Effect of different exercise interventions on patients with metabolic dysfunction-associated fatty liver disease： A systematic review and network Meta-analysis

ObjectiveTo investigate the effect of different exercise interventions on metabolism and liver parameters in patients with metabolic dysfunction-associated fatty liver disease （MAFLD）， and to provide evidence-based recommendations for clinical exercise rehabilitation.MethodsThis study was conducted according to the PRISMA guidelines， and the protocol was registered on the PROSPERO platform， with a registration number of CRD42025641717. PubMed， Web of Science， Scopus， Wiley Online Library， CNKI， Wanfang Data， and VIP were searched for related articles published up to September 2024. The Cochrane tool for assessing risk of bias was used to assess the quality of articles， and Stata MP 17.0 was used to perform the network meta-analysis.ResultsA total of 57 articles were included， involving 2 648 patients. The results showed that aerobic exercise combined with resistance exercise had the best effect in improving body mass index （mean difference ［WMD］=-0.97， 95% confidence interval ［CI］： -1.66 to -0.28］， P<0.05， surface under the cumulative ranking curve ［SUCRA］=85.4） and triglycerides （WMD=-29.6， 95%CI： -46.66 to 12.54， P<0.05， SUCRA=87.3）； resistance exercise was the optimal intervention method for improving total cholesterol （WMD=-15.99， 95%CI： -24.19 to -7.79， P<0.05， SUCRA=79.9） and glutamine transaminase （WMD=-8.08， 95%CI： -12.13 to -4.02， P<0.05， SUCRA=87.3）； low-intensity aerobic exercise had the best effect in improving aspartate aminotransferase （WMD=-4.3， 95%CI： -8.45 to -0.15， P<0.05， SUCRA=73.5）， gamma-glutamyl transpeptidase （GGT） （WMD=-3.26， 95%CI： -7.79 to 1.27， P>0.05， SUCRA=82.3）， and glycated hemoglobin （HbA1c） （WMD=-0.6， 95%CI： -2.02 to 0.82， P>0.05， SUCRA=78.8）； moderate-intensity aerobic exercise was the optimal intervention modality to improve Homeostasis Model Assessment of Insulin Resistance （WMD=-0.92， 95%CI： -1.51 to -0.33， P<0.05， SUCRA=69.4）. It should be noted that there were no significant differences in HbA1c and GGT across different exercise interventions （all P>0.05）， suggesting that there was currently no sufficient statistical evidence to support that exercise could improve these two indicators.ConclusionBased on the comprehensive league table and cumulative probability ranking， aerobic exercise combined with resistance exercise， resistance exercise， and low- and moderate-intensity aerobic exercise may be the best exercise modality for improving key indicators in MAFLD patients， and targeted exercise modalities should be selected for intervention against different indicators； however， due to limitations of the original studies， further studies are needed for validation and exploration.

研究目的：本研究旨在探讨不同运动干预方案对代谢功能障碍相关性脂肪肝（Metabolic Dysfunction-Associated Fatty Liver Disease, MAFLD）患者代谢与肝脏指标的影响，为临床运动康复提供循证医学推荐依据。
研究方法：本研究严格遵循PRISMA声明开展，研究方案已在PROSPERO平台注册，注册编号为CRD42025641717。检索截至2024年9月发表的相关文献，检索数据库包括PubMed、Web of Science、Scopus、Wiley Online Library、中国知网（CNKI）、万方数据、维普资讯（VIP）。采用Cochrane偏倚风险评估工具对文献质量进行评价，使用Stata MP 17.0软件开展网状meta分析。
研究结果：本研究共纳入57篇文献，涉及2648例患者。结果显示，有氧联合抗阻运动在改善体质量指数（均数差[WMD]=-0.97，95%置信区间[CI]：-1.66~-0.28，P<0.05，累积排序曲线下面积[SUCRA]=85.4）与甘油三酯（均数差[WMD]=-29.6，95%CI：-46.66~-12.54，P<0.05，SUCRA=87.3）方面效果最优；抗阻运动为改善总胆固醇（均数差[WMD]=-15.99，95%CI：-24.19~-7.79，P<0.05，SUCRA=79.9）与谷氨酰胺转氨酶（均数差[WMD]=-8.08，95%CI：-12.13~-4.02，P<0.05，SUCRA=87.3）的最优干预方案；低强度有氧运动在改善天门冬氨酸氨基转移酶（均数差[WMD]=-4.3，95%CI：-8.45~-0.15，P<0.05，SUCRA=73.5）、γ-谷氨酰转移酶（gamma-glutamyl transpeptidase, GGT，均数差[WMD]=-3.26，95%CI：-7.79~1.27，P>0.05，SUCRA=82.3）及糖化血红蛋白（glycated hemoglobin, HbA1c，均数差[WMD]=-0.6，95%CI：-2.02~0.82，P>0.05，SUCRA=78.8）方面效果最佳；中等强度有氧运动为改善胰岛素抵抗稳态模型评估（Homeostasis Model Assessment of Insulin Resistance, HOMA-IR）的最优干预方式（均数差[WMD]=-0.92，95%CI：-1.51~-0.33，P<0.05，SUCRA=69.4）。需注意的是，不同运动干预方案对HbA1c与GGT的改善效果均无统计学差异（所有P>0.05），提示当前尚无足够统计学证据支持运动可改善这两项指标。
研究结论：基于综合排序表与累积概率排名结果，有氧联合抗阻运动、抗阻运动、低强度与中等强度有氧运动或为改善MAFLD患者关键指标的最优运动方案，临床应针对不同指标选择针对性运动干预方式；但受原始研究局限性影响，仍需开展进一步研究加以验证与探索。