Nutrition and exercise for sarcopenia treatment

Abstract

Sarcopenia, the age-related loss of muscle mass, strength, and performance, is a significant concern in the aging population. Despite extensive research, no consensus exists on its prevention and treatment. Sarcopenia increases the risk of functional disability, falls, hospitalization, long-term care, morbidity, and mortality among older adults.

Currently, no approved pharmacological treatments for sarcopenia exist, making exercise and nutrition the most effective interventions. Evidence indicates that targeted exercise reduces risk factors, preventing or treating sarcopenia in older adults. Progressive, moderate-intensity exercise, alone or combined with nutritional supplementation, is recommended to mitigate muscle deterioration associated with aging. While non-pharmacological interventions are the primary approach, conflicting evidence exists regarding the most effective exercise and nutrition strategies. This review highlights that single intervention, such as exercise or nutritional supplementation alone, provide limited benefits for preventing or treating sarcopenia. In contrast, combined interventions, comprehensive exercise training and nutritional supplementation, effectively improve clinical indicators, including muscle mass, strength, and gait speed, in older adults with sarcopenia.

1. Introduction

Aging is the gradual decline of an organism's function and reserve capacity. Sarcopenia, the age-related loss of muscle mass, strength, and performance [[1], [2], [3]], contributes to adverse health outcomes, including impaired mobility, falls, fractures, disability, hospitalization, morbidity, and mortality in older adults [[4], [5], [6]]. Preventing and treating sarcopenia is crucial for preserving muscle function, improving health outcomes, prolonging independence, and reducing medical burdens.

Despite efforts to establish management strategies [[7], [8], [9], [10]], no consensus exists on non-pharmacological approaches for preventing or treating sarcopenia. Since 2016, it is recognized as a disease (ICD-10-CM, M62.84; www.prweb.com-prweb13376057) [11]. No effective pharmacological treatments are available [12]. Studies suggest that non-pharmacological interventions remain the most appropriate and effective management strategies [[13], [14], [15]]. Randomized controlled trials (RCTs) and meta-analyses demonstrate that exercise can prevent or delay sarcopenia progression [[16], [17], [18]].

In clinical practice, exercise is the primary intervention for sarcopenia, but evidence regarding the most effective type remains inconsistent. Several systematic reviews found that resistance training (RT) positively affected body fat mass, handgrip strength (HGS), knee extension strength (KES), gait speed, and the Timed Up and Go (TUG) test [8,18]. Other reviews suggested that mixed exercise and physical activity with nutritional supplementation were most effective in enhancing muscle strength and physical performance [19,20]. Additionally, exercise programs for sarcopenia vary in mode, duration, frequency, and intensity, with no established optimal strategy for this population.

Various nutritional interventions, including protein, essential amino acids (EAAs), creatine, n-3 polyunsaturated fatty acids, and vitamin D supplementation, have been explored to improve sarcopenia-related clinical indicators [10,[21], [22], [23]]. However, the independent effects of nutritional supplementation on sarcopenia measures remains inconclusive in older adults. Further high-quality RCTs are necessary.

This review aims to explore the current status of exercise and nutrition, alone or combined interventions for sarcopenia management and provides guidance on the most effective strategies for affected populations with sarcopenia.

2. Nutrition supplementation

Age-related muscle mass loss is associated with a decline in muscle protein synthesis rates in older adults. To counteract this deterioration, research has focused on protein, particularly EAAs and other nutrients. Studies have shown that leucine-enriched EAA mixtures and other components primarily contribute to muscle protein anabolism in older adults. Dillon et al. [24] reported that EAA supplementation can increase muscle mass in this population; however, increased muscle mass does not always correspond to improved muscle strength. EAA alone is likely insufficient to enhance muscle strength. There has been growing interest in other nutritional supplements, including whey protein [25], vitamin D [26], omega-3 fatty acids [27], and β-hydroxy-β-methylbutyrate (HMB) or HMB-rich nutritional supplements [28], as their efficacy in improving muscle mass and strength has been reported.

2.1. Leucine

L-leucine is an essential, nonpolar, branched-chain amino acid [29] that activates the transducer of regulated cAMP response element-binding protein activity 1 (TORC1) in human skeletal muscle. TORC1 activation initiates muscle protein synthesis by increasing amino acid availability through translation [30,31]. Studies suggest that L-leucine supplementation enhances muscle protein synthesis in older adults [32,33].

Table 1 presents a summary of nutritional supplementation interventions cited in this study. Included RCTs indicate that leucine does not improve clinical indicators of sarcopenia in older adults, such as muscle mass and strength [7,29,34,35]. However, one trial reported that leucine supplementation improved gait speed in older individuals with sarcopenia [29].

Table 1.

Summary of the nutritional supplementation for sarcopenia treatment in previous studies.

