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Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And we have a complex weight management panel for you today with three Northwestern Medicine physicians: Dr. Matthew Pittman is a bariatric surgeon, Dr. Eric Hungness is a Professor of Gastrointestinal Surgery and Medical Education, and Dr. Srinadh Komanduri is Associate Chief of Gastroenterology and Hepatology and a Professor of Medicine.

Doctors, thank you so much for being with us today for this panel. And Dr. Komanduri. I'd like to start with you. When you look at the full suite of options from the GLP-1 medications to endobariatic interventions to bariatric surgery, tell us a little bit about them and how you determine patient selection, which are best suited for each approach. And as we look at all the things that we know now—BMI thresholds, severity of metabolic disease, lifestyle, obviously, readiness, and then of course, access and insurance—kind of put that together for us for a little table setting and tell us about those options.

Dr. Srinadh Komanduri: Thank you. I think that's the whole podcast. I'm going to let my peers also chime in here. And I think that is the first and foremost statement I'll make, is the management of obesity in 2026 is truly one of our most multidisciplinary areas within medicine, and has become more so with a lot of what you described. The impact of treating obesity now goes well beyond weight loss and stems into metabolic disease and even inflammatory disease with some of our new novel medications.

I think the question around choosing between endoscopic options like endoscopic sleeve gastroplasty, traditional surgery, like a Roux-en-Y gastric bypass, and the novel GLP-1 medications really does depend on the patient's goals for weight loss, the willingness and acceptability of surgery, and long-term considerations, including what you brought out in terms of cost and insurance. I think, in 2026, surgery remains a standard of care for us to judge from.

However, we can really start to look at patients in a personalized fashion and stratify them based on their goals. And some of that's based on what their intent on weight loss really is, if it is about truly just weight loss and the goal that they're trying to reach for along with their starting BMI as was pointed out, where endoscopic sleeves result in a 15-20% total body weight loss, similar to even GLP-1s. For the patients who really are looking for more significant substantial weight loss, surgery still remains that top choice for them.

So, that's sort of, I think, step number one, is really understanding what we're trying to do here is a work in progress and not really siloed to one provider. And we together as the surgeons and gastroenterologists on this podcast, but also a much larger team, including dieticians, healthcare psychologists, and primary care physicians are critical to starting this journey all the way to the end.

Dr. Eric Hungness: I'll just add onto to that really, you know, the fact that we've got multidisciplinary presence on this podcast just tells you how we at Northwestern approach this. And even on the GLP-1, we don't have a representative today on that, but it's a comprehensive approach. When we think about the scope of obesity, there are probably right now about a hundred million people in the United States, adults, with a BMI greater than 30. The number of operation—bariatric surgeries—that are done per year maximum is 250,000. So essentially, you still have 99.75 million patients that are out there.

So, surgery alone is never going to address the entire disease burden of obesity. Medications aren't going to do that too. And endoscopic procedures aren't going to do that alone either. So, you really need a toolbox of therapies. I really like the idea of what Sri was saying about the personalized approach to medicine. There are a lot of patients out there suffering with obesity, and we now have more in our armamentarium to treat those patients.

Dr. Matthew Pittman: We're a little still neophytic in our knowledge of what's going to be the best treatment for each patient. And this is a specialty where patients in dire need of an opinion needs to be an integral part of how we move forward with our different treatment modalities. It's kind of a task of us weight loss providers to hopefully establish a good guideline and guidance for our patients with all these new options as to what's probably going to be the best chance at them achieving their goals, and then maintaining those goals for the rest of their life.

Dr. Srinadh Komanduri: One key point to drive home is although we're early in this, what we do understand is it's really all of the above, right? And I think this is whether I see the patient, Eric sees the patient, our medical obesity physicians see the patient, the answer is everything. And what I mean by that is this is a disease that is so complex and goes well beyond weight loss, that we have to be able to pivot. We have to be able to look at the patient, again, in that personalized manner to see, you know, what is actually possible and what are their goals.

And I think one of the good examples of that is, you know, some of the data around ESG or the endoscopic sleeve, in conjunction with post-procedural GLP-1s, really augments weight loss significantly into that 20-25% weight range. And so, you start to see this, the journey doesn't end with a procedure, right? And there's so much more that goes on from the patient, from a behavioral and psychological aspect and a nutritional aspect. But some of these treatments become synergistic, and I think that's a key thing to point out.

