“We may not be as sexy anymore, but we’re cheaper.” The phrase, coined by Ricardo Cohen, president of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), was repeated several times at the organization’s 2025 World Congress in Santiago, Chile. It encapsulates a growing consensus among experts who perform, research, and advocate for metabolic and bariatric surgery amid the surge in use of GLP-1 agonists and related anti-obesity medications.

Surgical approaches may no longer be as fashionable as pharmacologic treatments for obesity, but they remain more economical and cost-effective, according to David Cummings, MD, professor of medicine in the Division of Metabolism, Endocrinology, and Nutrition at the University of Washington in Seattle. Cummings, who studies the hormonal and metabolic mechanisms underlying the effects of metabolic and bariatric surgery on diabetes and body weight, noted that while GLP-1 receptor agonists are “great” and represent the fastest-growing drug class in medical history, “the problem is they are high cost.”

In the US, semaglutide and tirzepatide cost roughly US$900-US$1350 per month compared with US $17,000-$26,000 for a one-time metabolic surgery. Using one of these drugs for less than 2 years, he said, equals the cost of a Roux-en-Y gastric bypass, “which for most people will solve the problem for the rest of their lives.”

When analyzing cost per quality-adjusted life year (QALY) — a standard metric estimating years lived in perfect health — metabolic and bariatric surgery ranges between US$10,000 and US$25,000, which is considered 5-10 times below the affordability threshold. In contrast, semaglutide or tirzepatide costs nearly US$1 million per QALY, Cummings added.

He also cited an analysis published in JAMA Cardiology estimating that nearly half of US adults would qualify for GLP-1 therapy under the original BMI criteria. Treating that population, he said, would cost US$2.4 trillion annually — “approximately three times what we spend on our military and defense.”

Ildiko Lingvay, an endocrinologist, professor of medicine, and public health specialist at the University of Texas Southwestern Medical Center in Dallas, reinforced the argument. She acknowledged that pharmacologic treatments offer numerous advantages over surgery — they are noninvasive, reversible, scalable, and preferred by many patients — but pointed out that “several studies show that once pharmacologic treatment is stopped, the weight goes back up, and the trajectory is toward regaining the initial weight.” Sustaining treatment over time, she said, comes with substantial cumulative costs.

Lingvay cited a recent estimate from a research group in Tampa, Florida, indicating that just 9-11 months of treatment with drugs such as liraglutide or semaglutide equals the cost of a sleeve gastrectomy or Roux-en-Y bypass, respectively. Even the least expensive option studied — exenatide — becomes costlier than surgery after 15 months. And even if drug prices fell to one third of their current levels, the breakeven point would still be reached within 3 years.

Considering the long-term effectiveness and greater weight reduction achieved through bariatric surgery, Lingvay concluded, “If I were the financial adviser of these patients with severe obesity and they asked me which is the appropriate treatment option, I would have a very clear answer.”

‘Who Wouldn’t Want the Most Cost-Effective Treatment?’

The growing importance of economics in the field of metabolic and bariatric surgery was underscored at the IFSO Congress. The award for best oral presentation went to Michael Edwards, MD, associate professor of surgery at the Mayo Clinic in Jacksonville, Florida, for a study comparing out-of-pocket costs among more than 1000 insured patients who underwent Roux-en-Y gastric bypass or received GLP-1 receptor agonists for type 2 diabetes and class 2 or 3 obesity.

The findings were striking: after 2 years, surgery was associated with an average spending reduction of US$704 (P < .01) compared with pharmacologic treatment. The savings rose to US$1667 (P < .01) when the prescribed drug was semaglutide.

The issue of cost also featured prominently at a press conference on obesity drugs and bariatric surgery during the American College of Surgeons (ACS) Clinical Congress 2025, held in Chicago from October 4 to 7.

Beyond the demonstrated benefits for both quality of life and life expectancy, cost-effectiveness remains a “compelling argument” in favor of bariatric surgery as a treatment for severe obesity — and for the many comorbidities that accompany it, said Richard M. Peterson, MD, MPH, current president of the American Society for Metabolic and Bariatric Surgery, in response to a question from Medscape’s Spanish edition.

“Who wouldn’t want the most cost-effective treatment — one that maximizes investment, restores life to the fullest, and eliminates the diseases that limit activity?” said Peterson. “The cost of obesity, and of treating it, is enormous, both for patients and for health systems. We want to be responsible stewards of the care we deliver. If I were asked what I’d do to save more money and help the greatest number of people, the answer today is clearly surgery.”

Agreeing with that view, Thomas C. Tsai, MD, MPH, chief medical officer for health policy research at the ACS and associate professor of surgery at Harvard Medical School and Brigham and Women’s Hospital in Boston, emphasized that the true question is about value, not just cost.

“The key is not which treatment is most attractive or most cost-effective, but which provides the greatest overall value — for patients, health systems, public health, and society,” Tsai said. “And there’s no question that, right now, metabolic and bariatric surgery delivers the highest value — both in cost-benefit terms, given the high price of GLP-1 receptor agonists, and in helping patients achieve lasting results and a longer, higher-quality life.”

Combined Approach

In this context, specialists in metabolic and bariatric surgery are calling for a comprehensive approach to obesity — one that puts all therapeutic options on the table, including frank discussions about each treatment’s projected costs and expected effectiveness.

“It’s essential that patients have accurate information when making decisions about their care,” said Monali Misra, MD, bariatric surgeon and associate director of the Cedars-Sinai Marina Weight Management Center in Marina del Rey, California. “These drugs are designed for long-term use because obesity is a chronic condition. Just as we don’t stop blood pressure medication once it’s controlled, GLP-1 receptor agonists generally shouldn’t be discontinued once they’re working.”

Misra noted that while the new anti-obesity medications are effective tools for many patients, they may not be sufficient for others to achieve their health goals. “For example, if you take someone who weighs 136 kg, a 15% reduction in total body weight — which reflects real-world outcomes — means a loss of about 20 kg. That’s a great start, but often not enough to reverse serious diseases like diabetes or hypertension. The same patient, with bariatric surgery, could lose between 40 and 45 kg.”

She emphasized that bariatric surgery is effective, durable, and safe, citing data showing that “it’s even safer than gallbladder removal.” The procedure has been demonstrated to reduce multiple comorbidities, improve cardiovascular health and fertility, and lower cancer risk. “When we look at the latest research on cost-effectiveness, surgery remains significantly more economical than drugs alone,” she said.

The most successful outcomes, Misra added, often come from combining approaches. “We need to integrate nutritional therapy, physical activity, behavioral support, medication, and in some cases, surgery. Whether patients require drugs, surgery, or both, they should have an individualized plan. Our goal is to ensure they’re informed, supported, and set up for long-term lifestyle success.”

Cummings reported serving on the scientific advisory boards of GI Dynamics, Endogenex, and Gila Pharmaceuticals. Lingvay reported receiving consulting fees, research support, or other institutional payments from multiple companies, including AbbVie, Amgen, AstraZeneca, Eli Lilly, Novo Nordisk, Pfizer, Roche, and Sanofi, among others. Peterson reported receiving honoraria for lectures from Teleflex and Standard Bariatrics. Tsai and Misra declared having no relevant financial conflicts of interest. 

This story was translated from Medscape’s Spanish edition.