GLP-1s Are Surging, Bariatric Surgery Is Sliding — and More Than 90% of Patients With Obesity Are Still Getting Neither

 

OBESITY MANAGEMENT

GLP-1s Are Surging, Bariatric Surgery Is Sliding — and More Than 90% of Patients With Obesity Are Still Getting Neither

Two independent real-world analyses, presented within weeks of each other in 2026, land on the same uncomfortable number.

CLINICAL BOTTOM LINE GLP-1 prescribing for obesity has grown more than tenfold in a few years while bariatric surgery volumes have started to fall for the first time in over a decade. Yet across two separate large claims-database studies, more than 90% of patients with obesity received neither treatment. The takeaway for NPs is not GLP-1 vs. surgery — it's that both are underused, and the real work is identifying untreated patients and matching them to whichever tool actually fits their disease severity.

 

Two Studies, One Signal

A UC San Diego team drew on Epic Cosmos records from nearly 20 million patients with severe obesity and no diabetes, presenting at the 2026 ASMBS annual meeting. Separately, researchers from the Analysis Group and Harvard T.H. Chan School of Public Health analyzed national insurance claims from 11.7 million adults with obesity, overweight, or diabetes in a research letter published in JAMA Surgery. Different datasets, different patient populations, same headline finding: GLP-1 use is climbing fast, bariatric surgery use is falling, and the overwhelming majority of eligible patients are receiving no obesity treatment at all.

The Numbers

Study	GLP-1 Growth	Surgery Trend	Untreated
UC San Diego / ASMBS (2018–2025)	~4,600 to 1.4M+ Rx/yr	Rose to ~43K (2023), then fell to <40K	90–95%
Analysis Group / Harvard (2022–2024)	+140.4%	−34.1% (accelerating: −14.4% then −23.0%)	>90%

 

In the UC San Diego data, bariatric surgery utilization rose gradually from 0.03% of the active patient population in 2018 to 0.24% in 2023, then dropped to roughly 0.21% in 2024 and 2025 — the sharpest decline since GLP-1 agonists entered the obesity space. GLP-1 use over the same window climbed from 0.03% to 5.3%. The Harvard/Analysis Group study, covering a broader population including patients with overweight and diabetes, found 9.2% received GLP-1 receptor agonists and just 0.4% received metabolic bariatric surgery during 2022–2024.

The Part That Should Worry Us Most

Lead UC San Diego author Jeffery Reeves, MD, flagged what he called the most unexpected signal in the data: the decline in surgery appears concentrated among patients with the highest degrees of obesity and disease severity — precisely the patients who stand to benefit most from a durable, effective procedure. The Harvard/Analysis Group study reinforces this from the other direction, finding that patients who underwent surgery tended to be more medically complex than those on GLP-1s or receiving no treatment, with roughly a quarter carrying four or more comorbidities.

Put together, these findings raise a real clinical question: are the patients who need surgery most being steered toward, or settling for, a medication instead — and is that substitution actually serving them?

CASE FROM PRACTICE A 44-year-old man with BMI 46, obstructive sleep apnea, and early diabetic kidney changes asks you about "the weight loss shot" after seeing ads online. He has no prior workup for bariatric surgery and assumes surgery is a last resort he isn't ready for. This is exactly the profile these studies suggest is falling through the gap — high disease severity, a GLP-1 request driven by visibility and marketing rather than a comparison of options, and no documented discussion of surgery as a first-line, evidence-based treatment for his BMI class. A referral for a surgical evaluation alongside — not instead of — a GLP-1 conversation keeps both options on the table rather than defaulting to whichever one the patient asked about first.

 

Where GLP-1s and Surgery Actually Meet

The ASMBS authors floated a bridge hypothesis: for some patients, GLP-1 therapy may function as a step toward eventual surgery rather than a permanent alternative to it. A 2025 systematic review and meta-analysis in Langenbeck's Archives of Surgery, pooling 19 studies of GLP-1 agonists used specifically for insufficient weight loss or weight regain after bariatric surgery, supports the idea that these tools are complementary rather than competing. Across liraglutide, semaglutide, and tirzepatide, patients treated post-surgery for inadequate response lost an additional 5.3% to 29.1% of body weight, with tirzepatide outperforming semaglutide, and semaglutide outperforming liraglutide.

