For years, the treatment of obesity was seen through a standard lens. Either the person was on diet and exercise or had bariatric surgery. While newer medical therapies have expanded the range of treatment options, they have also spawned a debate that often loses sight of the real clinical problem.
It is not a question of whether medication is better than surgery or vice versa. But the real question is whether the treatment chosen is right for the patient's disease, co-existing health conditions and long-term goals. Obesity is a chronic disease of metabolism as with hypertension or diabetes, the treatment of this disorder must be guided by severity, medical evidence and expected outcomes rather than popularity or perception.
Obesity Calls for Individualised Treatment
Two patients of the same weight can have very different health profiles. Some may present with early obesity with few medical complications, others may already have uncontrolled diabetes, sleep apnea, hypertension, fatty liver disease, infertility, joint damage or cardiovascular disease.
The same treatment for both patients almost never produces the same result. Clinical decisions should take into account Body mass index, metabolic health, duration of obesity, previous attempts at weight loss, eating behaviour, age, mobility and existing medical conditions. Treatment planning is only meaningful if obesity is identified as a disease that advances over time, and not a cosmetic concern.
Medication Has a Defined Role
Medical therapy has provided important options for patients who need to lose weight but may not be ready for surgery. These drugs slow gastric emptying and reduce appetite, helping patients to eat fewer calories and better control blood glucose.
Many people find that they lose weight during the first few months of treatment. Reduced hunger also helps patients to adopt healthier eating habits.
But the limitations of medication deserve equal attention. Weight loss is generally a function of continued therapy. When therapy stops, many patients slowly regain the lost weight because the biological mechanisms that drive obesity are still operating. The hormonal messaging system that controls hunger and energy storage in the body is still set to regain weight.
The response also varies from one patient to another. Some people are able to lose a clinically significant amount of weight; some people lose only a modest amount, even with appropriate treatment.
Side effects, such as nausea, constipation, vomiting, abdominal discomfort, and digestive intolerance, also affect long-term compliance in some patients. Careful patient selection and regular follow-up are necessary for rare complications of the pancreas or gall bladder.
Another practical issue is affordability. Long-term treatment can be a financial strain, especially with limited insurance coverage.
Patients who lose weight rapidly, without structured nutrition program and resistance exercise, may also lose lean muscle mass and therefore become weaker despite having lost body weight.
So, there is a role for medication, but we shouldn't think of it as a panacea for all stages of obesity.
Surgery Changes Biology of Obesity
Bariatric surgery works by mechanisms that go far beyond reducing the volume of the stomach.
These procedures, like sleeve gastrectomy and gastric bypass, change gut hormones, improve the body's sensitivity to insulin, alter appetite regulation and modify the body's metabolic response to food. These biological changes serve to naturally decrease hunger and improve glucose metabolism.
The effects are clear early on. Blood sugar levels often get better within days of surgery, even before a lot of weight loss happens. Many patients reduce or stop their diabetes medications under medical supervision and some achieve long-term remission.
The benefits are for multiple obesity-related diseases. Hypertension, obstructive sleep apnea, fatty liver disease, polycystic ovarian disease, joint pain and fertility related problems often show improvement. Research has also shown a decreased risk of some obesity-related cancers such as breast, and colorectal cancers.
These improvements, unlike the transient weight loss, reflect correction of several underlying metabolic disturbances that accompany severe obesity.
Long-Term Data Support Surgery for Severe Obesity
The best argument in support of bariatric surgery is clinical evidence over the long term.
The study, called the ARMMS-T2D study, was funded by the National Institute of Diabetes and Digestive and Kidney Diseases and followed 262 participants over four major research centres in the United States for 12 years. It was published in JAMA.
Seven years later, the group that underwent bariatric surgery lost an average of about 20 percent of their body weight, compared with about 8 percent for the intensive medical and lifestyle treatment group. Over half of the surgical group achieved HbA1c levels below 7 percent and diabetes remission was significantly higher throughout follow-up.
The study also demonstrated positive outcomes in carefully selected patients with body mass index between 27 and 34, suggesting that metabolic benefits are not restricted to individuals with extreme obesity.
Some nutritional deficiencies were reported, especially iron deficiency but well managed with supplements and routine follow up. These findings build on decades of evidence supporting bariatric surgery as an established treatment for severe obesity and metabolic disease.
Recovery Has Changed Dramatically
Bariatric surgery procedures are mostly performed laparoscopically or robotically through small incisions. Patients are usually ambulating within hours of surgery and are discharged by the third postoperative day. Bariatric surgery is much safer than most people realize, with faster recovery, lower complication rates and shorter hospital stays.
Selecting the Correct Treatment
Medication and surgery are not to be viewed as competing therapies. They are different stages of the same disease.
In some patients, medication and lifestyle modification can provide significant improvement. Others still, despite appropriate medical treatment, are gaining weight and need surgery for durable metabolic control. Selected cases may even be prepared for surgery by reducing operative risk with medication.
The goal should not be to defend one treatment over another. The goal is to find the intervention that provides the maximum health benefit to the individual patient.
Treatment decisions in the successful management of obesity rely on clinical evidence, not public perception. The conversation changes when the question is not which treatment, drugs or surgery, but which treatment and when in the progression of the disease. That approach offers improved metabolic health, fewer complications of obesity and lasting outcomes well beyond weight reduction.
(By Dr. Ashish Gautam, Principal Director, Robotic and Laparoscopic Surgery, Max Super Speciality Hospital, Patparganj, New Delhi)
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