Great Debates: Undergoing the Knife versus Pill-Popping—The Comparative Efficacy and Cost-Effectiveness of Bariatric Surgery and GLP-1 Receptor Agonists in the Management of Obesity

Abstract

Bariatric surgery has long been the most effective intervention for obesity, providing significant and durable weight loss, with procedures like sleeve gastrectomy and gastric bypass achieving 10-year total weight loss (TWL) rates of 23.4% and 26.9%, respectively. More complex procedures, such as duodenal switch, result in even greater TWL. Recently, glucagon-like peptide-1 receptor agonists (GLP-1 RA) have emerged as a promising pharmacological alternative, demonstrating up to 25.3% TWL with tirzepatide. However, GLP-1 RA efficacy remains inferior to bariatric surgery, with high discontinuation rates due to adverse effects, cost, and limited insurance coverage. While surgery offers superior long-term outcomes and cost-effectiveness, it is underutilized, with less than 1% of eligible patients undergoing surgical intervention annually. GLP-1 RA can expand access to obesity treatment, particularly for patients hesitant or ineligible for surgery, and may serve as a bridge to surgery or an adjunct for postoperative weight regain. Despite their benefits, GLP-1 RAs require sustained adherence, and weight regain is common upon discontinuation. A multidisciplinary approach integrating surgical, pharmacological, and lifestyle interventions is essential for optimizing obesity management. Future research should focus on long-term GLP-1 RA efficacy, combination therapy strategies, and improving access to both surgical and medical obesity treatments.