1 Intervention

Multiple studies, including.^15,17,20,22 highlight resistance training's benefits: muscle and bone improvements, reduced fat mass, enhanced metabolism, improved quality of life, fall, and fracture risk reduction, disease burden alleviation, and potential lifespan extension.^12–14 Supported studies confirm resistance training's safety, efficacy, and feasibility for the elderly and osteosarcopenic obese.^.2,3,10

The rapid economic development in aging societies has led to a surge in aging-related diseases, including sarcopenia, obesity, and osteoporosis^1,21,22, Sarcopenia, characterized by muscle weakness, poses significant health challenges.²⁰ Osteoporosis and obesity are particularly concerning among elderly women due to their association with an increased risk of falls and fractures.²⁰ Obesity is linked to metabolic syndrome and chronic conditions like hypertension, hyperlipidemia, hyperglycemia, and cardiovascular diseases.^14,15 Osteoporosis notably heightens vulnerability to fragile fractures.¹¹ When osteoporosis, sarcopenia, and obesity coexist, it's termed osteosarcopenic obesity (OSO), imposing a substantial global health burden.¹⁰ Studies have shown a correlation between OSO and functional decline, frailty, and falls.^6,7,21 OSO describes a condition marked by the loss of bone and muscle mass accompanied by excessive fat accumulation.¹¹ Several tools have been created to identify and control OSO, including nutritional and exercise interventions.^9–18,21 Revised OSO diagnostic criteria, incorporating personalized adjustments based on gender and race, have been proposed.²² Further research is required to expand OSO diagnostic criteria and enhance treatment efficacy.

It has been demonstrated that resistance training is a useful treatment for osteosarcopenic obesity (OSO)..¹² Several studies have shown that resistance exercise increases strength and muscular mass, bone density, fat reduction, and metabolism.^15,17,20,22 Additionally, resistance training holds the potential to enhance quality of life, lower fall and fracture risks, mitigate disease burden, and potentially extend lifespan.^12–14 As a result, resistance training is seen as a practical, safe, and effective form of exercise, particularly for the elderly and those who suffer from osteosarcopenic obesity..^2,4,5,10

2 Methods

This review is registered on PROSPERO with registration number CRD:42,023,448,834.

The PICOS (Patients, Interventions, Comparisons, Outcomes, and Study Design) framework was adhered to while determining the inclusion criteria. Participants aged 60+, diagnosed with osteosarcopenic obesity (OSO), and no major comorbidities, were included. Interventions covered diverse resistance training, and comparisons involved controls or placebos. The OSO T-score and physical function measures like HGS and GS were the secondary objectives, whereas body composition measures like BFP, SMI, and BMD were the primary ones. DXA examined BMD, SMI, and BFP; standard dynamometry measured HGS; a 10-m walk test evaluated gait speed. The study design adhered to randomized controlled trial principles.

3 Search Strategies

The study's comprehensive, systematic search covered databases like UpToDate, PubMed, Web of Science, and more. No date or language restrictions ensured thorough literature coverage up to April 1, 2023. Specific keywords targeted osteosarcopenic obesity and resistance training in elderly women. Supplementary Materials (Table 1) present the PubMed strategy.

4 Study Selection

Two reviewers conducted the initial screening by assessing the titles and abstracts of potentially relevant studies. Full-text articles meeting the inclusion criteria were assessed independently. Discrepancies were resolved through discussion and consensus. This rigorous process ensured a comprehensive and unbiased selection of studies for analysis.

5 Quality Assessment

The PEDro scale assessed study quality, encompassing 11 items evaluating various design aspects. Scores ranged from 0 to 10, summing items 2 to 11. Scores indicated poor, fair, or good quality. This standardized tool gauges internal validity and bias. Note that PEDro isn't comprehensive and should complement other assessments. The study followed GRADE guidelines to assess outcomes, considering bias, consistency, precision, evidence directness, publication bias, effect size, dose-response, and confounding. Evidence received high, mediocre, and low, or very low, ratings, guiding recommendations.

