Effects of dietary interventions and different types of physical activity in sedentary obese adults: a network meta-analysis

doi:10.21203/rs.3.rs-4121834/v1

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Effects of dietary interventions and different types of physical activity in sedentary obese adults: a network meta-analysis

https://doi.org/10.21203/rs.3.rs-4121834/v1

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Obesity is one of the most important health problems facing society today. Body mass index is an important indicator used to measure the degree of obesity. Sedentary adults are one of the main groups suffering from obesity. This network meta-analysis (NMA) was designed to compare the effects of different training methods and diets on body mass index results in sedentary adult obese patients. PubMed, EBSCO and Web of Science were searched to identify the following:(1) randomized controlled trials (RCTs); (2) the study population means ages 18–65 with overweight and sedentary;(3) Body Mass Index (BMI) > 25 kg/m2;(4) No other diseases that interfere with the weight loss effect. All articles are written in English and published from January 1991 to January 2024. Random-effects NMA models were fitted in a frequentist approach. GRADE framework was used to assess the certainty of evidence. Forty-one RCTs with 3442 participants with obesity were included in this review. The group without dietary control and exercise was used as the baseline. The BMI index was used as the unit. The results of point estimation showed that in the case of dietary control, the best effect was combined training(combine CET and RT, 1.4, 95% CI: 0.53 to 2.3) and the worst was interval training (0.79, 95% CI:-0.86 to 2.4). In the absence of dietary control, the best effect was Hybridge-type training (1.1, 95% CI: 0.23 to 2.0), and the worst was the control group (as the baseline).

Health sciences/Health care/Public health

Health sciences/Health care/Weight management

body mass index

training interventions

obesity

network meta-analysis

sedentary obese adults

Obesity is a critical public health challenge in contemporary society ¹. The World Health Organization (WHO) has documented a steady rise in global obesity rates, particularly pronounced in developed nations. An increasing body of research focuses on the role of sedentary behaviors—activities characterized by minimal physical movement, such as prolonged sitting or lying down—in contributing to obesity ². A sedentary lifestyle is strongly linked to numerous health risks, including obesity ³, cardiovascular diseases, and diabetes ^4,5, underscoring the importance of reducing sedentary time and promoting physical activity for optimal health. Notably, obesity-related to sedentary habits is considered more manageable and preventable through targeted adjustments in physical activity and nutrition ⁶. This study examines the impacts of varying intensities of physical exercise on sedentary obesity in adults and assesses how these exercise regimes influence body composition, aiming to offer effective strategies for addressing sedentary-related obesity.

Historically, the medical community has relied on anthropometric measures to classify overweight and obesity ^7,8, eventually adopting the Body Mass Index (BMI) as a more reflective measure of body fat ⁹. In the BMI Table 1⁰, different ranges of BMI were defined as healthy(20–25 kg/m2), overweight(25–30 kg/m2) and obese(> 30 kg/m2), serving as a vital tool for monitoring obesity and malnutrition ^11,12. It's also applicable to assessing obesity in children and adolescents ^13,14.

A widely held view supports the efficacy of regular exercise and active lifestyles in managing excess body fat ¹⁵. Research indicates that exercise training not only enhances body composition and cardiorespiratory fitness in obese individuals but also that the intensity of such activities plays a crucial role in mitigating cardiovascular risks associated with metabolic syndrome ^16,17. While some studies advocate for the superiority of high-intensity training, others find no significant difference when compared to moderate-intensity efforts ^18,19; Whereas, other researchers argue that there is no significant difference in metabolic syndrome improvement between high-intensity training and moderate-intensity training ^20,21. Nevertheless, exercise intensity significantly impacts body metabolism, with evidence indicating that the rate of fat oxidation increases with low to moderate-intensity exercise and then declines with higher intensity ^22,23. The effect of endurance exercise at constant body weight remains somewhat controversial ²⁴. Additionally, incorporating resistance training into exercise routines is believed to optimize performance, resting metabolic rate, and energy expenditure ²⁵. Despite the preference for moderate-intensity aerobic exercises supplemented by resistance training in obese populations ²⁶, the effectiveness of mixed training methods remains a topic of debate ^27–29.

Moreover, dietary interventions, particularly low-calorie diets, have demonstrated significant weight loss benefits ³⁰, though very low-calorie diets are recommended for short durations to prevent adverse effects ³¹. This paper employs a network meta-analysis to compare the effectiveness of various training and dietary interventions on weight loss in obese individuals, aiming to provide comprehensive insights into the synergistic potential of exercise and diet in obesity management, such as continuous endurance training (CET), resistance training (RT), hybrid-type training (HYB), combined training (CT) ²⁹, and diet intervention. By integrating these approaches, we seek to equip overweight individuals and health professionals with more effective strategies for weight management.

