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Cited by 190Physical Activity and HealthCardiovascular and exercise physiologyObesity, Physical Activity, Diet

What exercise prescription is optimal to improve body composition and cardiorespiratory fitness in adults living with obesity? A network meta‐analysis

Open access
O'Donoghue, Grainne, Blake, Catherine, Cunningham, Caitriona, Lennon, Olive, Perrotta, Carla·2021·Obesity Reviews
DOI 10.1111/obr.13137PMC PMC7900983
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Abstract

Summary: Current international guidelines recommend people living with obesity should be prescribed a minimum of 300 min of moderately intense activity per week for weight loss. However, the most efficacious exercise prescription to improve anthropometry, cardiorespiratory fitness (CRF) and metabolic health in this population remains unknown. Thus, this network meta‐analysis was conducted to assess and rank comparative efficacy of different exercise interventions on anthropometry, CRF and other metabolic risk factors. Five electronic databases were searched for randomized controlled trials (RCTs) that compared different exercise modalities to improve anthropometry, CRF and/or metabolic health in adults living with obesity. RCTs were evaluated using the Cochrane risk of bias tool. A random effects network meta‐analysis was performed within a frequentist framework. Of the 6663 articles retrieved, 45 studies with a total 3566 participants were included. Results reveal that while any type of exercise intervention is more effective than control, weight loss induced is modest. Interventions that combine high‐intensity aerobic and high‐load resistance training exert beneficial effects that are superior to any other exercise modality at decreasing abdominal adiposity, improving lean body mass and increasing CRF. Clinicians should consider this evidence when prescribing exercise for adults living with obesity, to ensure optimal effectiveness.

AI snapshot

Written from the paper’s full text.

TL;DR

This network meta-analysis of 45 RCTs in 3566 adults with obesity found that exercise alone produces only modest weight loss, but combined aerobic plus resistance training is generally ranked most effective for improving body composition and cardiorespiratory fitness. Combined high-intensity aerobic and high-load resistance training (COM-HI) had the highest P scores for weight, BMI, percentage body fat, and fitness, while combined low-to-moderate training (COM-LM) ranked best for waist circumference.

Key findings

  • Across 45 RCTs and 3566 participants (mean age 43.3 years; 76% female), any exercise was more effective than control, but weight loss was modest, with mean reductions ranging from −0.05 to −1.01 kg.
  • COM-HI had the highest likelihood of being best for weight loss (P score = .83), BMI (.85), percentage body fat (.80), and fitness (.73); COM-LM ranked best for waist circumference (P score = .82).
  • Compared with control, COM-HI reduced BMI by −2.79 (95% CI −5.95, −0.36) and percentage body fat by −2.82 (95% CI −5.50, −0.14); COM-LM reduced waist circumference by −2.76 cm (95% CI −4.52, −1.00).
  • All exercise interventions increased absolute VO2max by 7% to 15%, but no statistically significant improvements in fitness were found; COM-HI produced the greatest increase (15%).

Methods

  • Systematic review and random-effects network meta-analysis of RCTs published January 1998 to November 2019, identified from five databases (PubMed, EMBASE, CENTRAL, CINAHL, Sport Discus); 6663 records were screened and 45 studies included.
  • Participants were adults aged ≥18 and <65 years with obesity defined as BMI >30 kg m⁻² or body fat >30% in women and >25% in men; exercise was the only intervention investigated, with comparators being other exercise modalities or no-exercise control.
  • Exercise interventions were classified using the F.I.T.T. principle into aerobic vigorous, aerobic moderate, resistance high-load, resistance low-to-moderate, combined high, combined low-to-moderate, and control; outcomes included body weight, BMI, waist circumference, percentage body fat, and absolute VO2max, analyzed with frequentist network meta-analysis in Stata and ranked by P scores.

Limitations

  • The paper states that study populations differed in age, country, and sex ratio; intervention duration varied, although duration did not explain variance in effect sizes; and direct evidence was sparse for some comparisons, especially resistance versus combined training.
  • The paper reports that 20 of 45 RCTs had high risk of bias and 12 had moderate risk; only 12 studies used intention-to-treat analysis, and more than 70% (n = 33) were judged at moderate to high risk of bias.
  • The paper states that metabolic outcomes (BP, TG, HDL, FBG) could not be included in the network meta-analysis because too few studies reported post-intervention data; evident from the text, aerobic exercise contributed 60–68% of intervention data across networks, while resistance and combined training contributed much less, and the abstract’s mention of lean body mass is not supported by a reported lean body mass outcome in the NMA.

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Integrity signals

Registry

Crossref · 10.1111/obr.13137

Cites

90 of 90 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 55 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Interventions combining high-intensity aerobic and high-load resistance training are superior to any other exercise modality at decreasing abdominal adiposity.

