Effects of 12-Week Multicomponent Training Program on Body Composition, Metabolic Health, and Physical Performance in Middle-Aged and Older Women: Exploratory Role of Baseline Adiposity

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I would like to appreciate the efforts of the authors in implementing the project and writing this article “Effects of Combined Functional Training and High-Intensity Interval Training on Body Composition, Metabolic Health, and Physical Fitness in Middle-Aged and Older Women: Influence of Baseline Adiposity”.

The aim of the present study was to evaluate the effects of a combined FT and HIIT program on body composition, metabolic health, and aerobic capacity in middle-aged and older women compared with a control group that maintained their usual lifestyle during the same intervention period.

This article is one of the few works that systematically evaluates the combination of functional training (FT), HIIT and water exercise in women aged 50-72 years, while also examining how baseline body fat levels influence training adaptations.

I have the following comments:

-             A flow diagram would help to better understand the design of the study

-             Has a Power Analysis been Performed?

-             I recommend to condense the discussion, especially to eliminate repetition of results, focus more on explaining findings, emphasize interpretation of results

-             Line 84-85: what does usual lifestyle mean? Describe better. How was their movement regime monitored? It can be described or used by standardized questionnaires.

-             I recommend to consider presenting some results through graphs (for clarity)

Author Response

Comment 1:
“A flow diagram would help to better understand the design of the study.”

Response 1:
Thank you for this valuable suggestion. We agree that a flow diagram improves the clarity and understanding of the study design and participant progression throughout the intervention.

Therefore, we included a flow diagram illustrating participant recruitment, allocation, follow-up, and final analysis.

Changes in manuscript:
This information was incorporated as Figure 1 in the Participants subsection of the Materials and Methods section.

Comment 2:
“Has a Power Analysis been Performed?”

Response 2:
Thank you for this important observation. A formal a priori power analysis was not conducted due to the exploratory and applied nature of the study, as well as practical constraints related to participant recruitment.

To address this concern, we strengthened the statistical analysis and interpretation of the results by incorporating effect size analyses (Cohen’s d), clearly acknowledging the quasi-experimental design, the relatively small sample size, and the exploratory nature of subgroup comparisons.

Additionally, the manuscript now explicitly states that the findings should be interpreted with caution due to the absence of covariance adjustments for baseline differences between groups.

Changes in manuscript:
These clarifications were incorporated into the Statistical Analysis and Discussion sections of the revised manuscript.

Comment 3:
“I recommend to condense the discussion, especially to eliminate repetition of results, focus more on explaining findings, emphasize interpretation of results.”

Response 3:
Thank you for this valuable suggestion. We agree that the Discussion section required a stronger emphasis on interpretation rather than repetition of results.

Therefore, the Discussion section was revised to improve clarity, conciseness, and scientific interpretation. Specifically, repetitive descriptions of the results were reduced, and greater emphasis was placed on the physiological and practical interpretation of the findings, particularly regarding aerobic adaptations, metabolic responses, functional performance, and the potential influence of baseline adiposity.

Changes in manuscript:
These modifications were incorporated throughout the Discussion section of the revised manuscript.

Comment 4:
“Line 84–85: what does usual lifestyle mean? Describe better. How was their movement regime monitored? It can be described or used by standardized questionnaires.”

Response 4:
Thank you for this important observation. We agree that the description of the control condition required further clarification.

Therefore, we revised the manuscript to better define “habitual lifestyle” as the continuation of normal daily activities without participation in any structured or supervised exercise program during the intervention period.

Additionally, we explicitly acknowledge that physical activity outside the intervention was not objectively monitored using standardized questionnaires or accelerometry, which is now recognized as a limitation of the study.

Changes in manuscript:
These modifications were incorporated into the Introduction, Participants subsection, and Discussion section of the revised manuscript.

Comment 5:
“I recommend to consider presenting some results through graphs (for clarity).”

Response 5:
Thank you for this valuable suggestion. We carefully considered the inclusion of additional graphical representations of the results. However, given the number of variables analyzed and the journal formatting recommendations, we opted to maintain the results primarily in tabular format to preserve clarity and facilitate comprehensive data presentation.

Changes in manuscript:
The results presentation was carefully revised to improve clarity and readability while maintaining the tabular format.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors

Thank you for your interesting paper. Here are my suggestions to improve your article's impact. Please consider them to empower your manuscript. 

