Effect of bariatric surgery and pharmacological treatments on cardiovascular risk factors for adults with overweight and obesity: a systematic review and network meta-analysis

BACKGROUND: To comprehensively evaluate the relative efficacy and safety of lifestyle interventions, pharmacological therapies (orlistat, liraglutide, and semaglutide), and bariatric surgeries [Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and biliopancreatic diversion (BPD)] on body weight and cardiovascular risk factors in adults with overweight and obesity. We conducted a systematic review and network meta-analysis of randomized controlled trials (RCTs). MATERIALS AND METHODS: Comprehensive searches were performed in PubMed, MEDLINE, Embase, and the Cochrane Library through 1 February 2025. The analysis focused on interventions in adults with overweight or obesity, assessing outcomes including changes in body mass index (BMI), glycated hemoglobin (HbA1c), lipids, blood pressure, and adverse events. RESULTS: This network meta-analysis included 26 RCTs. Bariatric surgery was the most effective modality for improving body weight and the majority of cardiovascular risk factors. Among surgeries, BPD demonstrated the greatest reductions in weight, BMI, and low-density lipoprotein cholesterol, but was also associated with the highest risk of serious adverse events (SAEs). RYGB and SG produced comparable weight loss, though RYGB showed unique advantages in improving high-density lipoprotein cholesterol and metabolic outcomes. Among pharmacological agents, semaglutide was the most efficacious, achieving weight loss, BMI reduction, and blood pressure control comparable to RYGB and SG. While liraglutide showed strong effects on glycemic control, semaglutide consistently outperformed both liraglutide and orlistat across most other outcomes and had a lower risk of discontinuation than liraglutide. Importantly, pharmacological agents, particularly semaglutide, had a significantly lower risk of SAEs than surgery. CONCLUSION: Bariatric surgery provides the most potent efficacy for weight loss and cardiometabolic improvement, with BPD being the most effective but also highest-risk procedure. Semaglutide emerges as a formidable therapeutic alternative, offering a degree of efficacy comparable to RYGB and SG in many key domains but with a superior safety profile. These findings underscore the need to shift from a "one-size-fits-all" approach to an evidence-based, individualized strategy that aligns each intervention's distinct efficacy and safety profile with specific patient goals and risk tolerance.