    “Interventions that combine high‐intensity aerobic and high‐load resistance training exert beneficial effects that are superior to any other exercise modality at decreasing abdominal adiposity, improving lean body mass and increasing CRF.”
    Quote in the paperSubstantial claim
  • Findingown data

    Weight loss induced by exercise interventions is modest.

    “Results reveal that while any type of exercise intervention is more effective than control, weight loss induced is modest.”
    Quote in the paperSubstantial claim
  • Findingown data

    Overall, weight loss was minimal, with mean values ranging from −0.05 to −1.01 kg.

    “Overall, weight loss was minimal, with mean values ranging from −0.05 to −1.01 kg.”
    • Also stated in: § DISCUSSION · hedged
      “our results indicate that exercise as an independent intervention, irrespective of which prescription, induced at best, a small reduction in weight loss (mean weight loss ranged from −0.05 to −1.01 kg).”
    Quote in the paperSubstantial claim
  • Findingown data

    Interventions that included an aerobic component were superior to resistance-only interventions for decreasing body weight.

    “and were superior to resistance only interventions (Table 3).”
    Quote in the paperSubstantial claim
  • Findingown data

    Intervention duration did not modify the estimates for each of the outcomes.

    “As the intervention duration did not modify the estimates for each of the outcomes (Table S2), we proceeded to NMA.”
    Quote in the paperSubstantial claim
  • The quote only partly states this claim. 3
  • Classified as probably not a substantial claim. 47
  • May combine two claims. 30

  • The quote only partly states this claim.

    Findingown data

    Interventions combining high-intensity aerobic and high-load resistance training are superior to any other exercise modality at improving lean body mass.

    “Interventions that combine high‐intensity aerobic and high‐load resistance training exert beneficial effects that are superior to any other exercise modality at decreasing abdominal adiposity, improving lean body mass and increasing CRF.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data

    Any type of exercise intervention is more effective than control.

    “Results reveal that while any type of exercise intervention is more effective than control, weight loss induced is modest.”
    Quote in the paperSubstantial claim

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

    Findingown data

    Of the 6663 articles retrieved, 45 studies with a total of 3566 participants were included.

    “Of the 6663 articles retrieved, 45 studies with a total 3566 participants were included.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Interventions combining high-intensity aerobic and high-load resistance training are superior to any other exercise modality at increasing cardiorespiratory fitness.

    “Interventions that combine high‐intensity aerobic and high‐load resistance training exert beneficial effects that are superior to any other exercise modality at decreasing abdominal adiposity, improving lean body mass and increasing CRF.”
    Quote in the paperSubstantial claim

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

    Findingown data

    Eighteen included studies were women only.

    “Eighteen studies were women only, § eight were men only ¶ and the remaining 19 included both men and women.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The mean baseline cardiorespiratory fitness was 2.46 L/min (SD 0.6).

    “Reported baseline demographics included mean BW (90.5 kg [SD: 8.5]), BMI (32.3 kg m−2 [SD: 3.3]), WC (105 cm [SD: 9.3]), %BF (37.9% [SD: 6.8]) and CRF (2.46 L min−1 [0.6]).”
    Quote in the paperNot a substantial claim

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

    Findingreasoning

    A total of 45 studies were included in this review.

    “The remaining 45 studies were included in this review.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The mean baseline body fat percentage was 37.9% (SD 6.8).

    “Reported baseline demographics included mean BW (90.5 kg [SD: 8.5]), BMI (32.3 kg m−2 [SD: 3.3]), WC (105 cm [SD: 9.3]), %BF (37.9% [SD: 6.8]) and CRF (2.46 L min−1 [0.6]).”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Nineteen included studies included both men and women.

    “Eighteen studies were women only, § eight were men only ¶ and the remaining 19 included both men and women.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The included studies were conducted in North America (n=16), Europe (n=11), Asia (n=9), Australia (n=5), South America (n=3), and Africa (n=1).

    “The studies were conducted in North America (n = 16), * Europe (n = 11), † Asia (n = 9), ‡ Australia (n = 5), 14 , 15 , 48 , 59 , 60 South America (n = 3) 39 , 42 , 66 and Africa (n = 1). 62”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Eight included studies were men only.

    “Eighteen studies were women only, § eight were men only ¶ and the remaining 19 included both men and women.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The mean baseline BMI was 32.3 kg/m2 (SD 3.3).

    “Reported baseline demographics included mean BW (90.5 kg [SD: 8.5]), BMI (32.3 kg m−2 [SD: 3.3]), WC (105 cm [SD: 9.3]), %BF (37.9% [SD: 6.8]) and CRF (2.46 L min−1 [0.6]).”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Of the 3566 participants, 2696 (76%) were female.

    “Of these, 2696 (76%) were female.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The mean baseline waist circumference was 105 cm (SD 9.3).

    “Reported baseline demographics included mean BW (90.5 kg [SD: 8.5]), BMI (32.3 kg m−2 [SD: 3.3]), WC (105 cm [SD: 9.3]), %BF (37.9% [SD: 6.8]) and CRF (2.46 L min−1 [0.6]).”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The included studies involved a total of 3566 people.

