Sports Medicine (2022) 52:2511–2522

https://doi.org/10.1007/s40279-022-01704-0

SYSTEMATIC REVIEW

Effects of Protein Supplementation Associated with Resistance

Training on Body Composition and Muscle Strength in Older Adults:
A Systematic Review of Systematic Reviews with Meta‑analyses
Alexandra Ferreira Vieira1,3 · Juliana Souza Santos2 · Rochelle Rocha Costa3 · Eduardo Lusa Cadore1 ·
Rodrigo Cauduro Oliveira Macedo4

Accepted: 15 May 2022 / Published online: 11 June 2022

© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022

Abstract
Background There are some controversial findings regarding the benefits of combining protein supplementation with resist-
ance training in order to optimize adaptations to training in older adults.
Objective The aim of this review was to summarize the evidence from meta-analyses assessing the effects of protein sup-
plementation combined with resistance training on body composition and muscle strength in the older population.
Methods We included systematic reviews with meta-analyses of randomized clinical trials that examined the effects of pro-
tein and/or amino acid supplementation associated with resistance training compared with resistance training alone on lean
body mass, muscle mass, and muscle strength in older people. The search was performed using the MEDLINE (PubMed),
Embase, Cochrane Database of Systematic Reviews, Google Scholar, and OpenGrey databases. Methodological quality was
assessed using the Assessing the Methodological Quality of Systematic Reviews 2 checklist, and the quality of evidence was
determined using the Grading of Recommendations Assessment, Development and Evaluation system. The pooled effect
estimates were computed from the standardized mean difference and the 95% confidence interval achieved by each meta-
analysis, using random effects models.
Results Five reviews were included, all of moderate methodological quality. In the analyses, protein supplementation com-
bined with resistance training was associated with greater increases in lean body mass and muscle mass when compared with
resistance training alone. However, no differences were observed between the interventions on muscle strength increases.
The quality of evidence ranged from moderate to very low.
Conclusion Protein supplementation associated with resistance training induces greater increases in lean body mass compared
with resistance training alone. In addition, it is suggested that the use of protein supplementation enhances gains in muscle
mass but does not promote greater increases in muscle strength.

Key Points

Protein supplementation enhances the increase in lean

body mass promoted by resistance training in older
adults.
The effect of protein supplementation combined with
resistance training has the potential to promote increases
* Alexandra Ferreira Vieira in muscle mass in the older population, although further
[email protected]
studies are needed to strengthen this evidence.
1
Universidade Federal do Rio Grande do Sul, 750, Felizardo
The available data do not support the use of protein sup-
Street, Porto Alegre, RS 90690‑200, Brazil
2
plementation when combined with resistance training for
Registered Dietitian, Porto Alegre, RS, Brazil
improving muscle strength in older people.
3
Faculdade Sogipa, Porto Alegre, RS, Brazil
4
Universidade de Santa Cruz do Sul, Santa Cruz do Sul, RS,
Brazil

Vol.:(0123456789)
2512 A. F. Vieira et al.

1 Introduction different systematic reviews, mainly related to the type of

protein supplementation used among the individual ran-
The biological aging process is associated with losses in domized clinical trials (alone or combined with another
skeletal muscle strength, power output and muscle mass [1], nutrient). Thus, further evidence on the effects of resist-
and these decreases may progress to geriatric syndromes ance training and protein supplementation on muscle size
such as sarcopenia, frailty, risk of falls, mobility impairment, and function in older adults is warranted. This evidence
and disability [2, 3]. There are two distinct phenotypes of could be provided from an analytical summary of these
aging, defined by patterns of living and, in particular, by the previous systematic reviews.
presence or absence of physical exercise. Physically active Albeit resistance training and protein supplementa-
older adults may prevent or improve diseases such as car- tion-induced effects on lean body mass, muscle mass and
diovascular, metabolic, or respiratory diseases, for example, strength in older adults are widely discussed, to the best of
as well as functional decline. On the other hand, sedentary our knowledge no systematic review of systematic reviews
lifestyle while aging is a major risk factor for most chronic with meta-analyses has been conducted on this issue. There-
diseases as well as geriatric syndromes [3]. fore, the purpose of the present study was to conduct a sys-
It has been widely shown that resistance training is the tematic review with meta-analysis of previous systematic
most effective intervention to prevent and reverse decreases reviews with meta-analyses of randomized clinical trials on
in maximal strength, power output and muscle mass in the effects of protein supplementation associated with resist-
healthy and frail older adults [1–5]. Along with neural adap- ance training compared with resistance training alone on
tations associated with muscular function improvements (i.e. lean body mass, muscle mass and muscle strength in older
muscle strength and power), resistance training also induces adults.
increases in muscle protein synthesis in skeletal muscle, pro-
moting muscle hypertrophy [6, 7].
Protein intake also stimulates muscle protein synthesis 2 Methods
[7]. On the contrary, anabolic resistance and chronic under-
nutrition, including inadequate protein intake, may induce a This systematic review followed the recommendations pro-
negative nitrogen balance and contribute to losses in muscle posed by the Cochrane Collaboration [21] and the Preferred
mass, sarcopenia and frailty syndrome [8, 9]. Lower food Reporting Items for Systematic Reviews and Meta-Analyses
and protein intake is related to genetic predisposition to (PRISMA) guidelines [22]. The study was previously regis-
poor appetite [10, 11], along with medical conditions such tered in the International Prospective Register of Systematic
as disease-related anorexia, physical and cognitive impair- Reviews (PROSPERO; CRD42020222466).
ment, changes in the gastrointestinal system, poor dental
health and taste, and smell disturbance [12–15]. 2.1 Eligibility Criteria and Search Strategy
Because of the above-mentioned difficulties of older
adults in obtaining an adequate protein intake on daily In this review, we considered systematic reviews with
food, protein supplementation has been proposed as an meta-analyses of randomized clinical trials that examined
alternative combined with resistance training in order to the chronic effects (> 8 weeks) of protein and/or amino
optimize muscle mass gains in this population [16]. In acid supplementation associated with resistance training
fact, some meta-analyses have been conducted summariz- (no limitations related to modality), compared with the
ing the effects of combining resistance training and pro- same resistance training without dietary protein supple-
tein supplementation on muscle mass and strength in older mentation (carbohydrate, placebo, or no supplementation),
populations [16–20]. Notwithstanding, these studies have on lean body mass, muscle mass and muscle strength in
reported controversial findings, since some authors have older people (aged > 50 years).
shown increases in lean body mass but not in muscle mass The search was performed in July 2021 using the elec-
[16], whereas others have shown muscle mass improve- tronic databases MEDLINE (PubMed), Embase, Cochrane
ment [20]. In addition, although the systematic review by Database of Systematic Reviews, Google Scholar and
Hou et al. [20] observed that simultaneous resistance train- OpenGrey. In addition, the records included in PROS-
ing and protein supplementation induced greater strength PERO were consulted and manual searches in the refer-
gains than resistance training alone, other meta-analyses ences of the included studies were performed. The search
have not shown differences between interventions (i.e., consisted of the following terms and Medical Subject
resistance training with and without protein supplementa- Heading (MeSH) terms (and their respective related
tion) [16, 18]. It is possible that these controversial findings terms) associated with each other: ‘aged’, ‘older’, ‘resist-
are associated with discrepant eligibility criteria among the ance training’, ‘dietary proteins’, ‘dietary supplements’,
Protein Supplementation and Resistance Training in Older People 2513

