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.

Keywords

GLP-1 bariatric surgery weight loss

Key Takeaway

Bariatric surgery continues to provide the highest durable weight loss for obese patients.

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 post-operative weight regain.

Introduction

The prevalence of obesity worldwide has doubled in the last 30 years, and in the United States (US) as of 2020. The CDC reports that approximately 41.9% of adults in US have obesity, equating to more than 100 million people.^1,2 Obesity is associated with the development of many other chronic health conditions like diabetes mellitus (DM), cardiovascular disease (CVD), hypertension (HTN), obstructive sleep apnea, and certain cancers.^1,3 Obesity and obesity related diseases pose a significant health burden, and treatment can be challenging.^1,2 Bariatric surgery has been established as a highly effective tool for treating obesity, and compared to medical weight loss alone, surgery can lead to meaningful long-term weight loss and greater resolution of some obesity related comorbidities.^4,5 However, medical weight loss strategies were generally limited to diet and exercise programs with medication adjuncts to treat comorbidities.⁶ The emergence of glucagon-like peptide-1 receptor agonists (GLP-1 RA) has introduced a promising pharmacological option for significant weight loss, leading some to consider them a viable alternative to surgery.⁷ This shift towards medical management of obesity offers quicker access to care and has the potential to expand the reach of obesity treatment on a public health magnitude. While GLP-1 RA demonstrate encouraging results, their weight loss efficacy still does not match that of bariatric surgery, even under the controlled conditions of randomized clinical trials. This manuscript reviews the reported outcomes, benefits, side effects, cost-effectiveness, and limitations of bariatric surgery and GLP-1 RAs in obesity management.

Advantages of Bariatric Surgery in the Treatment of Obesity

Efficacy and Durability

Both bariatric surgery and GLP-1 RAs improve the debilitating effects of obesity, but surgery has proven superior durable weight loss outcomes. Long-term data on GLP-1 RAs is still lacking, whereas bariatric procedures such as sleeve gastrectomy and gastric bypass have demonstrated 10-year total weight loss (TWL) outcomes of 23.4% and 26.9%, respectively.⁸ Procedures that include a malabsorptive component, such as single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) and duodenal switch (DS), achieve even greater long-term TWL, at 34% for SADI-S and 40.7% for DS.^9,10 Bariatric procedures achieve significant and sustained weight loss, even in patients with severe obesity (BMI >50), where medications alone may be insufficient.⁶ Moreover, procedures like SADI-S and DS add the effects of malabsorption to the benefits of the restrictive/metabolic surgeries, enabling greater improvements in obesity-related comorbidities. Conversely, GLP-1 RAs have shown to have 15.2% TWL at 104 weeks for semaglutide and up to 25.3% TWL at 88 weeks for tirzepatide, a dual agonist of GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptors. (Table 1).^6,11,12 Third generation GLP-1s are showing a potential for even greater weight loss; in a phase 2 clinical trial, retatrutide demonstrated a 24.2% weight reduction at 48 weeks.¹³ As research on pharmacologic therapies advances, the role of GLP-1 RAs in obesity management will likely expand, but for now, bariatric surgery remains the gold standard for long-term weight loss and metabolic health.

Table 1.

Surgery Versus GLP-1 Agonists on Total Weight Loss.

Intervention	Total Weight Loss Percentage
Sleeve gastrectomy	25.2 at 1 year⁵⁸
	18.8 at 5 years⁵⁸
Gastric bypass	31.2 at 1 year⁵⁸
	25.5 at 5 years⁵⁸
Semaglutide (GLP-1 RA)	14.9-17.4 at 68 weeks¹¹
	15.2 at 104 weeks¹¹
Tirzepatide (GLP-1, GIP RA)	20.9 at 72 weeks⁵⁷
	25.3 at 88 weeks⁵⁷