This systematic review has a predefined protocol published in the PROSPERO International Prospective Register of Systematic Reviews (CRD42023427132). We followed the PRISMA Extension for Network Meta-analyses (PRISMA-NMA) checklist when³² reporting methods and results of the current review.

2.1. Study Search

A systematic search was initiated in three electronic databases: MEDLINE（via PubMed）, Open Dissertations, Academic Search Premier, Business Source Premier, SPORT Discus, and Web of Science. The search strategy was established around the PICOS tool: (P) Population: sedentary adults living with obesity; (I) Intervention: physical exercise and diet; (C) Comparator: other exercise routine or no exercise control; (O) Outcomes: Body Mass Index (BMI). Search terms included cross-references and free-text nomenclature from MeSH in MEDLINE/PubMed. A complete list of the search terms is available in Table 1. In addition to the databases, the reference lists of included articles were scanned for articles that met the inclusion criteria.

Table 1. Search Terms.

Population

Intervention

obesity OR overweight OR fat OR fatness OR obese OR unhealthy weight OR high bmi OR adiposity

AND adult OR adulthood OR adults OR man OR men OR woman OR women

AND sedentary lifestyle OR sedentary OR sedentary behavior OR inactivity

Physical Education and Training OR exercise OR workout OR resistance OR aerobic OR combine resistance and aerobic

2.2. Study Selection

References of the studies identified were incorporated into EndNote 20 (Clarivate Analytics, Philadelphia, USA) for organized literature review recording. Duplicates were removed. The selection process consisted of three stages. Initially, two reviewers（Wang and Liu）autonomously scrutinized articles based on their titles; in ambiguous scenarios, they moved to the abstract review stage. In Phase 2, two articles were examined and deemed eligible by two distinct reviewers (Wang and Liu) via the abstract. Disagreements were resolved by consensus and consultation with an additional reviewer (Chow) on the panel. Lastly, the remaining articles underwent comprehensive review from an additional independent reviewer (Chow) per predesignated eligibility criteria. All discrepancies were ironed out again through broader intra-team dialogues.

2.3. Eligibility Criteria

Records were eligible for inclusion based on the following criteria stratified by participants/population, intervention/exposure and comparison, outcome measures and study design (PICOS)³³.

Inclusion criteria：

The research subjects are healthy adults (mean age 18-65) with obese and sedentary lifestyle, regardless of gender or race;
RCTs for reduce Body Mass Index (BMI) through aerobic exercise（CET）、resistance training(RT）、hybrid-type training（HYB）、combined training（CT）;
Primary outcome was change in Body Mass Index (BMI);
Studies were written in English and published from January 1991 to January 2024.

Exclusion criteria：

The research subjects are patients with metabolic disorders, Type II diabetes, or other comorbidities;
Studies did not adjust for any confounders (occupation, education level, gender, regional differences).

2.4. Exercise Categories

Six categories were used to classify the exercise interventions for the included RCTs:

Continuous endurance training (CET);
Interval training (INT);
Resistance training (RT);
Combined training (CT);
Hybrid-type training (HYB);
Control (CON).

Each category was devised using the frequency, intensity, time and type (F.I.T.T.) principle of exercise prescription and the ACSM's estimates of cardiorespiratory and resistance exercise intensity ³⁴. Continuous endurance training was defined as >45% VO2max or >50% HRR or >65% HRmax and interval training as 45–65% VO2max or >50–65% HRR or 65–75% HRmax. Resistance training was defined as ≥50% 1RM and hybrid-type training as >65% VO2max or >65% HRR or >75% HRmax. A detailed definition of each exercise category is provided in Table 2.

TABLE 2 Definition of the exercise training interventions using the F.I.T.T. principle.

Type of exercise	Abbreviation	Definition
Continuous endurance training	CET	Frequency: 3–5× per week Intensity: >45% VO2max or >50% HRR or >65% HRmax Time: 30–60 min per session Type: Any continuous traditional mode of aerobic training only (e.g., walking, running, cycling, swimming, aerobics, and stepping exercise)
Interval training	INT	Frequency: 3–5 times per week, each session lasting 30–60 min Intensity: 45–65% VO2max or >50–65% HRR or 65–75% HRmax Time: ≥8 weeks Type: Any mode of aerobic only (e.g., walking, running, cycling and swimming)
Resistance training	RT	Frequency: 2–3× per week Intensity: ≥50% 1RM Gross exercise time: 30–60 min per session Type: Any mode of resistance training, including circuit-based programs (e.g., free weights, weights machines, and resistance bands)
Combined training	CT	A combination of CET and RT
Hybrid-type training	HYB	Frequency: 2–3× per week Intensity: >65% VO2max or >65% HRR or >75% HRmax Gross exercise time: 30–45 min per session Type: Any intermittent multicomponent exercise mode engaging both the cardiovascular and the musculoskeletal system throughout a single exercise session using both muscle-strengthening and dynamic cardiovascular exercises (e.g., small-sided games in recreational sports, high-intensity functional training, integrated neuromuscular training, cardioresistance training, and multimodal training)
Control	CON	No exercise