    “A total of 3566 people with an average age of 43.3 (SD: 13.1) years, were investigated across the 45 studies.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The average age of participants across the included studies was 43.3 years (SD 13.1).

    “A total of 3566 people with an average age of 43.3 (SD: 13.1) years, were investigated across the 45 studies.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The mean baseline body weight of participants was 90.5 kg (SD 8.5).

    “Reported baseline demographics included mean BW (90.5 kg [SD: 8.5]), BMI (32.3 kg m−2 [SD: 3.3]), WC (105 cm [SD: 9.3]), %BF (37.9% [SD: 6.8]) and CRF (2.46 L min−1 [0.6]).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    COM-HI resulted in a much greater reduction in percentage body fat (−2.15 [CI = −4.0%, −0.3%]) than previously reported by Kim et al. and was shown to be significantly more effective than either isolated aerobic or resistance training.

    “This intervention resulted in a much greater reduction in %BF (−2.15 [CI = −4.0%, −0.3%]) than previously reported by Kim et al. 82 and was shown to be significantly more effective than either isolated aerobic or resistance training.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [82] Kim KB, Kim K, Kim C, et al. Effects of exercise on the body composition and lipid profile of individuals with obesity: a systematic review and meta‐analysis. J Obes Metab Syndr. 2019; 28(4): 278‐ 294. 31909371 PMC6939705 source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Although all interventions resulted in an increase in absolute VO2max, there were no statistically significant improvements in fitness found.

    “Although all interventions resulted in an increase in absolute VO2max, there were no statistically significant improvements in fitness found (Table 3).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Resistance training contributed between 12-18% and combined training between 10-18% of the intervention data.

    “In comparison, resistance training and combined only contributed between 12–18% and 10–18%, respectively.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    All exercise interventions brought about an increase in absolute VO2max of between 7% and 15%, although the findings in relation to fitness were statistically insignificant.

    “Although our findings in relation to fitness were statistically insignificant, all exercise interventions brought about an increase in absolute VO2max of between 7% and 15% (Table S4).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    20 of the 45 included randomized controlled trials recorded a high risk of bias and 13 a moderate risk of bias.

    “Finally, 20 of the 45 included RCTs recorded a high risk and 13, a moderate ROB.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    Disagreements in full-text review were resolved by discussion within the wider team.

    “Any disagreements between reviewers in this phase were again resolved by discussion within the wider team.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Three reviewers independently screened the yielded articles based on title.

    “In the initial phase, three reviewers independently screened the yielded articles based on title.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Randomized controlled trials were evaluated using the Cochrane risk of bias tool.

    “RCTs were evaluated using the Cochrane risk of bias tool.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    The study protocol was registered with PROSPERO under registration number CRD4201811373.

    “The study protocol was registered (registration number: CRD4201811373) with the International Prospective Register of Systematic Reviews (PROSPERO).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    Individual randomized controlled trials or pairwise meta-analyses often compare one or more exercise interventions with nonexercising control groups and therefore cannot discriminate between exercise modalities.

    “as often these studies were designed to compare one or more exercise interventions with data from nonexercising control groups and therefore cannot discriminate between exercise modalities”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Multiple exercise modalities with varying intensities feature in the obesity literature.

    “multiple exercise modalities, with varying intensities, feature in the obesity literature”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11] Petridou A, Siopi A, Mougios V. Exercise in the management of obesity. Metabolism. 2019; 92: 163‐ 169. 30385379 source

      Not checked in the free run.

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

    Study design and conductnone given

    The remaining articles were fully reviewed by the same two independent reviewers that reviewed abstracts, using predetermined inclusion criteria.

    “In the final phase, the remaining articles were fully reviewed by the same two independent reviewers that reviewed abstracts, using the predetermined inclusion criteria.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Disagreements in abstract review were resolved by discussion between reviewers and consultation with a third party from the review team.

    “Any disagreements were resolved by discussion between reviewers and consultation with a third party from the review team.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    All articles selected from the initial phase were reviewed by abstract and assessed for eligibility by two independent reviewers.

    “In Phase 2, all articles selected from the initial phase were reviewed by abstract and assessed for eligibility by two independent reviewers.”
    Quote in the paperNot a substantial claim

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

    Study design and conductcitation

    This systematic review and network meta-analysis is reported in accordance with the PRISMA statement.

    “This systematic review and NMA is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement. 25”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] Hutton B, Salanti G, Caldwell D, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta‐analysis of health care interventions: checklist and explanations. Ann Intern Med. 2015; 162: 777‐ 784. 26030634 source

      Not checked in the free run.

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

    Premisecitation

    Current guidelines recommend that exercise programmes for weight loss in obesity prioritize continuous moderate intensity aerobic exercise and supplement this approach, where possible, with resistance training.