Several studies have also evaluated effects of bariatric surgery and GLP-1 RAs on reducing other obesity-related conditions such as DM, CVD, HTN, kidney disease, and stroke. Diabetes remission rates for GLP-1 RAs are comparable to results of a sleeve gastrectomy, though are variable (32.5-92%) depending on the specific GLP-1 RA being studied.¹⁴ Treatment with semaglutide resulted in a 20% reduction in nonfatal MI, nonfatal stroke, and cardiovascular related death.¹⁵ A large retrospective cohort study by Dicker et al¹⁶ compared patients who had undergone bariatric surgery to those treated with a GLP-1 RA and found no statistically significant difference in all-cause mortality or major adverse cardiac events for patients with obesity and a diagnosis of diabetes for greater than 10 years.¹⁶

These medications are very effective but limited due to patient compliance and side effects. Although symptoms are usually transient and mild to moderate in severity, common adverse effects of semaglutide and tirzepatide include nausea (35% and 46%), diarrhea (21% and 23.5%), constipation (20% and 22%), and vomiting (16% and 15.5%), with 81-84% of patients reporting adverse events overall.^12,17-19 The high adverse event rates experienced by patients on GLP-1 RAs may affect patient compliance and explain the elevated discontinuation rates of up to 50% at 1 year.¹⁸ Patients are at a greater risk of experiencing adverse events with higher doses or during periods of dose escalation. There is some suggestion that adverse events are occurring less frequently with newer generation GLP-1 RAs; nonetheless, severe complications such as pancreatitis, cholecystitis, and medullary thyroid cancer (observed in mice) have also been reported but lack strong clinical correlation in large trials.^12,14,15,20 Despite their effectiveness, the long-term success of GLP-1 RAs is often limited by tolerability concerns, dose-dependent adverse effects, and the potential for rare but serious complications, highlighting the need for careful patient selection, monitoring, and continued research into improving their safety and adherence.

Compliance and Limitations of Medications

Adherence to GLP-1 receptor agonists is critical for sustained weight loss but is often challenging due to side effects, high costs, manufacturer availability, and limited insurance coverage. The discontinuation rates for GLP-1 RAs are high, with real-world studies showing that less than 50% of patients remain on these medications at one year, leading to weight regain.¹⁸ The STEP and SURMOUNT-4 trials demonstrated that upon discontinuation, patients regained approximately two-thirds of their lost weight, with cardiometabolic benefits disappearing.^17,20,21 Whether due to an unaffordable cost or due to side effects, discontinuation typically leads to weight regain. While still not fully understood, we know that weight regain after GLP-1 RA cessation is in part due to a surge of ghrelin, which stimulates the patient’s appetite and contributes to weight regain. Weight regain also occurs even in patients who continue lifestyle interventions like dietary changes and regular exercise.³ Interestingly, patients being treated for obesity alone had higher rates of medication discontinuation compared to patients with obesity and DM (50.3% compared to 43.2%).²² Rather than discontinuation due to adverse side effects, this may be due to limited insurance coverage of GLP-1 RAs for obesity during the study period, therefore incurring a higher out of pocket cost to the patient, and increased likelihood of discontinuation.²²

Cost-Effectiveness

Bariatric surgery offers superior cost-effectiveness over time compared to GLP-1 RAs. Studies by Docimo et al highlight that the cost of GLP-1 RAs (eg, Wegovy or Mounjaro) exceeds the cost of sleeve gastrectomy or gastric bypass within 8.3-14.72 months, depending on the medication and procedure.²³ Compared to traditional medical management of obesity, surgery is still more cost effective at five years post operatively, and cost-effectiveness continues to improve over a longer time period.²⁴ The weekly cost of semaglutide and tirzepatide can exceed $1,000, making these medications inaccessible for many patients. In contrast to weight loss medications, bariatric surgery does not rely on continuous compliance for effectiveness and provides more durable results with fewer long-term relapses. A cost-effectiveness analysis by Cunningham et al determined that patients treated with bariatric surgery have fewer long-term expenditures compared to currently available medical therapy options.²⁵ The Institute for Clinical and Economic Review’s 2022 report concluded that the cost of semaglutide or liraglutide exceeds commonly accepted thresholds for cost-effectiveness, requiring a price reduction of 44-57% to achieve value benchmarks.²⁶

