. Effectiveness of non-pharmacological interventions on the management of sarcopenic obesity: A systematic review and meta-analysis. Exp Gerontol. 2020;135: 110937. source

      Not checked in the free run.

    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingreasoning

    Further influential factors for imprecision were small sample sizes, wide CI, and overall effect being insignificant.

    “Further influential factors regarding imprecision were the small sample sizes, wide CI and the overall effect being insignificant.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Contradictory results were found for mixed exercise improving body composition and grip strength, with certainty of evidence ranging from moderate to very low.

    “Mixed exercise (combining resistance with aerobic training) was also one of the most frequently studied interventions, but contradictory results were also found for improving body composition and grip strength, with the certainty of evidence also ranging from moderate to very low.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingown data

    Hita-Contreras et al. [21] and Yin et al. [22] analysed mixed exercise combined with protein supplementation and resulted in slightly different results for each outcome despite same number of primary studies and participants.

    “For example, it came to our attention that both Hita-Contreras et al. [21] and Yin et al. [22] analysed the effects of mixed exercise combined with protein supplementation, but resulted in slightly different results for each of the outcomes concerning this intervention, although the same number of primary studies and the same number of participants were included.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [21] Hita-Contreras F, et al. Effect of exercise alone or combined with dietary supplements on anthropometric and physical performance measures in community-dwelling elderly people with sarcopenic obesity: A meta-analysis of randomized controlled trials. Maturitas. 2018;116:24–35. source

      Not checked in the free run.

    • cites [22] Yin YH, Liu JYW, Välimäki M. Effectiveness of non-pharmacological interventions on the management of sarcopenic obesity: A systematic review and meta-analysis. Exp Gerontol. 2020;135: 110937. source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Our umbrella review results reveal that protein supplementation combined with resistance training, protein supplementation combined with aerobic training, and mixed training are not significantly effective interventions for persons with SO (low certainty of evidence).

    “With a low certainty of evidence, our umbrella review results reveal that protein supplementation combined with resistance training and protein supplementation combined with aerobic training and mixed training are not significantly effective interventions for persons with SO.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingown data

    All reviews for aerobic training, WB-EMS, low-calorie+high-protein, resistance training, aerobic+protein, and mixed exercise+protein included only a single primary study, so imprecision was automatically rated very serious.

    “As all of the reviews regarding the outcomes for the interventions of aerobic training, WB-EMS, low-calorie combined with high-protein intake, resistance training, aerobic training combined with protein supplementation, and mixed exercise combined with increased protein intake included only a single primary study, the imprecision was automatically rated as very serious.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    The results of this umbrella review show that WB-EMS improved muscle mass, muscle strength, and physical function in persons with SO.

    “The results of this umbrella review show that WB-EMS improved muscle mass, muscle strength and physical function in persons with SO.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingown data

    Differences in AMSTAR ratings ranged from moderate to critically low, showing that methodological quality of individual systematic reviews impacts certainty of evidence and leads to variance in certainty.

    “Moreover, the differences in AMSTAR ratings ranged from moderate to critically low, showing that the methodological quality of the individual systematic reviews additionally impacts the certainty of the evidence and leads to variance in certainty.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    The effects of nutrition interventions and the combination of exercise and nutrition interventions have only been vaguely explored with regard to SO.

    “During the study, we realized that especially the effects of nutrition interventions as well as the combination of exercise and nutrition interventions have only been vaguely explored with regard to SO.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The systematic reviews included all relevant primary studies conducted on the effectiveness of interventions for persons with SO so far, despite none setting a time limit.

  • May combine two claims.

    Findingreasoning

    The low number of included primary studies resulted in most outcomes showing no serious inconsistencies, but serious inconsistencies noted were mainly due to partial overlap of CIs and considerable heterogeneity.

    “In contrast, the low number of included primary studies resulted in most of the outcomes showing no serious inconsistencies, but the serious inconsistencies noted were mainly due to a partial overlap of the CIs and considerable heterogeneity.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Due to partly substandard methodology of included reviews and low number of primary studies, we were unable to identify an ideal intervention for persons with SO.

    “Due to the partly substandard methodology of the included reviews and the low number of primary studies, we were unable to identify an ideal intervention for persons with SO.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • May combine two claims.

    Findingreasoning

    Indirectness was rated as low for all outcomes across all interventions because all reviews included primary studies in accordance with their inclusion and exclusion criteria.

    “Regarding indirectness, all reviews included primary studies in accordance with their inclusion and exclusion criteria,therefore, the indirectness was rated as low for all outcomes across all interventions.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    All other reviews and their outcomes had no serious risk of bias and publication bias.