    “Current guidelines recommend that exercise programmes for weight loss in obesity prioritize continuous moderate intensity aerobic exercise, and supplement this approach, where possible, with resistance training. 9 , 10”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [9] American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 10th ed. Philadelphia: Wolters Kluwer Health; 2018.

      Not checked in the free run.

    • cites [10] Yumuk V, Fried M, Schindler K, et al. European guidelines for obesity management in adults. Obes Facts. 2015; 8(6): 402‐ 424. 26641646 PMC5644856 source

      Not checked in the free run.

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

    Study design and conductnone given

    Articles in doubt at title screening were included in the abstract review phase.

    “In the case of doubt, the articles were included in the abstract review phase.”
    Quote in the paperNot a substantial claim

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

    Study design and conductcitation

    A network funnel plot was generated and visually inspected using the criterion of symmetry to check for bias due to small-scale studies.

    “To check for the presence of bias due to small‐scale studies, which may lead to publication bias in NMA, a network funnel plot was generated (Figure S8) and visually inspected using the criterion of symmetry. 37”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [37] Trinquart L, Chatellier G, Ravaud P. Adjustment for reporting bias in network meta‐analysis of antidepressant trials. BMC Med Res Methodol. 2012; 12: 150‐ 161. 23016799 PMC3537713 source

      Not checked in the free run.

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

    Study design and conductown data

    13 studies reported blinding of outcome assessment.

    “13 reported blinding of outcome assessment. §§”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    A nine-item, standardized and prepiloted data extraction form was used to record data from included studies.

    “A nine‐item, standardized and prepiloted data extraction form was used to record data from the included studies under the following headings:”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Nine studies showed low risk of bias in allocation concealment.

    “Nine studies showed low ROB in allocation concealment 17 , 45 , 56 , 59 , 60 , 61 , 67 , 68 , 69”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Pairwise meta-analytic estimates are usually reported in addition to network estimates.

    “As interventions are by definition heterogeneous and pairwise meta‐analytic estimates are usually reported in addition to the network estimates, 30 random effects pairwise meta‐analyses were first used to obtain pooled SMDs (with associated CIs) for weight loss, BMI, WC, %BF and fitness, respectively, with the I 2 statistic used to quantify heterogeneity.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Jackson D, Riley R, White I. Mutivariate meta‐analysis: potential and promise. Stat Med. 2011; 30: 2481‐ 2498. 21268052 PMC3470931 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Only 12 studies reported an intention-to-treat analysis, with the remaining 33 studies judged as being either at high or unclear risk of selective reporting.

    “Only 12 studies reported an intention‐to‐treat analysis ¶¶ with the remaining 33 studies judged as being either at high or unclear risk of selective reporting.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    14 of the 45 articles included showed high risk of bias in the domain of risk of other bias.

    “Finally, 14 of the 45 articles included showed high ROB in the domain of risk of other bias. ##”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The blinding of participants component was not included in the overall risk-of-bias score because it was impossible to blind participants to group assignment in exercise intervention protocols.

    “All studies would, by default, be classified as high ROB with respect to the category ‘blinding of participants’ given it was impossible to blind participants to group assignment in exercise intervention protocols. Therefore, this component was not included in the overall ROB score.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Overall, 13 articles were judged to be of low risk of bias, 12 of moderate risk of bias, and the remaining 20 were rated as at high risk of bias.

    “Overall, 13 articles were judged to be of low ROB, # 12 of moderate ROB ** and the remaining 20 rated as at high ROB. ††”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Consistency was tested through the Wald test and node splitting method.

    “Consistency, whereby the treatment effect estimated from direct comparisons are consistent with those estimated from indirect comparisons, was tested through the Wald test and node splitting method.”
    Quote in the paperSubstantial claim

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

    Study design and conductcitation

    Transitivity assumptions were assessed through assessment of individual studies inclusion criteria, whether all participants in the network could have been randomized to any intervention, logical inference and using consistency models.

    “In addition to the pairwise meta‐analysis, transitivity assumptions were also assessed through assessment of individual studies inclusion criteria, whether all participants in the network could have been randomized to any intervention, logical inference and using consistency models. 34”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] Rucker G, Schwarzer G. Ranking treatments in frequentist network meta‐analysis works without resampling methods. BMC Med Res Methodol. 2015; 15(58): 1‐ 9. 26227148 PMC4521472

      Not checked in the free run.

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

    Premisecitation

    Small-scale studies may lead to publication bias in network meta-analysis.

    “To check for the presence of bias due to small‐scale studies, which may lead to publication bias in NMA, a network funnel plot was generated (Figure S8) and visually inspected using the criterion of symmetry. 37”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [37] Trinquart L, Chatellier G, Ravaud P. Adjustment for reporting bias in network meta‐analysis of antidepressant trials. BMC Med Res Methodol. 2012; 12: 150‐ 161. 23016799 PMC3537713 source

      Not checked in the free run.