TITLE

The title is a bit too long and could be simplified to improve readability. The phrase “Influence of Baseline Adiposity” is appropriate, but the title should better clarify that the adiposity analysis is exploratory. Since the intervention also includes aquatic exercise, the title may be misleading because it only mentions functional training and HIIT. I suggest either revising the title to reflect the program's multicomponent nature or clarifying whether aquatic training is included in FT/HIIT. What do you think about this possible title? “A 12-Week Multicomponent Training Program Enhances Fitness and Metabolic Markers in Middle-Aged and Older Women: Exploratory Role of Adiposity" if you like it, please feel free to use it.

ABSTRACT

The abstract adequately summarises the study aim, sample, intervention, and main findings. However, the description of the intervention is unclear because “aquatic training” is mentioned without sufficient explanation. The authors should briefly specify what the aquatic session involved and whether it was equivalent in intensity and structure to the land-based sessions. The role of the control group also needs clearer reporting: did they maintain usual lifestyle only, receive advice, or perform any monitored activity? Finally, the conclusions should be more cautious because of the small sample size, quasi-experimental design, and exploratory subgroup analysis.

INTRODUCTION

The introduction is relevant but could be more focused and better aligned with the actual intervention. For example, the aquatic component appears suddenly in the methods and is not sufficiently introduced theoretically. What is the role of aquatic training? Is it different from gym training? what advantages can it brings to people? If aquatic exercise is part of the intervention, the introduction should explain why it was included and what additional physiological or adherence-related benefits were expected. In addition, you should also better justify the use of baseline adiposity as a moderator of training response. 

METHODS

The methods are mostly understandable, but several important points require clarification. First, the aquatic training component is not sufficiently described: the authors should explain the exercises, intensity, progression, monitoring, and whether HR targets were comparable to those in land-based HIIT. Second, the control group is unclear. The authors should state exactly what participants did during the 12 weeks, whether lifestyle, diet, and physical activity were monitored, and whether they received any instruction. Third, allocation was based on availability and willingness, which introduces selection bias; this limitation should be strongly acknowledged. Finally, the small sample size and lack of covariance adjustment reduce confidence in subgroup comparisons.

RESULTS

The results are clearly presented and supported by tables. The improvements in VO₂max, skeletal muscle mass, insulin, lipid profile, and functional performance are interesting. However, the results should be interpreted with greater caution because the control group was small and not randomized. The authors should avoid overemphasizing the role of baseline adiposity, since NF% and HF% analyses are exploratory and underpowered. It would also be helpful to report confidence intervals for effect sizes and change scores. Some variables show clinically interesting trends without statistical significance, and these should be discussed as trends rather than definitive effects.

DISCUSSION

The discussion is generally coherent and connects the findings with previous literature. However, the aquatic training component needs deeper interpretation: if it contributed to adherence or reduced joint stress, this should be supported and clearly linked to the protocol. The authors should also more explicitly discuss that the control group’s behaviour was not sufficiently characterised, which limits causal interpretation. I suggest adding comparisons with structured exercise interventions in other populations to contextualise the findings. In particular, the authors could cite Fanelli et al. (2022) on structured physical activity in adolescents with overweight/obesity and Goldfield et al. (2017) on the HEARTY Trial, which examined the effects of aerobic and resistance training in youth with obesity. These references would improve comparison across populations and help clarify whether metabolic and quality-of-life responses differ by age, adiposity, and intervention type.

Here you can find the complete citation of the article. Please feel free to use it or add/change it with other literature.

-) Fanelli E, Abate Daga F, Pappaccogli M, et al. A structured physical activity program in an adolescent population with overweight or obesity: a prospective interventional study. Appl Physiol Nutr Metab. 2022;47(3):253-260. doi:10.1139/apnm-2021-0092

-) Goldfield GS, Kenny GP, Alberga AS, et al. Effects of aerobic or resistance training or both on health-related quality of life in youth with obesity: the HEARTY Trial. Appl Physiol Nutr Metab. 2017;42(4):361-370. doi:10.1139/apnm-2016-0386 to improve comparison between different populations.

CONCLUSION

The conclusion is appropriate, but should be more conservative. The study suggests that a 12-week multicomponent program including FT, HIIT, and aquatic exercise may improve aerobic fitness, skeletal muscle mass, metabolic markers, and functional performance in middle-aged and older women. However, stronger causal claims should be avoided given the quasi-experimental design, small sample size, non-random allocation, and unclear control condition. The authors should also specify that the influence of baseline adiposity is exploratory. 

Comments on the Quality of English Language

The manuscript is generally understandable; however, the quality of English could be improved to enhance clarity and readability. Several sentences are overly long or repetitive, and there are occasional grammatical and lexical inaccuracies that make the scientific message less precise. A careful revision by a native English speaker or a professional editing service is recommended to improve flow, reduce redundancy, and ensure consistent use of scientific terminology throughout the manuscript.