Melanie Cole, MS: Well, I agree with you all. And as an exercise physiologist for a very long time myself, I see this epidemic and I see these, as you perfectly said, tools in your armamentarium. These are tools that can help with this epidemic. And so, Dr. Pittman, we were just mentioning briefly so far the GLP-1s. Now, they've gotten a lot of play in the media. You know, they're kind of talked about everywhere. And particularly, when we think of long-term weight maintenance and patient adherence, because we know certainly, as you were just saying after surgery, there are lifestyle modifications, things that have to go into all of these tools that make them so successful.

So, speak a little bit about some of the challenges or limitations that you see with these GLP-1s, because as I said, they're kind of everywhere. Are people having trouble with adherence? Are there side effects you're concerned about? Speak a little bit about that.

Dr. Matthew Pittman: Our GLP-1 medications, they are kind of new kid on the block here. We've now have GLP-1 medications. We have dual receptor agonists with our GLP-1s and GIP. We're likely soon to have our triple receptor agonists adding in the glucagon. And these are some really, really powerful game-changing medications. There's no question they're going to have a really important role in our armamentarium for weight loss long-term.

A common misconception that a lot of patients have with these GLP-1s is they're going to go on the medication, they're going to get down to their goal weight or close to it, they'll come off the medication, that will be it. And we know that that is just not the case. We now have strong evidence showing that greater than probably 80% of patients are going to see almost complete weight regain in about two years if they come off these GLP-1 medications and similar medications.

And so, we need patients to understand that this is a really effective tool. It's going to have a really good place in their overall metabolic improvement. But it is going to be for life. And that's something they need to understand, because that's a big responsibility when you decide that a medication is going to be for life.

 Also, not only is it just the weight gain that we see when patients come off those medications, we see them basically revert to their baseline fasting glucoses, blood pressures, and cholesterol levels. So, we don't see long-term improvement once they come off the medications. So, I think that's really essential for our patients to understand when really trying to decide what's the best route for them.

The second is cost. You know, obviously, procedures and surgeries have a pretty big sticker price on the upfront side. But when we talk long-term, being on these medications for the rest of their life, especially for our younger patients, that is a pretty substantial cost as well as a cost to overall healthcare in general.

And then, there's availability. Obviously, insurance companies are able to regulate what they're going to approve, not approve. And unfortunately, we see often when patient gets down to a BMI that we're healthy and happy with, that sometimes those insurance companies are then no longer covering it, even if that means that we're then expecting that patient to regain all that weight within two years. So, I fear that we may find ourselves in a yo-yo type situation with these GLP-1s where patients are forced to come off of them, they regain their weight, they go back on them. And is that really the best approach?

 As far as side effects, we know the common ones that most people are knowing and probably our providers are seeing in the clinic are the nausea and vomiting. And it's substantial in that we're seeing probably 40-70% of patients reporting some sort of nausea, vomiting. Diarrhea, constipation, as well.

But the one that gives me concern probably the most of all with these GLP-1s is, especially when not being provided or prescribed by a provider and followed closely, is that there can be a significant amount of lean muscle mass loss on these GLP-1s. Some studies are showing 25-40% of the weight loss that people are experiencing are actually lean muscle mass loss and we all know that weight loss, if it's from muscle, is not healthy weight loss. And in the end, that's going to drive down our basal metabolic rates and actually put the person in a worse situation afterwards. And so while these medications are very effective and can be used very well, it's really important that they're being managed appropriately.

Dr. Eric Hungness: I want to add a couple of things too about that. One is that the studies that have been done, it's kind of the best case scenario and best case outcome. And if you look at those studies, about 30% of people were not able to complete the trial because of adherence problems, and that's trying to get that study done. The real-world estimates are probably greater than 40% of people who start one of these medications will stop it within the first 12 months because of severe side effects. So, that's some of the real-world issues there.

Two is that most of these studies were designed for patients with class 2 obesity, BMI under 40, and they may perform well and in good outcomes. But for the BMI greater than 40, particularly greater than 50, the amount of weight that patients need to lose to see the conferred benefit to their health, reduction in comorbidities, et cetera, the medications really can't touch that.

And then, the other silent one that I think is creeping up is problems with acid reflux, GERD, and complex GERD issues as well. Studies have shown increased rates of erosive esophagitis, Barrett's esophagus, esophageal strictures. So, particularly for patients that already have reflux, starting them on a GLP-1 is probably not a good idea.