‘protein’, ‘protein supplementation’, ‘systematic review’, 2.5 Quality of Evidence

and ‘meta-analysis’. In the searches conducted, there
were no limitations on language or publication date of the The quality of evidence was determined by the Grading of
studies. The full search strategy performed in the Pub- Recommendations Assessment, Development and Evalu-
Med database is available in the electronic supplementary ation (GRADE) system [25]. The evaluation involved the
material (Online Resource). following GRADE aspects related to each outcome found
in each included study: risk of bias, inconsistency, indi-
2.2 Selection of Eligible Reviews rectness, imprecision and publication bias. Based on these
criteria, the evidence was classified as high, moderate, low
The selection of studies was based on the eligibility crite- or very low. The GRADE assessment was conducted inde-
ria previously adopted and performed independently and pendently by two investigators (AFV and RCOM).
in duplicate. First, the titles and abstracts of all studies
identified in the search were evaluated by two investi-
gators independently (AFV and JSS). Articles whose 2.6 Data Analyses
abstracts did not provide sufficient information regarding
the inclusion and exclusion criteria were assessed sepa- The pooled effect estimates were computed from the stand-
rately in full. Subsequently, each study selected in the ardized mean difference (SMD) and the 95% CI achieved
previous phase was fully evaluated and selected by the by each meta-analysis, as well as the number of partici-
reviewers independently. Disagreements were resolved by pants. The authors were contacted through emails for unre-
consensus and, in cases of persistence, by a third inves- ported data.
tigator (RCOM). The results are presented as SMD and calculations were
performed using random effects models. Statistical hetero-
geneity of treatment effects among studies was evaluated
2.3 Data Extraction using Cochran’s Q test and the I2 inconsistency test; it was
considered that values > 50% indicated high heterogeneity
Standardized forms were adopted for data extraction, per- [26].
formed independently by two investigators (AFV and JSS). Furthermore, publication bias was assessed using funnel
Eventual disagreements were resolved by consensus or by plots (of each trial’s effect size against the standard error).
a third investigator (RCOM). At this phase, the follow- Funnel plot asymmetry was evaluated using Begg and Egger
ing data were extracted from the included meta-analyses: tests [27] and a significant publication bias was considered if
list of authors and year of publication, number of studies the p-value was < 0.05. Trim-and-fill computation was used
included in the meta-analysis, information about search to estimate the effect of publication bias on the interpreta-
strategies, combined number of participants, characteris- tion of results.
tics of participants, interventions and comparators, results Forest plots were generated to present the pooled effects
of the outcomes of interest, risk of bias of primary studies, and SMD with 95% CIs. P-values < 0.05 were considered
effect size combined with 95% confidence interval (CI), statistically significant. All analyses were performed using
and I2 values. Comprehensive Meta Analysis Software version 2.0.