    “All other reviews and the respective outcomes that they measured had no serious risk of bias and publication bias.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    Hsu et al. [26] was the only study rated as having serious risk of bias and publication bias, due to lack of allocation concealment, blinding, and application of Egger's test.

    “Hsu et al. [26] was the only study that was rated as having a serious risk of bias as well as a publication bias. This was due to the lack of allocation concealment, blinding and application of Egger’s test.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Hsu KJ, et al. Effects of exercise and nutritional intervention on body composition, metabolic health, and physical performance in adults with sarcopenic obesity: a meta-analysis. Nutrients. 2019;11(9). source

      Not checked in the free run.

  • May combine two claims.

    Findingnone given

    Resistance training was the most frequently studied intervention and showed the most promising results for improving muscle strength and physical performance.

    “Resistance training was the most frequently studied intervention and showed the most promising results for improving muscle strength and physical performance.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The methodological quality of the included systematic reviews was evaluated using AMSTAR 2 and the certainty of evidence was assessed using GRADE.

    “The methodological quality was evaluated using AMSTAR and the certainty of evidence was assessed using GRADE.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The pooled global prevalence of sarcopenic obesity is 11%.

    “Nonetheless, a recently published systematic review and meta-analysis showed that the pooled global prevalence of sarcopenic obesity is at 11% [9•].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 9•

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    The random-effects model was applied and heterogeneity (I2) was assessed.

    “Furthermore, we applied the random-effects model and assessed the heterogeneity (I2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Ageing is associated with an increase in fat accumulation and a loss of muscle mass and strength.

    “Ageing is associated with a variety of changes in body composition, such as an increase in fat accumulation as well as a loss of muscle mass and strength [1–3].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [1] St-Onge MP, Gallagher D. Body composition changes with aging: the cause or the result of alterations in metabolic rate and macronutrient oxidation? Nutrition. 2010;26(2):152–5. source

      Not checked in the free run.

    • cites [2] Guo SS, et al. Aging, body composition, and lifestyle: the Fels Longitudinal Study. Am J Clin Nutr. 1999;70(3):405–11. source

      Not checked in the free run.

    • cites [3] Shilpa A, Kalyani S, Manisha S. Ageing process and physiological changes. In Gerontology, D.O. Grazia, G. Antonio, and S. Daniele, (Editors) 2018. IntechOpen: Rijeka. p. Ch. 1.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    With increasing age there is an increased risk of obesity and sarcopenia.

    “Consequently, with increasing age there is an increased risk of obesity, which is the excessive accumulation of fat [4], as well as the risk of sarcopenia, which is characterised by low muscle mass and muscle function [5].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [4] World Health Organization, Who European regional obesity report 2022. World Health Organization Copenhagen; 2022.

      Not checked in the free run.

    • cites [5] Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol. 2018;14(9):513–37. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Despite the lack of certainty of evidence, resistance training may be a suitable intervention for persons with sarcopenic obesity, in particular for improving muscle function.

    “Despite the lack in certainty of evidence, resistance training may be a suitable intervention for persons with SO, in particular for improving muscle function.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Whole-body electromyostimulation (WB-EMS) has emerged as a useful treatment for sarcopenia and sarcopenic obesity, showing promising effects due to its similarities to resistance training.

    “Furthermore, whole-body electromyostimulation (WB-EMS) has emerged in research as a useful treatment for sarcopenia [18] and sarcopenic obesity, showing promising effects due to its similarities to resistance training [5, 19, 20].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [5] Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol. 2018;14(9):513–37. source

      Not checked in the free run.

    • cites [18] de Oliveira TMD, et al. Effects of whole-body electromyostimulation on health indicators of older people: Systematic review and meta-analysis of randomized trials. J Bodyw Mov Ther. 2022;31:134–45. source

      Not checked in the free run.

    • cites [19] Lau RW, et al. The effects of whole body vibration therapy on bone mineral density and leg muscle strength in older adults: a systematic review and meta-analysis. Clin Rehabil. 2011;25(11):975–88. source

      Not checked in the free run.

    • cites [20] Verschueren SM, et al. The effects of whole-body vibration training and vitamin D supplementation on muscle strength, muscle mass, and bone density in institutionalized elderly women: a 6-month randomized, controlled trial. J Bone Miner Res. 2011;26(1):42–9. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Sarcopenia and obesity can occur simultaneously and synergistically aggravate each other, resulting in sarcopenic obesity.

    “Both sarcopenia and obesity can occur simultaneously and synergistically aggravate each other, resulting in sarcopenic obesity [5].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5] Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol. 2018;14(9):513–37. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The question of an optimal treatment strategy for sarcopenic obesity is left out and remains unanswered.

    “Therefore, the question of an optimal treatment strategy for sarcopenic obesity is left out and remains unanswered.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The main goals when treating sarcopenic obesity are to decrease body fat and to support the build-up or preservation of muscle mass and muscle function.

