Rethinking obesity treatment: a path towards sustainability and scalability

Obesity, one of the most profound challenges of modern medicine, casts a shadow over global health, defying decades of simplistic advice to "eat less, move more." For decades, Metabolic and Bariatric Surgery (MBS) has transformed lives by altering the body’s interaction with food through metabolic mechanisms. For patients with severe obesity, surgery has delivered life-altering results, improved metabolic health and reframing obesity as a systemic disease. Yet, MBS is an inherently resource-intensive endeavour. From single-use instruments contributing to hospital waste to individualized preoperative requirements such as psychological evaluation and mandated weight-loss trials, surgery is costly and fundamentally unscalable. It is not a population-wide solution.

The review by Cohen et al. in the BJS examines the integration of obesity-management medications (OMMs) with bariatric surgery, underscoring the shifting paradigm in obesity care. With obesity affecting over 40% of the U.S. population and an average of 18% across OECD countries, its impact in developed nations is undeniable. In the Global South, rising urbanization and dietary shifts are fuelling alarming increases in obesity, often alongside persistent undernutrition—a stark contrast to the entrenched rates seen in OECD nations. These dual burdens demand scalable solutions that account for regional disparities in healthcare infrastructure and economic resources.

Pharmacological innovation offers a transformative opportunity to address this crisis. GLP-1 receptor agonists, with over a decade of real-world use, have redefined treatment possibilities. Medications like Liraglutide and Semaglutide rival the efficacy of surgery, delivering substantial weight loss and metabolic improvement without the invasiveness of an operation. Emerging therapies, such as Tirzepatide and a growing wave of oral agents, promise even greater precision and adaptability. These treatments are inherently scalable, with the potential to reach millions at a fraction of the cost of surgery. In some regions, these therapies are already available for less than $100 per month, opening the door to equitable, population-wide access.

The challenge now lies in navigating a thoughtful transition. MBS has undeniably saved lives, advanced our understanding of obesity, and reshaped public perceptions of its causes. But as pharmacotherapy evolves, the role of surgery will narrow, focusing on rare and complex cases—such as extreme obesity or anatomical complications—where medication alone may not suffice. This shift will demand the reimagination of surgical training, the adaptation of healthcare systems, and a commitment to equity in distributing life-saving medications.

The future of obesity care will be shaped by innovation, but it must remain grounded in the human stories that surgery has transformed. As we embrace precision pharmacology, the lessons of surgery remind us to build systems that are not only scalable but also compassionate, ensuring that no one is left behind. This is not merely a shift in treatment modalities but an opportunity to rethink how we deliver care at scale, creating solutions that are inclusive, sustainable and globally relevant.

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Interested in more content from Robin Blackstone? Watch her BJS Lecture at the International Bariatric Club