Mark Twain once said, "History never repeats itself, but it does often rhyme."
As a weight-loss surgeon for over 20 years, I have witnessed the new obesity medications with both anticipation and nostalgia. Just like bariatric surgery experienced a generation ago, we are now hearing the same refrains for obesity medications move from excitement to doubt. Unlike previous weight-loss drugs plagued by concerns for inefficacy and jeopardy, the new medications are safe and effective. Simply put, these medications are paradigm-shifting for a disease that has been primarily surgically treated for the past generation.
Let's explore the similarities between the obesity medications and bariatric surgery stories, and examine how the two approaches to obesity management will fit together in practice.
Surgery was a first responder to obesity as surgery has been for other diseases such as tuberculosis, cancer, and heart disease. Bariatric surgery has experienced significant growth; demonstrated reduction in diabetes, cancer, and severe COVID; increased both quality and quantity of life for patients; and the field has established . Bariatric surgery has also provided a framework for understanding the disease of obesity and, most importantly, offered an effective therapy for patients through anatomic optimization until other treatment modalities were available. These new treatment modalities have now arrived. While bariatric surgery has many mechanisms for successful treatment, the mode of treatment common to both bariatric surgery and obesity medications is the hormone glucagon-like peptide-1, which produces satiety and glucose stabilization.
Beyond this molecular similarity for mechanism of action, bariatric surgery and obesity medications have also shared a similar cadence of public response. The same tropes regarding obesity treatment trotted out for bariatric surgery are now returning for obesity medications:
Patients should eat less and exercise more.
Famously, the showed that despite national exhortation to diet and exercise more, patients with obesity regained weight by diet and exercise alone.
This therapy won't work and isn't safe.
Both surgery and new obesity medications have Level 1, randomized trial evidence demonstrating safety and efficacy. By the way, obesity either.
This therapy won't work long-term.
Bariatric surgery now has 40-year data demonstrating gains in life-expectancy. While obesity medications are early in their experience, I expect that consistent weight loss should have an enduring health benefit.
We need to change the food supply and rely on prevention.
Terrific sentiment, but while we wait for this societal shift, what do we do for millions of patients in need? Sacrifice a generation?
These misconceptions did not hold true for bariatric surgery, and I don't believe they will hold true for medications either.
Of course, however, many questions remain about how these two approaches to obesity management will fit together in practice.
You may wonder whether, with successful obesity medications, I worry about losing patients as a bariatric surgeon. The answer is absolutely not -- there are so many patients in need. But obesity specialists will need to consider how obesity medications and bariatric surgery should interact. Separately or in combination, before or after surgery? Which comes first? When do you change therapy? What about cost? What determines therapy -- stage of disease? How do other diseases associated with obesity impact the treatment plan? Determining how the interactions should work and for which populations (for example, some patients will not respond to obesity medications or may be opposed to being on a medication for life) will require significant investigation in the hopes of precision medicine and surgery.
What I do worry about is patients not gaining access to safe and effective therapy. Ultimately, what drives utilization is the same regardless of the type of therapy -- it's about what is best for the patient.
Luckily, we're on the road toward better access. I'm thankful for the critical role obesity medications have played in raising awareness of obesity treatment through investigation, media interest, and inevitably, direct-to-consumer advertising. It is essential to discuss all treatment options with patients who for too long have been shamed into not seeking treatment, making obesity an often self-treated disease. Obesity poses a clear and present danger -- from its negative impact upon health, , and even -- that can be mitigated with safe and effective therapies.
Cancer care provides the best analogue for the paradigm I'd like to see for obesity care. Rather than segregating care to either medicine or surgery clinics, an ideal paradigm for obesity care is a cancer center approach for patients with obesity. Under one roof, these centers for weight management can provide all therapies using standardized, evidence-based practice. These centers for weight management can also provide a rich substrate for investigation and a defined model of insurance coverage for obesity medications. Like National Cancer Institute centers, these centers for weight management can be engines for treatment and innovation.
As a first responder to obesity, bariatric surgery provided a beachhead to the onslaught of obesity -- and now reinforcements have arrived. The waves of naysayers will continue but innovation won't stop when the need is so great. We are on the right path to treat patients with obesity. To quote Twain again, "Continuous improvement is better than delayed perfection."
is professor and vice chair in the Department of Surgery at Yale School of Medicine in New Haven, Connecticut.
Disclosures
Morton disclosed consulting payments from Ethicon (which makes surgical staplers used in bariatric surgery), Novo Nordisk (a manufacturer of obesity drugs), and Olympus.