			Sample size	Age, yrs		Duration (weeks)	Intervention
Nutrition	Study	Country			Diagnosis criteria		frequency, g/day, source	Control	Main results
Leucine	Kim et al., 2012	Japan	AAG = 39; CG = 39	AAG = 79.2 ± 2.8; CG = 78.7 ± 2.8	ASMI<6.42 kg/m2; KES<1.01 Nm/kg; GS<1.22 m/s	12	Two times daily leucine 3.0 g, packets of powdered amino acid supplements	Health education	Amino acid: improve gait speed, no change in muscle mass and knee extension strength
	Martínez-Arnau et al., 2020	Spain	Leucine = 28; Placebo = 22	Leucine = 78.4 ± 8.4; Placebo = 79.0 ± 7.6	EWGSOP 2010	13	L-leucine (6 g/day)	Lactose, 6 g/day	A significant difference in walking time (leucine group: 101.43 ± 6.00 vs placebogroup: 134.41 ± 10.47; p = 0.011). No significant differences in skeletal MM and hand grip strength
	Murphy et al., 2021	Ireland	Leu-pro = 38; Leu-pro + n-3 = 38; CG = 31	Leu-pro = 73 ± 7; Leu-pro + n-3 = 73 ± 6; CG = 73 ± 7	Low SMI: <6.75 kg/m2 females, <10.75 kg/m2 males; low HGS <20 kg females, <30 kg males	24	21.2 g protein/d (6.2 g leucine/d, with or without 4 g LC n–3 PUFAs/day)	Mixture of high-oleic sunflower and corn oil	No beneficial impact of 24 wk of supplementation on ALM, strength, performance in older adults at risk of sarcopenia.
	Achison et al., 2022	UK	Leucine = 72; No leucine = 73	Leu = 78.3 ± 5.9; No leu = 79.3 ± 6.1	EWGSOP 2010	12 months	2.5 g of leucine three times a day, a daily total of 7.5 g	4 mg of oral perindopril or a matching placebo	Neither perindopril nor leucine improved physical performance or muscle mass in this trial
Whey protein	Rondanelli et al., 2016	Italy	Protein = 69; Placebo = 61	Protein = 80.77 ± 6.29; Placebo = 80.21 ± 8.54	Relative muscle mass: <7.26 kg/m2 for men; <5.5 kg/m2 for women.	12	22 g of whey protein, 4 g of leucine, 100 IU of vitamin D, 4.7 g of carbohydrates, 0.4 g of fat, 2.2 g of fibers, and 0.4 g of minerals	Isocaloric product with maltodextrin	Supplementation plus physical activity increased FFM (1.4 kg gain, P<0.001), RSMM (0.21 kg/m2, P = 0.004), handgrip strength (3.2 kg gain, P = 0.001).
	Björkman et al., 2020	Finland	218	75–96	Older community-dwelling people with sarcopenia.	12 months	20 g × 2 whey-enriched protein supplementation.	All participants: home-based exercise, dietary protein, and vitamin D supplementation of 20 μg/d	The whey-enriched protein supplementation in combination with low intensity home-based physical exercise did not attenuate the deterioration of muscle and physical performance
	Li et al., 2021	China	123	65–79	ASMI: <7.0 kg/m2 in men and <5.4 kg/m2 in women	6 months	16 g/day of whey, soy, or whey-soy blend protein	Maintained habitual diets	Supplementation with whey, soy, or whey-soy blended protein for 6 months equally maintained lean muscle mass and physical performance
Vitamin D	Bauer et al., 2015	German	380	77.7	EWGSOP 2010	13	20.7 g of whey protein, 2.8 g of total leucine, 800 IU of vitamin D, 10.6 g of essential amino acid, 9.4 g of carbohydrates, 3 g of fat, a mixture of vitamins, 1.3 g of fibers, 1.3 g of minerals, and 0.3 g of trace elements	Isocaloric product with 31.4 g of carbohydrates, 3 g of fat, and 0.7 g of some minerals	Handgrip strength and SPPB improved in both groups without significant between-group differences. AG improved more in the chair-stand test compared with the CG, −1.01 s (−1.77 to −0.19), P = 0.018, and appendicular muscle mass 0.17 kg (0.004–0.338), P = 0.045.
	Lin et al., 2021	Taiwan		73.1	Sarcopenia (ASIA 2019)	12	Leucine 1.2g Vitamin D 120 IU Whey protein 8.5g + Diet advice	Diet advice; instructed to consume 1.5g protein/day	Whey protein and vitamin D can further improve gait speed in elderly sarcopenic subjects
HMB	Cramer et al., 2016	United States	330	≥ 65	EWGSOP	24	20 g protein; 499 IU vitamin D3; 1.5 g CaHMB, twice daily	14 g protein; 147 IU vitamin D3	Both groups improved grip strength, and gait speed from baseline with no treatment differences.
	Malafarina et al., 2017	Spain	107	≥ 65	EWGSOP	30 days of hospitalization	3 g/d, two bottles a day of HMB	A standard diet	A diet enriched in HMB improves muscle mass, prevents the onset of sarcopenia and is associated with functional improvement in elderly patients with hip fractures
	Lattanzi et al., 2019	Italy	HMB = 12, CG = 10	59.9 ± 6.2	ASMI or FFMI<5th percentil	12	3 g/day, 1.5 g dissolved in equal amounts (200 mL) of fruit juice taken twice a day	Fruit juice (200 mL) twice a day	ASMI and HG: a significant increase in HMB patients, 6MWTand TUG did not ignificant changes
	Nasimi et al., 2021	Iran	66	≥ 65 sarcopenia	AWGS	12	Yogurt fortified with 3 g HMB, 1000 IU vitamin D, and 500 mg vitamin C	Plain yogurt	A novel dairy product fortified with HMB, vitamin D, and vitamin C could enhance muscle strength and functionality
	Osuka et al., 2021	Japan	149	65–79	Skeletal muscle index<5.7 kg/m2	12	Calcium-HMB (1500 mg)	Placebo	HMB improved usual gait speed by 0.06 m/s (95% CI: 0.01, 0.11 m/s) relative to placebo
	Yang et al., 2023	China	34	≥ 60	AWGS	12	One sachet (3 g) of the HMB (Ca HMB 1.5g, carbohohydrates 1.2g, sodium 15 mg)	Placebo	HMB supplementation can enhance the effect of resistance exercise training on muscle strength, physical performance, and muscle quality