Dr. Srinadh Komanduri: Interestingly, Eric, to your point, I just actually saw a patient today with a very challenging scenario who has early esophageal cancer that we've been trying to eradicate endoscopically who really has been maximized on their anti-reflux medications. But the one thing that they've been struggling with is they've been on a GLP-1. And we've been trying to find the culprit as to why this reflux is so recalcitrant. And so, there are some real-world cases where this is a challenge.

I will say the other thing that's important, and not to get on a tangent, but really where these medications may be headed is also very different than their initial intent. And by really looking at their impact on weight loss, what we've actually found is these medications have a tremendous impact on many other diseases, not only cardiovascular, kidney disease, liver disease with metabolic liver disease, but things like sleep apnea. And more potentially important in the long run, some of their anti-inflammatory properties for early Alzheimer's dementia, psoriasis have really been extremely promising. And not to shift gears, but I think it's just a nice example of what we thought we're getting with these medicines may end up being a very different and beneficial outcome down the road. And something to also just keep in mind as physicians think about these drugs is other benefits that they do impart.

Melanie Cole, MS: I think that's common. Now, we're learning more and more about medications crossing over. That's so interesting that you brought that up. And Dr. Komanduri, for patients who are not surgical candidates, as we've discussed a little bit about patient selection and the criteria for bariatric surgery, and we'll get into that a little bit more in a minute. But for those who aren't candidates, who are not ready for surgery, what role do these endobariatic procedures play? How do their outcomes compare to the GLP-1s or the more invasive bariatric surgeries?

Dr. Srinadh Komanduri: First, when I see these patients, I want to make a distinction that they have all the information, right? I think it's easy and we have fallen into this pattern where patients will tend to come to what they perceive as the least invasive option, right?

So, I think it's important for us, as the gastroenterologists, who are the sort of gatekeepers for things like ESG and even GLP-1s to some extent, is to make sure that the patient really understands the differentiation between these options and how powerful surgery can be when it's done for the right purpose.

Now, definitely, if there's comorbidities associated that preclude the patient, and this really can apply to some of the patients I was talking about with metabolic liver disease and, especially in some of the range of the 30 to 40 BMI with comorbidity that may not benefit as much from a surgical operation, we really want to kind of weigh our options. I think, some of this is going to be dictated in the early years. And we can talk a little bit about where we stand in the financial and reimbursement aspect of the endobariatic world.

But a lot of it is right now contingent on failure of lifestyle and medication options. So in a way, they're holding us a little contingent on that. And so, fortunately, a lot of patients do try and are started on some of these GLP-1s who are non-operative candidates. And they come in with a lot of things that Eric talked about. Very long journeys and struggles with side effects and inability to tolerate these medicines or even to get them paid as well.

So, as we go from there, there's no question the numbers are similar, but the mechanisms are different. So between GLP-1s and endoscopic sleeves for these non-operative candidates, the weight loss, initially, between 15-20% total body weight loss is what we see. However, the drug is very much contingent on that being present forever. The durability data for ESG extends well beyond five years now, and maintenance of that 20% weight loss, and as I indicated, augmented by GLP-1s as well to go to much higher.

So, I think it's really trying to dissect the patient and ensuring they truly are not—from a goal perspective and sort of their clinical characteristics—a candidate for surgery. And then, if not, really trying to understand, which direction they would go. But for right now, in 2026, we're sort of in a paradigm where we most of the time will need to try medication upfront, and then consider an endobariatic option.

Melanie Cole, MS: Well then, based on that, Dr. Hungness, as we talk about bariatric surgery, and it remains the most effective long-term intervention for many patients, it's been around a long time, tried and true, i'd like you to speak about outcomes or comorbidity improvements that you're seeing in your own patient populations today as we think of all of this about quality of life. The other big reason is those comorbid conditions—blood pressure, diabetes, these sorts of things. What are you seeing?

Dr. Eric Hungness: That's obviously the most important thing, what are the outcomes. And like you said, the surgical options have remained the most effective treatment for most patients. The most important thing I want to say first is that the safety profiles of the operations have improved, dramatically. So, I know there are a lot of patients when you're considering any sort of therapy, the pros and the cons, and the cons and the complication rates and so forth this is not the early days of bariatric surgery. We have very robust data collection now. All the centers at Northwestern are part of a comprehensive quality outcomes project. And if you look nationwide, these operations are extremely safe as far as like the chance of dying from one of these operations, 0.05%; the chance of a serious complication happening in the low single digits.