•     Non-response (under 5% total weight loss) occurred in 27.1% of liraglutide-treated patients, 19.1% of semaglutide-treated patients, and 2.9% of tirzepatide-treated patients (single study).

•     Adverse events were common (36–80% depending on the study) but overwhelmingly mild gastrointestinal symptoms, and were rarely the reason patients discontinued therapy.

•     Metabolic benefits extended beyond weight — meaningful improvements were reported in HbA1c, blood pressure, and triglycerides across several of the pooled studies.

For NPs following patients longitudinally, this reframes the surgery-vs-GLP-1 framing in the news coverage: for a patient with weight regain or a suboptimal response after bariatric surgery, adjunct GLP-1 therapy already has a reasonable evidence base — it doesn't need to be an either/or decision made once and never revisited.

Reading the Data With Appropriate Caution

A NOTE ON THE NUANCE Both surveillance studies are retrospective claims/EHR analyses — they show association, not causation. They cannot tell us why an individual patient chose (or was steered toward) one treatment over another, or over none. The two studies used different populations (severe obesity without diabetes vs. a broader obesity/overweight/diabetes cohort) and different data sources, so their exact percentages aren't directly comparable — the value is in the convergent direction of both trends, not the precise figures. The bariatric surgery adjunct meta-analysis was limited by high heterogeneity, few RCTs (especially for semaglutide and tirzepatide), and inconsistent reporting of secondary outcomes, which the authors note prevented a full meta-analysis of metabolic endpoints. None of these studies isolate the specific barriers behind the 90%+ untreated figure — insurance coverage, drug cost, surgical access, stigma, and referral patterns are all plausible contributors but weren't directly measured.

 

Board & Practice Prep

•     Metabolic bariatric surgery remains the most effective and durable treatment for severe obesity, with a safety profile comparable to gallbladder surgery, appendectomy, and knee replacement — a fact often underestimated in patient counseling.

•     Only an estimated 1% of patients eligible for weight-loss surgery undergo it in any given year, per ASMBS — a gap that predates the GLP-1 era and isn't fully explained by it.

•     Tirzepatide is a dual GLP-1/GIP receptor agonist, mechanistically distinct from single-target agents like liraglutide and semaglutide, and has shown superior weight-loss outcomes in head-to-head comparisons.

•     Insufficient weight loss (IWL) after bariatric surgery is generally defined as excess weight loss under 50% within 18 months; weight regain (WR) is progressive gain after initial success — but definitions vary across studies, which limits direct comparison of "non-responder" rates.

•     The SELECT trial (semaglutide 2.4 mg vs. placebo, n=17,604) demonstrated a 20% relative reduction in major adverse cardiovascular events, underscoring that GLP-1 benefits extend past the number on the scale.

The Takeaway

The headline of "GLP-1s up, surgery down" undersells the real story: obesity care as a whole remains dramatically underutilized, and the patients with the most severe disease may be the ones least likely to receive the most effective option. NPs are well positioned to interrupt that pattern — by treating a GLP-1 request as an opening to discuss the full continuum of care, including surgical referral, rather than the end of the conversation.

References

As GLP-1 Use Skyrockets and Bariatric Surgery Slows, Most Obesity Goes Untreated [press release]. American Society for Metabolic and Bariatric Surgery; May 5, 2026.

Anderer S. Metabolic bariatric surgery declines as GLP-1 drug use increases. JAMA. 2026;335(24):2099. doi:10.1001/jama.2026.6202

Tan YW, Shang M, Davis S, Gananadha SK. GLP-1 receptor agonists as an adjunct to bariatric surgery for weight loss and metabolic outcome improvement: a systematic review and meta-analysis. Langenbecks Arch Surg. 2025;410:295. doi:10.1007/s00423-025-03831-4