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

    Study design and conductown data

    Two authors independently assessed risk of bias in accordance with the Cochrane Handbook version 5.1.0 tool for assessing risk of bias in RCTs.

    “Two authors (G.O. and C.C.) independently assessed the risk of bias (ROB), in accordance with the Cochrane Handbook version 5.1.0 tool for assessing ROB in RCTs.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Higgins JP, Altman DG, Gotzsche PC, et al. Cochrane Statistical Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011; 343: 1– 9, d5928 10.1136/bmj.d5928 PMC3196245 22008217 source

      Not checked in the free run.

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

    Study design and conductcitation

    The network meta-analysis was performed in accordance with current PRISMA NMA guidelines.

    “We used STATA software (Version 15.1) command ‘mvmeta’ to perform a multivariate NMA within a frequentist framework 33 in accordance with current PRISMA NMA guidelines. 25”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] Hutton B, Salanti G, Caldwell D, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta‐analysis of health care interventions: checklist and explanations. Ann Intern Med. 2015; 162: 777‐ 784. 26030634 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Several studies have reported percentage body fat to be more responsive to exercise than body weight.

    “Several studies have reported %BF to be more responsive to exercise than BW”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [81] Millstein R. Measuring outcome in adult weight loss studies that include diet and physical activity: a systematic review. J Nutr Metab. 2014; 13: 1‐ 13. PMC4262752 25525513 source

      Not checked in the free run.

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

    Premisecitation

    Resistance training has the potential to change the metabolic properties of skeletal muscles.

    “Resistance training has the potential to change the metabolic properties of skeletal muscles.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] Strasser B, Schobersberger W. Evidence for resistance training as a treatment therapy in obesity. J Obes. 2011; 7: 1‐ 9. PMC2931407 20847892 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    For weight loss, exercise alone is not an effective therapy; a hypocaloric balance is necessary.

    “with both authors reporting, that for weight loss, exercise alone is not an effective therapy, a hypocaloric balance is necessary.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [19] Thorogood A, Mottillo S, Shimony A, et al. Isolated aerobic exercise and weight loss: a systematic review and meta‐analysis of randomized controlled trials. Am J me. 2011; 124(8): 747‐ 755. 21787904 source

      Not checked in the free run.

    • cites [18] Clark J. Diet, exercise or diet with exercise: comparing the effectiveness of treatment options for weight loss and change of fitness for adults (18‐65 years old) who are overfat, or obese; a systematic review and meta‐analysis. J Diabetes Metab Disord. 2015; 14(1): 31– 58. 25973403 PMC4429709 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Aerobic training instigates changes in aerobic capacity, improves lipid profiles and increases insulin sensitivity.

    “Aerobic training instigates changes in aerobic capacity, improves lipid profiles and increases insulin sensitivity.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [78] Dinas P, Markati A, Carrillo A. Exercise‐induced biological and psychological changes in overweight and obese individuals: a review of recent evidence. ISRN Physiol. 2014; 2014: 1– 12, 964627. source

      Not checked in the free run.

    • cites [79] Castro E, Peinado AB, Benito PJ, et al. What is the most effective exercise protocol to improve cardiovascular fitness in overweight and obese subjects? J Sport Health Sci. 2017; 6(4): 454‐ 461. 30356640 PMC6189257 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    A recent meta-analysis reported exercise to have a significantly greater effect on mean change in percentage body fat (−0.39% [CI = −0.5, −0.3]) than on body weight (−0.3 kg [CI = −0.5, −0.2]).

    “A recent meta‐analysis reported exercise to have a significantly greater effect on mean change in %BF (−0.39% [CI = −0.5, −0.3]) than on BW (−0.3 kg [CI = −0.5, −0.2]).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [82] Kim KB, Kim K, Kim C, et al. Effects of exercise on the body composition and lipid profile of individuals with obesity: a systematic review and meta‐analysis. J Obes Metab Syndr. 2019; 28(4): 278‐ 294. 31909371 PMC6939705 source

      Not checked in the free run.

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

    Premisecitation

    In adults with obesity, aerobic training can lead to a decrease in leptin production, which in turn contributes to a reduction of adipose tissue accumulation.

    “In addition, particularly in adults with obesity, it can lead to a decrease leptin production, which in turn contributes to a reduction of adipose tissue accumulation.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [78] Dinas P, Markati A, Carrillo A. Exercise‐induced biological and psychological changes in overweight and obese individuals: a review of recent evidence. ISRN Physiol. 2014; 2014: 1– 12, 964627. source

      Not checked in the free run.

    • cites [79] Castro E, Peinado AB, Benito PJ, et al. What is the most effective exercise protocol to improve cardiovascular fitness in overweight and obese subjects? J Sport Health Sci. 2017; 6(4): 454‐ 461. 30356640 PMC6189257 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    In subjects with a BMI ≥ 30 kg m−2, a combined exercise intervention consisting of aerobic and resistance training (COM-HI or COM-LM) is the most promising for reducing waist circumference and percentage body fat, as well as increasing cardiorespiratory fitness, despite no substantial weight loss.

