Objectives: Obesity is a major risk factor for metabolic and cardiovascular diseases, requiring long-term and safe treatment strategies. Although Ephedrae Herba (Ephedra) has shown strong weight-reducing effects, its sympathomimetic adverse events have limited its clinical application. This study aims to systematically evaluate the evidence on non-Ephedra herbal interventions for obesity treatment. Methods: A comprehensive search was conducted in PubMed, Embase, Korean studies Information Service System, Research Information Sharing Service, and Oriental Medicine Advanced Searching Integrated System up to May 2025. Eligible studies were randomized controlled trials (RCTs) involving adults with body mass index (BMI) ≥23 kg/m², using herbal interventions listed in the Korean pharmacopoeia and published after the Consolidated Standards of Reporting Trials 2010 established. Primary outcomes were body weight and BMI. Risk of bias (RoB 2.0) and certainty of evidence Grading of Recommendations Assessment, Development and Evaluation were assessed. Results: 14 RCTs (n=1,134; analyzed n=937) were included. Approximately half of the trials demonstrated significant reductions in body weight or BMI compared with placebo. Notably, multi-herb formulas such as weight loss herbal intervention therapy and Xin-Ju-Xiao-Gao-Fang, and selected single extracts (e.g., pomegranate), showed clinically meaningful improvements. No serious adverse events were reported; most were mild gastrointestinal symptoms. However, methodological limitations, small sample sizes, and limited effect sizes led to most evidence being graded as low or very low certainty. Conclusions: Non-Ephedra herbal interventions may provide safe alternative options for obesity treatment, with some formulas and extracts showing promising effects. Nevertheless, the overall certainty of evidence remains low, highlighting the need for standardized protocols and large-scale multicenter RCTs.
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