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JKM > Volume 45(1); 2024 > Article
Park, Lim, and Kim: Review on Weight Loss Interventions that Can Prevent Muscle Mass Loss in Sarcopenic Obesity



The objective of this study was to review clinical studies conducted over the last ten years that investigated weight or fat loss interventions that can preserve muscle or fat-free mass in Sarcopenic obesity


PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Research Information Sharing Service (RISS) and Korea Studies Information Service (KISS) were searched for Randomized clinical trials that had investigated all-type of interventions on the management of sarcopenic obesity from October 2013 to September 2023.


A total of 14 studies met all the inclusion criteria. Interventions that increase muscle mass while reducing body fat at the same time included resistance training (including using elastic bands) and whole-body electromyostimulation(WB-EMS) in exercise intervention and Hypocaloric high-protein diet in nutritional intervention, exercise and nutritional combined intervention, and combination intervention of electrical acupuncture and amino acid supplementation. Among them, the most positive method of changing the body composition in sarcopenic obesity was the electric acupuncture and amino acid supplements.


Varying diagnostic criteria and management interventions for sarcopenic obesity in the included studies made it hard to maintain homogeneity across the studies. Well-defined criteria for diagnostic sarcopenic obesity should be considered. In addition, since all of the interventions examined did not show sufficient clinical effectiveness, follow-up studies are needed to confirm effective interventions for sarcopenic obesity patients in the future.

Fig. 1
Flow chart of the literature search process
Table 1
Characteristics of Studies Included in the Review
Author, Year, country Mean age Sex Intervention category Intervention Sample size Intervention duration Adherence Outcomes
Balachandran, 201412)
Power circuit(HSC): 71.6 ± 7.8
Hypertrophy (SH): 71 ± 8.2
HSC: F (100%)
SH: F (88%)
Exercise (2 arms)
  1. HSC: 3 sets of 10–12 repetitions(no recovery between sets)

    2x/wk for 40–45 min/session
  2. SH: 3 sets of 10–12 repetitions(1–2min recovery between sets) 70% of 1RM

    2x/wk for 55–60 min/session
1. 11
2. 10
15 weeks 1. 81%
2. 85%
SPPB, lower body and upper body power and strength, IADL, RPE, PBF, SMI, HG
Gadelha, 201613)
67.0 ± 5.2 F (100%) Exercise (2 arms)
  1. Resistance training: 3 sets of each machine(1min recovery) 3x/wk

60% of 1RM for 4wks, 70% of 1RM for 4wks, 80% of 1RM for 16wks
  1. Control: maintain their usual activities

1. 69
2. 64
24 weeks 100% Weight, BMI, Body Fat, TFFM, relative TFFM, AFFM, knee extensor isokinetic peak torque
Chen, 201714)
68.8 ± 3.3 F (80%) Exercise (4 arms)
  1. Aerobic training: 2x/wk for 60 min/session

  2. Resistance training: 60%–70% of 1RM 2x/wk for 60min/session

  3. Combination training: 1x/wk Aerobic + resistance

  4. Control: prohibited from engaging in any exercises

1. 22
2. 24
3. 25
4. 22
8 weeks 64.5% Weight, SMM, ASM, BFM, BMI, PBF, VFA, HG, Maximum Back Extensor Strength, Maximum Knee Extensor Muscle Strength, IGF-1
Park, 201715)
74.1 ± 6.1 F(100%) Exercise (2arms)
  1. Aerobic & resistance group: 5x/wk for 50–80/min, resistance exercise(elastic band exercise) 3x/wk + Aerobic(various walking activities) 5x/wk

  2. Control: health and family life education twice

1. 25
2. 25
24weeks 100% PBF, ASM, WC, HG, 30-s chair stand-up test, sit-and-reach test, Maximum walking speed, IPAQ, CIMT, CLD, PSV, EDV
Huang, 201716)
69.2 ± 5.0 F(100%) Exercise (2arms)
  1. Elastic resistance: progressive (20%) elastic band resistance training program, 3x/wk for 55min

  2. Control: a 40-min course about home exercise for sarcopenic obesity

1. 18
2. 17
12 weeks 100% BW, BMI, SMI, PBF, Laboratory data, Total BMD, T-score, Z-score
Liao, 201817)
67.3 ± 5.2 F(100%) Exercise (2arms)
  1. Elastic resistance: moderate-intensity 3x/wk for 55 min

  2. Control: no intervention

1. 33
2. 23
12 weeks 89.2% PBF, TSM, ALM, LMI, AMI, SMI, HG, maximal isometric quadriceps strength, Physical capacity
Muscariello, 201618)
66.7 ± 4.9 F(100%) Nutrition (2arms)
  1. Normal protein intake hypocaloric diet: 0.8 g/kg DBW/day of proteins

