A False Choice: Drugs vs Surgery for Obesity

A new study in Acta Diabetologica offers up a comparison of drugs vs surgery for obesity, glycemic control, and cardiovascular risk. It grabbed our attention because liraglutide was the reference drug for the comparison, and that drug has just been recommended for approval in obesity treatment by an expert FDA committee. But the study leaves us with a decidedly mixed reaction.

On one hand, they document superior outcomes for weight loss, glycemic control, and cardiovascular risk in patients with type 2 diabetes and severe obesity who received gastric bypass or vertical sleeve gatrectomy compared to matched patients who had liraglutide added to their medical management. It’s not terribly surprising that medical management of severe obesity and type 2 diabetes would not deliver outcomes as dramatic as what can be achieved with surgery.

But on the other hand, we have to take this study — and the false dichotomy it sets up — with a big grain of salt. Obviously, the retrospective design has limitations. The authors concede that. A more hidden flaw is the doses of liraglutide that are used: 1.2-1.8 mg daily. That’s the right dose for diabetes, but the data presented to FDA for liraglutide in obesity make it clear that 3 mg daily is the optimal dose for treating obesity.

The biggest problem, however, is the false choice between medical and surgical management of obesity that seems to drive the thinking behind the study. Surgery can indeed deliver superior outcomes for patients who need it and are well-prepared for it. But for many people, even with severe obesity, it’s not an option they can or will accept. Many reasons contribute to this fact: dodgy practices of health plans, exaggerated perceptions of risk, outright bias against aggressive obesity treatment, and more.

Much as we may disagree with these barriers to surgery, they are currently a fact. So we are left with a gap in treatment options that will only be filled through innovation. The innovation will be needed in many forms: medical therapies, drugs, devices, public policy, patient education, and advocacy.

Until this gap is filled, the impact of obesity on everyone affected will continue to be costly in both human and economic terms.

Click here to read the study in Acta Diabetologica.

Pyramids at Giza, photograph ©Wilhelm Joys Andersen / flickr

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