This umbrella review aimed to synthesize evidence from systematic reviews and meta-analyses of randomized controlled trials (RCTs) evaluating the effectiveness, safety, and metabolic outcomes of bariatric surgery, endoscopic procedures, and GLP-1 receptor agonists (GLP-1RAs). 

Eligible studies included systematic reviews and meta-analyses of RCTs involving adults with obesity (BMI ≥30 kg/m²) and assessing at least one of the three intervention classes. Primary outcomes included changes in body weight, BMI, and waist circumference; secondary outcomes included glycemic control, lipid profile, quality of life, and adverse events.

A total of 44 systematic reviews with meta-analyses were included, encompassing over 370,000 participants. Most reviews were rated as critically low (59.1%) or low (29%) quality, with 20% using the GRADE approach. Bariatric surgery demonstrated the largest and most durable reductions in body weight (mean differences up to –25.9 kg) and the highest rates of type 2 diabetes remission (60–80%). GLP-1RAs, particularly semaglutide, showed consistent, dosedependent weight loss (up to –15%) and significant improvements in glycemic indices. Endoscopic interventions, such as intragastric balloons and endoscopic sleeve gastroplasty, achieved intermediate weight loss (4–12%) with a favorable safety profile. 

Bariatric surgery remains the most effective option for substantial weight and metabolic improvements, particularly in severe or refractory obesity. GLP-1RAs offer a potent non-surgical alternative, while endoscopic therapies provide a minimally invasive option for patient’s ineligible for or unwilling to undergo surgery. A tiered, individualized approach to obesity treatment; guided by intervention efficacy, safety, and patient characteristics, supported by the current evidence base.