Advantages of GLP-1 RAs in the Treatment of Obesity

Expanding Access to Care

Currently in the US, less than 1% of eligible patients undergo bariatric surgery annually for the treatment of obesity.²⁷ There are many reasons contributing to this, but one of the major barriers to undergoing bariatric surgery is related to concerns from both patients and primary care physicians (PCP) regarding complications from surgery.²⁸ This in turn affects PCP referral patterns.²⁹ Focus groups conducted with PCPs in Wisconsin demonstrated that decision making often over-emphasizes risk of bariatric surgery, while under-prioritizing treatment for obesity.³⁰ This negative perception of bariatric surgery is also shared by patients. Multiple studies interviewing patients suffering from obesity highlighted that patients had concerns over the legitimacy of bariatric surgery for the treatment of obesity or viewed surgery as a last resort.^31,32

The fear of bariatric surgery is largely unfounded, as its safety is well-established, yet it still limits access to obesity care.³³ The hope is that GLP-1 RAs will help expand access to care as these medications are perceived as safe and have been prescribed for many years by PCPs for the management of diabetes. A recent study demonstrated that unlike bariatric surgery, the perceived side effects of these medications by PCPs was actually lower than those reported in clinical trials.³⁴ PCPs are also more familiar with these medications. A survey of over 750 health care professionals showed that 65% of providers were very or extremely familiar with GLP-1 RA.³⁵ Until we can dispel the current stigma regarding bariatric surgery, GLP-1 RAs provides an easier avenue for access to obesity care.

GLP-1 RA may also improve access to effective obesity treatment for patients who are not surgical candidates. A cohort study published by Ilanga, et al evaluated patients with a BMI >50 who were deemed too high risk to undergo bariatric surgery, and individuals treated with GLP-1 RAs were able to lower their BMI by an average of 5.5 points, therefore successfully bridging them to bariatric surgery.³⁶ For patients with obesity who are in need of other elective surgeries like hernia repair or orthopedic surgery, utilizing GLP-1 RAs for weight loss and comorbidity management can be a successful alternative to bariatric surgery.^37,38 Patients with obesity in need of elective hernia repair who were treated with GLP-1 RAs preoperatively had an average BMI reduction by 6 points, and had a shorter time to surgery compared to controls.³⁷

Shorter Time to Treatment

Another hypothesis for the low prevalence of bariatric surgery for the treatment of obesity is due to surgical resource limitations and restricted access to surgery based on insurance qualifications or insurance payer type.^39-41 Alvarez et al found that patients with Medicaid insurance were significantly more likely to have long wait times to surgery compared to those with private insurance (OR 3.02).⁴¹ Other studies have also identified public insurance to be associated with long-wait times.³⁹ These delays are a huge deterrent to receiving care, and up to 49.1% of patients cited long wait times as the primary reason they did not follow through with bariatric surgery after surgical consultation.⁴² In the US, several studies have evaluated regional wait times. Alvarez et al utilized a state-wide database in Michigan and identified median wait times ranging from <67 days (lowest quartile) to >204 days (highest quartile).⁴¹ Similar variability in time from initial consultation to surgery was seen in published data from Stanford (mean 150 days, range 7-1813 days), and the University of Chicago (mean wait time 11.2 months, range 3-38 months).^39,43

