Rochester bariatric surgeons: GLP-1s are important new tools, but patients still often better served by surgery
By Matthew Liptak
The popularity of GLP-1 weight loss drugs has skyrocketed within the last couple years. And bariatric surgeries in Rochester and around the United States have felt a corresponding drop in volume.
Surgeons caution, though, that GLP-1s are not wonder drugs — surgery remains more effective, they say.
“The first problem is that obesity is a disease,” said Rochester General Hospital bariatric surgeon Dilendra Weerasinghe. “The more treatment options that are available, it is better for the patient and the consumer.”
Weerasinghe is upbeat that data shows GLP-1 medication can reduce pounds in patients by 15% to 21% of their body weight. The truth is, though, when a patient has a body mass index of more than 35, maybe even well more than 40, GLP-1 weight loss may not likely to be enough alone to eliminate the patients’ very real and dangerous comorbidities, like diabetes, high blood pressure or even increased danger of cancers and cardiovascular trouble.
“The perception is that GLP-1s are for everyone. The reality is that it isn’t,” Weerasinghe said.
Kaci Schiavone, bariatric surgeon for Highland Hospital, agreed that GLP-1s are part of a growing inventory of applications to help correct obesity, but are not a solution by themselves.
“The causes of obesity are multifactorial,” she said. “There are genetic components. There are hormonal components. Certainly, there are environmental components. Each patient is a little bit different, so I think that’s why the treatment of their obesity should be different as well.
“In our mind, lifestyle changes like diet and exercise are one tool that you have in your toolbox for managing obesity. GLP-1s are another tool and then bariatric surgery is a tool. I think most patients would benefit from using more than one of those tools in their journey,” according to Schiavone.
Weerasinghe said that the known facts regarding bariatric surgery are strongly in support of the treatment, while GLP-1s are newer and showing more mixed results. He cited Blue Cross Blue Shield data indicating upwards of 50% of GLP-1 users had ceased taking the medication one year after starting, even though lifetime GLP-1 therapy is widely thought to be required.
Weerasinghe also cited a trial study showing that after four years taking GLP-1, users had gained half their weight back, even while remaining on the medication.
“The most effective tool of treating obesity and metabolic disease is bariatric metabolic surgery,” he said. “We have 20-plus years of data showing the safety and efficacy of bariatric surgery, not only in reducing weight but, more importantly, improving health. Not only do these patients live longer, but they live longer and healthier.”
Both doctors acknowledged there can be a negative stigma regarding bariatric surgery. People fear elective invasive surgery and a possibility of complications. But both surgeons remarked that modern bariatric surgery has a better track record than relatively common gall bladder surgery.
“The community is often very afraid of surgery and don’t realize that, at least from a risk profile, it’s safer than getting your gall bladder removed,” Schiavone said. “Everybody sort of thinks of gall bladder surgery as a run-of-the-mill surgery and it’s very common. But bariatric surgery is an elective surgery, so we wouldn’t accept any kind of risk associated with it, so we’ve really done everything we can to make it as safe as possible. The risk of the surgery is generally less than the effect of the comorbidities affecting your life. Bariatric surgery has been shown to increase your life span significantly.”
While both Rochester doctors welcome the advance of GLP-1 weight loss drugs as an important advancement, the drop in the surgical volume in their practices have caused concern, not simply from the bottomline budget perspective, but in looking toward the true welfare of patients who may not be thinking through their options objectively.
“I think there’s a right patient for a GLP-1 and a right patient for surgery, ” Schiavone said. “There are patients that GLP-1s aren’t going to lead to enough loss of excess weight to reduce the medical comorbidities that they have associated with obesity. Those are things like diabetes, high blood pressure, sleep apnea. There are patients that still — in order to achieve long-term, durable, effective weight loss — surgery really is the only option.”