6 Risk Bias

The Cochrane Risk of Bias Tool's Use of Study Bias was assessed. Two reviewers conducted independent checks, and consensus was reached through a third reviewer to resolve discrepancies.

7 Data Synthesis and Statistical Analyses

Review Manager 5.4 is commonly used for meta-analysis. It simplifies inputting pre-extracted data like means, effect sizes, and confidence intervals, which are computed using sample sizes and standard deviations. Mean difference and standardized mean difference are vital effect size measures used for studies with the same or different measurement methods, respectively.

8 Results

8.1

8.1 Study Selection

A search across six databases yielded 50 articles, reduced to 25 after removing duplicates. Screening, based on preset criteria, involved a title and abstract review, excluding 18 articles. One non-randomized controlled trial and one inaccessible study were excluded. Four studies remained, with two sharing data; only four were included in the qualitative analysis. Exclusion reasons in Table 2.¹⁹ were included due to comprehensive data. Meta-analysis details are in Fig. 1.

Table 2 Includes OSO diagnostic criteria used in studies.

Study	Body composition assessment tool	Diagnostic criteria for osteopenia	Diagnostic criteria for sarcopenia	Diagnostic criteria for obesity
Liao et al. (2017)	BIA	BMD and DXA	EWGSOP	BMI
Huang et al. (2017)	DXA and BIA	T-score between −1 and −2.5	Muscle mass index below the 2nd percentile of the normal population's mean, with a deviation of two standard deviations.	BMI ≥25 kg/m2, BMI ≥30 kg/m2, waist circumference ≥90 cm, and Body Fat Percentage (BFP) of ≥30 % for females and ≥25 % for males are considered as having obesity.
Banitalebi et al. (2020)	DXA	Measurement criteria: T-score range −2.5 to −1.0, measured at L1-L4, total femur or femoral neck.	10 MWT ≤1 m/s2, SMI ≤28 % or ≤7.76kg/m2.	BFP>32 %, BMI>30 kg/m2.
Lee et al. (2021)	DXA and BIA	BMD	AWGS: male 7.0 kg/m2, female 5.7 kg/m2. Grip strength: Males 26 kg, Females 18 kg. Gait speed: 0.8 m/s.	BMI

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Fig. 1 Study selection.

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8.2

8.2 Characteristics Studies

8.2.1

8.2.1 Resistance Training Protocol

The included studies reported diverse outcomes related to body composition and physical function. These outcomes encompassed fat mass, lean mass, BMI, waist circumference, handgrip strength, 6-min walk distance, and chair rise test. All studies highlighted significant improvements in at least one area. Nevertheless, variations existed in outcomes, measures used, and effect sizes across studies. Please consult Table 1 for a summarized overview of the outcomes.

These studies involved resistance exercises using elastic bands three times a week for 12 weeks. In one trial, the osteoporotic group combined weight training and aerobic exercises. In a single trial, participants in the control group were assessed at baseline and after 12 weeks, while other studies evaluated both pre- and post-intervention. Bone density and body fat percentage showed low-quality evidence, whereas the primary outcome (skeletal muscle mass index) demonstrated high-quality evidence. Secondary outcomes (gait speed, chair rise test, osteosarcopenic obesity T-score) had high-quality evidence. However, due to bias risk and consistent findings, hand grip strength and timed up-and-go test evidence were rated as moderate.

All four of the studies that were considered and later included in this analysis had an intervention period that lasted 12 weeks. Three times a week, elastic bands were used to execute the resistance training sessions. It's important to note that one study especially targeted participants who were elderly women, and another study combined weight training and aerobic exercise in the osteoporotic intervention group. In one study, the parameters were assessed both before and after the 12-week intervention, whereas the other studies evaluated the parameters both before and after the intervention. Trial-to-trial consistency was observed in the length of the intervention, frequency of training sessions, and using elastic bands for resistance training.