In some of those studies, wait times were also found to be increasing over the study period, despite data demonstrating that there is no health benefit to this delay to surgical treatment and no difference or improvement in surgical outcomes.^40,41,43,44 For these reasons, GLP-1 RAs offer an opportunity to improve timely access to obesity treatment, and patients could potentially start treatment after their first contact with the health care system. Over the last four years the US has seen a 2-fold increase in use of GLP-1 RAs for treatment of obesity, rather than a primary treatment for DM.⁴⁵ FDA approvals in 2024 mirrored this trend, and approved indications for use of GLP-1 RAs to include treating obesity alone (BMI >30), being overweight (BMI >27) with one weight-related comorbidity, and even for obese patients with obstructive sleep apnea.⁴⁶ With increasing access to and availability of GLP-1 RAs it is not surprising that from 2022 to 2023 privately insured patients experienced a two times increased use of GLP-1 RAs for the treatment of obesity, and a 25.6% decrease in patients undergoing bariatric surgery during that same time period.⁷

Easier Lifestyle Adjustment

Although surgery has proven health benefits and overall success rates for weight loss, many patients will still experience issues with weight regain in the long-term, or experience symptoms related to complications from surgery.^4,5 Recent studies indicate that roughly one-third of patients (35.4%) had experienced weight regain of >25% from their nadir weight at four years postoperatively.⁴⁷ At five years post operatively, 36% of patients who were initially satisfied after surgery were later unsatisfied with their results. Dissatisfied patients were individuals who experienced higher percent weight regain, had a lower percent total weight loss, and those who had discomfort from somatic symptoms at 5 years.⁴⁸

Complications from bariatric surgery are relatively rare and rates have been declining, but surgically altered anatomy puts the patient at risk for long-term complications like dumping syndrome, marginal ulcers, or nutritional deficiencies for the remainder of their lives.^49-51 While most of these complications are managed with dietary or lifestyle changes, this requires patients to adhere to permanent lifestyle adjustments, which may be difficult to sustain over time.^52,53 The psychosocial consequences of lifestyle changes after bariatric surgery may also play a role in patients’ ability to adhere to permanent lifestyle changes, including challenges with eating in social settings and patient reported feelings of isolation related to these limitations.⁵⁴

Although adverse events can also occur from GLP-1 RA use, most commonly these are reported as gastrointestinal in nature and include nausea, vomiting, and diarrhea or constipation. Multiple studies have documented that the vast majority of side effects are non-serious, mild to moderate in severity, and transient.^12,19 Notably, in clinical trial data the most common consequence of experiencing adverse events are interruptions in doses (12%) or cessation of the medication (1.6-6%), and very few patients experience permanent or long-term effects from GLP-1 RAs use.^12,19 Gorgojo et al published recommendations from a multidisciplinary expert panel on how to mitigate the intensity of adverse events from GLP-1 RAs, including improving patient education and slower dose adjustments. Overall, they concluded that in select patients GLP-1 RAs are considered easy to manage and have a good tolerability profile.¹⁹ Patients are also generally satisfied with the ease of use of GLP-1 RAs available in pen injection devices, and more likely to adhere to medication use with weekly injections.⁵⁵

Conclusion

While bariatric surgery demonstrates superior efficacy and durability, obesity is a complex, chronic disease that requires a multifaceted approach. Ultimately, more studies are needed comparing GLP-1 RA use to surgery for the treatment of obesity. Combining surgical, pharmacological, and lifestyle interventions is essential for comprehensive care, analogous to the total comprehensive care seen in cancer treatment protocols. Current data suggests that GLP-1 RAs can serve as adjunctive treatments by improving preoperative weight loss (akin to neoadjuvant therapy) to prehabilitate patients with BMI >50. This not only enhances their surgical candidacy with a greater reduction in BMI pre-operatively, but also decreases their perioperative risk.³⁶ Additionally, GLP-1 RAs may play a role in treating post-surgical weight regain (adjuvant therapy), with promising results in weight loss maintenance. In patients who experienced weight regain after bariatric surgery and were treated with either liraglutide or semaglutide, the median patient lost 67.4% of the weight regained after the last bariatric procedure.⁵⁶