    “Our main findings indicate that in subjects with a BMI ≥ 30 kg m−2, a combined exercise intervention consisting of aerobic and resistance training (COM‐HI or COM‐LM) is the most promising for reducing WC and %BF, as well as increasing CRF, despite no substantial weight loss.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Abdominal adiposity is independently associated with all-cause mortality and is recognized as a better predictor of obesity-related conditions than either body weight or BMI.

    “Beyond total body fat, abdominal adiposity is independently associated with all‐cause mortality and is recognized as a better predictor of obesity‐related conditions than either BW or BMI. 83 , 84 , 85”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [83] Cerhan J, Moore S, Jacobs E, et al. A pooled analysis of waist circumference and mortality in 650,000 adults. Mayo Clin Proc. 2014; 89(3): 335‐ 345. 24582192 PMC4104704 source

      Not checked in the free run.

    • cites [84] de Koning L, Merchant AT, Pogue L, Anand S. Waist circumference and waist‐to‐hip ratio as predictors of cardiovascular events: meta‐regression analysis of prospective. Eur Heart J. 2007; 28(7): 850‐ 856. 17403720 source

      Not checked in the free run.

    • cites [85] Staiano A, Reeder B, Elliott S, et al. Body mass index versus wasit circumference as predictors of mortality in Canadian adults. Int J Obes (Lond). 2012; 36(11): 1450‐ 1454. 22249224 PMC4120111 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Both types of training together can contribute to greater improvements in both cardiorespiratory fitness and body composition, and in turn, enhance overall health.

    “Hence, it is reasonable to suggest that both types of training together can contribute to greater improvements in both CRF and body composition, and in turn, enhance overall health.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Resistance training results in an increase in lean body mass, lowers exercise-induced oxidative stress in the overweight and those with obesity, and decreases glycated haemoglobin levels in people with an abnormal glucose metabolism.

    “It results in an increase in lean body mass, lowers exercise‐induced oxidative stress in the overweight and those with obesity and decreases glycated haemoglobin levels in people with an abnormal glucose metabolism.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] Strasser B, Schobersberger W. Evidence for resistance training as a treatment therapy in obesity. J Obes. 2011; 7: 1‐ 9. PMC2931407 20847892 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Aerobic training increases growth hormone and adiponectin levels, which play a role in lowering abdominal fat and circulating free fatty acids.

    “It also increases growth hormone and adiponectin levels, which play a role in lowering abdominal fat and circulating free fatty acids.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [78] Dinas P, Markati A, Carrillo A. Exercise‐induced biological and psychological changes in overweight and obese individuals: a review of recent evidence. ISRN Physiol. 2014; 2014: 1– 12, 964627. source

      Not checked in the free run.

    • cites [79] Castro E, Peinado AB, Benito PJ, et al. What is the most effective exercise protocol to improve cardiovascular fitness in overweight and obese subjects? J Sport Health Sci. 2017; 6(4): 454‐ 461. 30356640 PMC6189257 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Body fat is the most metabolically harmful tissue type, and it may be a more meaningful measure of health change for evaluating exercise interventions.

    “because body fat is the most metabolically harmful tissue type, it may be a more meaningful measure of health change for evaluating exercise interventions.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [81] Millstein R. Measuring outcome in adult weight loss studies that include diet and physical activity: a systematic review. J Nutr Metab. 2014; 13: 1‐ 13. PMC4262752 25525513 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The effect size reported for both outcomes was small, and as exercise was reported as a single modality irrespective of the mode, frequency or intensity, it is difficult to decipher which specific exercise prescription/s resulted in these changes.

    “However, the effect size reported for both outcomes was small, and as exercise was reported as a single modality irrespective of the mode, frequency or intensity, it is difficult to decipher which specific exercise prescription/s resulted in these changes.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [82] Kim KB, Kim K, Kim C, et al. Effects of exercise on the body composition and lipid profile of individuals with obesity: a systematic review and meta‐analysis. J Obes Metab Syndr. 2019; 28(4): 278‐ 294. 31909371 PMC6939705 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    The risk of bias rating remained the case when performance bias was excluded from the global risk-of-bias rating, which was high for all studies due to the inability to blind participants to exercise training.

    “This remained the case when performance bias was excluded from the global ROB rating, which was high for all studies due to the inability to blind participants to exercise training.”
    Quote in the paperSubstantial claim

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

    Study design and conductown data

    There was more variation in the duration of the interventions.

    “there was more variation in the duration of the interventions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Most recent meta-analyses investigating the effectiveness of different exercise interventions for adults living with obesity continue to exclusively focus on anthropometric measures to establish efficacy or effectiveness and do not include CRF in their analyses.