  2. High protein intake hypocaloric diet: 1.2 g/kg DBW/day of proteins

1. 50
2. 54
12 weeks N/A MMI, BMI, WC, PFM, FMI, HG, IPAQ-SF
Sammarco, 201719)
55.0 ± 9.6 F(100%) Nutrition (2arms)
  1. Hypocaloric high-protein diet: 1.2–1.4 g/kg body weight reference/day obtained with the addition of 15 g daily of protein supplement, basal metabolic rate – 10% according to calorimetry

  2. Hypocaloric + placebo: 0.8–1 g/kg body weight reference/day, basal metabolic rate – 10% according to calorimetry

1. 9
2. 9
16 weeks 100% BMI, FM, FFM, HG, SPPB, REE
Yin, 202320)
68.13 ± 6.12 F(70%) Nutrition (2arms)
  1. Dietary behaviour change: A Moderate hypocaloric diet (12% reduction in calories from the estimated daily energy expenditure) + a dose of 1.2–1.5 g/kg body weight/day of protein intake+ BCTs(HAPA model)

  2. Control: regular health talks

1. 30
2. 30
15 weeks 83.3% Feasibility and Acceptability of the intervention, BW, BFM, BMI, PBF, SMI, WC, HG, 6-m gait speed, SPPB, HAPA Nutrition Self efficacy Scale: DQI-I, Food diary MNA, SF-36
Kemmmler, 201621)
77.0 ± 4.3 F (100%) Exercise Nutrition Combined (3arms)
  1. WB-EMS: 1x/wk for 20 min + vitamin-D 800 IU/day

  2. WB-EMS&Protein: WB-EMS + 40 g/day (21g whey protein)

  3. Control: Vitamin-D 800 IU/day

1. 25
2. 25
3. 25
26 weeks 89.3% Sarcopenia Z-Score, SMI, HG, gait speed
Kemmmler, 201722)
77.4 ± 4.8 M (100%) Exercise Nutrition Combined (3arms)
  1. WB-EMS&Protein: 1or2 sets of 8 repetitions, 1.5x/wk for 20 min + Protein + Vitamin-D

  2. Protein: 1.7–1.8 g/kg day protein(whey protein) + Vitamin-D 800 IU/day

  3. Control: Vitamin-D 800 IU/day

1. 33
2. 33
3. 34
16 weeks 92% Sarcopenia Z-Score, TBF, SMI, HG
Kim, 201623)
81.1 ± 4.6 F (100%) Exercise Nutrition Combine (4arms)
  1. Exercise + Nutrition

  2. Exercise: 2x/wk for 60 min Resistance + Aerobic

  3. Nutrition: EAA 30 g + Vitamin-D 20 μg + 540 g catechin

  4. Health education: once every 2wk, Total 6 times, only health education, no exercise or nutrition

1. 36
2. 35
3. 34
4. 34
12 weeks 98.6% Muscle mass, BFM, PBF, SMI, HG, Peak isometric force, walking speed
Nubuco, 201924)
69.1 ± 4.1 F(100%) Exercise Nutrition combined (2arms)
  1. Whey protein + RT: 35 g whey protein, resistance training: 3x/wk

  2. Placebo+ RT: mixed with non-caloric sugar-free drinks, resistance training: 3x/wk

1. 13
2. 13
16 weeks 100% BW, height, WC, HP, ALST, lower LST, total LST, total BFM, PBF, TFM, 1RM tests, 10MW, RSP
Zhou, 201825)
69.5 ± 5.2 M(100%) Electrical acupuncture (2arms)
  1. Electrical acupuncture + Nutrition: electrical acupuncture using the LI14 and LI11 pair, and the ST31 and ST34 pair for 20 min with a frequency of 5 Hz, wave duration of 1 ms, and strength of 1.5 mA, every 3 days for 12 weeks. + EAAs orally twice per day (20 g in total) for 28 weeks