Author Response

Comment 1:
“The title should better reflect the multicomponent nature of the intervention and the exploratory role of baseline adiposity.”

Response 1:
Thank you for this valuable suggestion. We agree that the title required refinement to better reflect both the multicomponent nature of the intervention and the exploratory assessment of baseline adiposity.

Therefore, the title was revised accordingly.

The updated title is:
“Effects of a 12-Week Multicomponent Training Program on Body Composition, Metabolic Health, and Physical Performance in Middle-Aged and Older Women: Exploratory Role of Baseline Adiposity”.

Changes in manuscript:
The revised title has been incorporated on the title page of the manuscript.

Comment 2:
“The abstract requires clarification regarding the aquatic component, the role of the control group, and the interpretation of the conclusions considering the study limitations.”

Response 2:
Thank you for this valuable comment. We agree that the Abstract required additional clarification and a more cautious interpretation of the findings.

Therefore, the Abstract was revised to improve clarity and completeness. Specifically, the aquatic training component is now described as a combination of functional and interval-based exercises performed in a water environment. Additionally, the role of the control group was clarified, indicating that participants maintained their habitual lifestyle without engaging in structured exercise.

Furthermore, the conclusions were revised to adopt a more cautious tone, explicitly acknowledging the quasi-experimental design, relatively small sample size, and exploratory nature of subgroup analyses.

Changes in manuscript:
These modifications were incorporated throughout the Abstract section of the revised manuscript.

Comment 3:
“The Introduction should better justify the inclusion of aquatic exercise and the rationale for examining baseline adiposity as a moderator of training responses.”

Response 3:
We appreciate this important observation. We agree that the rationale for the aquatic component and the exploratory role of baseline adiposity required further development.

Therefore, the Introduction was revised to better align with the intervention design. Specifically, we incorporated a clearer rationale for the inclusion of aquatic exercise, emphasizing its role in reducing joint stress, improving adherence, and enabling combined functional and interval-based training in middle-aged and older women.

Additionally, we strengthened the justification for examining baseline adiposity as a potential modulator of physiological adaptations induced by exercise interventions. We also incorporated a statement highlighting the limited number of studies simultaneously evaluating FT, HIIT, aquatic exercise, and baseline adiposity in this population.

Changes in manuscript:
These modifications were incorporated into the Introduction section of the revised manuscript.

Comment 4:
“The exercise intervention and methodological procedures require additional detail, particularly regarding the integration of FT, HIIT, aquatic exercise, intensity monitoring, and the characterization of the control group.”

Response 4:
Thank you for highlighting these important methodological considerations. We agree that additional details regarding the intervention structure and control condition improve the reproducibility and clarity of the study.

Therefore, the description of the exercise intervention was expanded to clearly specify the integration of FT, HIIT, and aquatic-based sessions. We also clarified the structure of the aquatic sessions, including the incorporation of functional and interval-based exercises adapted to the aquatic environment.

Additionally, the manuscript now specifies that HIIT sessions were performed at intensities ≥85% of maximum heart rate (HRmax), with continuous heart rate monitoring throughout the sessions.

The control group was also more clearly defined as participants who maintained their habitual lifestyle without engaging in structured or supervised exercise during the intervention period.

Furthermore, we explicitly acknowledge that physical activity and dietary intake outside the intervention were not objectively monitored, which is now recognized as a limitation of the study.

Changes in manuscript:
These modifications were incorporated into the Exercise Intervention subsection (Section 2.4) and the Discussion section of the revised manuscript.

Comment 5:
“The Results section should avoid overinterpretation, particularly regarding subgroup analyses and variables that did not reach statistical significance.”

Response 5:
Thank you for this important comment. We agree that the interpretation of the findings, particularly subgroup analyses, required a more cautious and balanced approach.

Therefore, the Results and Discussion sections were revised to avoid overinterpretation. Subgroup comparisons are now consistently described as exploratory, and variables showing meaningful trends without statistical significance are discussed more cautiously.

Additionally, we explicitly acknowledge the absence of confidence intervals for effect sizes and change scores as a limitation that may affect the precision and interpretability of the observed effects.

The limitations related to the quasi-experimental design, relatively small sample size, and absence of covariance adjustments for baseline differences were also strengthened throughout the manuscript.

Changes in manuscript:
These modifications were incorporated into the Results, Discussion, and Statistical Analysis sections of the revised manuscript.

