Weight-loss surgery outperforms GLP-1 drugs for diabetes and obesity, study finds

A new large-scale study came to the conclusion that weight-loss surgery gives people with type 2 diabetes and obesity a healthier, more extended life than is possible using the best drugs of the modern age.

Even with advanced drug therapies, surgery remains superior in the long term for survival, cardiac health, and prevention of serious complications from diabetes.

The research followed 3,932 adults treated at Cleveland Clinic with type 2 diabetes and obesity. Of those adults, 1,657 underwent metabolic surgery, gastric bypass or sleeve gastrectomy, while 2,275 were given GLP-1 receptor agonist medication. Those drugs, liraglutide, dulaglutide, exenatide, semaglutide, and tirzepatide, are often prescribed to lower blood sugar, decrease appetite, and lead to weight loss.

The research tracked participants for a mean of nearly six years, and some were tracked for ten years. In order to give an equal platform of comparison, researchers controlled variables like age, health status, and other risks.

Glucagon-like peptide-1 drugs have been hyped for decades as a cure-all for obesity and diabetes. But would they match or surpass the results of metabolic surgery, previously sensationalized as the miraculous disease-fighter for obesity?

The most recent evidence confirms that surgery still stands supreme with results far greater than anything new drugs have to offer.

The survival difference was evident. By the 10th year, 9 percent of the patients in the surgery group had died, compared with 12.4 percent of those in the drug group. That equated to the surgery group having a 32 percent reduced risk of death, even taking into account variations in health at the beginning of the study.

"Even with the most sophisticated drugs available today, metabolic surgery has unique and long-term advantages for people with diabetes and obesity," said Dr. Ali Aminian, director of the Bariatric & Metabolic Institute at the Cleveland Clinic and study senior author.

Cardiovascular health is an essential determinant where coronary heart disease is the leading cause of death in diabetic patients. The study established that surgery had lowered the prevalence of serious cardiac events such as heart attack, stroke, and heart failure hospitalization by 35 percent compared to GLP-1 therapy.

Senior Study Author, Dr. Steven Nissen, Chief Academic Officer, Heart, Vascular & Thoracic Institute, Cleveland Clinic, called the findings amazing. "Even in the era of these powerful new drugs for obesity and diabetes therapy, metabolic surgery might have something else to offer, including a survival benefit."

Diabetes causes injury to the small blood vessels, and it spills over to damage kidneys and eyes like retinopathy. The patients undergoing surgery in the trials were 47 percent less likely to develop advanced kidney disease and 54 percent less likely to develop eye damage than GLP-1-treated patients.

These side effects are guaranteed to cause a lifetime disability, and surgery's protective function in this aspect is therefore very important.

Another one of the largest problems with treating obesity is how to maintain weight loss in the long run. At 10 years post-treatment, those who were treated with surgery lost an average of 21.6 percent of their body weight, compared to only 6.8 percent among those on medication.

That kind of maintained weight loss is never observed other than with surgery. It's also going to be a likely big reason why patients were so far ahead in survival and heart health.

Diabetes care is just a function of keeping blood sugar in check, and once more surgery was better. Hemoglobin A1c, an indicator of patients' ability to keep glucose in check over the longer term, fell by 0.86 percentage points in the surgery group but by just 0.23 in those on GLP-1 medication.

Better sugar control can protect against the quiet damage that diabetes causes to blood vessels, nerves, and organs over several decades.

The other advantage of surgery was less prescription drug requirement. Patients undergoing surgery required fewer diabetes, hypertension, cholesterol, and kidney disease medicines in the long term.

For patients, this can mean less expense, fewer side effects, and less dependency on pills a day.

The study was the largest and longest ever to directly compare surgery with GLP-1 drug therapy in actual patients. Nearly 4,000 patients were followed for some and up to 10 years in some, and the scientists used advanced methods of balancing between groups.

But the research wasn't random, so patient and doctor choices—and insurance—would have had to consider who received surgery and who didn't. The second limitation is that not all participants in the study were given the most recent and most powerful GLP-1 medications. Comparison studies in the future will have to match surgery with the newer drugs, semaglutide and tirzepatide, which narrowed some of the disparity.

The study findings are that surgery must be taken extremely seriously by most with diabetes and obesity even prior to treatment. The advantages went much deeper than weight reduction, lowering risks of death, heart disease, kidney disease, and blindness.

Surgery does not come without work, however. There is the risk of complications, time off, and cost. Not everyone can qualify, and not everyone wishes to have a big operation.

To physicians, what the implications teach is that surgeons must think of surgery more as an option of greater gravity, and less so an option of last resort. To health systems, what the implications raise is how the resources are being allotted.

GLP-1 medicines are costly and must be taken daily for life, whereas surgery is performed once for life and it is cost-saving in the long term through reduced drug consumption and hospitalization.

Study authors cite randomized trials directly comparing metabolic surgery with existing GLP-1 therapy. On the other hand, this study has some of the strongest evidence available showing surgery to be an effective treatment for enhancing survival and health in persons with obesity and diabetes.

Research findings are available online in the journal Nature Medicine.

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