  2. Nutrition: EAAs orally twice per day (20 g in total) for 28 weeks

1. 23
2. 25
28weeks 100% ASM/Height2, PBF

RM: repetition maximum, SPPB: Short Physical Performance Battery, IADL: instrumental activities of daily living, RPE: ratings of perceived exertion, PBF: percentage of body fat, SMI: skeletal muscle index, HG: Hand grip, BMI: body mass index, TFFM: total fat free mass, AFFM: appendicular fat free mass, SMM: skeletal muscle mass, ASM: appendicular skeletal muscle, BFM: body fat mass, VFA: visceral fat area, IGF-1: insulin like growth factor-1, WC: waist circumference, IPAQ: international physical activity questionnaire CIMT: carotid intima-media thickness CLD: carotid artery luminal diameter, PSV: peak systolic flow velocity, EDV: end diastolic flow velocity, BMD: bone mineral density, TSM: total skeletal muscle mass, ALM: appendicular lean body mass, LMI: Lean body mass index, AMI: appendicular lean body mass index, MMI: muscle mass index, PFM: percentage of fat mass, FMI: fat mass index, IPAQ-SF: International Physical Activity Questionnaire–Short Form, DBW: desirable body weight, FM: fat mass, FFM: fat free mass, REE: resting energy expenditure, BCT: behavior change techniques, HAPA: health action process approach, DQI-I: Dietary Quality Index-International, MNA: Mini Nutritional Assessment, SF-36: 36-item short form health survey, WB-EMS: Whole-body electromyostimulation TBF: total body fat, EAA: essential amino acid, RT: resistance training, HP: hip circumference, ALST: appendicular lean soft tissue, LST: lean soft tissue, 10MW: 10m walk test, RSP: rising from sitting position test

Table 2
Diagnostic Criteria for Sarcopenic Obesity Used in the Included Studies
Author, year Measurement of Body composition Diagnostic criteria for sarcopenia Diagnostic criteria for obesity
Reference Muscle mass Other criteria BMI (kg/m2) PBF (%)
Adjusted by weight (%) Adjusted by height2 (kg/m2)
Balachandran, 201412) BIA (single-frequency) EWGSOP, 201026) SMI
M <10.76 kg/m2
F <6.76 kg/m2
Gadelha, 201613) DXA Newman, 200327) Lowest 20th percentile of residuals (obtained from linear regression of appendicular lean mass (kg) on height (meters) and fat mass (kg)) and the ratio (aLM/ht2) of aLM (kg) and height squared (m2) ≥30
Chen, 201714) BIA (multifrequency) Chang, 201328) ASM/weight
M ≤32.5%
F ≤25.7%
Park, 201715) BIA (multifrequency) Lim, 201029) ASM/weight
F <25.1%
Huang, 201716) BIA during the screening (multifrequency)
DXA during the trial
Janssen, 200230) TSM/weight
F <27.6%
Liao, 201817) BIA (multifrequency) Janssen, 200230) TSM/weight
F <27.6%
Muscariello, 201618) BIA (single-frequency) N/A MMI
F <7.3 kg/m2
Kemmmler, 201621) BIA during the screening (multifrequency)
DXA during the trial
EWGSOP, 201026) SMI
F <5.75 kg/m2
Kemmmler, 201722) BIA (multifrequency) FNIH, 201432) ASMM/BMI
M <0.789
Kim, 201623) DXA N/A SMMI
F< 5.67 kg/m2
Nubuco, 201924) DXA FNIH, 201432) Appendicular lean soft tissue <15.02 kg >35
Zhou, 201825) BIA (Multifrequency) ASWG, 201433) ASM
M ≤7.0 kg/m2
Sammarco, 201719) BIA (single-frequency) N/A Lean body mass was <90% of the subject’s ideal fat free mass >34.8
Yin, 202320) BIA (Multifrequency) ASWG, 201931) Low handgrip strength M <28 kg, F <18 kg or low physical performance in the 5-time chair stand test of 12s ≥28

MI: body mass index, PBF: percentage of body fat, BIA: Bioelectrical Impedance Analysis, EWGSOP: European Working Group on Sarcopenia in Older people, SMI: skeletal muscle index, DXA: Dual Energy X-ray Absorptiometry, ASM: appendicular skeletal muscle, TSM: total skeletal muscle, MMI: muscle mass index, ASWG: Asian Working Group for Sarcopenia, FNIH: The Foundation for the National Institutes of Health, ASMM: appendicular skeletal muscle mass, SMMI: skeletal muscle mass index

Table 3
Absolute Muscle Mass or Fat-Free Mass and Body Fat Percentage Changes Following Interventions
Author, year Interventions Absolute muscle mass (kg) PBF (%)

(T)FFM Other muscle mass parameters

Baseline After Mean difference Parameters Baseline After Mean difference Baseline After Mean Difference
Gadelha, 201613) RT 36.39±4.16 0.60±0.15* AFFM 13.80±1.86 0.29±0.11* 39.85±6.27 −0.88±0.33

Chen, 201714) RT 22.9±4.0 23.0±4.1 39.7±5.6 38.7±6.4
AT SMM 20.0±3.3 20.2±3.2 40.0±4.4 39.0±4.6
RT + AT 20.7±4.0 21.4±3.7 39.7±5.8 37.4±5.3

Park, 201715) RT + AT ASM 14.1±1.8 14.5±1.9 41.0±3.6 39.0±3.9*

Sammarco, 201719) LCD 47.7±3.34 48.0±2.83 55.4±4.46 53.2±4.8*
LC-HPD 47.6±2.45 48.7±2.11* 51.4±4.52 48.0±6.1*