Note: Abbreviations: F.I.T.T., frequency, intensity, time and type; HRmax, maximum heart rate; HRR, heart rate reserve; RM, repetition maximum; VO2max, maximal oxygen uptake.

2.5. Data Extraction

For the meta-analysis SMD and 95% CI for the highest consumption were directly extracted from the included records. We converted the 95%CI. Some records reported outcome measures separately for overweight and obesity while others reported outcome measures for overweight/obesity combined. Data were extracted by the first reviewer (Wang) and any doubts or questions concerning data extraction were resolved with the second reviewer (Liu). Discrepancies were solved in discussion with the third reviewer (Chow). Data extraction forms were created by the authors in Microsoft Excel and included author (year published), interventions, time, sample size, mean and standard deviation (SD). Reviewers were engaged with authors to respond to queries or address concerns, or to request missing or incomplete data. Data representation is via mean and standard deviation (SD) at the end of this study. Interventionary studies involving animals or humans, and other studies that require ethical approval, must list the authority that provided approval and the corresponding ethical approval code.

2.6. Risk of Bias Assessment

We used the Risk of Bias Assessment Tool (ROB) of Cochrane systematic reviews, which is currently the mainstream risk assessment tool for meta-analysis³⁵. This scale evaluates the risk of bias in the literature in terms of selection, implementation, detection, loss to follow-up, reporting and other risk of bias in qualitative evaluation studies. The methodical quality of included records was assessed using an adapted version of risk of bias. Representativeness of source of information clear, whether to state sample inclusion exclusion criteria, whether to give the intervention time, does the same group of people receive the intervention, whether supervisor metrics affect results, whether the article is assessed for quality assurance, whether to account for culled subjects, whether to describe measures to control irrelevant variables, how to handle missing values, whether to summarize subjects' response rates or the completeness of data collection, and total sample size of articles³⁵. All fields are assessed as low risk, then risk of bias is low risk. At least one area assessed as high risk, then risk of bias is high risk. At least two area assessed as unclear risk, then risk of bias is "some concerns".

2.7. Statistical Analysis

We computed the mean difference (MD) along with the corresponding 95% confidence intervals (95% CI) between the change scores in all available comparisons, which served as effect measures for subsequent analyses³⁶. A random-effects network meta-analysis (NMA) was conducted for each outcome using a Bayesian framework, and utilized network graphs to depict direct comparisons between different exercise modes³⁶. The node size reflects the sample size available for each exercise modality, while the line thickness corresponds to the number of studies available for comparison³⁶.

Network meta-analysis by comparing multiple interventions simultaneously while maintaining internal randomization of individual trials. We displayed the results of the NMA through forest plots and league tables. To determine the relative ranking of exercise modalities in their effects on anthropometric outcomes, we computed P-scores³⁶. P-score is a frequentist method alternative to the surface under the cumulative ranking curve in Bayesian approaches. A P-score value between 0 and 1 indicates which intervention performed the worst and the best³⁶.

Consistency is achieved when the treatment effect estimated from direct comparisons agrees with the effect estimated from indirect comparisons. We employed the technique of node-splitting, which delineates evidence from a particular comparison into direct and indirect effects to detect any local inconsistencies.

We conducted all analyses in R version 4.3.0, with the use of packages meta and gemtc.

3.1. Literature Selection

Initially, a total of 24001 studies were identified. Based on a review of titles and abstracts, 1866 studies were selected for full manuscript review. The remaining 45 studies were included in this review. The detailed process is illustrated in Fig. 1.

3.2. Intervention characteristics

This study aimed to explore the most effective approach for reducing BMI in sedentary obese adults through exercise training and dietary control. The intervention groups were categorized into those with both dietary control and exercise training, and those without either.