2.4 Methodological Quality Assessment 3 Results

Two authors (AFV and JSS) assessed the methodologi- 3.1 Study Selection
cal quality of the systematic reviews using the Assess-
ing the Methodological Quality of Systematic Reviews 2 The search of the MEDLINE (PubMed), Embase and
(AMSTAR-2) checklist [23]. This checklist contains 16 Cochrane Database of Systematic Reviews databases pro-
items and each item was answered with ‘yes’, ‘no’, ‘can- vided a total of 245 citations. In addition, 56 records in
not answer’, or ‘not applicable’. Based on these answers, PROSPERO were identified and 9 duplicates were removed,
only the ‘yes’ answer counted as a point in the total score totaling 292 titles and abstracts evaluated. At this stage, 280
for the assessed study. Thus, the meta-analyses were cat- studies were excluded, resulting in 12 reports being assessed
egorized as high quality (at least 80% of the items were for eligibility. Of these, eight reviews were excluded after
satisfied), moderate quality (between 40 and 80% of the reading the full-texts, resulting in four studies for inclusion.
items were satisfied) or low quality (< 40% of the items Furthermore, 23 studies were identified from the gray litera-
were satisfied) [24]. ture (Google Scholar), of which two reports were assessed
2514 A. F. Vieira et al.

and one was excluded. Thus, five studies met the inclusion in the meta-analysis performed by Gomes-Neto et al. [18]
criteria and were included in the analysis (Fig. 1). consisted of 12–24 weeks of resistance training (3 times a
3.2 Characteristics of the Meta‑analyses Included week, 80% of 1RM, 2–3 sets of 6–12 repetitions) associated
with consumption of 20–40 g of whey protein. In the study
The five studies included in this review were published performed by Hidayat et al. [19], the interventions consisted
between 2015 and 2019 (three were published in 2017). of 12–72 weeks of milk protein supplementation (0.3 and
These meta-analyses resulted in the analysis of 46 primary 0.8 g/kg/day or 13.2–40 g/day) associated with resistance
studies (ranging from 3 to 21 per review) and 2925 par- training (2–5 times a week, 70–85% of 1RM, 2–4 sets of
ticipants (ranging from 249 to 1249 per review). All studies 8–20 repetitions). Lastly, Hou et al. [20] included protocols
included male and female participants and the samples were comprising 10–72 weeks of resistance training (2–4 times
composed of older people aged ≥ 60 years, with the excep- a week) and consumption of proteins (20–40 g or 0.3 g/
tion of one study that included participants aged > 50 years kg of whey protein; 12–45 g or 1.2–1.3 g/kg of protein) or
[20]. In general, the interventions comprised the consump- amino acids (3–10 g). The interventions included in meta-
tion of 12–40 g of proteins [16–20] or 3–10 g of amino analyses were compared with resistance training associated
acids [16, 20] associated with resistance training. The with placebo or no supplementation. The evaluation methods
study by Colonetti et al. [17] included protocols involving described in the included studies were dual-energy X-ray
12–24 weeks of resistance training (most studies used a fre- absorptiometry [17, 20], bioelectrical impedance analysis
quency of three times a week) and consumption of 15.6–40 g [20], and air-displacement plethysmography [20] for the out-
of whey protein. Finger et al. [16] analyzed the consumption come lean body mass; appendicular skeletal muscle mass
of protein supplements and extra protein provided in a habit- [20] and muscle cross-sectional area [20] for the outcome
ual diet (0.3–0.8 g/kg or 13.2–40 g) or essential amino acids muscle mass; and isokinetic dynamometry [18], 1RM [18,
(6 g) plus resistance training (2–3 times a week, 70–85% 20], and hand-grip strength [20] for the outcome muscle
of one repetition maximum (1RM), 1–4 sets of 8–20 rep- strength (Table 1).
etitions) during 12–72 weeks. The interventions included