    “even the most recent meta‐analyses investigating the effectiveness of different exercise interventions for adults living with obesity continue to exclusively focus on anthropometric measures to establish efficacy or effectiveness 18 , 89 and do not include CRF in their analyses.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [18] Clark J. Diet, exercise or diet with exercise: comparing the effectiveness of treatment options for weight loss and change of fitness for adults (18‐65 years old) who are overfat, or obese; a systematic review and meta‐analysis. J Diabetes Metab Disord. 2015; 14(1): 31– 58. 25973403 PMC4429709 source

      Not checked in the free run.

    • cites [89] Andreato L, Esteves J, Coimbra D, Moraes A, de Carvalho T. The influence of high‐intensity interval training on anthropometric variables of adults with overweight or obesity: a systematic review and network meta‐analysis. Obes Rev. 2019; 20(1): 142‐ 155. 30450794 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    A considerable sample size of adults living with obesity (n = 3566) were included, providing the power to detect statistically significant mean differences.

    “A considerable sample size of adults living with obesity (n = 3566) were included, thus providing the power to detect statistically significant mean differences.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Waist circumference is often used as a surrogate marker of abdominal fat mass, as changes in waist circumference are associated with changes in intra-abdominal fat and in turn changes in health risk profile.

    “WC is often used as a surrogate marker of abdominal fat mass, as changes in WC are associated with changes in intra‐abdominal fat and in turn changes in health risk profile. 84”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [84] de Koning L, Merchant AT, Pogue L, Anand S. Waist circumference and waist‐to‐hip ratio as predictors of cardiovascular events: meta‐regression analysis of prospective. Eur Heart J. 2007; 28(7): 850‐ 856. 17403720 source

      Not checked in the free run.

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

    Study design and conductnone given

    The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42018111373).

    “Our study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO); registration number: CRD42018111373.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    A previous meta-analysis indicates the optimal length of exercise intervention differs depending on the outcome being measured and beneficial effectiveness is not indicated for any anthropometric, fitness or metabolic measures until after 8 weeks of continuous training, with peak effectiveness noted anywhere between 12 and 32 weeks.

    “Results from a previous meta‐analysis reporting the impact of exercise intervention duration 91 indicates the optimal length differs depending on the outcome being measured and beneficial effectiveness is not indicated for any anthropometric, fitness or metabolic measures until after 8 weeks of continuous training with peak effectiveness being noted anywhere between 12 and 32 weeks.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [91] Clark JE. The impact of duration on effectiveness of exercise, the implication for periodization of training and goal setting for individuals who are overfat, a meta‐analysis. Biol Sport. 2016; 33(4): 309‐ 333. 28090136 PMC5143767 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Study design and conductreasoning

    Incorporating cardiorespiratory fitness (CRF) as an outcome measure in the network meta-analysis strengthened the study.

    “Incorporating CRF as an outcome measure in the NMA also strengthened this study”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    An improvement in fitness of between 8% and 10% is associated with a 12% decrease in mortality.

    “Previous research has shown an improvement in fitness of between 8% and 10% is associated with a 12% decrease in mortality 6”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Myers J, Froelicher V, Do D, Partington S, Atwood E. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002; 346(11): 793‐ 801. 11893790 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Study design and conductnone given

    The review was systematic and exhaustive.

    “The review was systematic and exhaustive.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    COM-LM exercise was most effective when it came to reducing waist circumference and this is associated with a 5.5% decrease in cardiovascular disease risk, followed by AE-V and AE-M with a 4.5% and 4% decrease, respectively.

    “Using these findings in reverse and the fact that even modest reductions in WC (<2 cm) confer improvements in all metabolic risk factors, 86 it is evident from this NMA that COM‐LM exercise was most effective when it came to reducing WC and this is associated with a 5.5% decrease in CVD risk, followed by AE‐V and AE‐M with a 4.5% and 4% decrease, respectively.”
    Quote in the paperSubstantial claim
72 of 72

  • The paper relies on this without support.

    No systematic review has pooled the effects of different training modalities on outcomes of anthropometry, cardiorespiratory fitness and cardiometabolic risk factors, focusing exclusively on adults living with obesity and including only randomized controlled trials where exercise is the only intervention being investigated.

    “To date, no systematic review has pooled the effects of different training modalities on outcomes of anthropometry, CRF and cardiometabolic risk factors, focusing exclusively on adults living with obesity and including only RCTs where exercise is the only intervention being investigated.”

  • The authors state this as an assumption.

    Indirect comparison is a valid estimate of the unobserved direct comparison.

    “Transitivity is a key assumption of NMA and refers to the belief that indirect comparison is a valid estimate of the unobserved direct comparison 31 and that all studies have homogenous distribution of effect modifiers. 32”

  • The authors state this as an assumption.

    All studies have a homogenous distribution of effect modifiers.