    “As well as reducing the accompanied complications such as cardiovascular disease, the main goals when treating sarcopenic obesity are to decrease body fat and to support the build-up or preservation of muscle mass and muscle function [5, 11••, 12].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [5] Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol. 2018;14(9):513–37. source

      Not checked in the free run.

    • cites 11••

      Not checked in the free run.

    • cites [12] Bouchonville MF, Villareal DT. Sarcopenic obesity: how do we treat it? Curr Opin Endocrinol Diabetes Obes. 2013;20(5):412–9. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Sarcopenic obesity has been linked to increased risk of falling, cardiovascular diseases, comorbidity, early mortality, and institutionalisation.

    “Furthermore, sarcopenic obesity has been linked to several negative health consequences, such as an increased risk of falling, cardiovascular diseases, comorbidity and early mortality, as well as institutionalisation [7].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Roh E, Choi KM. Health Consequences of Sarcopenic Obesity: A Narrative Review. Front Endocrinol. 2020;11:332. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Two independent reviewers selected titles, abstracts and full texts according to the inclusion criteria, with disagreements resolved by discussion and, if necessary, a third person.

    “Two independent reviewers (M.T., S.B.) selected titles, abstract and full texts according to the inclusion criteria. If disagreements arose, a consensus was reached by discussion, and, if necessary, a third person was consulted to make a final decision.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    GRADE was used to assess the quality of evidence of the included studies.

    “To assess the quality of the evidence of the included studies, we used the Grading of Recommendation Assessment, Development and Evaluation (GRADE), which classifies the strength of evidence as high, moderate, low, or very low.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [25] Guyatt GH, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    AMSTAR 2 was used to assess the methodological quality of the systematic reviews.

    “We used the Assessment tool AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews) to assess the methodological quality of the systematic reviews.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [24] Shea BJ, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358: j4008. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Two reviewers with experience working with GRADE assessed the quality of evidence for each outcome, with disagreements resolved by consensus and, if necessary, a third person.

    “Two reviewers (D.E., S.B.) who had had experience working with GRADE assessed the quality of the evidence for each outcome. Disagreements were discussed until a consensus was met, and, if necessary, a third person was consulted (L.R.) to arrive at a final decision.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The umbrella review was registered at PROSPERO (CRD42022342822).

    “This umbrella review was registered at PROSPERO (CRD42022342822).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The umbrella review was conducted in accordance with PRISMA guidelines.

    “To address the research question, we conducted an umbrella review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [23].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] Page MJ, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. J Clin Epidemiol. 2021;134:178–89. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Sarcopenic obesity often is overlooked because high fat mass masks low muscle mass.

    “Furthermore, it must be taken into consideration, that sarcopenic obesity often is overlooked due to the fact that high fat mass masks low muscle mass [10•].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 10•

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Data extraction was conducted by two authors using a data extraction sheet.

    “The extraction process was conducted by two authors (M.T., S.B.) using a data extraction sheet.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A recent systematic review measuring WB-EMS in older adults found significant improvement in gait speed, hand grip strength, lower limb strength, and ASMMI.

    “The results show a significant improvement in gait speed, hand grip strength, lower limb strength and ASMMI [18].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] de Oliveira TMD, et al. Effects of whole-body electromyostimulation on health indicators of older people: Systematic review and meta-analysis of randomized trials. J Bodyw Mov Ther. 2022;31:134–45. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The literature search of this umbrella review was restricted to the last five years.

    “Firstly, the literature search of this umbrella review was constricted to the last five years.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A recent systematic review and meta-analysis including 114 trials reported that resistance training significantly decreases body fat percentage and overall fat mass in overweight or obese adults of all ages.

    “A recent systematic review and meta-analysis which included 114 trials reported that resistance training significantly decreases the percentage of body fat and overall fat mass in overweight or obese adults of all ages [29•].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29•]

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    The same review stated that low certainty of evidence exists against using a combination of resistance training and nutritional supplementation, such as increased protein intake.

    “However, the same review also stated that a low certainty of evidence exists against using a combination of resistance training and nutritional supplementation, such as increased protein intake [30].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [30] Beckwée D, et al. Exercise interventions for the prevention and treatment of sarcopenia. A systematic umbrella review. J Nutr Health Aging. 2019;23(6):494–502. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Contradictory results are reported regarding protein supplementation with or without exercise in persons with sarcopenia, which supports our results.

    “However, contradictory results are also reported regarding protein supplementation with or without exercise in persons with sarcopenia [31], which supports our results.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] Cruz-Jentoft AJ, et al. Prevalence of and interventions for sarcopenia in ageing adults: a systematic review. Report of the international sarcopenia initiative (EWGSOP and IWGS). Age Ageing. 2014;43(6):748–59. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The variety of criteria and definitions of sarcopenia can be seen in the characteristics of the included reviews and might explain the lack of significant results.