A total of 45 articles were included, with the following intervention characteristics: twenty three studies utilized CET as the exercise intervention, including 7 studies with dietary control (432 participants) ^29,37–42 and 16 studies without dietary control (902 participants)^{29,40,43–59}. Additionally, 2 studies incorporated both dietary control and no dietary control ^29,40. Furthermore, 10 studies utilized INT as the exercise intervention, including 1 study with dietary control (18 participants) ³⁸ and 9 studies without dietary control (187 participants)^{39,44,53,54,58,60–63}. Moreover, 6 studies employed CT as the exercise intervention, with 2 studies including dietary control (82 participants)^64,65 and 6 studies without dietary control (232 participants)^{56,59,64–67}. Two of the six studies included both dietary control and no dietary control ^64,65.Additionally, 5 studies used HYB as the exercise intervention, including 1 study with dietary control (38 participants)³⁷and 4 studies without dietary control (89 participants ^44,56,59,68. Lastly, 2 studies selected RT as the exercise intervention, including 1 studies with dietary control (17 participants)⁴² and 1 study without dietary control (10 participants)⁴⁵. The remaining 1435 participants formed the control group, with 189 individuals in the dietary control group ^40,65 and 1246 individuals in the no dietary control group ^{29,38,40,41,43,44,46–68}.

The mean length of exercise interventions was 23.5 weeks (SD = 20.4), ranging from 6 to 104 weeks, with 77% of the studies reporting exercise interventions that lasted or over 12 weeks in duration. Moreover, the maximum duration of intervention was 104 weeks. Further details relating to the interventions are reported in Table 3.

Table 3

Summary of studies included in network meta-analysis indicating the exercise intervention used and the outcome measures reported for comparison within the analysis.
Study	Duration (weeks)	Sample Size	Exercise category	Summary description of exercise intervention Frequency, intensity, time and type (F.I.T.T.)
Weiss et al⁶⁴	52	18	No_diets_CT	Cardiovascular exercise (e.g., brisk walking and cycling) and funct ional physical activities (e.g., walking to work or performing yard work)
		18	Diets_CT
		10	No_diets_control	No exercise
Batrakoulis A et al²⁹	40	14	No_diets_CET	A 10-min warm-up (low-intensity endurance exercise, stretching exercises and mobility exercises) and followed by a 5-min cool-down period (walking/stretching exercises). Exercises (~ 10–12/session) were performed in circuit fashion using prescribed time (20–40 sec) of effort and recovery intervals.
		14	Diets_CET
		21	No_diets_control	No exercise
Joao G. Alves et al⁴³	24	78	No_diets_CET	Aerobic in nature, consisting of a 5-minute warm-up followed by 40 minutes of moderate-intensity exercise (such as walking and rhythmical continuous movements in time to fast-tempo music) and a 5-minute cool-down.
Joao G. Alves et al⁴³	24	78	No_diets_control	No exercise
Barbara J et al⁶⁵	78	71	Diets_control	No exercise
		67	No_diets_CT	An aerobic phase (15 min), a resistance-training phase (15 min),a second aerobic phase (15 min), and a cool-down phase (15 min).
		64	Diets_CT
		70	No_diets_control	No exercise
Madjd, A et.al³⁷	24	37	Diets_CET	50 min/d brisk walking, 6 d/wk (300 min/wk)
Madjd, A et.al³⁷	24	38	Diets_HYB	100 min/d brisk walking, 3 d/wk (300 min/wk)
Freitas et al³⁹	12	26	No_diets_INT	Aerobic and resistance exercises (two sessions per week, 3 months); Aerobic training intensities were based on 50–75% of peak VO2
Freitas et al³⁹	12	25	Diets_CET	Exercises (stretching and breathing)

Table 3

Cont.
Study	Duration (weeks)	Sample Size	Exercise category	Summary description of exercise intervention Frequency, intensity, time and type (F.I.T.T.)
Chiu et al	12	12	No_diets_CET	Exercise for 40–50% HRR*, as determined by using a walking treadmill exercise test.
		12	No_diets_HYB	Exercise for 40–50% HRR during weeks 1–6, increasing to 50–70% HRR during weeks 7–12.
		12	No_diets_INT	Exercise for 40–50% HRR during weeks 1–6, increasing to 70%80% HRR during weeks 7–12.
		12	No_diets_control	No exercise
Rosenkilde et al³⁸	12	18	Diets_CET	The two exercise groups were instructed to engage in daily endurance exercise and to increase their exercise EE by either 300 kcal/day (MOD) or 600 kcal/day (HIGH), and over the course of the intervention subjects consumed a self-selected ad libitum diet.
		18	Diets_INT
		17	No_diets_control	No exercise
Avigdor D.A et al	14	9	No_diets_INT	High-intensity interval training
Avigdor D.A et al	14	11	No_diets_control	No exercise
Carolyn L. Lekavich et al	24	11	No_diets_CET	2,000 kcal/week at 65–80% peak VO2 using at least two of three modalities: stationary cycling, treadmill walking or stair climbing/elliptical training
Carolyn L. Lekavich et al	24	10	No_diets_RT	three sessions/week of three sets of 12–15 repetitions of nine resistance exercises at 70–85% 1RM*
Donnelly et al	40	37	No_diets_CT	Walking/jogging on motor-driven treadmills
Donnelly et al	40	18	No_diets_control	No exercise
Zoe L. Hewett et al	16	29	No_diets_HYB	The Bikram yoga practice consisted of 45–50 min of standing asanas starting with a deep breathing exercise, and 40–45 min of floor-based asanas, including a quick, forceful breathing exercise
Zoe L. Hewett et al	16	34	No_diets_control	No exercise
Christina M. Die li-Conwright et al	16	48	No_diets_CT	Moderate-to-vigorous—65–85% of heart rate maximum—aerobic and resistance exercise three times per week
Christina M. Die li-Conwright et al	16	45	No_diets_control	No exercise
Chih-Hui Chiu et al	12	12	No_diets_CET	40–50% HRR
Chih-Hui Chiu et al	12	12	No_diets_control	No exercise
Broskey N T et al.	24	14	No_diets_CET	All exercise on a treadmill or stationary bicycle. The exercise intensity was set at 65–85% of VO2peak
Broskey N T et al.	24	13	No_diets_control	No exercise

