Comparative efficacy of combined exercise and nutritional interventions for sarcopenia: A systematic review and network meta-analysis incorporating remote delivery models

• Applying rigorous network meta-analysis methodology, this review systematically compares interventions for sarcopenia, though the GRADE analysis reveals limited certainty in the available evidence. • Resistance exercise, when combined with other forms of physical activity and nutritional support, proves to be more effective for addressing sarcopenia than resistance exercise alone. • Our analysis clarifies that nutritional supplementation alone is insufficient, redirecting focus towards synergistic multimodal approaches and highlighting the need for future research on personalized nutrition protocols within combination therapies. To identify the most effective interventions to delay the progression of sarcopenia and potentially improve muscle strength and mass, with the ultimate goal of reversing sarcopenia, by comparing all pharmacological and non-pharmacological interventions. Systematic review and network meta-analysis. This analysis identified 115 randomized controlled trials (RCTs) with 10,967 participants which an average age of 74.85 years, together evaluating 27 different interventions. For the primary outcome, endurance training followed by resistance training yielded the highest effect on muscle strength (SMD 2.59, 95% CI 1.50 to 3.69), while general remote training was most effective for lean mass (SMD 1.35, 95% CI 0.41 to 2.29) and physical performance (SMD 2.39, 95% CI 1.26 to 3.53). The combination of nutrition with aerobic and resistance training significantly improved muscle strength (SMD 1.25, 95% CI 0.64 to 1.87) and physical performance (SMD 1.73, 95% CI 1.09 to 2.37). Resistance training significantly improved multiple secondary outcomes: body fat mass (SMD -0.57, 95% CI -0.75 to -0.40), blood inflammatory markers (SMD -1.69, 95% CI -1.95 to -1.43), and knee extension strength (SMD 0.55, 95% CI 0.33 to 0.76). Aerobic exercise reduced body fat (SMD -0.48, 95% CI -0.87 to -0.09) and inflammation (SMD -1.98, 95% CI -2.31 to -1.66), while improving quality of life (SMD 0.71, 95% CI 0.53 to 1.03). Subgroup and meta-regression analyses identified sample size, age, and intervention duration as significant moderators of treatment effects, while sensitivity analyses confirmed the robustness of findings to statistical methods. This network meta-analysis concludes that applying a multimodal approach involves combining resistance training, aerobic exercise, and targeted nutrition to the sarcopenia population, which will be the most effective strategy for managing sarcopenia. Future efforts should focus on enhancing remote intervention delivery to improve accessibility and adherence among older adults.