Weight Loss Medication or Weight Loss Surgery?

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With more than 40% of the US adults being obese, more and more people are looking for best treatment options for obesity. In addition to lifestyle modification, diet, and exercise, weight loss medications and weight loss surgery are the two most effective ways to help people lose weight.

The newer weight loss medications such as Wegovy (Ozempic) and Zepbound (Mounjaro) are much more effective than previous generations of medications. Many patients are wondering which is a better option for them, weight loss medications or weight loss surgery such as sleeve gastrectomy and Roux-en-Y gastric bypass?

Why do people lose weight with weight loss medications?

The newer weight loss medications such as Wegovy and Zepbound can affect the central nervous and digestive systems to help people lose weight by:

Reducing the appetite and decreasing food intake.
Increasing the feeling of fullness by slowing down gastric emptying.
Decreasing the hunger feeling by acting on the brain regions responsible for food intake and energy balance.

Why do people lose weight with weight loss surgery?

Reduce food intake because the size of the remaining stomach after sleeve gastrectomy and the gastric pouch after Roux-en-Y gastric bypass surgery are much smaller. People feel full after eating small amount of food.
Reduce the appetite/hunger feeling by reducing the hunger hormones.
In Roux-en-Y gastric bypass patients, there is slightly decreased calorie absorption.

Advantages of Weight Loss Medications

Compared with weight loss surgery, weight loss medications have quite a few advantages.

No surgery needed. The medications are completely non-invasive.
Can stop the medications anytime. On the other hand, sleeve gastrectomy surgery is not reversible and Roux-en-Y gastric bypass surgery is not 100% reversible.
No risks to develop weight loss surgery associated complications.

Advantages of Weight Loss surgery

Weight loss surgery leads to more weight loss than weight loss medications. The expected weight loss is about 10-15% for Wegovy (Ozempic), 15-21% for Zepbound (Mounjaro), and 25-35% for bariatric surgery.
Weight loss surgery has data with very long-term follow-up. For example, gastric bypass surgery with 20 years follow up showed that patients still kept most of the lost weight off. We don’t have long term (more than 5-10 years) weight loss data with the Wegovy (Ozempic) and Zepbound (Mounjaro) yet.
Weight loss medications require long term and possibly lifelong use to keep the weight off. The weight regain after stopping the weight loss medication is usually rapid. On the other hand, most patients only need to have weight loss surgery once.
Many patients stopped using the weight loss medications after a few weeks/months. The reasons for non-compliance include side effects, lack of efficacy, medication shortage, insurance coverage, cost, unwillingness to take the drugs for long term. On the other hand, we don’t need to worry about compliance issues with weight loss surgery because sleeve gastrectomy is irreversible and very rarely people want to have their Roux-en-Y gastric bypass surgery reversed.
Muscle loss is much more with weight loss medications than with weight loss surgery.

Who should consider Weight Loss Medications?

Weight loss medication are indicated for people with a BMI of 30 and above or BMI between 27-29.9 with obesity associated co-morbidities, while weight loss surgery is indicated for patients with BMI over 40 or BMI between 35-39.9 with obesity associated co-morbidities (for diabetic patients, the indication for bariatric surgery can be as low as BMI greater than 30). The obesity associated co-morbidities include hypertension, type 2 diabetes, hyperlipidemia, obstructive sleep apnea and fatty liver disease.
For some patients, they should primarily consider weight loss medications, not weight loss surgery.

Patients with lower BMI. For example, a patient with BMI of 28 and hypertension should consider weight loss medication.
Patients with contraindications for surgery.
Patients who are at high risk for surgery.

For some patients, they should strongly consider weight loss surgery.

Patients with very high weight (BMI). These patients are unlikely to get close to normal weight range from weight loss medication alone.
Obese patients with type 2 diabetes. The randomized clinical trials have shown that diabetic patients lose less weight with Wegovy and Zepbound compared with non-diabetic patients. Bariatric surgery has been shown to help obese diabetic patients lose weight and control their diabetes much better.
Patients who cannot tolerate the weight loss medications. Almost 50% of patients taking Wegovy (Ozempic) or Zepbound (Mounjaro) develop some degree of gastro-intestinal side effects including nausea, vomiting, reflux, diarrhea, and constipation. Although these side effects are usually mild and temporary, some patients may find it difficult to stick to the treatment.
Patients who don’t respond to weight loss medications well.
People who don’t want to take these medications for long-term or those who are non-compliant with the medications. To keep the weight off, patients need to use the weight loss medications continuously. However, some people don’t want to use the weight loss medication for long-term.

For some patients, they may need both weight loss medications and weight loss surgery.

People with very high weight (BMI). For these patients, they may need all the effective treatment options to help them to reach a healthy weight. The combination of both surgery and medications may help them to achieve that goal.
People with weight regain after weight loss surgery. Most patients achieve the best weight loss 12-18 months after weight loss surgery. Many patients regain some weight back after that time. For patients who regained a lot of weight back or have inadequate weight loss after weight loss surgery, adding a weight loss medication can help them to lose weight again.

Since obesity can lead to serious medical conditions and complications, it is very important for people to lose weight and stay healthy. With the development of modern weight loss surgery and newer weight loss medications, patients now have much more effective treatment options. Patients should consult with their primary care physicians and other providers to discuss all the available options and decide what is the best for them.