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