HMB, β-hydroxy-β-methylbutyrate; UK, United Kingdom; AAG, amino acid group; CG, control group; Leu, leucine; pro, protein; Leu-pro, leucine-enriched protein; Leu-pro + n–3, leucine-enriched protein plus long-chain–3PUFAs; ASMI, appendicular skeletal muscle mass index; KES, knee extension strength; GS, gait speed; EWGSOP, European working group on sarcopenia in older people; HGS, hand grip strength; FFMI, fat-free mass index; AWGS, Asian working group for sarcopenia; IU, international unit; Ca HMB, calcium β-hydroxy-β-methylbutyrate; ALM, appendicular lean mass; FFM, fat-free mass; RSMM, relative skeletal muscle mass; CI, confidence interval.

A meta-analysis found no significant effects on total lean mass or strength measures, including HGS and leg press. However, leucine supplementation combined with vitamin D significantly improved HGS (weighted mean differences (WMD) = 2.17 kg; 95% confidence interval (CI): 0.24, 4.10, P = 0.027) and gait speed (WMD = 0.03 m/s, 95% CI: 0.01, 0.05, P = 0.008) [36].

2.2. Whey protein

While previous studies reported that whey protein supplementation alone maintained muscle mass and physical performance [37,38], another found no improvement in clinical indicators of sarcopenia [39], leading to inconsistent findings (Table 1). These discrepancies may be due to differences in nutritional prescriptions and participant characteristics.

A systematic review found that whey protein supplementation did not significantly affect lean mass or muscle strength. However, doses exceeding 20 g improve muscle strength (standardized mean difference (SMD) = 0.252; 95% CI: 0.051, 0.453), and interventions lasting >12 weeks enhanced physical performance (SMD = 1.042; 95% CI: 0.503, 1.582) [25].

2.3. Vitamin D

Several trials have shown that vitamin D supplementation affects muscle mass and strength in older adults. Studies included in this review indicate that vitamin D, when combined with whey protein, leucine, and EAAs, improves clinical indicators such as muscle mass, strength, and gait speed in older adults with sarcopenia [10,21] (Table 1).

A meta-analysis found a significant decline in Short Physical Performance Battery scores with vitamin D supplementation compared to placebo (mean difference (MD) = 0.23; 95% CI: 0.40, 0.06, P = 0.007). However, vitamin D supplementation did not affect HGS, the TUG test, general muscle strength, or overall physical performance [26].

Several factors should be considered in nutritional interventions for sarcopenia, including duration, source, dosage, and frequency. Studies have administered vitamin D supplementation daily [40], twice daily [41], weekly [42], twice monthly [43], or every 3 months [44]. The duration of supplementation exceeded 12 months in some studies [40,43], while others had shorter interventions [42,44]. Bischoff-Ferrari et al. (2014) [45] suggested that maintaining optimal serum 25-hydroxyvitamin D concentrations (50–75 nmol/L) is essential for preserving extremity muscle strength and enhancing protein anabolism. Most studies evaluating the effects of vitamin D supplementation on sarcopenia have included co-supplementation with whey protein, leucine, and/or EAAs, with limited investigations of vitamin D alone [10,21]. Previous studies suggest that combining vitamin D with whey protein or branched-chain amino acids may improve muscle strength [23], regardless of physical exercise. Therefore, the effect of vitamin D supplementation alone in older adults with sarcopenia remains unclear.

2.4. HMB or HMB-rich nutritional supplements

HMB plays a crucial role in protein metabolism, insulin activity, and skeletal muscle hypertrophy [46]. It stimulates the mechanistic target of rapamycin signaling pathway, promoting protein synthesis while inhibiting degradation via the proteasome pathway [46,47].

A summary of studies included in this review indicates that HMB, alone or combined with protein, vitamin D, and carbohydrates, improves muscle mass, strength, and gait speed in adults with sarcopenia [[48], [49], [50], [51], [52]] (Table 1).

Several meta-analyses report no statistically significant differences in skeletal muscle index or gait speed. Even at an HMB dosage of ≤ 3 g, no significant effects were observed on these outcomes [28]. For HGS, no significant differences were found when the intervention lasted < 12 weeks. However, with a duration of ≥ 12 weeks, significant improvements in HGS were observed between the HMB and control groups (MD = 1.31; 95% CI: 0.43, 2.18, P = 0.003). Whether administered alone (MD = 1.78; 95% CI: 0.31, 3.25, P = 0.02) or in combination with other supplements (MD = 0.51; 95% CI: 0.21, 0.81, P = 0.0008), HMB demonstrated a statistically significant effect on HGS. Additionally, a significant difference in HGS was observed in HMB dosage of 3 g (MD = 2.07; 95% CI: 0.53, 3.60, P = 0.008) or less than 3 g (MD = 0.51; 95% CI: 0.21, 0.81, P = 0.0008).