Table 3. Cont.

Study	Duration (weeks)	Sample Size	Exercise category	Summary description of exercise intervention Frequency, intensity, time and type (F.I.T.T.)
Lugones-Sanchez C. et al.	12	231	No_diets_control	No exercise
Lugones-Sanchez C. et al.	12	209	Diets_CET	At least 30 minutes of moderate activity 5 days a week, or 20 minutes of vigorous activity 3 days a week
Malandish A. et al.	12	14	No_diets_INT	50–60 min/day, 3 days/week at 65–70% of maximal HRR
Malandish A. et al.	12	13	No_diets_control	No exercise
Michał T. B et al	24	42	No_diets_CET	3 times/week for 60 minutes (40 minutes within the exercise zone of 60–75% HRmax)
Michał T. B et al	24	38	No_diets_control	No exercise
Schuna J. M. et al.	12	21	No_diets_CET	The treadmill desk twice daily on workdays for up to 45 minutes/session (90 minutes/day)
Schuna J. M. et al.	12	20	No_diets_control	No exercise
Foster-Schubert K. E. et al.	52	87	No_diets_control	No exercise
		118	Diets_control	No exercise
		117	No_diets_CET	Facility-based exercise consisted of treadmill walking, stationary bicycling; while a variety of home exercises were encouraged including walking/hiking, aerobics, and bicycling. A small amount of resistance training to strengthen joints and limit injury was recommended.
		116	Diets_CET
Friedenreich C. M. et al.	52	152	No_diets_CET	45 min of moderate-to-vigorous aerobic exercise five times per week, with at least three of the sessions being facility based.
Friedenreich C. M. et al.	52	155	No_diets_control	No exercise
Gram A. S. et al.	12	16	No_diets_control	No exercise
Gram A. S. et al.	12	6	No_diets_CET	An endurance exercise
Kearney T. M. et al.	24	25	No_diets_control	No exercise
Kearney T. M. et al.	24	52	No_diets_CET	30 minutes of accumulated walking
Kraushaar L. E. et al.	24	22	No_diets_control	No exercise
Kraushaar L. E. et al.	24	60	No_diets_INT	High-intensity interval training (HIIT) of thrice weekly at 20 min (either running or cycling)
Irwin M. L. et al.	52	87	No_diets_CET	At least 45 minutes of moderate-intensity exercise 5 d/wk 40% of maximal heart rate for 16 minutes per session and gradually increased to 60–75% of maximal heart rate for 45 minutes per session
Irwin M. L. et al.	52	86	No_diets_control	No exercise

Table 3. Cont.