    “Transitivity is a key assumption of NMA and refers to the belief that indirect comparison is a valid estimate of the unobserved direct comparison 31 and that all studies have homogenous distribution of effect modifiers. 32”

  • The authors state this as an assumption.

    Interventions are by definition heterogeneous.

    “As interventions are by definition heterogeneous and pairwise meta‐analytic estimates are usually reported in addition to the network estimates, 30 random effects pairwise meta‐analyses were first used to obtain pooled SMDs (with associated CIs) for weight loss, BMI, WC, %BF and fitness, respectively, with the I 2 statistic used to quantify heterogeneity.”

  • The paper relies on this without support.

    Other meta-analyses that have included cardiorespiratory fitness as a primary outcome are not specific to populations with obesity.

    “Others that have included CRF as a primary outcome are not specific to populations with obesity, do not distinguish between exercise types and report fitness in relative terms.”

  • The paper relies on this without support.

    Other meta-analyses that have included cardiorespiratory fitness as a primary outcome do not distinguish between exercise types.

    “Others that have included CRF as a primary outcome are not specific to populations with obesity, do not distinguish between exercise types and report fitness in relative terms.”

  • The paper relies on this without support.

    Other meta-analyses that have included cardiorespiratory fitness as a primary outcome report fitness in relative terms.

    “Others that have included CRF as a primary outcome are not specific to populations with obesity, do not distinguish between exercise types and report fitness in relative terms.”

  • The paper relies on this without support.

    The association between fitness improvement and mortality reduction observed in previous research applies to adults living with obesity.

    “When applying this finding to our study, we find that while aerobic exercise (AE‐V = 12.9%; AE‐M = 9.2%) outperformed both types of resistance training (R‐HI = 7.4%; R‐LM = 7.2%) as a single modality, combined low high (COM‐HI = 15%) intensity training resulted in the greatest increase in fitness and consequently should be considered as the preferential exercise intervention to improve CRF in this”
8 of 8

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.

  • Claim of significant COM-HI superiority conflicts with body-fat comparison

    Major

    The discussion claims COM-HI was significantly more effective than isolated aerobic training, but the table's COM-HI versus AE-V percentage-body-fat comparison has a confidence interval spanning zero.

  • COM-HI is recommended for waist circumference despite no reported WC study

    Major

    The conclusion identifies COM-HI as optimal for WC, but the WC results say no study of COM-HI reported that outcome.

  • PROSPERO registration numbers differ

    Minor

    The registration section and trial-registration section give different PROSPERO numbers for the study protocol.

  • Percentage-body-fat study counts disagree

    Minor

    The characteristics section says 19 studies reported percentage body fat, whereas the results section says 20 reported it and were included in that analysis.

  • COM-HI body-fat reduction is attributed the COM-LM value

    Minor

    The discussion gives −2.15 as the COM-HI reduction in percentage body fat. The results assign −2.15 to COM-LM and −2.82 to COM-HI.

  • A study published before the stated eligibility window was included

    Minor

    The eligibility criteria start in January 1998, but the included Dengel study is dated 1996 in the references.

6 of 6

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. Medicine ACoS, 2018, ACSM's Guidelines for Exercise Testing and Prescription
  2. Arslan F, 2011, The effects of an eight‐week step‐aerobic dance exercise programme on body composition parameters in middle‐aged sedentary obese women, Int Sport Med J, 12, 160
  3. Mengistie AB, 2013, The effects of workout‐based combination of aerobic and resistance exercise training in obese adults if Northwest Ethiopia, Int J Sports Sci Fitness, 3, 96

Cited by

Sorted by citations

Related

Authors
O'Donoghue, G., Blake, C., Cunningham, C., Lennon, O., & Perrotta, C.
Affiliations
  • School of Public Health, Physiotherapy and Sports Science University College Dublin Dublin Ireland
  • University College Dublin (IE)
ORCID
Venue
Obesity Reviews
Publisher
Wiley
Published
2020-09-08
Volume
22
Issue
2
Pages
e13137-e13137
ISSN
  • 1467-7881 (ISSN-L)
  • 1467-789X
DOI
10.1111/obr.13137
PMC
PMC7900983
OpenAlex
W3083774739
Semantic Scholar
b30198cf9efabb5a41d48312ee4fd2446bcadec5
Cited by
190
References
90
Citations by year
2026: 37 · 2025: 42 · 2024: 40 · 2023: 34 · 2022: 28 · 2021: 9
FWCI
2.26
Type
journal article
Language
en
Open access
Licence
Locations
  • Obesity Reviews (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Physiology › Physical Activity and Health
  • Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
Keywords
obesity, exercise prescription, cardiorespiratory fitness, body composition, weight loss, high-intensity aerobic training, resistance training, concurrent training, abdominal fat, lean body mass, metabolic health, anthropometry
MeSH terms
Cardiorespiratory Fitness, Adult, Body Composition, Humans, Obesity, Exercise

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 2026-10-10.

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

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