Bariatric Surgery vs GLP-1 Receptor Agonists: A Comparative Analysis for Obesity Treatment

A two-year cohort analysis found that metabolic bariatric surgery delivered substantially greater mean weight loss and lower total costs over two years than continuous GLP-1 receptor agonist therapy — results that quantify clear clinical and economic trade-offs for patients with class II–III obesity.

The study used a large US claims and EHR cohort with at least 24 months of follow-up and applied propensity score weighting to balance baseline risk.

Weight-loss outcomes favored surgery by a wide margin. In the BMI-adjusted clinical subset, metabolic bariatric surgery was associated with mean total weight loss of 28.3% (SE 0.3%) versus 10.3% (SE 0.5%) for GLP-1 receptor agonists (P < .001); 96% of surgical patients achieved ≥10% sustained weight loss compared with 46% on medication. Excess weight loss and rates meeting 5% and 10% thresholds were also significantly higher after surgery, indicating both greater magnitude and apparent durability of effect in this cohort.

Metabolic benefits paralleled the weight outcomes. The surgical group had higher rates of diabetes remission and larger improvements in glycemic control using prespecified remission definitions and last-available HbA1c, and showed greater declines in obesity-related comorbidities. Surgery was also associated with lower subsequent rates of hypertension, hyperlipidemia, and sleep apnea across follow-up, supporting a stronger short-term metabolic advantage versus GLP-1 therapy in this sample.

Total-cost analysis confirmed lower two-year expenses with surgery despite higher upfront spending, as shown in the study’s economic comparison. Although index-day and early postprocedural costs were higher, ongoing pharmacy expenditures for GLP-1 therapy drove mean adjusted total costs to $63,483 for GLP-1 RAs versus $51,794 for surgery over two years (mean savings ≈ $11,689; P < .001). The principal driver was sustained medication spending in year two rather than recurring surgical costs, a finding with direct implications for payer budgeting and clinic-level pathway design when long-term drug persistence is expected.

Patient selection and safety trade-offs remain central. For people with class II–III obesity, substantial cardiometabolic burden, and goals focused on durable weight loss and metabolic remission, surgery offered greater durability and lower two-year utilization. By contrast, high perioperative risk, limited surgical access, or preference for noninvasive therapy may favor GLP-1 agents; those agents, however, require ongoing adherence, monitoring, and are commonly associated with gastrointestinal adverse effects. Choosing between approaches therefore requires weighing durable efficacy and downstream utilization against concentrated perioperative risk and individual patient priorities — and discussing these trade-offs explicitly during shared decision-making.