Are drugs or surgery superior for obesity treatment?
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We now have drugs available that provide potent and consistent weight loss for people with obesity that has so far proved to be durable.
Today, we are closer than ever to achieving the weight loss seen with bariatric surgery, and we are starting to see emerging evidence of cardiovascular risk reduction, type 2 diabetes remission, improvement in heart failure with preserved ejection fraction (HFpEF) and more. This “new” class of medications has been around for more than 18 years. We know the safety profiles; they are manageable.
The latest GLP-1 receptor agonists approved for weight management or diabetes — semaglutide (Ozempic/Wegovy, Novo Nordisk) and tirzepatide (Mounjaro/Zepbound, Eli Lilly) — have shown weight loss of 15%, 20%, even up to 25% for those without diabetes and only slightly less for those with diabetes. That weight loss is durable, so long as the patient stays on the medication. Bariatric surgery is an irreversible procedure. Not everyone responds to surgery; some will need medications anyway. For an individual patient, the weight loss may be the same with either method.
With these potent obesity medicines come issues of cost and access. Bariatric surgery has demonstrated a return on investment. We simply do not have that health economic data with our newest obesity medicines.
In a few years, the picture will be much different. CMS in March announced that Medicare Part D plans can begin to cover semaglutide to lower risk for CV events among adults with overweight or obesity with preexisting CVD. That is a welcome change.
GLP-1 receptor agonists are safe; however, we need to obey the contraindications and not prescribe them to people with, for example, a history of medullary thyroid cancer. There is a small subgroup, maybe 5%, who cannot tolerate the drugs due to severe nausea and vomiting. There is a small risk for renal failure with these drugs that can be avoided by keeping the patient hydrated.
The surgery community worked hard on access to care and on putting rigorous standards of care into place, creating centers of excellence in bariatric surgery. There are fellowship training programs for bariatric surgeons. There is a robust system to ensure bariatric surgery can be delivered safely and effectively. We do not have that with medications. Currently, anyone with a medical license can write a prescription for these drugs. We need to follow the example of our surgeons and put together programs that support patients with the amount of weight loss they are going to experience.
- For more information:
- Donna H. Ryan, MD, MABOM, is a professor emerita at the Pennington Biomedical Research Center at Louisiana State University in Baton Rouge, Louisiana.
Bariatric surgery is the most effective long-term treatment for obesity and its comorbid medical problems.
Even with the impressive weight loss seen with newer obesity medications, bariatric surgery has demonstrated longer-term resolutions of many comorbidities. The weight loss is profound, but it is secondary compared with the profound medical benefits we see with bariatric surgery that we do not see with the current anti-obesity medications. We have lots of evidence to support the health benefits of bariatric surgery: a reduction in CV events, diabetes remission, improvement in nonalcoholic steatohepatitis, a reduction in mortality. We have seen some data with GLP-1s showing a reduction in risk for CV events for people with obesity at high CVD risk, but we have not seen data suggesting decreased all-cause mortality risk with these drugs.
We also have economic data showing cost savings within about 3 years. The average bariatric surgery can cost about $25,000. The most effective anti-obesity medications, the GLP-1 receptor agonists taken once weekly, cost about $1,300 per month, or $16,000 per year. Those costs will come down over time. Currently, there are only two companies in the space for GLP-1 receptor agonists. Many more are coming online and liraglutide (Saxenda, Novo Nordisk) will become a generic medicine later this year. But from a population health standpoint, cost is something to consider.
From a safety standpoint, the safety profile of bariatric surgery has significantly changed, in part due to the creation of centers of excellence by American Society for Metabolic and Bariatric Surgery. From a behavioral medicine standpoint, there is an increase in risk for issues such as depression and suicidality among some bariatric surgery patients. Appropriate patient selection and counseling is important. There are also concerns about micro- and macronutrient deficiencies in bariatrics. However, as we continue to follow patients prescribed GLP-1 receptor agonists and see greater, longer-term weight loss, we are seeing similar micronutrient deficiencies there as well.
All drugs have safety issues. We must train prescribers how to manage weight loss. Not everyone responds. The medications are expensive, difficult to produce and supply. We must overcome these issues.
Obesity is a chronic, relapsing disease. Even though bariatric surgery is very effective, we often need dual therapy with adjunctive anti-obesity medications. Oftentimes, we need preoperative and postoperative anti-obesity medications. Whether you have medical weight loss or surgical weight loss, the physiology of obesity and weight regain is present for both methods.
- For more information:
- Christopher Still, DO, FACP, is medical director for the Center for Nutrition and Weight Management and director of the Geisinger Obesity Research Institute at Geisinger Medical Center in Danville, Pennsylvania.
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