And so, that's the first thing, is that these operations are safe. We're seeing that at Northwestern, whether you're being treated at the central campus or any of the regional campuses, we share our quality data. We have regular quality meetings. We standardize our treatment pathways. So, seeing that across the entire system.

As far as weight loss is concerned, consistently, we're seeing as a system, depending how you measure it, whether it's 20-25% total body weight loss or greater than 60-65 excess body weight loss, and particularly for the higher BMI patients, BMI greater than 40, that's what you're going to need to drive those comorbidity improvements and decreased cardiovascular events, mortality, all causes of mortality, which have been proven on a nationwide level.

As far as those improvement in comorbidities, the big one is diabetes. And we're seeing greater than 80-85% diabetes remission when you look long-term. But these are safe operations and they're really helping our patients a lot.

Dr. Matthew Pittman: I could not agree more. And I think you elaborate on the safety profile, it's so key because I think that too often the misconception is that these are risky procedures and am I going to take this risk? And we just know through our evidence that that is not the case. These are incredibly safe procedures. And when we look at the comorbidity improvement, I think there's a solid argument that the risk is letting these various conditions go untreated. When we're talking about a procedure that can resolve diabetes, high blood pressure, sleep apnea, improve cholesterol, reduce cardiovascular risk, and is well proven to add years onto our life, there's no question if a patient is appropriate for surgery, that not operating is the the higher risk situation. Unfortunately, I don't think that we've really gotten that message out as strongly as we need to.

Dr. Srinadh Komanduri: The one other comment I'll make safety is the key. And I think, from perspective of an endoscopic sleeve gastroplasty, the data is really there. And I think it's important for everyone to know that this is just like surgical operations as was indicated. ESG has also been studied very critically. And in fact, the main pivotal trial called the MERIT study, which was published in the Lancet a couple years ago, really highlights that significant adverse event rate for ESG is 2% or less. So, similar to surgery, I mean, in the sense of very low rates of adverse events for a lot of these procedures. So, it's important for patients to understand that you're getting into something that's important to ensure you have a good grasp of all your options. But the procedural side of this weight loss in 2026 comes with a lot of options that are extremely safe.

Melanie Cole, MS: So, along those lines then, when other providers are counseling their patients, before they refer them, Dr. Pittman, and across these three modalities, as we've mentioned, safety and briefly touched on misconceptions, what are some of the ones, the biggest ones, that you've heard about these various obesity treatments?

I've heard so many in my 35 years. I've heard so many misconceptions. And one of them being that it's the easy way out, when really this is a tool. I mean, that's the biggest one that I've always heard. And certainly, none of this is easy. So, what are you hearing and how do you reset those expectations for other providers to help counsel their patients on what success really looks like and expectations on what they need to do?

Dr. Matthew Pittman: The first issue is the framing of this as weight loss procedures or weight loss medications. These are metabolic medications and metabolic procedures and metabolic surgeries. We're not doing this to obtain a certain number on the scale or a certain pants size. I mean, we're really trying to improve overall metabolic health. And I think you need to approach it from that mindset in order to figure out what success from these should look like.

And you are exactly right, these are a tool. So if you think that this is going to be a quick fix from any of these modalities, it's going to be wrong. They are a tool, they're very effective tool. But they have to be used appropriately because without the lifestyle changes, including diet and exercise, none of them are going to be successful long-term. There is not a surgery we can do without lifestyle changes. It shouldn't be viewed as a quick fix. We know that obesity is a chronic disease. It's going to require appropriate multidisciplinary management. And to think that this is going to be a quick fix is just not the case.

When we talk about weight regain, that shouldn't be shameful. That shouldn't be thought of as, "If I failed one modality, well, that's it. That's all I have." I think we need to know that, thank God, we have a much larger toolbox now. Our armamentarium is growing daily on options we have for patients. Just like we were treating any other chronic disease, we wouldn't give up if your first blood pressure medication didn't work. We would continue to work to find the right regimen to help with you. That includes psychology, our nutritionists, our dieticians, our exercise specialists. Everyone plays a role here, because all of our patients are coming from a very different place, and their obesity is multifactorial.

