Treatment of obesity: will incretin agonists make bariatric surgery a thing of the past?

The prevalence of obesity continues to increase worldwide. Obesity is associated with an increased risk of cardiometabolic and other diseases, reduced quality of life and shortened life expectancy. Highly effective therapies are required to achieve meaningful and sustained weight reduction to prevent, slow or reverse disease associated with obesity. Bariatric surgery is a highly effective intervention to induce weight loss, with observational data demonstrating durability of weight loss over 10 or more years. In addition, bariatric surgery improves cardiometabolic risk factors, including hyperglycaemia and type 2 diabetes, hypertension and dyslipidaemia. Observational data have shown a reduction in all-cause mortality, cardiovascular events and mortality and a reduction in cancer risk and mortality in patients who have undergone bariatric surgery compared to matched patients who did not have surgery. The emergence of newer incretin agonists, particularly semaglutide and tirzepatide, have demonstrated remarkable efficacy in inducing and maintaining weight loss with ongoing use. As for bariatric surgery, incretin agonist therapies also improve type 2 diabetes outcomes, cardiovascular mortality and other obesity-related complications, with new evidence emerging and long-term outcome data awaited. This perspective compares bariatric surgery and incretin agonist therapy, assessing their relative efficacies in weight reduction, impact on obesity-related complications, their respective risk profiles and considerations of cost-effectiveness and equity of access. These comparisons seek to evaluate whether these increasingly popular medications could make bariatric surgery a thing of the past.