BACKGROUND: The aim of this meta-analysis was to compare the long-term efficacy of diet plus exercise (D+E) versus diet (D), D+E versus exercise (E) and D versus E on anthropometric outcomes and cardiovascular risk factors in overweight and obese participants. METHODS: Electronic searches were performed in Medline and the Cochrane Central Register of controlled trials. Inclusion criteria were as follows: body mass index >= 25 kg/m2 and a minimum intervention period including follow-up of >= 12 months. Outcomes of interest were as follows: anthropometric parameters, blood lipids, blood pressure and cardiorespiratory fitness. Pooled effects were calculated using pairwise random effects and Bayesian random effects network meta-analysis. Results of the corresponding fixed effects models were compared in sensitivity analyses. RESULTS: Overall, 22 trials (24 reports) met the inclusion criteria and 21 (including 3,521 participants) of them were included in the quantitative analysis. As compared with D, D+E resulted in a significantly more pronounced reduction in body weight (mean differences (MD) -1.38 kg, 95% confidence interval (CI) -1.98 to -0.79), and fat mass (MD -1.65 kg, 95% CI -2.81 to -0.49), respectively. When comparing D+E with E, MD in change of body weight (-4.13 kg, 95% CI -5.62 to -2.64), waist circumference (-3.00 cm, 95% CI -5.81 to -0.20), and fat mass (-3.60 kg, 95% CI -6.15 to -1.05) was in favour of combined diet and exercise, respectively. Comparing E versus D, diet resulted in a significantly more pronounced decrease in body weight (MD -2.93 kg, 95% CI -4.18 to -1.68), and fat mass (MD -2.20 kg, 95% CI -3.75 to -0.66). D+E yielded also the greatest reductions with respect to blood lipids and blood pressure when compared to single applications of D and E, respectively. Results from the network meta-analyses confirmed these findings. CONCLUSIONS: Moderate-quality evidence from the present network meta-analysis suggests that D+E can be highly recommended for long-term obesity management. Furthermore, the evidence suggests a moderate superiority of D over E with respect to anthropometric outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42013003906.

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