For those patients who do not wish to undergo surgery, new research is indicating that GLP-1 RAs may be a safe and less invasive option for weight loss and resolution of obesity-related comorbidities. However, while GLP-1 RAs offers a less invasive alternative for those unwilling or unable to undergo surgery, bariatric surgery still outperforms GLP-1 RAs in long-term weight loss, durability, and cost-effectiveness. Surgery does carry risks, but these are generally rare and manageable, and the benefits of sustained weight loss often outweigh the potential complications. Conversely, GLP-1 RAs face challenges related to compliance, cost, and long-term efficacy. Moving forward, a multidisciplinary team (including, but not limited to primary care providers, endocrinologists, gastroenterologists, psychologists, and surgeons) that integrates both surgical and pharmacological interventions may optimize obesity management. Advocacy for improved access, reduced costs, and comprehensive follow-up to both surgical procedures and pharmacological treatments is crucial to leveraging all available tools in the fight against obesity.

Footnotes

Author Contributions

All authors participated in manuscript writing and editing.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Paul Brosnihan

Christian Perez

References

Obesity and overweight. Accessed January 20, 2025.https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

CDC . Adult obesity facts. Obesity. 2025. https://www.cdc.gov/obesity/adult-obesity-facts/index.html. Accessed 20 January 2025.

Abdullah bin

Ahmed I

. A comprehensive review on weight gain following discontinuation of glucagon-like peptide-1 receptor agonists for obesity. J Obes. 2024;2024(1):8056440. doi:10.1155/2024/8056440

Eisenberg

Shikora

Aarts

, et al. 2022 American society of metabolic and bariatric surgery (ASMBS) and international federation for the surgery of obesity and metabolic disorders (IFSO) indications for metabolic and bariatric surgery. Obes Surg. 2023;33(1):3-14. doi:10.1007/s11695-022-06332-1

Courcoulas

Patti

, et al. Long-term outcomes of medical management vs bariatric surgery in type 2 diabetes. JAMA. 2024;331(8):654-664. doi:10.1001/jama.2024.0318

Sarma

Palcu

. Weight loss between glucagon‐like peptide‐1 receptor agonists and bariatric surgery in adults with obesity: a systematic review and meta‐analysis. Obesity. 2022;30(11):2111-2121. doi:10.1002/oby.23563

Lin

Mehrotra

Tsai

. Metabolic bariatric surgery in the era of GLP-1 receptor agonists for obesity management. JAMA Netw Open. 2024;7(10):e2441380. doi:10.1001/jamanetworkopen.2024.41380

Salminen

Grönroos

Helmiö

, et al. Effect of laparoscopic sleeve gastrectomy vs Roux-en-Y gastric bypass on weight loss, comorbidities, and reflux at 10 years in adult patients with obesity: the SLEEVEPASS randomized clinical trial. JAMA Surg. 2022;157(8):656-666. doi:10.1001/jamasurg.2022.2229

Sánchez-Pernaute

Herrera

MÁR

Ferré

, et al. Long-term results of single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). Obes Surg. 2022;32(3):682-689. doi:10.1007/s11695-021-05879-9

10.

Bolckmans

Himpens

. Long-term (>10 yrs) outcome of the laparoscopic biliopancreatic diversion with duodenal switch. Ann Surg. 2016;264(6):1029-1037. doi:10.1097/SLA.0000000000001622

11.

Bergmann

Davies

Lingvay

Knop

. Semaglutide for the treatment of overweight and obesity: a review. Diabetes Obes Metab. 2023;25(1):18-35. doi:10.1111/dom.14863

12.

Aronne

Sattar

Horn

, et al. Continued treatment with tirzepatide for maintenance of weight reduction in adults with obesity: the SURMOUNT-4 randomized clinical trial. JAMA. 2024;331(1):38-48. doi:10.1001/jama.2023.24945

13.

Jastreboff

Aronne

Ahmad

, et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med. 2022;387(3):205-216. doi:10.1056/NEJMoa2206038

14.