3. Exercise

Several systematic reviews have examined the benefits of exercise in older adults. Exercise in this population may help mitigate risk factors associated with age-related muscle mass reduction [53]. RT in older adults increases strength by 9%–15% [54] and lean body mass by approximately 1.1 kg [55]. Additional improvements have been observed with high-intensity volume-RT.

Although RT is effective in older adults, the same effect is not consistently observed in those with sarcopenia. Exercise prescriptions should ensure safe intensity, duration, and frequency to prevent injury and complications [56]. Identifying appropriate exercise regimens for older adults with sarcopenia requires comparing the effects of different types, durations, intensities, and frequencies on key outcomes.

3.1. Intervention characteristics

Table 2 summarizes the exercise prescriptions used for sarcopenia treatment in previous studies.

Table 2.

Summary of the exercise prescription used for sarcopenia treatment in previous studies.

						Intervention			Duration, week
	Study	Country	Sample size	Age, yrs	Sarcopenia diagnosis	Mode	Training movement (session time)	Intensity	days/week	Contrpl group	Main results
Resistance Training as an Exercise Training Mode
	Piastra et al., 2018	Italy	Resistance = 35; Postal = 37	Resistance = 69.9 ± 2.7; Postal = 70.0 ± 2.8	EWGSOP 2010	Two different adapted physical activity program	RT: 15 min warming up, 30 min muscle toning, and 15 min cooling down (60 min).	At low/moderate intensity with low weight loads (0.5, 1, or 1.5 kg)	9-month, 2	Postural training	RT: significantly improve muscle mass and muscle strength. Postura: positive effects on static balance.
	Vikberg et al., 2019	Sweden	RT = 36; CG = 34	RT = 70.9 ± 0.28; CG = 70.0 ± 0.29	EWGSOP-2010, Pre-sarcopenia	Body weight and suspension bands	Squats, Calf Raises, Chair Stands, Half Lunges, Biceps Rowing, Push ups, and Bridge	W1: 2sets/12reps; W2-4: 3sets; W5-7: 4sets; W8-10: 4sets/10reps. Borg RPE 10	10, 3	Non-exercise	No significant effect on SPPB. RT was effective in maintaining strength and increasing muscle mass in pre-sarcopenia.
	Seo et al., 2021	Korea	EG = 12; CG = 10	EG = 70.3 ± 5.38; CG = 72.9 ± 4.75	EWGSOP 2010	Elastic band	Resistancetraining: a total of 48 sessions. Each session included a 50min resistance exercise (60 min)	Each training session included a 5 min warm-up, and a 5min cool-down.	16, 3	No exercise intervention provided.	RT group: improved in grip strength, gait speed, and isometric muscle strength. CG: did not change.
	Flor-Rufino et al., 2023	Spain	EG = 20; CG = 18	EG = 79.9 ± 7.2; CG = 79.6 ± 7.7,	EWGSOP 2010	Circuit	Resistance training: 6 exercise programs of 65 min per session (65 min)	High-intensity	6 months, 2	Telephone follow-up	Increase in muscle mass (1.1 kg, P < 0.05) and SMI (0.4 kg/m2); a significant interaction effect in strength variable.
Whole Body Vibration Training as an Exercise Training Mode
	Wei et al., 2017	Hong Kong	LL = 20; MM = 20; HS = 20; CG = 20	75 ± 6; 76 ± 6	EWGSOP 2010	WBV platform	Stood on the platform of a WBV machine without shoes	LL(20 Hz × 720 s); MM(40 Hz × 360 s); HS(60 Hz × 240 s)	12, 3	Non-WBV	Combination of MM (40 Hz and 360 s) of exercise had the best outcome.
	Wei et al., 2017	Hong Kong	LG = 20; MG = 20; HG = 20; CG = 20	78 ± 4; 75 ± 6; 74 ± 5; 76 ± 6	EWGSOP 2010	WBV platform	Stood barefoot with knee joint flexed at 60° on the platform of the WBV	20 Hz × 720 s, 4 mm 40 Hz × 360 s, 4 mm 60 Hz × 240 s, 4 mm	12, 3	Non-WBV	Medium-frequency increased in chair test, walking speed, and TUG
	Zhuang et al., 2025	China	RT = 13; WBVT = 14	73.556 ± 3.916	AWGS 2019	TheraBand elastic bands	RT: 20 min of RT (30 min) WBVT: 20 min of vibration training (30 min)	60% 1RM for weeks 1–4, 65% 1RM for weeks 5–8, and 70% 1RM for weeks 9–12	12, 3		WBVT and RT both improved the physical condition. RT excelled in muscle strength, but WBVT offered an alternative
Tai chi as an Exercise Training Mode
