Efficacy and Safety of Pharmacological, Endoscopic, and Surgical Treatments for Obesity: A GRADE‐Based Network Meta‐Analysis

TL;DR

This study compares the effectiveness and safety of different obesity treatments, finding that surgery is most effective long-term, while newer medications show strong short-term results.

Contribution

A GRADE-based network meta-analysis comparing pharmacological, endoscopic, and surgical obesity treatments in adults.

Findings

Metabolic bariatric surgery (MBS) showed superior long-term weight loss compared to other treatments.

Tirzepatide and semaglutide performed as well as MBS in the short term.

Endoscopic bariatric procedures (EBP) had higher safety risks than pharmacological treatments.

Abstract

This review compared antiobesity strategies—obesity management medications (OMM), endoscopic bariatric procedures (EBP), and metabolic bariatric surgery (MBS)—with lifestyle intervention, placebo, or no therapy (LSI/Pbo/NT).

This network meta‐analysis included randomized clinical trials comparing OMM, EBP, and MBS versus LSI/Pbo/NT or active comparators in adults with obesity. MEDLINE and Embase were searched up to December 1, 2024. The primary endpoint was total body weight loss percentage (TBWL%), analyzed at 26–52, 53–104, 105–156, and ≥ 156 weeks. This study was registered with PROSPERO (CRD42024623707).

Of 139 RCTs, 54 evaluated MBS (n = 61,961), 21 EBP (n = 2934), and 64 OMM (n = 5991). At 26–52 weeks, most treatments showed significant effects versus the reference. TBWL% exceeded 10% with most surgeries and tirzepatide. Long‐term data were lacking for most OMM and all EBP. Most treatments maintained their efficacy over time, except greater curvature plication. EBP and MBS were generally associated with a higher SAE risk than OMM; BPD showed the highest long‐term SAE incidence.

MBS appears superior in the long term (particularly for higher‐efficacy procedures, such as RYGB, SG, SADI, and BPD). EBP, except ESG, was less effective than newer OMM. Semaglutide and tirzepatide showed no inferior short‐term results in comparison with MBS.

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