Essop

Tran

Purdy

Daly

. Comparative effects of GLP-1 agonists, sleeve gastrectomy and Roux-en-Y gastric bypass on diabetes mellitus outcomes. Curr Diab Rep. 2024;24(12):273-289. doi:10.1007/s11892-024-01554-2

15.

Drucker

. Efficacy and safety of GLP-1 medicines for type 2 diabetes and obesity. Diabetes Care. 2024;47(11):1873-1888. doi:10.2337/dci24-0003

16.

Dicker

Sagy

Ramot

, et al. Bariatric metabolic surgery vs glucagon-like peptide-1 receptor agonists and mortality. JAMA Netw Open. 2024;7(6):e2415392. doi:10.1001/jamanetworkopen.2024.15392

17.

Rubino

Abrahamsson

Davies

, et al. Effect of continued weekly subcutaneous semaglutide vs placebo on weight loss maintenance in adults with overweight or obesity: the STEP 4 randomized clinical trial. JAMA. 2021;325(14):1414-1425. doi:10.1001/jama.2021.3224

18.

Gleason

Urick

Marshall

Friedlander

Qiu

Leslie

. Real-world persistence and adherence to glucagon-like peptide-1 receptor agonists among obese commercially insured adults without diabetes. J Manag Care Spec Pharm. 2024;30(8):860-867. doi:10.18553/jmcp.2024.23332

19.

Gorgojo-Martínez

Mezquita-Raya

Carretero-Gómez

, et al. Clinical recommendations to manage gastrointestinal adverse events in patients treated with Glp-1 receptor agonists: a multidisciplinary expert consensus. Journal of Clinical Medicine. 2023;12(1):145. doi:10.3390/jcm12010145

20.

Khan

Ndumele

Kazi

. Discontinuation of glucagon-like peptide-1 receptor agonists. JAMA. 2024;333:113-114. doi:10.1001/jama.2024.22284

21.

Wilding

JPH

Batterham

Davies

, et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: the STEP 1 trial extension. Diabetes Obes Metab. 2022;24(8):1553-1564. doi:10.1111/dom.14725

22.

Lee

Peasah

Good

Inneh

Patel

. GLP-1 receptor agonist discontinuation among patients with obesity and/or type 2 diabetes. JAMA Netw Open. 2024;7(5):e2413172. doi:10.1001/jamanetworkopen.2024.13172

23.

Docimo

Shah

Warren

Ganam

Sujka

DuCoin

. A cost comparison of GLP-1 receptor agonists and bariatric surgery: what is the break even point? Surg Endosc. 2024;38(11):6560-6565. doi:10.1007/s00464-024-11191-1

24.

Lauren

Lim

Krikhely

, et al. Estimated cost-effectiveness of medical therapy, sleeve gastrectomy, and gastric bypass in patients with severe obesity and type 2 diabetes. JAMA Netw Open. 2022;5(2):e2148317. doi:10.1001/jamanetworkopen.2021.48317

25.

Cunningham

Bloomfield

Chen

, et al. Bariatric and foregut; an alalysis of the cost-effectiveness of Roux-en-Y gastric bypass and sleeve gastrectomy for obesity management. Journal of the American College of Surgeons. 2024;239(5):S21. doi:10.1097/XCS.0000000000001157

26.

Atlas

Kim

Nhan

, et al. Medications for obesity management: effectiveness and value: a summary from the institute for clinical and economic review’s New England comparative effectiveness public advisory council. J Manag Care Spec Pharm. 2023;29(5):569-575. doi:10.18553/jmcp.2023.29.5.569

27.

English

DeMaria

Hutter

, et al. American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States. Surg Obes Relat Dis. 2020;16(4):457-463. doi:10.1016/j.soard.2019.12.022

28.

Funk

Jolles

Fischer

Voils

. Patient and referring practitioner characteristics associated with the likelihood of undergoing bariatric surgery: a systematic review. JAMA Surg. 2015;150(10):999-1005. doi:10.1001/jamasurg.2015.1250

29.