Melanie Cole, MS: This is really such a good discussion, and we could go on for a long time. But I'd love to give you each a chance for a final thought here. So, Dr. Pittman, looking ahead, when you think of these treatment options integrating, do you envision more combination therapy? Do you envision them working together? What is your vision for the future of this obesity epidemic that we find ourselves in?

Dr. Matthew Pittman: I do think that multimodal management is going to be the norm moving forward. I think from a provider standpoint, it's basically we need to be working to help develop algorithms and plans for patients so that we can direct them into the best route for success individualized for them, much like our cancer center models, where a patient comes in with a disease and we can bring in multiple different disciplines, evaluate that patient as an individual, and hopefully present a solid long-term plan to be able to give them success. And the bigger the toolbox, the better to help best individualize the treatment plan for that patient.

Melanie Cole, MS: It's true. And Dr. Hungness, when you think of the future and these treatment options, and we're looking at the GLP-1s and the endobariatic and bariatric procedures, what in your opinion should be that sequencing strategy? If you were with your patients and you're speaking to other providers, what are you looking for them to do first? What are you looking for them so that they are optimizing any perioperative situations that the patients going to be in? Give us a little timeline from your perspective and what you want other providers to take away from this.

Dr. Eric Hungness: So, a couple things. I would say most of the patients that I see in evaluating for weight loss surgery, they're ready to go. They don't necessarily need that preoperative optimization. A lot of them have already tried a GLP-1, et cetera. So, I would say most of the patients are ready to go and can benefit from timely surgical therapy.

There is probably a subset of patients that could be optimized preoperatively. And I'm thinking again about the very high BMI patient. A lot of times now, we unfortunately have to do it in a staged way where we stay, we do one operation first, and then a second operation a year or two later.

I think that the GLP-1 could be a nice on-ramp to get them to just a single destination surgery. That's one thing. Particularly avoiding the sleeve and going right to bypass. So, getting more of your super high BMI patients right to bypass. The second one is going to be on maintenance therapy.

Even after surgery, we know that after about 12 to 15 months, you're going to hit your lowest weight loss after surgery. It behooves us as a medical community to figure out the timing, which patients would benefit from that maintenance. Let's start a low-dose GLP-1 at that time to maintain that weight or even further the weight loss even more. So, I think those are the two big areas. I think we need to be thought leaders. I think we need to drive the research. And we have that ability at Northwestern, so we're going to do that.

Melanie Cole, MS: And Dr. Komanduri, why don't you take it home for us. I'd like you to speak just a little bit about what Dr. Hungness was just mentioning as far as postoperative weight maintenance and the things that go into that, and where do you see the evolving research going? What are you hoping will happen?

Dr. Srinadh Komanduri: I do want to finish with, you know, it would behoove me to stress the new kid on the block here, which is the endoscopic sleeve and more so just because I want people to be aware of it. And a couple of things that are important, you know, in Northwestern Medicine, as you've gleaned, this is a complex multidisciplinary program. And so, our major hubs really are at Northwestern Memorial and out in the west at CDH. And together, we will work as a team to not only provide patients with all these options, but advance the science of it as well.

I think one important aspect to just emphasize with the endoscopic option is, as of January 1st, the endoscopic sleeve did achieve a level I CPT code. So, this is really critical in a reimbursement frontier that over this year, all the payers will begin to accept this and cover this in terms of our patients when we do make the decision. Also, just leveling the playing field, then moving forward as you go through our programs, we will individualize the care for each patient and make sure they have looked at every option on the table and algorithmically make the right decision for the patient.

I think the last, but not least, our team extends well beyond us. As we've said today, we're just the physician representatives of a much larger group that will be a part of the patien'S journey. And I think making sure patients understand this isn't a drug or a procedure. It is a journey. And the journey goes on for life. And I think it's critical, perhaps more critical, what happens after a surgery or an endoscopic sleeve to maintain that. And having the counseling from a mental health standpoint, from a nutritional standpoint, but also looking at before we do these types of procedures, making sure the patient has a plan and is committed to all the different changes they might need to make to make this a durable solution.

Melanie Cole, MS: Well said. And it certainly is such a multidisciplinary approach to a really complex issue. Thank you all for such a lively discussion. This was a great talk today. And to refer your patient to Dr. Pittman, Dr. Hungness, or Dr. Komanduri or for more information, please visit our website at breakthroughsforphysicians.nm.org/gastroenterology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.