Fig. 1  Flow diagram of the search process

Protein Supplementation and Resistance Training in Older People 2515

3.3 Effects of Interventions moderate methodological quality. None of the reviews met

the AMSTAR-2 items 3, 10 and 12 criteria, referring to the
3.3.1 Lean Body Mass explanation for including the study designs, sources of fund-
ing for the included studies, and the impact of risk of bias on
Data on lean body mass were available from four studies the results, respectively. Moreover, all studies met items 4,
[16, 17, 19, 20], with a total of 43 trials and 2676 individu- 6, 8, 9, 11 and 16 criteria, related to literature search strat-
als evaluated. Of these meta-analyses, one found no signifi- egy, data extraction in duplicate, description of the included
cant difference between groups and three showed significant studies, technique for assessing the risk of bias, methods for
results in favor of the intervention (Table 1). From these statistical combination of results, and potential sources of
data, protein supplementation combined with resistance conflict of interest, respectively (Table 2).
training was associated with a significantly greater increase
in lean body mass when compared with resistance training 3.5 Quality of Evidence
without dietary protein intervention (SMD 0.294, 95% CI
0.126–0.462; p = 0.001, I2 = 39%) (Fig. 2). The analysis of Based on the GRADE assessment, the included studies were
publication bias for this outcome showed no significant bias considered as providing very low (five analyses), low (four
(p = 0.372). analyses), or moderate quality of evidence (three analyses).
3.3.2 Muscle Mass For risk of bias, most reviews detected risk of bias in the
included studies and were thus rated as ‘serious’ in this cri-
Data on muscle mass were available from two studies [16, terion. Two studies were considered as having very serious
20], with a total of 30 trials and 1711 individuals evaluated. inconsistency and all studies were considered as having non-
Of these meta-analyses, one found no significant difference serious indirectness. The analyses were mostly considered
between groups and the other showed a significant result in as being ‘precise’ on the imprecision GRADE item (seven
favor of the intervention (Table 1). From these data, pro- analyses). Finally, one study (five analyses) was considered
tein supplementation combined with resistance training was as ‘strongly suspected’ on the publication bias GRADE item
associated with a significantly greater increase in muscle (Table 3).
mass when compared with resistance training without die-
tary protein intervention (SMD 0.250, 95% CI 0.007–0.494;
p = 0.044, I2 = 59%) (Fig. 3). It was not possible to perform 4 Discussion
the analysis of publication bias for this outcome due to the
insufficient number of studies. This systematic review of systematic reviews with meta-
analyses summarized the evidence regarding the effects of
3.3.3 Muscle Strength protein supplementation associated with resistance training
compared with resistance training without dietary protein
Data on muscle strength were available from three studies intervention on body composition and muscle strength in
[16, 18, 20], with a total of 33 trials and 1960 individuals older adults. Based on individual results of included reviews
evaluated. Among these meta-analyses, two found no signifi- and analysis of pooled quantitative data, protein supplemen-
cant differences between groups and one showed significant tation in combination with resistance training may promote
results in favor of the intervention (Table 1). For reasons improvements in body composition, as evidenced by the
of standardization of the outcome evaluated, the analysis significant increase in lean body mass and muscle mass.
was performed based on the results of knee extension mus- On the other hand, no significant difference was identified
cle strength. From these data, no significant difference was between protein supplementation associated with resistance
found between resistance training combined with protein training and resistance training alone on muscle strength in
supplementation and resistance training alone on knee exten- older participants. These results were derived from system-
sion muscle strength (SMD 0.163, 95% CI − 0.005 to 0.331; atic reviews with meta-analyses of moderate methodological
p = 0.057, I2 = 26%) (Fig. 4). The analysis of publication bias quality, and the quality of evidence presented in these stud-
for this outcome showed no significant bias (p = 0.463). ies ranged from moderate to very low.
Body composition, especially muscle mass, depends on
3.4 Methodological Quality Assessment energy intake and the balance between muscle protein syn-
thesis and muscle protein breakdown [28]. Protein synthe-
The methodological quality of the five included meta-anal- sis may be stimulated by different factors, including resist-
yses is summarized in Table 2. The studies scored from ance training and dietary proteins (amino acids). It has
43.75% (7 points) to 68.75% (11 points) of the maximum been shown that resistance training and protein consump-
16 points. Therefore, all studies were classified as being of tion independently stimulate muscle protein synthesis with
 2516

Table 1  Summary of the meta-analyses included in the review

Reference No. of included Databases used Search date Intervention Comparator Results/findings Standardized mean 95% CI I2
studies (sample difference
size)

Colonetti et al. [17] 3 (391) MEDLINE, August 2015 Whey protein Resistance training Lean mass: No Lean mass: 0.26 Lean mass: − 0.43 to Lean mass: NR
LILACS, and resistance and placebo or no difference Muscle mass: NE 0.95 Muscle mass: NE
Embase, training supplementation Muscle mass: NE Muscle strength: Muscle mass: NE Muscle strength: NE
Cochrane Muscle strength: NE Muscle strength: NE
NE
Finger et al. [16] 9 (462) PubMed, January 2014 Proteins or amino Resistance training Lean mass: Lean mass: 0.23 Lean mass: 0.05–0.42 Lean mass: 0%
Cochrane, acids, or increase and placebo or no Intervention was Muscle mass: 0.14 Muscle mass: − 0.05 Muscle mass: 0%
Embase, in dietary supplementation associated with Muscle strength: to 0.32 Muscle strength: 0%
LILACS protein content increase 0.13 Muscle
and resistance Muscle mass: No strength: − 0.06 to
training difference 0.32
Muscle strength:
No difference
Gomes-Neto et al. 3 (249) MEDLINE, June 2015 Whey protein Resistance training Lean mass: NE Lean mass: NE Lean mass: NE Lean mass: NE
[18] LILACS, and resistance and placebo Muscle mass: NE Muscle mass: NE Muscle mass: NE Muscle mass: NE
Embase, Sci- training Muscle strength: Muscle Muscle Muscle strength:
ELO, CINAHL, No difference strength: − 0.18 strength: −  − 0.72 69% (knee exten-
PEDro, (knee extension), to 0.36 (knee exten- sion), 96% (leg
Cochrane 22.33 (leg press) sion), − 22.84 to press)
67.51 (leg press)
Hidayat et al. [19] 10 (574) PubMed, Web September 2016 Milk proteins or Resistance training Lean mass: Lean mass: 0.74 Lean mass: 0.30–1.17 Lean mass: 12.40%
of Science, dairy products and placebo or no Intervention was Muscle mass: NE Muscle mass: NE Muscle mass: NE
Cochrane and resistance supplementation associated with Muscle strength: Muscle strength: NE Muscle strength: NE
training increase NE
Muscle mass: NE
Muscle strength:
NE
Hou et al. [20] 21 (1249) PubMed, MED- May 2018 Proteins or amino Resistance training Lean mass: Lean mass: 0.23 Lean mass: 0.09–0.38 Lean mass: 3.80%
LINE, Embase acids and resist- and placebo or no Intervention was Muscle mass: 0.39 Muscle mass: Muscle mass:
ance training supplementation associated with Muscle strength: 0.14–0.64 45.90%
increase 0.29 (hand grip), Muscle strength: Muscle strength:
Muscle mass: 0.27 (knee exten- 0.08–0.50 (hand 0% (hand grip),
Intervention was sion), 0.33 (leg grip), 0.06–0.47 37.60% (knee
associated with press) (knee extension), extension), 19%
increase 0.01–0.64 (leg (leg press)
Muscle strength: press)
Intervention was
associated with
increase

