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By Mary Carpenter
TWO WOMEN, E.C. and J.B., both in their early 70s and recently retired from executive jobs, recently lost more than 50 pounds on the new weight-loss “GLP-1” drugs. Both women had mild health issues—high blood pressure, excessive pressure on joints; both had struggled for years to lose weight; and both now face a dilemma: whether to stay indefinitely on the very expensive drugs or risk regaining the weight. After E.C. stopped the medication, despite sticking to a rigorous program of diet and exercise, her weight crept back up—about five pounds every week.
Another option—considered minimally invasive, reversible and “non-surgical,” because there are no external incisions—is endoscopic sleeve gastroplasty (ESG). Like the GLP-1 drugs, ESG alters hormones that affect feelings of fullness and hunger— helping “to stabilize your metabolism,” according to the Cleveland Clinic website. On the other hand, the procedure requires general anesthesia; a recovery period of weeks or months with reduced exercise and diet limitations; and creates scar tissue that can make reversal difficult.
(ESG surgery involves inserting an endoscope tube down the throat and suturing the stomach from the inside, which can reduce gastric volume by 40%-80%. In contrast to surgical methods that remove part of the stomach, ESG uses stitches to bring folds of the stomach together, called an accordion procedure, which could allow for reversal at a later date.)
Many people who have struggled for decades to lose excess weight long for help. But both medical and surgical interventions have restrictions in terms of eligibility and reimbursement, and both have side effects and health risks: little is known about long-term effects of the weight-loss drugs. For both women, after losing weight successfully with medication, ESG remains a step too far. Said J.B., “I’m good on the drugs…surgery scares me.”
“We know from years of studying bariatric surgery that it slashes the risks of cancer, heart disease and diabetes-related death,” writes Johann Hari, author of “Magic Pill: The Extraordinary Benefits – and Disturbing Risks – of the New Weight-Loss Drugs,” and a recent essay in the New York Times. Noting that the new drugs might increase the risk for thyroid cancer and diminish muscle mass, Hari writes, “early indications are that the new anti-obesity drugs are moving people in a similar radically healthier direction.”
“Surgery is the only obesity treatment that rewires your body’s metabolic programming after obesity to prevent weight regain,” according to the Cleveland Clinic site. “Weight loss surgery is considered successful if you lose 50% of your excess weight and keep it off. By this standard, the success rate [of surgery] is 90%…usually the weight regained is less than 25%.”
“More effective weight-loss options like ESG…have been overshadowed by the excitement about the recent GLP-1 weight loss medications,” Harvard and Mass General radiologist Jagpreet Chhatwal told the Harvard Gazette. ESG “mirrors the effect of more invasive bariatric surgeries to reduce stomach volume…but presents far fewer of the risks.”
“Lifestyle intervention and bariatric surgery represent 2 extreme ends of the spectrum of obesity treatment,” according to Jama Network. “Bariatric surgery remains underused due to its perceived invasiveness, cost and limited insurance coverage.” But according to the Gazette, because gastroplasty “can be a permanent fix…the savings continue to mount in the months and years afterward.”
“I would compare bariatric surgery to a total knee replacement,” past president of the Obesity Medicine Association Ethan Lazarus told the American Medical Association’s public health site. “It’s going to be for the more advanced patients with obesity where they’re going to get a lifespan benefit…the reason to do it is to a make the person healthier…better quality of life and spend less time seeing doctors for all the obesity comorbidities.”
Who qualifies and how to cover the costs are central issues in both medical and surgical approaches to overweight and obesity: “Statistics show that only about 1% of people who meet the basic qualifications for bariatric surgery actually move forward with it,” writes Miami gastroenterologist Okeefe Simmons. “One of the most blatant disservices that obese patients have been presented with is the BMI qualification for eligibility to have bariatric surgery,”
“According to the standard BMI scale, an individual who is 5’ 7″ and weighs 191 pounds has a BMI of 30. For them to qualify for bariatric surgery with a BMI of 35, they would have to weigh 223 pounds.” Simmons explains. “And if they didn’t have a health condition, they would have to wait until their BMI reached 40…weighing in at 255. So potentially, they would have to gain 64 pounds before they could get help.”
For weight-loss GLP-1 drugs, a BMI of at least 27 plus at least one weight-related medical condition may qualify. But Simmons points out that, even for those with a qualifying BMI plus a serious health problem, currently medical insurance does not cover ESG or other less invasive procedures —which “are not yet considered methods used to improve a patient’s health…they are considered cosmetic weight loss procedures.”
But the two retired executives also face the problem that both have now lost enough weight for their BMIs to fall from close to 35 to below 25, which is too low to be eligible for any treatment other than remaining on weight-loss drugs. And although minimal surgery might help maintain weight loss, a 2023 literature review found that “limited evidence is available on the weight loss effect of combining [GLP-1 drugs] with endoscopic bariatric therapy (EBT).”
For now, ESG seems like “a step too far” for most people who share the dilemma facing the two women—and for most people struggling with serious health issues related to overweight and obesity. In addition, questions persist about the use of BMI as a qualifying criterion for either medical or surgical intervention—and even as a measure of overall health. For me, choosing something drastic like surgery to prevent regaining weight that has been lost is understandable —based on my experience of quitting cigarette smoking, after which I never ever wanted to endure again the months of difficulties I had while stopping.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