	Zhu et al., 2019	China	Tai chi = 24; WBV = 28; CG = 27	Tai chi = 88.8 ± 3.7; WBV = 89.5 ± 4. 4; CG = 87.5 ± 3.0	AWGS	Tai chi, WBV platform	.Simplified eight-style Tai chi was performed (40 min) . Stood barefoot: joint flexed at 60° (40 min)	The training load was progressively increased 20Hz × 720s (12m); 40Hz × 360s (6m); 60Hz × 240s 4m)	8, 5	Not change level of physical exercise or lifestyle.	Muscle mass did not significantly changes. Muscle strength was significantly increased in the Tai chi and WBV groups compared to the control group (P < 0.01).
	Morawin et al., 2021	Poland	EG = 27; CG = 36	70.5 ± 5.8	EWGSOP 2018	Tai chi	.Tai chi training: exercises were performed (40 min)	2–4 exercises were added monthly	10 months, 2	Health education	ASMI by 1.76 ± 3.17% and gait speed by 9.07 ± 11.45%
	Hunag et al., 2022	Taiwan	Tai chi = 804; CG = 872	70–89.5	Meta-analysis: eleven RCTs	Yang-style Tai chi (n = 9)	Movement ranged from 6 to 24 (2–7 sessions/weeks, and 30–90 min/session)		8–48 weeks	Non exercised	Tai chi; improved in the 30-s CS, TUG. No difference in muscle mass, grip strength, gait speed, or SPPB score
Walking as an Exercise Training Mode
	Yuenyongchaiwat & Akekawatchai, 2022	Thailand	EG = 28; CG = 29	EG = 69.23 ± 6.71; CG = 71.93 ± 5.19	AWGS 2019	Elastic TheraBand	Walking-based home program: average of 7574.84 steps/day	increased PA by encouraging walking, 7500 steps daily,	12, 5	Routine daily activities	Muscle strength and performance improved in the intervention group after the 12-week program but not in the control group.
Mixed Training as an Exercise Training Mode
	Kim et al., 2012	Japan	EG = 39; CG = 39	EG = 79.0 ± 2.9; CG = 78.7 ± 2.8	ASMI<6.42 kg/m2; KES<1.01 Nm/kg; GS<1.22 m/s	Resistance band or ankle weight	RT(chair exercise with ankle-weight and resistance bands), balance, and gait training (60 min)	1set/10reps; Borg RPE 12–14; Weights: 0.50, 0.75, 1.00, and 1.50 kg	12, 2	Education (1 time/month, 3 times)	Walking speed significantly increased in exercise group. No change in leg muscle strength
	Kim et al., 2013	Japan	EG = 32; CG = 32	EG = 79.6 ± 4.2; CG = 80.2 ± 5.6	ASMI<6.42 kg/m2; KES<1.01 Nm/kg; GS<1.10 m/s	Resistance band or ankle weight	RT(chair exercise with ankle-weight and resistance bands), balance, and gait training (60 min)	1set/10reps; Borg RPE 12–14; Weights: 0.50, 0.75, 1.00, and 1.50 kg	12, 2	Education (1 time/month, 3 times)	Usual walking significantly increased in EG (4.84%, P = 0.020), and slight decreased in CG.
	Hassan et al., 2016	Egypt	EG = 21; CG = 21	85.9 ± 7.5	EWGSOP 2010	Air-pneumatic equipment	RT and balance exercise	Borg RPE 12–14	6 months, 2	Non-exercise	Exercise group experienced a significant increase in grip strength
	Maruya et al., 2016	Japan	EG = 26; CG = 14	EG = 69.2 ± 5.6; CG = 68.5 ± 6.2	AWGS	Locomotion-training, Weight	Home exercise programs: walking with lower limb RT	3 sets/6 reps; 20 reps 20–30 min/day	6 months	Non-exercise	Improved single-leg standing and knee extension strength.
	Tsekoura et al., 2018	Greece	GB = 18; HB = 18; CG = 18	GB = 74.56 ± 6.04; HB = 71.17 ± 6.47; CG = 72.89 ± 8.31	EWGSOP 2010	Weight	Walk(100 min per week), RT(20–30-min), balance, and gait training(20 min) (60 min)	W1–4: Borg RPE 10–11 W5–8: Borg RPE 10–12 W9–12:Borg RPE 12	12, 2 or 3	Advice on diet, lifestyle, and activity	Group-based exercise was more effective than home-based for improving functional performance
	Makizako et al., 2020	Japan	EG = 36; CG = 36	EG = 74.1 ± 6.6; CG = 75.8 ± 7.3	AWGS	Resistance band	Resistance, balance, flexibility, and aerobic training (60 min).	5 resistance levels/10 reps; Borg RPE 12–14	12,	Education (60 min, 1 time)	Exercise program improved chair stand and TUG. No significant interaction in ASMI.
	Moghadam et al., 2020	Iran	ET + RT = 10; RT + ET = 10; CG = 10	ET + RT = 63.8 ± 3.6; RT + ET = 64.1 ± 3.3; CG = 65 ± 3.9	EWGSOP 2010	Resistance machine, cycle ergometer	1.RT: leg extension, leg curl, bench press, and abdominal crunch; 2.ET: a fixed-speed cycle ergometer	Beginning: 40–75% 1RM Beginning: 55–70% maxHR	8, 3	Non-exercise	Performing ET before RT during CT may provide the greatest therapeutic benefits