NE not evaluated, NR not reported, 95% CI 95% confidence interval,CI confidence interval, I2 inconsistency test
A. F. Vieira et al.
Protein Supplementation and Resistance Training in Older People 2517

synergistic effects on skeletal muscle anabolism [29–31]. resistance training, but the quality of this evidence is low.
Thus, the association of these strategies may be considered Therefore, the available results regarding muscle mass
a more effective alternative to promote an increase in lean outcome should be treated with caution and further stud-
body mass and attenuate the progression of sarcopenia in ies are needed to confirm whether the increase in lean
older individuals. Of the four studies assessing lean body body mass obtained with protein supplementation may
mass included in the present review, three studies found reflect an increase in muscle mass or another tissue in
significant increments when protein supplementation was older populations.
combined with resistance training. Only one meta-analysis Another physiological change related to aging is a gradual
[17] did not show a difference between interventions for this loss of motor neurons, which promotes a decline in mus-
outcome, but included a single study in the analysis and cle fiber number and size, resulting in impaired mechanical
the quality of evidence was considered very low. Although muscle performance, including reduction in muscle strength
the quality of evidence from the other studies ranged from [1]. To compensate these age-induced losses, resistance
very low [19], low [20] and moderate [16], the results of the training plays a key role in promoting adaptive changes in
analyses corroborate each other. Therefore, it is possible to muscle and nervous system function that reflect in increased
suggest that protein supplementation associated with resist- muscle strength [1, 4, 39, 40]. Thereby, resistance training is
ance training is an important strategy to increase lean body considered the most potent non-pharmacological stimulus to
mass in older people, promoting greater enhancements when improve muscle strength. Notwithstanding, it is possible that
compared with resistance training alone. there are no differences in this adaptation when resistance
Because of several physiological factors inherent to training is associated or not with protein supplementation
aging, including anabolic resistance, the protein requirement in the older population. From three included studies that
is increased for the older population [32]. Recommendations assessed muscle strength, only one [20] found a significant
for daily protein intake for older active people are discussed effect related to protein intervention, and the quality of this
in the literature [28, 32–36]. It is suggested that dietary pro- evidence was rated as low. Other meta-analyses that were not
tein intake should be greater than the current recommended included in the present review (did not meet the eligibility
dietary allowance (1.0–1.6 g/kg of body mass/day) to main- criteria because studies evaluating other supplements associ-
tain a positive protein status and thus prevent or postpone ated with protein supplementation were accepted) [41–43]
age-related muscle disorders. In addition, it is recommended also concluded that protein supplementation combined with
that this amount should be distributed in meals containing resistance training does not provide additional benefits in
at least 0.4 g/kg of protein to achieve optimal muscle pro- muscle strength compared with resistance training alone.
tein synthesis stimulation [28, 33]. These amounts can be However, it is important to emphasize that our quantitative
achieved through diet (i.e., eggs, milk, beef, fish, beans, analysis for this outcome was performed only with the val-
peas, and other plant sources) or through protein supple- ues referring to knee extension muscle strength and therefore
mentation. Nevertheless, the supplement may be considered few data were included. Thus, more studies are needed to
a practical and easy-to-administer alternative, especially in confirm these results, mainly involving other exercises in
the frail older population. As older individuals usually have the assessment of muscle strength. In view of the evidence
difficulties in achieving energy intake [37], which results in available to date, it is possible to suggest that the adapta-
reduced protein consumption through diet, supplementation tions in muscle strength resulting from resistance training
of this macronutrient may help to meet the increased needs are not influenced by the effects of protein intake in older
related to aging and, together with the stimulus provided by individuals, and this result may be justified by the fact that
resistance training, positively impact body composition [38]. the increments in this outcome are mainly related to neural
On the other hand, the evidence regarding the effects of factors (i.e., increases in the maximal motor unit recruit-
protein supplementation on muscle mass is less consistent. ment, maximal motor unit firing rate, spinal motor neuronal
Although the pooled result of the included meta-analyses excitability, and efferent motor drive) [1, 4, 39].
favored the intervention (protein supplementation plus This systematic review of systematic reviews with meta-
resistance training), only two studies [16, 20] evaluated analyses has some limitations, such as the small number
this outcome, and the results between them are divergent. of studies included and the heterogeneity observed in some
Finger et al. [16] found no differences between protein analyses. In addition, it was not possible to precisely inves-
supplementation associated with resistance training com- tigate this heterogeneity because of the low number of
pared with resistance training without protein interven- included reviews in each analysis. Nevertheless, the present
tion, and the quality of this evidence was considered study was performed with high methodological rigor, based
moderate. However, the results found by Hou et al. [20] on well-defined eligibility criteria. Because of this, some
indicate that protein supplementation promotes greater studies identified in the searches had to be excluded (con-
increases in muscle mass in older people who perform tributing to the low number of included studies), mainly due
2518 A. F. Vieira et al.

