When endocrinologist Mary Elizabeth Patti looks at a patient with type 2 diabetes who could benefit from weight loss, she sees more than body mass index and blood glucose levels. She also recognizes the challenges of social vulnerability, understanding how low income, food insecurity, and limited access to health care might matter in treatment choice. After all, those factors are strongly linked to developing type 2 diabetes and obesity in the first place.
For more than a dozen years,Patti has been a leader of long-running randomized clinical trials conducted in four U.S. cities that compared bariatric surgery to medication and lifestyle management for type 2 diabetes. In 2024, one of those trials demonstrated the superiority of bariatric surgery for patients, measured by lower blood glucose levels, higher weight loss (28% vs. 10%), less use of diabetes medications, remission of diabetes to the point of no longer needing to inject insulin, and reduced risk factors for cardiovascular disease.
In a new secondary analysis of the larger trial published Monday in the Annals of Internal Medicine, Patti and her colleagues asked how different social determinants of health affected outcomes after bariatric surgery compared to medical therapy for people with type 2 diabetes and obesity.Bariatric surgery was better than medical therapy across all social backgrounds, they found, and not just in areas of higher deprivation. The ancillary study was smaller, and some of the participants randomized in earlier stages crossed over from medical to surgical treatment, and the reverse. The authors acknowledged and accounted for these limitations, along with the rapid development of more powerful obesity drugs not fully captured in the study.
Still, “Bariatric surgery remains an underutilized approach. Even in comparison to these really wonderful medications that we now have access to, it is indeed still better,” Patti, an endocrinologist and director of the hypoglycemia clinic at Joslin Diabetes Center in Boston, told STAT. “I’m not a surgeon,but I think we need to keep in mind that surgery offers an approach which can be a durable therapy for type 2 diabetes and obesity.”
At the overall study’s start, carried out in Boston, Cleveland, Pittsburgh, and Seattle, 355 participants where randomly assigned to undergo medical therapy or one of three surgical approaches: gastric bypass, sleeve gastrectomy, or adjustable gastric lap banding. Medical and lifestyle interventions, based on the well-known Diabetes Prevention Program, included individualized nutrition counseling and instruction on exercise and how to monitor glucose. As time passed, fewer people chose lap band surgery, which has now fallen out of favor, and newer obesity drugs were increasingly available in the trials’ later stages.
Some people from the medication group later chose surgery, and some people who’d had surgery began taking obesity drugs. By year 12, more than a third of participants in the medical therapy groups and more than a quarter in the surgical groups were receiving incretin-based therapy, the class of drugs that includes older ones like liraglutide (sold as Saxenda) as well as newer GLP-1s like tirzepatide (sold as Mounjaro).
the smaller study analyzed dat
Hear’s a breakdown of the key themes and arguments presented in the provided text,focusing on extracting details without replicating the source’s style or structure:
Core Argument: The article discusses the evolving landscape of obesity treatment,specifically comparing and contrasting bariatric surgery with newer GLP-1 medications. It argues that while GLP-1s are generating meaningful excitement,surgery remains a highly effective option that shouldn’t be overlooked,and that the underlying biological mechanisms of both approaches are surprisingly similar.
Key Points:
* Multiple Treatment Options: There’s a growing range of choices for individuals managing obesity, potentially including a combination of therapies.
* Surgery vs. Medication – Weight Loss Goals: Surgery tends to be more effective for considerable weight loss (e.g., 100 pounds) than medications.
* Biological Similarities: Both surgery and GLP-1 medications impact appetite and metabolism by influencing GLP-1 hormone secretion and intestinal interactions. Surgery itself increases GLP-1 production.
* Durability & Sustainability: Surgery offers a potentially more sustained effect, less reliant on ongoing medication adherence and insurance coverage.
* Underutilization of Existing Therapies: Both bariatric surgery and obesity medications are currently underused despite their potential benefits.
* Challenges with GLP-1s: Access to GLP-1 medications is hindered by affordability, insurance coverage, and the need for ongoing use. Long-term effects (durability, tolerability) of newer drugs are still being studied.
* individualized Approach: The “best” treatment strategy depends on the individual patient’s circumstances and needs.
* Surgery’s Proven Track Record: Large-scale studies demonstrate surgery’s effectiveness in improving diabetes control, achieving remission, reducing complications, and improving survival rates.
Expert Perspectives:
* Patti: Advocates for keeping surgery as a viable option in the conversation, emphasizing its long-term benefits and sustained impact.
* Melanie jay: Highlights the chronic nature of obesity,requiring lifelong management,and the potential need for multiple treatment modalities.
* Jason Samuels: Points out the underuse of both surgical and medical treatments and stresses the importance of long-term studies to determine optimal strategies.
Overall Tone: The article presents a balanced view, acknowledging the promise of GLP-1 medications while reinforcing the continued relevance and effectiveness of bariatric surgery. It emphasizes the need for individualized treatment plans and further research.