EG, exercise group; CG, control group; RT, resistance training; LL, low-frequency long duration; MM, medium-frequency medium duration; HS, high-frequency short duration; LG, low-frequency; MG, medium-frequency; HG, high-frequency; GB, Group-based exercise; HB, home-based exercise; WBV, whole body vibration; ET, endurance training; EWGSOP, European working group on sarcopenia in older people; AWGS, Asian working group for sarcopenia; min, minute; ASMI, appendicular skeletal muscle mass index; KES, knee extension strength; GS, gait speed; W, week; reps, repetitions; 1RM, one repetition maximum; RPE, rated perceived exertion; maxHR, maximum Heart Rate; SPPB, short physical performance battery; SMI, skeletal muscle mass index; CS, chair stand; TUG, timed up and go; CT, concurrent training.

Type: Many studies included RT [16,[57], [58], [59]], whole-body vibration training (WBVT) [[60], [61], [62]], Tai-Chi [63,64], walking [65], and multicomponent interventions exercise modalities [7,[66], [67], [68], [69], [70], [71]].

Duration: Interventions lasted 8 weeks to 10 months [64,71], with 3 months being the most common duration [7,[60], [61], [62],65,66,69,70]. Session durations ranged from 30 to 90 min [72], with most studies prescribing 60-min sessions [7,57,59,66,69,70].

Frequency: Most exercise interventions were conducted two to three times per week [7,16,[57], [58], [59], [60], [61], [62],64,66,67,69,71], though some studies increased frequency to five times per week [63,65].

Intensity: In a few studies, intensity was assessed using a perceived exertion scale [7,58,66,67,69,70]. Most RT programs specified three sets of 6–12 repetitions at 60%–70% of the individual's one-repetition maximum (1RM) [62]. Some programs progressively increased the load from 40% to 75% of 1RM [71].

3.2. Effectiveness of exercise intervention

3.2.1. Muscle mass

As shown in Table 2, many studies found that exercise, particularly RT and mixed training, significantly increased muscle mass [16,57,58], strength [[57], [58], [59],62], and walking speed [7,59,66] compared to control groups. However, tai chi did not lead to significant changes in muscle mass [72].

A systematic review and meta-analysis of 594 community-dwelling older adults with sarcopenia across 10 RCTs found no significant muscle mass changes in the exercise groups compared with the control groups [73].

3.2.2. Muscle strength

Table 2 provides a summary of exercise modalities for sarcopenia treatment. Despite differences in exercise type, all interventions led to significant improvements in muscle strength, including HGS, chair stand performance, and KES.

A systematic review reported a significant increase in KES scores in the exercise group compared to the control group (SMD = 0.86; 95% CI: 0.55, 1.16, P < 0.00001). Subgroup analysis showed that RT (SMD = 1.36; 95% CI: 0.71, 2.02, P < 0.0001) and multicomponent training (MT) (SMD = 0.62; 95% CI: 0.29, 0.95, P = 0.0002) significantly improved KES scores, whereas WBVT did not [9]. HGS was significantly higher in the exercise group than in the control group. WBVT did not yield significant differences in HGS between groups. Similarly, chair stand performance showed no significant difference between exercise and control groups when all exercise modalities were combined. Subgroup analysis found no significant effects of RT, WBVT, or MT.

3.2.3. Physical performance

As shown in Table 2, despite differences in exercise type, all interventions led to significant improvements in walking ability, CS, and TUG.

A systematic review and meta-analysis reported a significant improve in TUG times in combined exercise group compared to the control group (SMD = −0.66; 95% CI: −0.94, −0.38, P < 0.00001). Subgroup analysis showed that RT (SMD = −0.92; 95% CI: −1.30, −0.55, P < 0.00001), WBVT (SMD = −0.30; 95% CI: −0.60, 0.00, P = 0.05) and MT (SMD = −0.69; 95% CI: −1.22, −0.15, P = 0.01) significantly improved TUG times. GS was significantly higher in the combined exercise group than in the control group (SMD = 0.82; 95% CI: 0.43, 1.21, P < 0.0001). Subgroup analysis showed that RT (SMD = 2.01; 95% CI: 1.04, 2.97, P < 0.0001) and MT (SMD = 0.69; 95% CI: 0.29, 1.09, P = 0.0008) significantly improved GS times, whereas WBVT did not. For CS, no significant differences were found when all exercise modes combined, and found no significant effects of RT, WBVT, or MT [9].

4. Exercise and nutrition

The combination of exercise and nutritional supplementation has been widely studied. Nutritional supplementation alone provides benefits such as increased walking speed, while exercise, as previously discussed, improves muscle strength. Together, exercise and nutritional supplementation significantly enhance muscle mass, strength, and performance. However, the combination of resistance exercise and a carbohydrate mixture containing small amounts of soy protein is particularly effective in enhancing muscle strength. High-resistance exercise alone increases both muscle mass and strength, whereas carbohydrate supplementation alone does not [74]. These findings suggest that effectiveness varies depending on nutritional components.

To efficiently prevent sarcopenia, greater emphasis should be placed on eliminating variable risk factors. Recent studies indicate that the combination of exercise and nutritional supplementation is more effective than either intervention alone. However, determining the optimal exercise mode and nutritional components is crucial for effective combined interventions.

4.1. Effectiveness of combination intervention

Although all studies classified participants as having sarcopenia, subcategories included healthy individuals, pre-sarcopenia, and sarcopenia. Furthermore, many studies used validated operational definitions, such as functional sarcopenia [75], skeletal muscle index [52], European Working Group on Sarcopenia in Older People [2,76], and Asian Working Group for Sarcopenia [77,78], while others relied on non-validated definitions [7,66].

4.1.1. Muscle mass

Table 3 presents the characteristics and main findings of combination interventions for sarcopenia treatment. Many studies indicate that progressive RT or comprehensive interventions incorporating amino acids, collagen peptides, catechins, whey protein, and vitamin D improve muscle mass, including fat-free mass, skeletal muscle mass, and the skeletal muscle mass index.

Table 3.

Summary of the exercise and nutritional prescriptions used for sarcopenia treatment in previous studies.