Study	Duration (weeks)	Sample Size	Exercise category	Summary description of exercise intervention Frequency, intensity, time and type (F.I.T.T.)
Kong Z. et al.	12	18	No_diets_INT	HIIT*, repeated 4–min cycling at 90% VO2max interspersed with 3–min rest
		19	No_diets_CET	Continuous cycling at 60% VO2max
		17	No_diets_control	No exercise
Alizadeh Z. et al	12	12	No_diets_control	No exercise
		10	No_diets_INT	40 min moderate Intensity exercise in 3 bouts per day for 5 days per week
		9	No_diets_CET	The heart rate is in the range of 64–76% of maximum heart; RPE* is between 13 and 14
Bacchi E. et al.	16	13	Diets_CET	60 minutes per session at 60%-65% of HRR
Bacchi E. et al.	16	17	Diets_RT	3 series of 10 repetitions at 70%80% 1-RM, with 1 minute of recovery between series.
Bergström I. et al.	52	48	No_diets_CET	Level 1, 01 walks/week; Level 2, three walks/ week; Level 3, 13 walks and one aerobic session/ week; Level 4, three walks and two aerobic sessions/ week. Compliance with at least 95% at training intensity 34 was required to be counted as successful completion of intervention. All women received supplement with vitamin D (800 IU/day) and calcium (1,000 mg/day).
Bergström I. et al.	52	44	No_diets_control	No exercise
Mundbjerg L. H. et al.	104	22	No_diets_INT	15 min of bike training followed by 10 min of resistance training for the upper extremities (lateral raises, lateral pull-downs and chest press). This was followed by 15 min optional training (stair climbing, treadmill walking or rowing machine).
Mundbjerg L. H. et al.	104	20	No_diets_control	No exercise
Gram A. S. et al.	24	16	No_diets_control	No exercise
		19	No_diets_CET	Bike
		31	No_diets_CT	~ 50% VO2peak
		24	No_diets_HYB	~ 70% VO2peak
Arsenault B. J. et al.	24	82	No_diets_control	No exercise
Arsenault B. J. et al.	24	267	No_diets_CET	Heart rate corresponding to 50% of each woman’s peak VO2.

Table 3. Cont.

Study	Duration (weeks)	Sample Size	Exercise category	Summary description of exercise intervention Frequency, intensity, time and type (F.I.T.T.)
Benham J. L. et al.	24	17	No_diets_control	No exercise
		16	No_diets_INT	10 cycles of 30 s at highintensity (90% of heart rate reserve (HRR), or 9/10 on a modified Borg scale18) alternating with 90 s of low-intensity aerobic exercise.
		14	No_diets_CET	40 min of moderate-intensity aerobic exercise (50–60% HRR, or 4–6/10 on a modified Borg scale).
Quist J. S. et al.	24	16	No_diets_control	No exercise
		19	No_diets_CET	Active commuting (bike)
		31	No_diets_CT	Leisure-time exercise of moderate 50% VO2peak
		24	No_diets_HYB	Vigorous intensity 70% VO2peak

*Abbreviations: 1RM, one repetition maximum; HITT, high-intensity interval training; HRmax, heart rate maximum; HRR, heart rate reserve; RPE, rate of perceived exertion; VO2, oxygen uptake.

3.3. Risk of Bias

Detailed information regarding the ROB assessment for each study is presented in Fig. 2. Overall, 33 articles were judged to have low ROB, 5 articles had moderate ROB, and the remaining 7 articles were rated as having high ROB. For each ROB domain, 20 studies showed high or unclear ROB in sequence generation. 5 studies had high ROB in handling missing data and 12 studies had high or unclear risk in reporting the response rate of participants or data collection completeness. Finally, out of the 45 articles included, 6 articles showed higher ROB in other bias risk domains. The specific results are contained in Appendix A.

3.4. Network Meta-Analysis

In Fig. 3, the size of the nodes is proportional to the total number of participants allocated to exercise modality, and the thickness of the lines is proportional to the number of studies evaluating each direct comparison. The significance and value of the network diagram lies in the fact that when more interventions are included in the network meta-analysis, it may be difficult to identify the number of studies directly compared between various interventions by relying on data and tables alone. The emergence of the network diagram has solved this problem.

In Fig. 4, Interval plot summarizing mean difference with 95% confidence interval for all interventions. On the left side of the forest chart is a short abbreviation of each intervention method, in which the point estimate of the blank control group without diet control is set as the baseline. The more deviation from the baseline means the greater the difference from the blank control group without diet control. The nodes represent the point estimate of the effect, the length of the line segment represents the 95% confidence interval of each intervention, and the longer the line segment, the wider the confidence interval, the more unstable the results of this intervention method.

3.5. Inconsistency

The node-splitting approach did not suggest important differences between direct and indirect estimates in any of the considered comparisons. Net heat plots suggested the presence of moderate inconsistency for all outcomes.