Fig. 2  Standardized mean difference in lean body mass observed square represents study-specific estimates, and filled diamond rep-
between protein supplementation associated with resistance training resents pooled estimates of random-effects meta-analyses. CI confi-
and resistance training without dietary protein intervention. Filled dence interval

Fig. 3  Standardized mean difference in muscle mass observed square represents study-specific estimates, and filled diamond rep-
between protein supplementation associated with resistance training resents pooled estimates of random-effects meta-analyses. CI confi-
and resistance training without dietary protein intervention. Filled dence interval

Fig. 4  Standardized mean difference in muscle strength observed square represents study-specific estimates, and filled diamond rep-
between protein supplementation associated with resistance training resents pooled estimates of random-effects meta-analyses. CI confi-
and resistance training without dietary protein intervention. Filled dence interval

to the inclusion of clinical trials evaluating the effects of the influence of this bias in the results is probably minimal
other supplements associated with protein supplementation, since the isocaloric amount of the dietary supplement (inter-
which may be considered a confounding factor that would vention or control) may not have been sufficient to reverse
influence the results. Another possible bias in the present a possible malnutrition. Nevertheless, to our knowledge,
results is that the between-group differences may possibly this is the first systematic review of systematic reviews that
be smaller in studies comparing protein versus carbohydrate examined the effects of protein supplementation associated
supplementation in cases of malnutrition of the participants. with resistance training compared with resistance train-
However, because the included systematic reviews included ing without dietary protein intervention on body composi-
in their analyses original studies with different comparators tion and muscle strength in older adults. From our analy-
(i.e., no supplementation, carbohydrate supplementation), ses, it is possible to obtain a summary regarding existing
Table 2  Results of the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2) quality assessment
AMSTAR items

Reference 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Score (%)

Colonetti No Yes No Yes Yes Yes Yes Yes Yes No Yes Cannot No Cannot Not appli- Yes 9 (56.25)
et al. answer answer cable
[17]
Finger Yes No No Yes Yes Yes Yes Yes Yes No Yes No Yes Yes No Yes 11 (68.75)
Protein Supplementation and Resistance Training in Older People

et al.
[16]
Gomes- No No No Yes Yes Yes No Yes Yes No Yes No No No No Yes 7 (43.75)
Neto
et al.
[18]
Hidayat Yes No No Yes Cannot Yes Yes Yes Yes No Yes No Yes Yes Yes Yes 11 (68.75)
et al. answer
[19]
Hou et al. Yes No No Yes Yes Yes Yes Yes Yes No Yes No No Yes Yes Yes 11 (68.75)
[20]
2519
2520 A. F. Vieira et al.

Table 3  Results of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment
Certainty assessment Certainty
Study Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations

Colonetti et al. [17] Randomized trials Seriousa Very ­seriousb Not serious Very ­seriousc Only 1 study included in ⨁◯◯◯
Lean mass the analysis Very low
Finger et al. [16] Randomized trials Seriousa Not serious Not serious Not serious None ⨁⨁⨁◯
Lean mass Moderate
Finger et al. [16] Randomized trials Seriousa Not serious Not serious Not serious None ⨁⨁⨁◯
Muscle mass Moderate
Finger et al. [16] Randomized trials Seriousa Not serious Not serious Not serious None ⨁⨁⨁◯
Muscle strength Moderate
Gomes-Neto et al. [18] Randomized trials Seriousa Very ­seriousd Not serious Very ­seriousc None ⨁◯◯◯
Muscle strength (knee Very low
extension)
Gomes-Neto et al. [18] Randomized trials Seriousa Very ­seriousd Not serious Very ­seriousc None ⨁◯◯◯
Muscle strength (leg Very low
press)
Hidayat et al. [19] Randomized trials Seriousa Not serious Not serious Seriousc None ⨁◯◯◯
Lean mass Very low
Hou et al. [20] Randomized trials Seriousa Not serious Not serious Not serious Publication bias ⨁⨁◯◯
Lean mass strongly ­suspectede Low
Hou et al. [20] Randomized trials Seriousa Not serious Not serious Not serious Publication bias ⨁⨁◯◯
Muscle mass strongly ­suspectede Low
Hou et al. [20] Randomized Trials Seriousa Not serious Not serious Not serious Publication bias ⨁⨁◯◯
Muscle strength (hand strongly ­suspectede Low
grip)
Hou et al. [20] Randomized trials Seriousa Not serious Not serious Not serious Publication bias ⨁⨁◯◯
Muscle strength (knee strongly ­suspectede Low
extension)
Hou et al. [20] Randomized trials Seriousa Not serious Not serious Seriousc Publication bias ⨁◯◯◯
Muscle strength (leg strongly ­suspectede Very low
press)
a
Risk of bias detected
b
Unreported heterogeneity
c
Wide confidence intervals
d
Unexplained heterogeneity
e
Language limited to English

meta-analyses on the topic, providing the reader with a map number of eligible reviews, mainly considering muscle mass
of the available evidence. (i.e., two meta-analyses). In order to confirm the afore-
mentioned information, more well-designed clinical trials
and meta-analyses with high methodological quality are
5 Conclusion warranted.