					Duration, week	Intervention
References	Country	Sample size	Age, yrs	Diagnosis criteria	Times/Week	Exercise	Nutrition	Control group	Main results
Kim et al., 2012	Japan	E + NG = 38; EG = 39; NG = 39; CG = 39	E + NG = 79.5 ± 2.9; EG = 79.0 ± 2.9; NG = 79.2 ± 2.8; CG = 78.7 ± 2.8	ASMI<6.42 kg/m2; KES<1.01 Nm/kg; GS<1.22 m/s	12, 2	Progressive RT with resistance bands or ankle weights, 60 min/time	3g amino acid, twice/day	Diet as usual	Exercise and AAS together may be effective in enhancing muscle mass, strength, and walking speed.
Shahar et al., 2013	Malaysia	CG = 16; EG = 19; PrG = 15; E + PrG = 15	CG = 67.25 ± 5.48; EG = 69.74 ± 5.46; PrG = 65.93 ± 4.37; EG + PrG = 65.20 ± 4.87	Assessed using bioimpedance analysis, skeletal muscle<10.75 kg/m2 for men and 6.75 kg/m2 for women	12, 2	60 min (RT with TheraBand: 30 min, aerobic and balance exercise)	A soy protein drink in a powder form to maintain the protein intake up to 1.5 g/kg/day.	Diet as usual	Exercise program improved in muscle strength and body composition, while protein supplementation reduced body weight and increased upper body strength,
Kim et al., 2013	Japan	E + NG = 32; EG = 32; NG = 32; CG = 32	E + NG = 81.1 ± 3.7; EG = 79.6 ± 4.2; NG = 80.0 ± 4.0; CG = 80.2 ± 5.6	ASMI<6.42 kg/m2; KES<1.01 Nm/kg; GS<1.22 m/s	12, 2	RT with resistance bands, 30 min/time	540 mg catechin, once/day	Diet as usual	The combination of exercise and tea catechin supplementation had a beneficial effect on walking ability and muscle mass.
Zdzieblik et al., 2015	Germany	TG = 26; PG = 27	TG = 72.3 ± 3.7; PG = 72.1 ± 5.53	EWGSOP	12, 3	RT withfitness facilities for 60min	15g collagen peptide, Once/day	Placebo: silicon dioxide	Collagen peptide supplementation in combination with RT further improved in FFM, muscle strength and the loss in FM.
Rondanelli et al., 2016	Italy	E + NG = 69; PG = 61	E + NG = 80.77 ± 6.29; PG = 80.21 ± 8.54	ASM/height2<7.26 kg/m2 for men and <5.5 kg/m2 for women.	12, 5	Upper and lower body strengthening with resistance bands per week, 20min/time	Whey protein (22 g), essential amino acids (10.9 g, including 4 g leucine), and vitamin D [2.5 μg (100 IU)]	Placebo	Supplementation plus physical activity increased fat-free mass, relative skeletal muscle mass, handgrip strength, insulin-like growth factor I, and lowered C-reactive protein.
Amasene et al., 2019	Spain	Protein = 15; Placebo = 13	Protein = 82.9 ± 5.59; Placebo = 81.7 ± 6.45	EWGSOP	12, 2	RT, 1h/time	3g leucine, 20g whey protein, 2 times/week	Placebo: maltodextrin	12 weeks of RT are enough to improve physical function in a post-hospitalized elderly population with no further benefits for the protein-supplemented group.
Zhu et al., 2019	China	113	≥ 65 and with sarcopenia; community-dwelling	AWGS	12, 2	90-min group training and one-home session weekly	17.22g protein, 2.42g HMB, 260 IU vitamin D, and 0.58g ω-3fatty acids, Once/day	Diet as usual	The exercise program with and without nutrition supplementation had no significant effect on the gait speed but improved the strength and the five-chair stand test
Rondanelli et al., 2020	Italy	CG = 70; IG = 70	CG = 81.0 ± 5.0; IG = 80.7 ± 7.0	EWGSOP 2010	8, 5	Loading exercises, Leg stretches and hip bends with resistance bands per week, 20–30min/time	40g of powder (whey proteins 20g, leucine 2.8g, carbohydrates 9g, fat 3g, vitamin D 800 IU, and a mixture)	40 g of a flavoured powder containing maltodextrins	A whey protein-based nutritional formula enriched with leucine and vitamin D improved physical performance and function, as well as muscle mass
Osuka et al., 2021	Japan	156(E + HMB = 39; E + P = 39; HMB + Ed = 39; P + Ed = 39)	E + HMB = 73.5 ± 4.2; E + P = 71.8 ± 4.1; HMB + Ed = 71.5 ± 4.5; P + Ed = 71.6 ± 4.2	Skeletal muscle index<5.7 kg/m2	12, 2	RT	Calcium-HMB 1500 mg	Placebo	No significant interactions between exercise and HMB on any primary outcomes. HMB improved usual gait speed by 0.06 m/s
Chang et al., 2023	Taiwan	Sarcopenia = 57; Control = 57	Sarcopenia = 75.02 ± 5.91; Control = 75.00 ± 5.87	EWGSOP 2010	12, 2	Comprehensive intervention(warm-up, three sets of 10 repetitions of leg press, leg extension, and leg curl, cool-down)	Two sticks (BCAA: calcium 600 mg and vitamin D3 800 IU), (leucine 0.54 g, valine 0.36g, isoleucine 0.43g, glutamine 0.65g, arginine 0.61g, and other1.01 g)	Did not receive any intervention and served as a baseline comparator	Significant improvements in grip strength and skeletal muscle mass index with a notable reduction in TNF-α (p = 0.003), IL-1β (p = 0.012) and IL-6 (p = 0.001) levels.
Eggimann et al., 2024	Switzerland	EG = 751; Vitamin D = 746; Omega-3s = 752	EG = 74.9 ± 4.4; Vitamin D = 75.0 ± 4.5; Omega-3s = 74.9 ± 4.3	Physically active community-dwelling adults	3 yrs, 3	A strength-training exercise program of 30 min	(1) 2000 IU/d of vitamin D; (2) 1 g/d of omega-3s (330 mg of EPA plus 660 mg of DHA from marine algae	Placebo vitamin D	Incidence of sarcopenia were not improved by treatment of daily 2000 IU vitamin D, daily 1 g Ω-3s, or a simple home exercise program compared with control over 3 years
Liao et al., 2024	China	219 (CG = 59; EG = 50; NG = 58; ComG = 52)	CG = 73.2 ± 14.98; EG = 72.04 ± 5.02; NG = 72.68 ± 5.59; ComG = 70.52 ± 3.30	Aged 65 years or older with sarcopenia	16, 5	Warm-up, RT (dumbbells) and relaxation; each lasting 45–60 min	Protein 24.2 g (including plant oligopeptide 11 g, casein peptide 4 g, BCAA 5 g), CaHMB2.5 g per day	Received individualized nutrition education	Both oral peptide nutrition and exercise interventions can improve the muscle strength or function. However, there were no increases in muscle mass observed.
Ji et al., 2025	Korea	IG = 21; CG = 21	IG = 77.86 ± 4.46; CG = 78.24 ± 4.47	Functional sarcopenia	12, 2	RT (30 min) and aerobic exercises (20 min).	The powder; mixed (13 g of protein, 1.4 g of fat, and 8 g of carbohydrates	Exercise and nutrition education	Exercise and nutritional intervention significantly enhanced physical performance, grip strength, and QOL.