3.6. Ranking of Training Effectiveness

Table 4

Rank of different interventions.
	V1	V2	V3	V4	V5	V6	V7	V8	V9	V10	V11		V12
Diets_CET(V1)	2.910%	9.040%	14.120%	18.525%	17.905%	15.050%	10.645%	6.610%	3.550%	1.400%		0.240%	0.005%
Diets_control(V2)	15.645%	19.805%	17.700%	13.225%	10.675%	8.350%	5.765%	4.100%	2.730%	1.490%	0.505%		0.010%
Diets_CT(V3)	15.870%	19.690%	17.420%	13.780%	10.680%	8.395%	5.660%	4.055%	2.505%	1.445%	0.465%		0.035%
Diets_HYB(V4)	17.650%	8.080%	6.090%	5.315%	5.360%	5.270%	5.810%	5.615%	7.790%	10.700%	11.315%		11.005%
Diets_INT(V5)	9.940%	7.150%	5.330%	5.735%	5.715%	5.810%	6.300%	7.405%	8.890%	14.075%	13.870%		9.780%
Diets_RT(V6)	14.035%	14.395%	12.715%	11.405%	10.060%	9.060%	7.335%	6.825%	6.310%	4.875%	2.365%		0.620%
No_diets_CET(V7)	0.020%	0.070%	0.305%	1.045%	2.610%	5.555%	11.905%	21.455%	28.575%	22.280%	6.180%		0.000%
No_diets_control(V8)	0.000%	0.000%	0.000%	0.000%	0.000%	0.005%	0.010%	0.135%	2.335%	15.795%	46.160%		35.560%
No_diets_CT(V9)	2.385%	5.355%	8.295%	10.465%	12.220%	14.210%	14.780%	12.955%	10.410%	6.410%	2.385%		0.130%
No_diets_HYB(V10)	8.280%	9.635%	10.250%	10.585%	11.495%	11.740%	11.450%	9.835%	7.990%	6.020%	2.470%		0.250%
No_diets_INT(V11)	1.150%	2.795%	4.925%	7.320%	10.385%	13.440%	17.315%	17.640%	14.525%	8.005%	2.455%		0.045%
No_diets_RT(V12)	12.115%	3.985%	2.850%	2.600%	2.895%	3.115%	3.025%	3.370%	4.390%	7.505%	11.590%		42.560%

When the different intervention items were ranked and analyzed, it was found that the diet control group was mostly superior to the no diet control group, but diets_INT (14.075%) had a lower probability in the whole ranking, and diets_HYB (17.650%) had the greatest probability in the diet control group, which was ranked in the first place. In the no diet control group, no_diets_HYB (11.740%) had the greatest probability in the first place and no_diets_RT (42.560%) had the lowest probability in the twelfth place.

4.1. Comparison with Other Studies

In this comprehensive review and series of meta-analyses, we sought to evaluate the effect of various exercise modalities in conjunction with dietary strategies on Body Mass Index (BMI). Systematic reviews and meta-analyses are crucial for effectively comparing interventions. Yet, the simultaneous evaluation of multiple interventions within a randomized controlled trial poses considerable challenges. Traditional meta-analyses are adept at comparing effects across numerous primary studies but are typically limited to analyzing one or two interventions at a time. The innovative approach of our study lies in the application of network meta-analysis, which enables the concurrent comparison of several interventions, assessing not only their individual effectiveness but also the impact of intervention duration on weight loss outcomes. Our results indicate that while all exercise modalities contribute to weight loss, combinations of exercise with dietary modifications prove most effective in BMI reduction, significantly more so than either strategy alone ⁶⁹. Evidence suggests that physical activity without dietary adjustments results in minimal weight loss ^69,70. The principle of energy balance underlines that obesity stems from an excess of energy intake over expenditure, highlighting that effective weight loss requires a negative energy balance ⁷¹, achievable through a combination of physical activity and dietary management.

Recent studies have explored the effects of various exercise types (aerobic, resistance, and mixed), their frequency, volume, intensity, and duration on weight loss. Our findings corroborate the effectiveness of both aerobic exercises and resistance training under diet control for weight loss, consistent with extensive research ^72,73. However, the definitive benefits of high-intensity training on weight or fat loss remain unproven ⁷⁴. Our analysis further validates that resistance training, when paired with dietary control, is particularly beneficial for weight loss due to its role in enhancing muscle mass and, consequently, energy expenditure—not only during physical activity but also at rest. This suggests that despite resistance training's lower immediate energy expenditure, its long-term effects on energy balance significantly contribute to weight management ⁷¹. Moreover, resistance training may enhance fat utilization as an energy source, for instance, Treuth et al. reported that 16 weeks of resistance training in older women contributed more to weight control than endurance training⁷⁵. You, T et al. noted that dietary weight loss coupled with high-intensity exercise training would be more effective in reducing abdominal fat cell size, also further validating the conjecture of this study⁷⁶.

Based on our study, healthcare professionals can tailor weight loss strategies more effectively to an individual's lifestyle and physical activity background. For sedentary individuals lacking an exercise routine, an aerobic exercise program with dietary modifications might be recommended, whereas those with some exercise experience could benefit from a more advanced resistance training regimen paired with a diet focusing on increased protein intake ⁷⁷. This nuanced approach acknowledges the varying levels of motivation and adherence among different groups.