    “This can also be seen in the characteristics of the included reviews of this study and might be an explanation of the lack of significant results.”
    Quote in the paperSubstantial claim
63 of 63

  • The paper relies on this without support.

    The current study is the first umbrella review on sarcopenic obesity.

    “To our knowledge, the current study represents the first umbrella review on sarcopenic obesity conducted to provide comprehensive insights into the effectiveness of different nutrition and exercise interventions for adults”

  • The paper relies on this without support.

    Sarcopenic obesity is a relatively new topic in research.

    “This limitation was set as sarcopenic obesity is a relatively new topic in research.”

  • The authors state this as an assumption.

    The systematic reviews included all relevant primary studies conducted on the effectiveness of interventions for persons with SO so far, despite none setting a time limit.

    “as none of the included systematic reviews had set a time limit, it was presumed that the systematic reviews included all relevant primary studies conducted on the effectiveness of interventions for persons with SO so far.”

  • The authors state this as an assumption.

    The authors of the systematic reviews extracted and pooled data from primary studies to the best of their abilities.

    “we did not consider data from the primary studies and trusted that the authors of the systematic reviews had extracted and pooled the data from the primary studies to the best of their abilities.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Aerobic training plus protein is called nonsignificant despite table p-values

    Major

    Table 3 reports p = 0.003 for both total fat mass and total muscle mass, while the results call both effects nonsignificant. The table also gives confidence intervals that cross zero, so its p-values conflict with its own intervals.

  • List of combined interventions omits aerobic training plus protein

    Minor

    The results list only three exercise-and-nutrition combinations, whereas Table 3 includes aerobic training plus protein supplementation as a fourth.

  • WB-EMS alone is said to improve strength despite nonsignificant grip-strength results

    Minor

    The discussion says WB-EMS improved muscle strength, but the results section says WB-EMS did not significantly improve grip strength. The significant grip-strength result reported elsewhere is for WB-EMS combined with supplementation.

  • Yin review is also marked as considering risk of bias

    Minor

    The text says Eglseer was the only review to consider risk of bias when interpreting results, but Table 2 marks critical item 13 as "Y" for Yin as well.

  • Wrong review is cited for the WB-EMS combination's fat-mass result

    Minor

    The text attributes the 2.01 kg fat-mass result to Hita-Contreras et al. [22], whereas Table 3 attributes it to Hita-Contreras et al. [21].

  • Low-calorie high-protein analyses include two primary studies, not one

    Minor

    The GRADE discussion says the reviews of this intervention's outcomes included only a single primary study. Table 3 lists two primary studies for each of its three outcomes.

6 of 6

Cites

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Cited by

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Related

Authors
Reiter, L., Bauer, S., Traxler, M., Schoufour, J. D., Weijs, P. J. M., Cruz-Jentoft, A., Topinková, E., & Eglseer, D.
Affiliations
  • Medical University of Graz (AT)
  • Amsterdam University of Applied Sciences (NL)
  • Amsterdam Public Health (NL)
  • Instituto Ramón y Cajal de Investigación Sanitaria (ES)
  • Charles University (CZ)
Corresponding author
Eglseer, Doris
ORCID
Venue
Current Obesity Reports
Publisher
Springer Science and Business Media LLC
Published
2023-05-30
Volume
12
Issue
3
Pages
250-263
ISSN
2162-4968 (ISSN-L)
DOI
10.1007/s13679-023-00509-0
PMC
PMC10482763
OpenAlex
W4378745097
Semantic Scholar
73a88e0e7e93b2f7d03c5d0696a2efdae0ee6d1a
Cited by
35
References
33
Citations by year
2026: 11 · 2025: 14 · 2024: 9 · 2023: 1
FWCI
1.25
Type
journal article
Language
en
Open access
Licence
Locations
  • Current Obesity Reports (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
Funders
  • Horizon 2020 (ERA-NET Cofund action N° 727565)
  • Medical University of Graz
Topics
  • Health Sciences › Medicine › Physiology › Nutrition and Health in Aging
  • Health Sciences › Medicine › Physiology › Body Composition Measurement Techniques
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Muscle Physiology and Disorders
Keywords
sarcopenic obesity, nutrition interventions, exercise intervention, resistance training, protein supplementation, hypocaloric diet, aerobic exercise, walking speed, leg strength, grip strength, skeletal muscle mass, body fat percentage, muscle function
MeSH terms
Diet, Reducing, Exercise Therapy, Humans, Nutritional Status, Obesity, Meta-Analysis as Topic, Randomized Controlled Trials as Topic, Sarcopenia

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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