Nubuco, 201924) Whey protein + RT ALST 13.9±0.9 14.7±1.1* 40.9±4.1 39.7±4.1*
RT 13.9±0.8 14.2±0.8* 39.6±4.4 39.5±4.9*

(T)FFM: (total) fat free mass, PBF: percentage of body fat, RT: resistance training, AFFM: appendicular fat free mass, AT: aerobic training, SMM: skeletal muscle mass, ASM: appendicular skeletal muscle, LCD: low caloric diet, LC-HPD: low caloric-high protein diet, ALST: appendicular lean soft tissue

* Significant difference from baseline value (P < 0.05)

† Significant difference from control or placebo (P <0.05)

Baseline and After Data presented as mean±standard deviation, Mean difference presented as mean±standard error

Table 4.
Relative Muscle Mass or Fat-Free Mass and Body Fat Percentage Changes Following Interventions
Author, year Intervention Relative muscle mass
Adjusted by BMI (kg/(kg/m2))

Index Baseline After Mean difference Baseline After Mean difference
Kemmler, 2017 [22] WB-EMS+P (ASMM/BMI) 0.709 (0.695, 0.734) 0.018 (0.011, 0.026)* 31.6 (30.5, 32.9) -2.05* (-1.40, -2.68)
P 0.703 (0.681, 0.723) 0.008 (0.001, 0.015)* 31.4 (30.4, 32.4) -1.13* (0.48, -1.78)
Author, year Intervention Relative muscle mass
PBF (%)
Adjusted by height2 (kg/m2)
Adjusted by weight (%)

Index Baseline After Mean difference Index Baseline After Mean Difference Baseline After Mean difference
Balachandran, 2014 [12] HSC SMI 6.5±0.66 6.6±0.59 45.2±4.7 44.5±4.5
SH 6.7±0.45 6.8±0.42 43.8±6.5 43.4±5.9
Gadelha, 2016 [13] RT Relative TFFM 0.27±0.07* -0.88±0.33
Chen, 2017 [14] RT ASM 24.1±2.4 24.3±2.6 39.7±5.6 38.7±6.4
AT 23.0±2.0 23.4±2.1 40.0±4.4 39.0±4.6
RT+AT 23.7±2.7 24.4±2.4 39.7±5.8 37.4±5.3
Huang, 2017 [16] ER SMM 22.37±2.14 22.47±2.45 41.66±7.65 37.68±5.36*
Liao, 2018 [17] ER AMI 6.09±0.83 6.37±0.76 0.33 (0.13, 0.52) SMI 29.94±2.80 30.15±3.16 0.28 (-0.50, 1.06) 41.65±4.02 40.89±3.77 -2.17 (-4.13, 0.21)
Yin, 2023 [20] DBC SMI 7.31±0.16 7.23±0.19 SMM 33.31±0.65 33.02±0.79 39.35±1.09 39.83±1.25*
Kemmmler 2016 [21] WB-EMS SMI 5.67 (5.50, 5.83) 0.14 (0.08, 0.21)* 37.3 (35.6, 39.0) -0.34 (-0.78, 0.10)
WB-EMS+P 5.66 (5.48, 5.83) 0.11 (0.04, 0.19)* 37.5 (36.2, 38.7) -0.52 (-0.98, 0.06)
Kim, 2016 [23] E+N SMI 1.1±0.5 38.1±4.3 -4.0±0.9
E 0.1±0.7 37.0±4.1 -3.9±0.8
N 0.6±0.6 37.8±3.3 -3.0±0.7
HE 1.2±0.8 38.5±4.9 -3.0±0.7
Zhou, 2018 [25] EA+AA AMI 6.04±0.50 6.19±0.52* 33.17±2.66 27.30±1.96*
AA 5.94±0.49 5.96±0.48 31.80±2.83 30.16±2.84*

PBF: percentage of body fat, HSC: power circuit, SH: hypertrophy, SMI: skeletal muscle index, RT: resistance training, TFFM: total fat free mass, AT: aerobic training, ASM: appendicular skeletal muscle, ER: elastic band resistance exercise, SMM: skeletal muscle mass, DBC: dietary behavior change, WB-EMS: whole body electromyostimulation, P: protein, E: exercise, N:nutrition, HE: health education, EA: electrical acupuncture, AA: amino acid, AMI: appendicular muscle index, BMI: body mass index, ASMM: appendicular skeletal muscle mass

* Significant difference from baseline value (P < 0.05)

† Significant difference from control or placebo (P <0.05)

Baseline and After Data presented as mean±standard deviation or mean (95% CI), Mean difference presented as mean±standard error or mean (95% CI)


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