Our review applied stringent systematic criteria to analyze 45 relevant studies involving a substantial cohort of obese and sedentary adults, enabling the detection of statistically significant differences in weight loss strategies. This meta-analysis advances our understanding of how different exercise and diet combinations affect BMI reduction, offering valuable insights for sedentary obese individuals seeking effective weight management strategies.^78–81.

This meta-analysis advances our understanding of how different exercise and diet combinations affect BMI reduction, offering valuable insights for sedentary obese individuals seeking effective weight management strategies. ^{79,80,82–84}. This meta-analysis advances our understanding of how different exercise and diet combinations affect BMI reduction, offering valuable insights for sedentary obese individuals seeking effective weight management strategies.

4.2. Clinical and Research Implications

Guided by the network meta-analysis (NMA), this study meticulously reviewed three decades of research on training and diet control in sedentary obese adults to identify the most effective strategy for BMI reduction and enhanced health outcomes. Our analysis of diverse literature and comparison of 12 distinct control methods (as shown in the Table 4) revealed that diet control alone significantly outperformed other approaches in reducing BMI among sedentary obese adults. This underscores the effectiveness of dietary management in curbing excess calorie intake, echoing findings from other studies ^64,65,85,86. However, this comparison overlooks the potential of specific training regimes to augment fat loss and lean muscle gain, potentially skewing the perceived efficacy of diet control.

The study's findings indicate varied effectiveness among training modalities post-diet control, with some modalities successfully reducing BMI in the obese population. Interestingly, the HYB group [-0.180 (-2.372, 2.018)] and INT group [-0.130 (-1.859, 1.609)] showed no significant decrease, and in some instances, an increase in BMI, diverging from other research. This anomaly may stem from substantial individual variances within the study population, expanding the 95% confidence interval range.

Notably, the CT group demonstrated significant BMI reduction after diet control, highlighting the innovative outcomes of this research. The CT group, merging the CET and RT modalities, suggests that a blend of resistance training and aerobic endurance, particularly with significant strength training to build lean muscle and aerobic exercises to diminish fat content, optimally reduces BMI when complemented by dietary adjustments for proper nutrient intake.

Furthermore, the study discovered that the HYB group, a blend of various training techniques for a comprehensive approach to fat reduction, was notably more effective in reducing BMI without stringent dietary control ^56,56,87. This suggests a lessened reliance on diet modifications for achieving weight loss goals.

In summary, incorporating dietary control within training regimens proved more efficacious in BMI reduction than training alone. Specifically, the CT group under dietary management emerged as the most effective in decreasing BMI among sedentary obese adults, surpassing the outcomes of the HYB group without dietary control. This finding supports the conclusion that a synergistic approach of dietary management and tailored exercise programs holds the greatest potential for effective weight management and health improvement in the sedentary obese population.

The main findings of the paper are as follows: The results under the Bayesian framework show that any exercise intervention with diet control has a better weight loss than any exercise intervention without diet control. Unexpectedly, from the perspective of BMI, the implementation of diet control and no exercise interventions are more effective than many interventions that implement diet control and exercise. This can be attributed to exercise improving muscle ratios, which in turn increases BMI. We can also get the same conclusion by observing the effect of Resistance training.

Future studies should consider assess the potential implications of distinct CT modalities more rigorously, e.g., utilization of consistent or fluctuating resistance, cardiorespiratory zones for aerobic exercise, etc.

Author Contributions: S.C., X.L. and C.P. designed the research and develop the protocol; X.L. and C.P. conducted the research; X.L., C.P. and S.C. resolved conflicts over screening and study selection. S.C. performed the statistical analysis. S.C., X.L. and C.P. wrote the initial manuscript; S.C., X.L. revised the manuscript; P.Z. supervised and reviewed the manuscript. All authors have read and agreed to the published version of the manuscript.

Data availability: Available upon reasonable requests by contacting the corresponding author.

Funding: This research received no external funding.

Institutional Review Board Statement: Not applicable.

Conflicts of Interest: The authors declare no conflict of interest.

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No competing interests reported.

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Effects of dietary interventions and different types of physical activity in sedentary obese adults: a network meta-analysis

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Abstract

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1. Introduction

2. Materials and Methods

3. Results

3.1. Literature Selection

3.2. Intervention characteristics

3.3. Risk of Bias

3.4. Network Meta-Analysis

3.5. Inconsistency

3.6. Ranking of Training Effectiveness

4. Discussion

4.1. Comparison with Other Studies

4.2. Clinical and Research Implications

5. Conclusions

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References

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