The list of proven health benefits of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for people living with obesity, with and without diabetes, continues to grow as new research is released. During the 85^th Scientific Sessions, a pair of experts weighed how the efficacy of this pharmacotherapy impacts the relevance of another treatment option—metabolic surgery—for this patient population.

In the session, Ask the Expert—Is There Still a Place for Bariatric Surgery?, Ali Aminian, MD, Professor of Surgery and Director of the Bariatric and Metabolic Institute at the Cleveland Clinic, made the case that it would be unethical and against evidence-based practice to ignore the option of bariatric surgery for suitable candidates. Neda Rasouli, MD, Director of the Diabetes and Endocrinology Clinical Trial Program and Professor of Medicine at the University of Colorado School of Medicine, presented evidence that existing pharmacotherapy for obesity and new drugs being evaluated in ongoing clinical trials make medication the preferred approach to treatment.

New anti-obesity medications have comparable efficacy to bariatric surgery, they are non-invasive, they improve clinical outcomes through cardiorenal metabolic benefits independent of weight loss, and dose flexibility supports personalized care, Dr. Rasouli said.

“Right now, we have Roux-en-Y surgery with the highest efficacy in weight loss, then sleeve gastrectomy after that. Then we have tirzepatide as a dual agonist and the [anti-obesity drug] which is approved right now with the highest efficacy in weight loss, but where are we going to be a few years from now?” she said. “We’re going to have, hopefully, a few other medications approved, especially our triple agonists, which are getting to a weight loss that is the same level of a sleeve gastrectomy.”

Dr. Rasouli highlighted four incretin-based therapies in the pipeline that result in 10%–20% weight loss, have favorable safety profiles, are well-tolerated by a majority of individuals, and have a more than 80% response rate: retatrutide, CargriSema, orfoglipron, and MariTide.

However, over the past two decades, the health benefits of GLP-1 RAs have already been shown to be achievable through bariatric surgery, Dr. Aminian noted. These include improved diabetes outcomes beyond weight loss, including cardiovascular benefits, metabolic dysfunction-associated steatohepatitis (MASH) improvement, and increased quality of life.

Moreover, Dr. Aminian said metabolic surgery has proven to be a safe and effective avenue to significant and sustained weight loss, while durable weight reduction through GLP-1 RAs is a challenge because of compliance issues.

“Less than half of the patients stay on GLP-1 RAs at one year, and we know that most of the lost weight is regained within a year after stopping,” he said. “However, bariatric surgery is one and done. You do the two-hour procedure, and you don’t need to be taking a shot for the rest of your life.”

In randomized controlled trials (RCTs) and in the real world, people living with obesity, with or without diabetes, and people living with diabetes achieve about 25%–35% weight loss following bariatric surgery, Dr. Aminian reported. People living with obesity, with or without diabetes, achieve about 16% weight loss while taking GLP-1 RAs in RCTs, and about 11% weight loss while taking GLP-1 RAs outside of a trial. Meanwhile, people living with diabetes experience a weight reduction of about 10% while taking GLP-1 RAs in RCTs, and about 7% weight reduction while taking one of these drugs outside of a trial.

While acknowledging the proven efficacy of metabolic surgery in the treatment of obesity, Dr. Rasouli said the need for this option is waning despite a growing number of people living with obesity. Globally, an estimated one in two people will be living with the disease—and the myriad comorbidities that come with it—within the next 10 years, she said.

“Obesity is a multifactorial disease,” Dr. Rasouli said. “Environmental, social-economic or social-cultural, genetic, epigenetic, physiological, and behavioral factors play important roles in the pathophysiology of this disease. Therefore, it makes sense for the management of obesity to a consider multifaceted approach.”

Additionally, despite a recommendation for metabolic surgery in the Standards of Care in Diabetes—2025 from the American Diabetes Association^® (ADA) that states surgery should be considered as “a weight and glycemic management approach in people with diabetes with a body mass index (BMI) of ≥ 30 kg/m2 (or ≥ 27.5 kg/m2 in Asian American individuals) who are otherwise good surgical candidates,” only 1% of the people who meet National Institutes of Health criteria for metabolic surgery go through with the procedure, Dr. Rasouli noted.

That doesn’t minimize the overall need for effective treatment for obesity.

“There’s plenty of room for everybody in this space,” Dr. Aminian said. “Unfortunately, there are so many patients around who don’t have access to any treatment, or they don’t seek treatment, so patients and providers must have the choice to choose between all evidence-based therapies, including medications, bariatric surgery, combination therapy, lifestyle—anything.”

On-demand access to recorded presentations from this session will be available to registered participants of the 85^th Scientific Sessions through August 25.