Based on four investigations, this study evaluates how elastic band resistance training affects older individuals' physical function and body composition.¹⁶ These four studies' primary goal was to assess the impact of resistance training using elastic bands.¹⁹ Across the four studies, the resistance training interventions consisted of exercises performed with elastic bands, conducted three times per week over 12 weeks (refer to Table 3).

Table 3 Three times per week, lasting for 12 weeks.

Outcome	No. of Studies	Design	Risk of Bias	Inconsistency	Indirectness	Imprecision	Other Considerations	Resistance Training (n)	Control (n)	Relative Effect (95 % CI)
BMD (mean 12-week follow-up; measured by DXA; lower values indicate worse).	4	Randomized controlled trials	Serious	No serious inconsistencies were found.	No serious inconsistencies were found.	Serious	None	90	81	MD 0.01 higher (0–0.02 higher)
Body fat % (mean 12-week follow-up; measured by DXA; lower values indicate better).	4	Randomized controlled trials	No bias risk was detected	Serious	No serious inconsistencies were found.	Serious	None	58	50	MD 1.61 lower (0 higher to 0.28 lower)
SMM (mean 12-week follow-up; measured by DXA, BIA; higher values indicate better).	3	Randomized controlled trials	No bias risk was detected	No serious inconsistencies were found.	No serious inconsistencies were found.	Serious	None	58	50	MD 1.19 higher (0.5–1.89 higher)
SMI (mean 12-week follow-up; measured by DXA; higher values indicate better).	3	Randomized controlled trials	No bias risk was detected	No serious inconsistencies were found.	No serious inconsistencies were found.	Serious	None	58	50	MD 0.2 higher (0.25 lower to 0.64 higher)
HGS (mean 12-week follow-up; measured by dynamometer; higher values indicate better).	1	Randomized controlled trials	No bias risk was detected	Serious			No serious indirectness	Serious	None	32
GS (mean 12-week follow-up; measured by 10-m walk test; higher values indicate better).	3	Randomized controlled trials	No bias risk was detected	No serious inconsistencies were found.	No serious inconsistencies were found.	Serious	None	58	50	Not pooled
TUG (mean 12-week follow-up; lower values indicate better).	3	Randomized controlled trials	No bias risk was detected	Serious			No serious indirectness	Serious	None	58
TCR (mean 12-week follow-up; lower values indicate better function).	3	Randomized controlled trials	No bias risk was detected	No serious inconsistencies were found.	No serious inconsistencies were found.	Serious	None	58	50	Not pooled
OSO T-score (mean 12-week follow-up; higher values indicate better outcomes).	2	Randomized controlled trials	No bias risk was detected	No serious inconsistencies were found.	No serious inconsistencies were found.	Serious	None	35	29	Not pooled

8.2.2

8.2.2 Standard of the Included Research

The PEDro scale was used to evaluate the study's quality. The mean score was 7.75 ± 1.258, ranging from 7 to 8. All studies were rated as excellent quality, showing accurate baseline comparisons, suitable statistical analysis, and follow-up rates exceeding 85 % due to concealed allocation and assessor blinding.

The bias assessment results for the four studies examined in this review are as follows: Fig. 2 presents the results of the research projects using the Cochrane tool. Since none of the trials mentioned allocation concealment, the risk of bias was considered low.⁸ In two experiments, the bias risk was low due to blinding employees and subjects.¹⁹ Blinding was clear in two studies.² One study's risk of bias was minimal (full outcome data).¹⁶ This review found evidence of reporting or selection bias in the included studies. Overall, the overall quality of the included studies was considered high; however, there are some limitations in the bias risk assessment, including unclear reporting of blinding and allocation concealment, as well as incomplete outcome data.

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Fig. 2 Bias and Stud Summary.