Aly

Hachey

Pernar

LIM

. Gender disparities in weight loss surgery. mis. 2020;4:21. doi:10.20517/2574-1225.2019.57

30.

Funk

Jolles

Voils

. Obesity as a disease: has the AMA resolution had an impact on how physicians view obesity? Surg Obes Relat Dis. 2016;12(7):1431-1435. doi:10.1016/j.soard.2016.05.009

31.

Chao

Diaz

Ghaferi

Dimick

Byrnes

. Questioning the legitimacy of bariatric surgery: a qualitative analysis of individuals from the community who qualify for bariatric surgery. Surg Endosc. 2022;36(9):6733-6741. doi:10.1007/s00464-021-08949-2

32.

Murtha

Alagoz

Breuer

, et al. Individual-level barriers to bariatric surgery from patient and provider perspectives: a qualitative study. Am J Surg. 2022;224(1):429-436. doi:10.1016/j.amjsurg.2021.12.022

33.

Aminian

Brethauer

Kirwan

Kashyap

Burguera

Schauer

. How safe is metabolic/diabetes surgery? Diabetes Obes Metab. 2015;17(2):198-201. doi:10.1111/dom.12405

34.

Krishnan

Srivastava

Attaluri

, et al. Physician perceptions of the safety and efficacy of GLP-1 receptor agonists: underestimation of cardiovascular risk reduction and discrepancies with clinical evidence. J Cardiovasc Dev Dis. 2025;12(1):19. doi:10.3390/jcdd12010019

35.

Garvey

Mahle

Bell

Kushner

. Healthcare professionals’ perceptions and management of obesity & knowledge of glucagon, GLP-1, GIP receptor agonists, and dual agonists. Obes Sci Pract. 2024;10(3):e756. doi:10.1002/osp4.756

36.

Ilanga

Heard

McClintic

, et al. Use of GLP-1 agonists in high risk patients prior to bariatric surgery: a cohort study. Surg Endosc. 2023;37(12):9509-9513. doi:10.1007/s00464-023-10387-1

37.

Spurzem

Broderick

Ruiz-Cota

, et al. GLP-1 receptor agonists are a transformative prehabilitation tool for weight loss in obese patients undergoing elective hernia repair. Surg Endosc. 2025;39(1):440-447. doi:10.1007/s00464-024-11308-6

38.

Jacofsky

Springer

Mont

Ushakumari

Sladen

. The impact of glucagon-like peptide-1 agonists on hip and knee arthroplasty and perioperative considerations. J Arthroplasty. 2024;39(6):1455-1458. doi:10.1016/j.arth.2023.12.002

39.

Schlottmann

Baz

Dreifuss

Masrur

. Long wait times for bariatric surgery: the challenge of standardized and efficient preoperative assessments. Surg Obes Relat Dis. 2022;18(10):1255-1256. doi:10.1016/j.soard.2022.07.005

40.

Doumouras

Albacete

Mann

Gmora

Anvari

Hong

. A longitudinal analysis of wait times for bariatric surgery in a publicly funded, regionalized bariatric care system. OBES SURG. 2020;30(3):961-968. doi:10.1007/s11695-019-04259-8

41.

Alvarez

Bonham

Buda

Carlin

Ghaferi

Varban

. Factors associated with long wait times for bariatric surgery. Ann Surg. 2019;270(6):1103-1109. doi:10.1097/SLA.0000000000002826

42.

Eghbali

Jahanshahi

Garakani

, et al. Reasons for preoperative patient attrition among bariatric surgery candidates: patients’ point of view. Obes Surg. 2023;33(2):492-497. doi:10.1007/s11695-022-06373-6

43.

Eng

Garcia

Khoury

Morton

Azagury

. Preoperative weight loss: is waiting longer before bariatric surgery more effective? Surg Obes Relat Dis. 2019;15(6):951-957. doi:10.1016/j.soard.2019.03.012

44.

