Today in Nature Medicine, compelling new research tells that long-term outcomes with metabolic surgery are superior to the outcomes with GLP-1 agonists in persons with diabetes and obesity. These are impressive and important results. But we have to wonder if anyone is really listening. The enthusiasm for advanced obesity medicines is so great that many people are looking right past surgery.

Perhaps more important, we have some doubts about framing surgery versus medicine as a simple binary choice. Though it is easy to think in those terms, that kind of thinking is quite deceptive. It leads people to hope for a one-and-done approach to obesity. But the truth is that this is a chronic disease that requires lifelong care for the best outcomes.

Less Risk of Death and Serious Long-Term Problems

This is a ten-year analysis and the results are compelling. Hamlet Gasoyan and colleagues at the Cleveland Clinic compared outcomes for 1,657 metabolic patients with type 2 diabetes and obesity to 2,275 similar patients managed with GLP-1 agonists and without surgery. They used a doubly robust estimation method to balance baseline characteristics between groups.

What they found was a reduction in deaths by a third and a similar reduction in heart attacks, heart failure, and stroke. Kidney disease and retinopathy were cut in half.

Two limitations are important to note. First, of course, this was an observational study. Though these investigators tried to minimize the potential effects of confounding factors, they could not eliminate it. Second, these data come from a time early in the adoption of semaglutide and tirzepatide. So most of the GLP-1 agonists were older agents like liraglutide, dulaglutide, and exenatide.

Multimodal Therapy, Not a Horse Race

Senior study author Ali Aminian says these data are an important reminder for the important, continuing role of metabolic surgery:

“Our findings indicate that surgery should remain an important treatment option for obesity and diabetes. These long-term benefits are harder to achieve with GLP-1 medicines alone, as many patients stop using the medications over time.”

Facing up to the challenge of obesity is not easy. People are more reluctant to consider surgery for obesity than for other conditions. They recoil from the thought of needing long-term therapy. They are more used to thinking in terms of weight loss – a simple and misleading answer for a complex and chronic disease.

Joe Nadglowski, CEO of the Obesity Action Coalition, cautions against pitting surgery against obesity medicines:

“We need all of the tools we can bring to bear for dealing with obesity over a lifetime. The question should not be which one of them is best. But rather, it should be how can we use each of the options we have for the best outcomes in each and every person living with obesity.”

This is what multimodal obesity care is all about.

Click here for the new study in Nature Medicine and here for further perspective.

The Race Track, painting by Albert Pinkham Ryder / Wikimedia Commons