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The Cochrane technique was employed to evaluate the risk of bias, and the results are presented in Fig. 2. One study had a clear risk of bias due to a lack of mention regarding allocation concealment.⁸ In one study, blinding participants and researchers was not feasible given the nature of the intervention, resulting in a low risk of bias in this domain.¹⁶ In another study, it remained unclear whether participants or researchers were blinded.² There was no evidence of selection or reporting bias in any of the studies. Overall, the included studies were rated as of high quality.

8.2.3

8.2.3 Resistance Training Effects on Outcomes

A total of four studies, specifically,^2,8,16,19 The analysis incorporated four studies, focusing on resistance exercise effects on BMD and body fat percentage. These studies involved a total of 171 participants. Among these, three studies^8,16,19 with 108 participants measured the Skeletal Muscle Mass Index (SMI).

According to the forest plot analysis, elastic band resistance training increased bone mineral density (BMD) and skeletal muscle mass while decreasing body fat percentage. In the experiment, the Skeletal Muscle Mass Index (SMI) demonstrated a statistically significant impact. Significant increases were observed in bone mineral density (P < 0.001, I² = 98 %, CI: 0.39–0.71), a significant reduction in body fat percentage (CI: −262.55–260.11, P < 0.001, I² = 100 %), and a significant change in SMI (P < 0.001, I2 = 98 %, CI: 0.31–0.71). (Fig. 3.Fig. 4).

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Fig. 3 Elastic band resistance training (BMD.SMI.BFP.TUG).

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Fig. 4 Elastic band resistance training (T-score. TCR. GS).

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8.2.4

8.2.4 Resistance Training's Effects on Secondary Outcomes

Based on the survey results from two studies,^16,19 this study investigated the impact of resistance training on body fat, bone mineral density T-scores, skeletal muscle mass (SMM), and OSO T-scores. The findings indicated a significant increase in OSO T-scores due to resistance training.

In terms of handgrip strength (HGS), timed chair rise (TCR), timed up and go (TUG), and gait speed (GS), the two studies presented varying results. It is noteworthy that resistance training with elastic bands significantly increased TCR and had an impact on GS. However, there were some differences in the results for GS and TUG. One study observed an improvement in GS, leading to an increase in TUG, while another study found an increase in GS, also affecting TUG (Fig. 4).

8.2.5

8.2.5 Quality of Outcome Indicators

The quality of the evidence in the studies varies from very low to high based on GRADE evaluation.^2,8,16,19 Interpret the results cautiously, as studies with small sample sizes are included. Furthermore, the interpretation of the results should take into account the specific intervention being studied. For example, when considering the results related to bone mineral density (BMD), the study found that combined resistance training with aerobic exercise does not have a serious risk of bias.

The quality of the evidence for the results varies from very low to high based on GRADE evaluation. However, caution is advised when interpreting all results due to the small sample sizes included. Refer to the study.¹⁶ Combining resistance training with aerobic exercise may introduce bias, potentially impacting the credibility of bone mineral density (BMD) results. The results for Body Fat Percentage (BFP), Timed Up and Sit (TUS), and Timed Up and Go (TUG) may exhibit inconsistency due to opposite findings or high heterogeneity among studies. The quality of evidence for primary outcomes varies; skeletal muscle mass (SMM) is moderate, while BMD and BFP have higher quality evidence. Secondary outcomes, such as Gait Speed (GS), Timed Chair Rise (TCR), and Z-score for Osteoporosis Self-Assessment Tool for Asians (OSO), have moderate-quality evidence. Handgrip Strength (HGS) and TUG have high-quality evidence due to bias and consistency among studies, as shown in Table 3.

8.2.6

8.2.6 Sensitivity Analysis

The sensitivity analysis demonstrated that the reliability of the meta-analysis findings is contingent upon the inclusion of individual studies. Caution should be exercised when interpreting the BMD results, which were heavily influenced by the¹⁶ study. In contrast, the BFP results were deemed more reliable, as the exclusion of one study resulted in more significant outcomes. These findings underscore the importance of considering individual studies and their impact on meta-analysis results, cautioning against drawing definitive conclusions based solely on the outcomes of meta-analyses.