Horwitz

Saunders

Ude-Welcome

Parikh

. Insurance-mandated medical weight management before bariatric surgery. Surg Obes Relat Dis. 2016;12(3):496-499. doi:10.1016/j.soard.2015.09.004

45.

Yeo

Rezaie

Hsieh

TYJ

, et al. Shifting trends in the indication of glucagon-like peptide-1 receptor agonist prescriptions: a nationwide analysis. Ann Intern Med. 2024;177(9):1289-1291. doi:10.7326/M24-0019

46.

Commissioner O of the FDA approves first medication for obstructive sleep apnea. FDA. 2024. https://www.fda.gov/news-events/press-announcements/fda-approves-first-medication-obstructive-sleep-apnea. Accessed 3 February 2025.

47.

Ibrahim

Fadel

Ahmad

Ballout

Ahmad

. Long-term outcomes of bariatric surgery: an eight-year study at a tertiary care hospital in Lebanon. Surgery Open Digestive Advance. 2024;14:100135. doi:10.1016/j.soda.2024.100135

48.

Lundin Kvalem

Gabrielsen

Eribe

Kristinsson

Mala

. Predicting satisfaction with outcome and follow‐up care 5 years after bariatric surgery: a prospective evaluation. Obes Sci Pract. 2022;8(5):595-602. doi:10.1002/osp4.594

49.

Seeras

Acho

Lopez

. Roux-en-Y gastric bypass chronic complications. In: StatPearls. Petersburg, Fl: StatPearls Publishing; 2025. https://www.ncbi.nlm.nih.gov/books/NBK519489/. Accessed 22 January 2025.

50.

Ramadan

Loureiro

Laughlan

, et al. Risk of dumping syndrome after sleeve gastrectomy and Roux-en-Y gastric bypass: early results of a multicentre prospective study. Gastroenterol Res Pract. 2016;2016:2570237. doi:10.1155/2016/2570237

51.

Salame

Teixeira

Lind

, et al. Marginal ulcer and dumping syndrome in patients after duodenal switch: a multi-centered study. J Clin Med. 2023;12(17):5600. doi:10.3390/jcm12175600

52.

Chan

JKY

Vartanian

. Psychological predictors of adherence to lifestyle changes after bariatric surgery: a systematic review. Obes Sci Pract. 2024;10(1):e741. doi:10.1002/osp4.741

53.

Sundgot-Borgen

Bond

Sniehotta

, et al. Associations of changes in physical activity and sedentary time with weight recurrence after bariatric surgery: a 5-year prospective study. Int J Obes. 2023;47(6):463-470. doi:10.1038/s41366-023-01284-7

54.

Tolvanen

Christenson

Surkan

Lagerros

. Patients’ experiences of weight regain after bariatric surgery. Obes Surg. 2022;32(5):1498-1507. doi:10.1007/s11695-022-05908-1

55.

Zhou

Trujillo

. Comparison of usability, accuracy, preference, and satisfaction among three once-weekly GLP-1 receptor agonist pen devices. Diabetes Spectr. 2018;31(4):359-366. doi:10.2337/ds17-0048

56.

Jensen

Renström

Aczél

, et al. Efficacy of the glucagon-like peptide-1 receptor agonists liraglutide and semaglutide for the treatment of weight regain after bariatric surgery: a retrospective observational study. Obes Surg. 2023;33(4):1017-1025. doi:10.1007/s11695-023-06484-8

57.

Stefanski

Bunck

Liu

, et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med. 2022;387(3):205-216. doi:10.1056/NEJMoa2206038

58.

Arterburn

Wellman

Emiliano

, et al. Comparative effectiveness and safety of bariatric procedures for weight loss: a PCORnet cohort study. Ann Intern Med. 2018;169(11):741-750. doi:10.7326/M17-2786