For people with obesity, surgeries that shrink, reshape, or otherwise alter the anatomy of the stomach have long reigned supreme as the surest way to weight loss. But in the last few years, with the approval of GLP-1 drugs like Wegovy and Zepbound, more and more people are opting for obesity medicines over gold-standard surgical treatments.
“On a population level, among a subset of commercially insured individuals, that is the tradeoff that is happening” said Thomas Tsai, the lead author of a new study that looked at health records of 17 million privately insured Americans with obesity. It found that between 2022 and 2023, as prescriptions for GLP-1 drugs more than doubled, rates of bariatric surgery fell by 25.6%.
The findings, published Wednesday in JAMA Network Open, mark a sharp turnaround from trends over the last decade, and spell an uncertain future for hospitals and clinics that derive a significant portion of their revenues from such procedures.
Amid growing awareness that obesity is a chronic biological, and therefore treatable, disease, bariatric surgery volumes steadily increased from 158,000 people in 2011 to 280,000 in 2022, according to the American Society for Metabolic and Bariatric Surgery. For many surgical programs, 2022 was a record year, due to pent-up demand from the Covid-19 pandemic, when many elective surgeries were paused. “But that growth trajectory dropped precipitously during 2023, corresponding with a massive uptake in GLP-1 drugs,” Tsai said.
As a practicing bariatric surgeon at Brigham and Women’s Hospital in Boston, he had noticed an uptick in last-minute cancellations, especially among patients who had recently started taking GLP-1 medications. After hearing similar stories from other physicians, Tsai, who is also a health policy researcher at Harvard Medical School and the T.H. Chan School of Public Health, wanted to know if what they were seeing on the front lines was part of a national shift from surgical toward pharmacological management of obesity.
“It’s obvious that there’s been a decrease in bariatric surgeries, and the assumption we’ve been making as a field is that it’s related to the increase in GLP-1s,” said Marc Bessler, chair of surgery at Northwell Lenox Hill Hospital in New York City and CEO of EndObetes, a startup focused on developing endoscopic devices to treat obesity and diabetes. “This study shows that they’re clearly temporally related.”
What’s less clear is whether the downturn will be a temporary blip, or a permanent fixture of the future of obesity medicine.
Some researchers believe what they’re witnessing is the start of the replacement of bariatric surgery — an effective but more invasive (and permanent) intervention — with drugs that are getting even easier to take and showing additional benefits like reducing heart complications and protecting the brain from Alzheimer’s related neurodegeneration.
Others think that the surging popularity of GLP-1 drugs will have a “rising tides effect” and ultimately increase the number of patients seeking surgical treatment — that as the excitement over weight loss drugs recasts obesity as a disease rather than a cosmetic issue or a moral failing, and reduces the weight stigma that is still pervasive in many corners of the health care system, more people will seek out proven therapies for weight loss.
“Some of those individuals who now believe they deserve care will ultimately choose surgery as the option,” Randy Seeley, director of the Michigan Nutrition Obesity Research Center, told STAT in an email. “Make no mistake, pharmacological use will dwarf surgery in terms of the number of patients but it will remain a viable option.”
Some choose surgery because they don’t want to stay on the medications forever or because of side effects or because the drugs don’t work for them; in clinical trials, about 15% of people didn’t see meaningful weight loss. Others may choose surgery because it’s better covered by insurance.
Although GLP-1 drugs are catching up to bariatric surgery in terms of their effectiveness in reducing obesity and related health conditions, they are expensive — $900 to $1,350 per month — and must be used indefinitely to maintain weight loss. Medicare doesn’t cover them and many insurers are cracking down on prescriptions or adding lifetime caps in an effort to rein in spiraling costs. Recent studies suggest that bariatric surgery, even though it has higher upfront costs, may be a better deal in the long run.
In one, researchers from the University of South Florida found that the cost of ongoing use of some GLP-1 drugs like Saxenda and Wegovy surpasses bariatric surgery in 9 to 12 months. Another analysis, from a team at Northwestern University Feinberg School of Medicine, found that bariatric surgery, which typically costs between $17,000 and $23,000, delivered two more healthy years of life and saved about $9,000 a year, compared to GLP-1 drugs. The results, which were presented at the American College of Surgeons Clinical Congress last week, will likely inform how insurance companies decide to cover both treatments going forward.
“Right now there’s just a high degree of uncertainty for what this all means in terms of bariatric surgery volume in the long-term,” Tsai said. “But for patients, with all the different treatment options that now exist, this truly is a golden age. The challenge for the next few years is making sure patients are able to access them.”
In their latest analysis, Tsai and his colleagues found that among the commercially insured, less than 6% of people with obesity were being treated with either surgery or GLP-1 drugs, underscoring that despite the shifts underway, obesity remains a profoundly underaddressed public health issue.
The new data also add empirical weight to anecdotes of bariatric programs closing in Boston and other parts of the country due to a mix of decreases in demand, and ongoing health care consolidation. Over the summer, when a large medical weight loss clinic in Oklahoma abruptly shuttered its bariatric surgery program — staff were laid off, procedures canceled, and patients left in the lurch — hospital executives blamed the explosive popularity of GLP-1 drugs like Wegovy and Zepbound.
At Northwell, surgeons aren’t being let go, Bessler said. But the hospital is also not hiring new ones. “We’re not dramatically changing our mindset toward bariatric surgery,” he said. His expectations are that within the next three to five years, surgery volumes will return to baseline levels. “I think a lot of people are somewhat betting on that and not closing down.”
But many in the field remain concerned that even a short-term constriction in capacity could have ripple effects far into the future. Currently, only about 1% of patients eligible for bariatric surgery actually receive the treatment. “There are a lot of financial headwinds, and where surgical programs may not be able to wait this out long enough, it has the potential to create further imbalance,” Tsai said.
In the last few years, obesity medicine has been moving toward a more precision medicine model — identifying different subtypes and tailoring treatments to patients. “With volume in bariatric surgery decreasing so quickly, we’re almost refragmenting that more multidisciplinary approach,” Tsai added. “My worry is people aren’t thinking about all of obesity and all of metabolic disorders and some of the tradeoffs.”