Comment 6:
“The Discussion should better interpret the role of aquatic exercise and further contextualize the findings in relation to previous literature and study limitations.”

Response 6:
Thank you for this valuable suggestion. We agree that the Discussion required a more detailed interpretation of the aquatic exercise component and additional contextualization of the findings.

Therefore, the Discussion section was expanded to better explain the potential contribution of aquatic exercise to the observed physiological and functional adaptations, particularly regarding reduced joint stress, improved accessibility, and enhanced adherence in middle-aged and older women.

We also incorporated additional comparisons with previous structured exercise interventions to better contextualize the present findings within the existing literature.

Furthermore, the implications of the limited characterization of the control group and the absence of objective monitoring of physical activity outside the intervention were explicitly acknowledged as limitations affecting causal interpretation.

Changes in manuscript:
These modifications were incorporated throughout the Discussion section of the revised manuscript.

Comment 7:
“The conclusions should adopt a more cautious tone considering the study design and limitations.”

Response 7:
We agree with the reviewer and appreciate this important observation. Therefore, the Conclusion section was revised to adopt a more conservative and scientifically cautious tone.

The findings are now presented using more cautious language (e.g., “may improve”), and we explicitly acknowledge the quasi-experimental design, relatively small sample size, non-random allocation, and exploratory nature of subgroup analyses as important limitations affecting the interpretation of the results.

Changes in manuscript:
These modifications were incorporated into the Conclusions section of the revised manuscript.

Comment 8:
“The manuscript requires improvements in language, readability, and overall clarity.”

Response 8:
Thank you for this observation. We agree that improving the clarity and readability of the manuscript strengthens the overall quality of the study.

Therefore, the manuscript was carefully revised to improve language, reduce redundancy, enhance readability, and ensure greater consistency in scientific terminology and writing style throughout the document.

Changes in manuscript:

Language and grammatical revisions were implemented throughout the entire revised manuscript.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

The revised version of the manuscript has improved substantially compared with the previous submission. I appreciate the authors’ efforts to clarify several methodological aspects, particularly the rationale and description of the aquatic-training component, the characterisation of the control group, and the more cautious interpretation of the findings and limitations. Overall, the manuscript is now clearer and scientifically stronger.

However, my previous comment regarding the Discussion section has only been partially addressed. In particular, the manuscript still lacks comparison with structured exercise interventions conducted in other populations, especially studies involving overweight/obese individuals and younger cohorts. As previously suggested, incorporating the following references would strengthen the contextualization and translational relevance of the findings:

• Fanelli E, Abate Daga F, Pappaccogli M, et al. A structured physical activity program in an adolescent population with overweight or obesity: a prospective interventional study. Appl Physiol Nutr Metab. 2022;47(3):253-260.
• Goldfield GS, Kenny GP, Alberga AS, et al. Effects of aerobic or resistance training or both on health-related quality of life in youth with obesity: the HEARTY Trial. Appl Physiol Nutr Metab. 2017;42(4):361-370.

Including these studies in the Discussion would enable the authors to better compare exercise-induced adaptations across age groups and adiposity profiles, particularly with respect to cardiometabolic outcomes, functional performance, and responsiveness to structured exercise interventions. I therefore encourage the authors to further improve the Discussion section by more explicitly integrating these comparisons.

Comments on the Quality of English Language

The English has improved substantially compared with the previous version; however, minor language edits are still recommended to enhance readability and correct residual typographical and stylistic inconsistencies.

Author Response

Comment 1:

“The revised manuscript has substantially improved in clarity, methodological transparency, and interpretation of the findings. However, the Discussion section could be further strengthened by integrating comparisons with previous studies conducted in populations with overweight/obesity and younger individuals exposed to structured exercise interventions. The following references may be useful for contextualizing the translational relevance of the findings:

1. Fanelli et al. (2022)
2. Goldfield et al. (2017)

 Minor English editing is also recommended to improve readability.”

Response 1:
We sincerely thank the reviewer for the positive evaluation of our revised manuscript and for the valuable suggestions provided.

In response to this comment, we expanded the Discussion section to incorporate comparisons with previous structured exercise interventions conducted in overweight/obese and younger populations. Specifically, we integrated the studies by Fanelli et al. (2022) and Goldfield et al. (2017) to better contextualize the translational relevance of the present findings and further support the role of baseline adiposity as a potential modulator of exercise-induced adaptations across populations.

Additionally, the manuscript was carefully revised to improve English readability and correct minor typographical and formatting inconsistencies throughout the text.

Changes in manuscript:

These modifications were incorporated into the Discussion section and throughout the revised manuscript.