In view of the results obtained, it is possible to conclude that

protein supplementation associated with resistance training Supplementary Information The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 40279-0​ 22-0​ 1704-0.
induces greater increases in lean body mass compared with
resistance training alone in older participants. In addition,
it is suggested that the effect of protein supplementation Declarations
on lean body mass is extended to the increase in muscle
Ethics approval Not applicable.
mass, while no additional effect of protein supplementation
was observed on muscle strength in older adults. Despite Consent to participate Not applicable.
the presence of statistical significance in some results, it is
Consent for publication Not applicable.
important to note that the findings were based on a limited
Protein Supplementation and Resistance Training in Older People 2521

Code availability Not applicable. 11. Deutz NEP, Bauer JM, Barazzoni R, Biolo G, Boirie Y, Bosy-
westphal A, et al. Protein intake and exercise for optimal muscle
Funding This study was funded by the National Council for Scien- function with aging: recommendations from the ESPEN Expert
tific and Technological Development (CNPq), the Coordination for Group. Clin Nutr. 2014;33:929–36.
the Improvement of Higher Education Personnel (CAPES), and the 12. Morley JE. Decreased food intake with aging. J Gerontol A Biol
Research Support Foundation of the State of Rio Grande do Sul Sci Med Sci. 2001;56:81–8.
(FAPERGS). 13. Amarya S, Singh K, Sabharwal M. Changes during aging and
their association with malnutrition. J Clin Gerontol Geriatr.
2015;6:78–84.
Conflicts of interest Alexandra Ferreira Vieira, Juliana Souza Santos,
14. Kazemi S, Savabi G, Khazaei S, Savabi O, Esmaillzadeh A, Kes-
Rochelle Rocha Costa, Eduardo Lusa Cadore and Rodrigo Cauduro
hteli AH, et al. Association between food intake and oral health in
Oliveira Macedo declare that they have no conflict of interests with the
elderly: SEPAHAN systematic review no. 8. Dent Res J (Isfahan).
content of this article.
2011;8:S15–20.
15. Guido D, Perna S, Carrai M, Barale R, Grassi M, Rondanelli M.
Author contributions Rodrigo Cauduro Oliveira Macedo conceived the
Multidimensional evaluation of endogenous and health factors
idea for the article. All authors contributed to the study conception and
affecting food preferences, taste and smell perception. J Nutr
design. Alexandra Ferreira Vieira, Juliana Souza Santos and Rochelle
Health Aging. 2016;20:971–81.
Rocha Costa performed the literature search and data analysis. The first
16. Finger D, Goltz FR, Umpierre D, Meyer E, Rosa LHT, Schneider
draft of the manuscript was written by Alexandra Ferreira Vieira, and
CD. Effects of protein supplementation in older adults undergoing
Rodrigo Cauduro Oliveira Macedo and Eduardo Lusa Cadore com-
resistance training: a systematic review and meta-analysis. Sport
mented on previous versions of the manuscript. All authors read and
Med. 2015;45:245–55.
approved the final manuscript.
17. Colonetti T, Grande AJ, Milton K, Foster C, Alexandre CM, Laura
M, et al. Effects of whey protein supplement in the elderly submit-
Data Availability The authors declare that the manuscript data are
ted to resistance training: systematic review and meta-analysis. Int
available in electronic supplementary material 2 (Online Resource).
J Food Sci Nutr. 2017;68:257–64.
18. Gomes-Neto M, Braga da Silva TLT, Carvalho VO. Whey protein
supplementation in association with resistance training on addi-
tional muscle strength gain in older adults: a meta-analysis. Sci
References Sports. 2017;32:214–20.
19. Hidayat K, Chen G, Wang Y, Zhang Z, Dai X, Szeto IMY, et al.
1. Aagaard P, Suetta C, Caserotti P, Magnusson SP, Kjær M. Role of Effects of milk proteins supplementation in older adults under-
the nervous system in sarcopenia and muscle atrophy with aging: going resistance training: a meta-analysis of randomized control
strength training as a countermeasure. Scand J Med Sci Sport. trials. J Nutr Health Aging. 2018;22:237–45.
2010;20:49–64. 20. Hou L, Lei Y, Li X, Huo C, Jia X, Yang J, et al. Effect of protein
2. Fragala MS, Cadore EL, Dorgo S, Izquierdo M, Kraemer WJ, supplementation combined with resistance training on muscle
Peterson MD, et al. Resistance training for older adults: position mass, strength and function in the elderly: a systematic review
statement from the national strength and conditioning association. and meta-analysis. J Nutr Health Aging. 2019;23:451–8.
J Strength Cond Res. 2019;33:2019–52. 21. MP, RMF, LAB, DP, LH. Chapter V: overviews of reviews. JPTH,
3. Izquierdo M, Merchant RA, Morley JE, Anker SD, Aprahamian JT, JC, MC, TL, MJP, et al. (eds) Cochrane handbook of sys-
I, Arai H, et al. International Exercise Recommendations in Older tematic reviews and interventions. Version 6.2 (updated Febrary
Adults (ICFSR): expert consensus guidelines. J Nutr Health 2021). Cochrane; 2021. http://​www.​train​ing.​cochr​ane.​org/​handb​
Aging. 2021;25:824–53. ook. Accessed 3 May 2021.
4. Cadore EL, Izquierdo M. How to simultaneously optimize muscle 22. Page MJ, Mckenzie JE, Bossuyt PM, Boutron I, Hoffmann TC,
strength, power, functional capacity, and cardiovascular gains in Mulrow CD, et al. The PRISMA 2020 statement: an updated
the elderly: an update. Age. 2013;35:2329–44. guideline for reporting systematic reviews. BMJ. 2021;372: n71.
5. Cadore EL, Casas-Herrero A, Zambom-Ferraresi F, Izquierdo 23. Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J,
M. Multicomponent exercises including muscle power train- et al. AMSTAR 2: a critical appraisal tool for systematic reviews
ing enhance muscle mass, power output, and functional out- that include randomised or non-randomised studies of healthcare
comes in institutionalized frail nonagenarians. Age (Omaha). interventions, or both. BMJ. 2017;358: j4008.
2014;36:773–85. 24. Grgic J, Grgic I, Pickering C, Schoenfeld BJ, Bishop DJ, Pedisic
6. Campbell WW, Marilyn CC, Young VR, Joseph LJ, Evans WJ. Z. Wake up and smell the coffee: caffeine supplementation and
Effects of resistance training and dietary protein intake on protein exercise performance-an umbrella review of 21 published meta-
metabolism in older adults. Am J Physiol. 1995;268:E1143–53. analyses. Br J Sport Med. 2020;54:681–8.
7. Phillips SM. Physiologic and molecular bases of muscle hyper- 25. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J,
trophy and atrophy: impact of resistance exercise on human skel- et al. GRADE guidelines: 1. Introduction-GRADE evidence
etal muscle (protein and exercise dose effects). Appl Physiol Nutr profiles and summary of findings tables. J Clin Epidemiol.
Metab. 2009;34:403–10. 2011;64:383–94.
8. Burd NA, Gorissen SH, Van LLJC. Anabolic resistance of 26. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring
muscle protein synthesis with aging. Exerc Sport Sci Rev. inconsistency in meta-analyses. BMJ. 2003;327:557–60.
2013;41:169–73. 27. Egger M, Smith GD, Schneider M, Minder C. Bias in meta-anal-
9. Clegg A, Young J. The frailty syndrome. Clin Med (Lond). ysis detected by a simple, graphical test. BMJ. 1997;315:629–34.
2011;11:72–5. 28. Mckendry J, Currier BS, Lim C, Mcleod JC, Thomas ACQ, Phil-
10. Volpi E, Campbell WW, Dwyer JT, Johnson MA, Jensen GL, Mor- lips SM. Nutritional supplements to support resistance exercise
ley JE, et al. Is the optimal level of protein intake for older adults in countering the sarcopenia of aging. Nutrients. 2020;12:2057.
greater than the recommended dietary allowance? J Gerontol A
Biol Sci Med Sci. 2013;68:677–81.
2522 A. F. Vieira et al.