9 Discussion

The purpose of this systematic review and meta-analysis was to ascertain how older women's body composition is affected by resistance training using elastic bands, including bone mineral density, skeletal muscle mass, and osteosarcopenic obesity. According to the results, resistance exercise with elastic bands significantly enhances osteosarcopenic obesity, bone mineral density, and body composition in older females. Specifically, after a 12-week training program, skeletal muscle mass (SMM), body fat percentage (BFP), and bone mineral density showed significant improvements, as did positive effects on the OSO T-score and TCR. However, the impact on Skeletal Muscle Index (SMI) and Gait Speed (GS) was not significant, and the results for Handgrip Strength (HGS) and Timed Up-and-Go Test (TUG) were inconclusive due to inconsistent findings and limited data for meta-analysis. The study emphasizes the need for further research to validate the value of resistance training in improving physical function and body composition in older individuals with osteosarcopenic obesity. Overall, the study suggests that resistance training with elastic bands is a promising intervention for this population.

According to our research, resistance exercise may improve bone mineral density (BMD), but the hormone analysis of the four BMD studies¹⁹ yielded mixed results. While one study¹⁶ showed a substantial increase in BMD, the remaining three trials demonstrated significant differences between the experimental and control groups. Additionally, it's worth noting that Lee et al.'s intervention included elastic band resistance training, making it challenging to determine the exact contribution of resistance training to the final intervention benefit. However, the overall evidence from the included trials supports the use of resistance training with elastic bands as an effective intervention to enhance physical function and body composition in older adults with osteoporosis.

It is important to recognize the limitations of this study. Firstly, the analysis included only four studies with small sample sizes, which may have reduced the accuracy and generalizability of the findings. Additionally, all four studies had a short intervention period of only 12 weeks, which might not have been sufficient to assess the long-term effects of elastic band resistance training fully. Nonetheless, the results of this study suggest that resistance training with elastic bands may benefit older people with osteosarcopenic obesity in terms of their physical function and body composition. However, to validate these results and investigate the potential long-term benefits or risks associated with resistance training for this demographic, more extensive research with larger sample numbers and longer intervention durations is required. Despite these limitations, the current study provides valuable insights into the potential benefits of elastic band resistance training for older adults with osteosarcopenic obesity and underscores the need for continued research in this area.

10 Conclusion

Resistance exercise effectively improves body composition, increasing body fat percentage and the skeletal muscle mass index. age-related osteoporosis (OSO), in older persons Elastic bands improve physical performance securely and efficiently.

Ethical Statement

1.Data Collection and Sources: All data utilized in this integrative analysis study are sourced from legal and publicly available repositories, and have been ensured to be used in accordance with the respective data usage terms. Throughout the entire research process, we adhered to best practices in data collection, ensuring proper acknowledgment of the sources of all data.2Financial Interests: The authors declare the absence of any financial interests or other conflicts of interest that could potentially influence the outcomes of the study throughout its entirety.

Funding

Not applicable’ for that section.

Entanglements in interest

The writers say they have no conflicting agendas.

Ethics Verified

Under the registration number CRD42023448834, the current review is included in the International Prospective Register of Systematic Reviews (PROSPERO).

Consent to Participate

This study involved the collection of no patient-identifiable data. There was only anonymous data gathered. Before collecting anonymous data, prior authorization from the Deputy Data Protection Officer was secured. The Research Ethics Committee of China Medical University Hospital deemed this study to be a low-risk retrospective chart review, so the participants' express agreement was not necessary.

Permission to Publicate

For that section, not applicable.

Data accessibility

The authors might seek access to the datasets created for this study.

CRediT authorship contribution statement

Hsuan-Wei Liu: Writing – original draft, Writing – review & editing, Conceptualization, Formal analysis, Methodology, Roles. Oscar Kuang-Sheng Lee: Supervision, Validation, Visualization, Roles.