E, exercise; EG, exercise group; NG, nutrition group; PrG, protein supplementation group; CG, control group; TG, treatment group; PG, placebo group; IG, intervention group; ASMI, appendicular skeletal muscle mass index; KES, knee extension strength; GS, gait speed; EWGSOP, European working group on sarcopenia in older people; ASM, appendicular skeletal muscle mass; AWGS, Asian working group for sarcopenia; IU, international units; BCAA, branched chain amino acid; EPA, eicosapentaenoic acid; DHA, docosahexaenoic acid; CaHMB, calcium β-hydroxy-β-methylbutyrate; AAS, amino acid supplementation; FFM, fat-free mass; FM, fat mass; TNF, Tumor necrosis factor; IL, interleukin; QOL, quality of life.

Six studies reported lean body mass, with 229 participants in the experimental group and 214 in the control group. The results showed no significant difference in lean body mass between groups. Additionally, five studies found no significant difference in appendicular skeletal muscle (ASM), while six studies reported no significant difference in the ASM index [79].

4.1.2. Muscle strength

Numerous studies have shown that progressive RT or comprehensive interventions incorporating amino acids, collagen peptides, catechins, whey protein, and vitamin D improve muscle strength, including HGS, chair stand performance, and upper body strength (Table 3).

Eight studies reported a statistically significant difference in HGS between the experimental and control groups (weighted mean difference (WMD) = 1.87; 95% CI: 0.01, 3.74, P = 0.049). However, five studies found no significant difference in chair stand test performance between the experimental and control groups [79].

4.1.3. Physical performance

Several studies have demonstrated that progressive RT or comprehensive interventions incorporating amino acids, collagen peptides, catechins, whey protein, vitamin D, and HMB improve performance measures such as gait speed, walking ability, and overall physical performance (Table 3).

Four studies reported no significant difference in the TUG test between groups, while seven studies found no significant difference in gait speed. Subgroup analyses based on the presence of protein and vitamin D in the nutritional intervention revealed improvements in HGS (WMD = 2.72; 95% CI: 0.38, 5.05, P = 0.022) and gait speed (SMD = 0.36; 95% CI: 0.08, 0.63, P = 0.011) in the protein and vitamin D subgroup, whereas no statistically significant improvements were observed in the subgroup without these components [79].

5. Conclusions

In summary, inconsistencies in non-pharmacological strategies for sarcopenia prevention and treatment are evident in the literature. Single interventions, such as exercise or nutritional supplementation alone, are weakly recommended for sarcopenia. However, combined interventions, particularly those incorporating RT and nutritional supplementation, are effective and recommended. Nevertheless, the effects of combined interventions have been confirmed for only certain outcomes, not all. Furthermore, exercise and nutrition programs for sarcopenia vary widely in dosage, duration, and frequency across studies, and no global guidelines have been established for exercise and nutrition in sarcopenic populations. Therefore, further research is necessary to develop optimal exercise and nutrition strategies for older adults with sarcopenia.

CRediT authorship contribution statement

Hunkyung Kim: Conceptualization, Resources, Writing – original draft. Jiwan Kim: Data curation, Writing – review & editing. Chahee Lee: Data curation, Writing – review & editing. Seohee Kim: Data curation, Writing – review & editing.

Conflicts of interest

The authors declare no competing interests.