29. Burd NA, Tang JE, Moore DR, Phillips SM. Exercise training and 38. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Mor-
protein metabolism: influences of contraction, protein intake, and ley JE, et al. Evidence-based recommendations for optimal dietary
sex-based differences. J Appl Physiol. 2009;106:1692–701. protein intake in older people: a position paper from the PROT-
30. Escobar KA, Vandusseldorp TA, Kerksick CM. Carbohydrate AGE Study Group. J Am Med Dir Assoc. 2013;14:542–59.
intake and resistance-based exercise: are current recommenda- 39. Duchateau J, Enoka RM. Neural adaptations with chronic activ-
tions reflective of actual need? Br J Nutr. 2017;116:2053–65. ity patterns in able-bodied humans. Am J Phys Med Rehabil.
31. Phillips SM. A brief review of critical processes in exercise- 2002;81:S17-27.
induced muscular hypertrophy. Sport Med. 2014;44:S71–7. 40. Courel-Ibáñez J, Vetrovsky T, Dadova K, Pallarés JG, Steffl M.
32. Coelho-Junior HJ, Marzetti E, Picca A, Cesari M, Uchida MC, Health benefits of β-hydroxy-β-methylbutyrate (HMB) supple-
Calvani R. Protein intake and frailty: a matter of quantity, quality, mentation in addition to physical exercise in older adults: a sys-
and timing. Nutrients. 2020;12:2915. tematic review with meta-analysis. Nutrients. 2019;11:2082.
33. Nunes EA, Currier BS, Lim C, Phillips SM. Nutrient-dense pro- 41. Labata-Lezaun N, Llurda-Almuzara L, López-de-Celis C, Rod-
tein as a primary dietary strategy in healthy ageing: please sir, ríguez-Sanz J, González-Rueda V, Hidalgo-García C, et al. Effec-
may we have more? Proc Nutr Soc. 2021;80:264–77. tiveness of protein supplementation combined with resistance
34. Pedersen AN, Cederholm T. Health effects of protein intake in training on muscle strength and physical performance in elderly:
healthy elderly populations: a systematic literature review. Food a systematic review and meta-analysis. Nutrients. 2020;12:2607.
Nutr Res. 2014;11:58. 42. Ten Haaf DSM, Nuijten MAH, Maessen MFH, Horstman AMH,
35. Rondanelli M, Nichetti M, Peroni G, Faliva MA, Naso M, Gas- Eijsvogels TMH, Hopman MTE. Effects of protein supplementa-
parri C, et al. Where to find leucine in food and how to feed tion on lean body mass, muscle strength, and physical perfor-
elderly with sarcopenia in order to counteract loss of muscle mass: mance in nonfrail community-dwelling older adults: a systematic
practical advice. Front Nutr. 2021;7: 622391. review and meta-analysis. Am J Clin Nutr. 2018;108:1043–59.
36. Yeung SSY, Chan RSM, Woo J. Protein and physical activity in 43. Thomas DK, Quinn MA, Saunders DH, Greig CA. Protein supple-
older persons. Curr Opin Clin Nutr Metab Care. 2021;24:42–7. mentation does not significantly augment the effects of resistance
37. Jadczak AD, Visvanathan R. Anorexia of aging—an updated short exercise training in older adults: a systematic review. J Am Med
review. J Nutr Health Aging. 2019;23:306–9. Dir Assoc. 2016;17:959.e1-959.e9.