Evidence-based strategies of exercise and nutrition in sarcopenia care in liver cirrhosis patients

We read with great interest in a systematic review and meta-analysis of the effectiveness of exercise and nutrition interventions for improving sarcopenia in patients with liver cirrhosis (1). This article prompts us to rethink the clinical management of liver cirrhosis-associated sarcopenia. A previous meta-analysis demonstrated that resistance exercise combined with aerobic exercise significantly reduced serious events in patients with liver cirrhosis (2). This combination approach may be beneficial for improving prognosis. While exercise alone (mainly resistance) did not show a statistically significant reduction in serious events overall, the specific strategy of combining aerobic and resistance exercise significantly reduced the risk of death or serious complications in patients with liver cirrhosis. Since there are a few studies have focused on the role of exercise and nutrition in sarcopenia, a meta-analysis on this topic is timely and necessary. Though this is a well-conducted meta-analysis, aside from the limitations mentioned in the article, the following potential limitations and improvement recommendations are identified based on study design and result analysis.

First, this study did not adequately account for differences in etiology and disease severity. The studies included in this article (seven randomised controlled trials) focused on patients with cirrhosis as a whole and did not stratify analyses by etiology (e.g., viral, alcoholic, or metabolic) or Child-Pugh classification. It is known that the mechanisms by which patients with alcoholic cirrhosis may have comorbid malnutrition and muscle damage are different from those of viral cirrhosis (3), whereas metabolic disorders and comorbidities in patients with Child-Pugh class C may affect the efficacy of interventions. Existing studies suggest that sarcopenia in patients with metabolism-associated fatty liver disease (MAFLD)-associated cirrhosis is strongly correlated with insulin resistance and requires targeted interventions (4), but such subgroups were not analyzed in this meta-analysis. Second, as mentioned in Hsu et al.’s study, short duration of interventions among the seven included studies was identified in this review. Most interventions in the included studies lasted between 8 to 12 weeks, which is relatively short to assess long-term outcomes for sarcopenia in liver cirrhosis patients. Longer follow-up periods, especially extending beyond 12 months, are crucial to evaluate the sustained effects of exercise and nutrition strategies. On the other hand, longer durations could help assess whether the benefits are maintained or if additional interventions are necessary. Third, inadequate standardization of intervention protocols and adherence issues existed in this study. The specific form, intensity, and frequency of exercise and nutritional interventions varied widely in the studies (e.g., exercise included resistance training and walking, and nutritional supplementation involved proteins, branched-chain amino acid, and vitamins), and patients’ long-term adherence to the interventions was not assessed. For example, branched-chain amino acid supplementation may lead to decreased adherence due to taste or gastrointestinal distress, while symptoms such as fatigue and ascites, which are common in patients with cirrhosis, may affect exercise participation. Existing literature highlights the need for individualized intervention programs to incorporate patient physical status and preferences (5), but this study does not include adherence data or intervention modification strategies. Besides, the variability in the type and intensity of interventions makes it challenging to draw definitive conclusions about the optimal treatment protocol. Thus, a more standardized approach to interventions would help clarify the most effective methods. Fourth, psychosocial factors and quality of life assessments are neglected in this study. Patients with cirrhosis often have comorbid psychological problems such as anxiety and depression, which may affect the effectiveness of exercise and nutritional interventions (6). In addition, financial burden (e.g., cost of nutritional supplements) and insufficient social support may also limit the implementation of interventions. This article only focuses on physiological indicators [e.g., skeletal muscle index (SMI) and albumin] and does not assess patients’ quality of life (e.g., fatigue level and ability to perform daily activities) or psychological status, which are closely related to the progression of sarcopenia. Last, this meta-analysis lacks of universal diagnostic criteria for sarcopenia. Sarcopenia is commonly assessed via skeletal muscle index, handgrip strength, and walking speed. The lack of a universally accepted definition and consistent diagnostic criteria hinders comparability across studies and may affect the reliability of results. Sarcopenia’s diagnosis currently lacks standardization, with variations in defining muscle mass, strength, and physical performance across guidelines [e.g., European Working Group on Sarcopenia in Older People (EWGSOP) vs. Asian Working Group for Sarcopenia (AWGS)]. Future studies should adopt a core set of outcomes, including SMI (via dual-energy X-ray absorptiometry or computed tomography), hand grip strength, and 6-minute walk distance, aligned with international guidelines. This would enable pooled analyses to identify optimal intervention thresholds. Besides, future research should quantify adherence metrics, identify barriers and facilitators, assess long-term adherence impacts as well as integrating functional assessments, patient-reported outcomes, and economic and healthcare utilization data. Building on Hsu et al.’s foundation, future research should prioritize adherence as a modifiable determinant of success and expand outcomes to reflect what matters most to patients. This shift would transform promising physiological findings into interventions that truly improve lives.

To sum up, Hsu et al.’s study provides evidence that exercise and nutritional interventions improve sarcopenia in patients with cirrhosis, but further exploration is needed in the areas of etiological stratification, standardization of interventions, integration of psychosocial factors, and using universal diagnostic criteria. Future studies should rely on multidisciplinary collaboration and emerging technologies to construct precise and sustainable integrated management programs, leading to more effective and personalized interventions.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-288/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-288/coif). The authors have no conflicts of interest to declare.

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