Joey Wahler (Host): With GLP-1 medications becoming so popular, who should consider bariatric Surgery? Our guest is Dr. John Scott, a bariatric surgeon. This is Flourish, a podcast from Prisma Health. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Scott. Welcome.

Dr. John Scott: Nice to be here.

Host: Great to have you with us. We appreciate the time. So first, how has the rise of GLP-1 meds like Ozempic, of course, and others changed the conversation around obesity treatment? What are you hearing?

Dr. John Scott: So, one of the most important things about the new GLP-1 era, it is changed how society thinks about obesity. You know, for decades, obesity was framed as this failure of willpower. But now, we have medications that clearly demonstrate that obesity is more about the biology of appetite regulation and gut hormones and energy balance. And that's really shifted the conversation from the blame from the patient to biology.

And the second major change about obesity treatment, it's finally being discussed alongside other chronic diseases. Nobody expects a patient with like hypertension or cancer to manage their condition with willpower. So, we're starting to apply that same framework to obesity. For doctors, the conversation has expanded. Instead of having a choice of just between surgery and lifestyle, we now have a whole spectrum of therapies. So, there's behavioral treatment, medications like GLP-1 and metabolic surgery. The real progress is that we can start matching the right treatment to the right patient instead of pretending that there is just one single solution.

Host: Gotcha. And that being said, in this age of these highly effective GLP-1 drugs, how should patients and clinicians alike think about the role of bariatric and metabolic surgery these days?

Dr. John Scott: I think the key point is that the difference between GLP-1 medications and bariatric surgery is that they're not competitors. They're different tools that treat the same disease. Now, GLP-1s are very powerful. They're powerful pharmacologic therapy that can help patients lose meaningful weight. And bariatric surgery, on the other hand, remains the most effective and durable treatment that we have for severe obesity and metabolic surgery.

The way that I frame it for patients is this, medications and surgery exist on the same treatment continuum. For some patients, medication will be the right first step. But for others, especially for patients with severe obesity, diabetes, obesity-related complications, surgery may offer a more durable metabolic reset. The goal is not medication versus surgery. The goal is the right therapy for the right patient at the right time.

Host: Okay. So, let's delve into that a little bit more. Who would you say is an ideal candidate for GLP-1 therapy? And what are the expectations that patients should realistically have regarding weight loss and using them long-term?

Dr. John Scott: So for patients that want a non-surgical approach to treatment, I think GLP-1 therapy is the perfect option for them. If you look at clinical trials and in real-world practice, patients often lose about maybe 10-20% of their body weight depending on which medication you use. And that can have a significant impact on some of the diseases like diabetes, hypertension, fatty liver disease, sleep apnea. But expectations are important. These medications were designed to treat a chronic disease, and that means you have to take them long-term. When patients stop the medications, weight regain is common because the biology hasn't changed. So, that's what I tell patients. These work best, but they're viewed the same way that you view taking a blood pressure medication or a medication for cholesterol. They are a long-term therapy for a chronic condition. As far as surgery's concerned, surgery is a much more durable, long-lasting option for patients.

Host: And so, when is GLP-1 therapy not an option because of other factors, side effects, access, cost, or maybe the challenges of adhering to what needs to be done?

Dr. John Scott: The biggest barriers that we see for patients when it comes to GLP-1 therapy are cost and access. Many insurance plans don't cover anti-obesity medications. And the out-of-pocket cost can be substantial. And there's also an issue of long-term adherence. These medications require long-term ongoing use, and some patients prefer a more definitive treatment. So when patients cannot tolerate the medications or can't access it or simply just prefer a different approach, metabolic surgery becomes a very important option. There was a recent study that showed that almost 50% of patients that were placed in GLP-1 therapy will discontinue use of those medications within the first year.

Host: Interesting indeed. So, which patients would you say, Doctor, are better serve then by metabolic and bariatric surgery rather than just medication?

Dr. John Scott: So recently, the indications for bariatric surgery were updated. Patients that have A BMI over 30 with comorbidity related to weight, or patients that have a BMI greater than 35 are potential candidates for bariatric surgery and would show the most benefit. Surgery is very powerful for patients that have type 2 diabetes, metabolic syndrome, or significant obesity-related complications.

In these cases, surgery does more than just produce weight loss. It fundamentally changes the metabolic physiology and can lead to remission of diabetes. And other diseases related to weight. Another group of patients, that have benefits are those that have struggled for many years with multiple different treatments, multiple different medications, and want a more durable intervention.

So when we talk about surgery, we're not talking about a last resort. We're talking about the most effective therapy that we have for certain patients with metabolic disease.

Host: Gotcha. And so, naturally, Doc, people joining us, I'm sure, wondering more so than anything else about outcomes, results at the end of the road, if there is such a thing here. How do outcomes compare then between GLP-1 meds and bariatric surgery in terms of things like weight loss, durability, metabolic disease, remission and, of course, overall quality of life, period?

Dr. John Scott: In real-world studies, GLP medications typically produce anywhere from 10-20% total body weight loss, depending on the medication that you're taking and if you continue with treatment. Bariatric surgery—once again, varies between which metabolic procedure you have—produces about 25-30% total body weight loss. And most importantly, much of that weight loss can be maintained long-term after your surgery.

From a metabolic standpoint, surgery also has very high rates of type 2 diabetes remission, and significant improvements in cardiovascular risk factors. Quality of life often improves with both therapies. What patients care about most—mobility, energy, metabolic health longevity—can substantially improve with either approach. So, the difference isn't what works and what doesn't. But what's been shown substantially is that surgery currently provides the most powerful and the most durable metabolic effect of the two options.

Host: So, what about GLP-1 meds and bariatric surgery working together—medication before surgery or after surgery, or perhaps as part of long-term weight maintenance?

Dr. John Scott: Absolutely. One of the most exciting things about the current area is that we can combine therapies. Some patients benefit from medication before surgery to help reduce operative risk. Other patients use medications after surgery to treat weight recurrence, or optimize metabolic control. We're increasingly thinking about obesity the way we think about cancer or cardiovascular disease by using combination therapy.

So rather than asking whether medications replace surgery, the better question is how can we integrate medications and surgery together to achieve the best long-term outcomes for patients?

Host: Misconceptions, of course, are always a factor here with people reading things on the internet that may or may not be as accurate as possible. What are the misconceptions you find that patients commonly have about bariatric surgery in this GLP-1 era? and how do you help patients make individualized evidence-based decisions rather than poorly informed ones here?

Dr. John Scott: One of the most common misconceptions about metabolic surgery is that it's somehow either outdated or an extreme treatment now that medications exist. In reality, metabolic surgery is probably one of the most studied operations in modern medicine and remains the most effective treatment for severe obesity.

Another misconception that people have about these surgeries is that it's purely about weight loss. In truth, it fundamentally changes the metabolism of a patient. It alters hormones. It changes the way your body signals about appetite. It alters your glucose metabolism in ways that medications alone cannot fully replicate.

The way that I help patients think about this is obesity is a complex chronic disease. Some patients do well with medications. Other patients will do better with surgery. Some patients will do better with a combination of both. The most important step is not choosing a specific treatment first. It's making sure that patients are evaluated by clinicians who can offer the full spectrum of therapy and help them choose the best approach that fits their weight loss goals.

Host: Couple of other things for you. One being, how important is it for experts here like yourself to remind those using either of these routes that they're going to have work to do for the remainder of their lives, regardless of which option they choose, right? You're going to have to change your ways when it comes to exercise and diet one way or the other, yes?

Dr. John Scott: I think that's a true statement. There's no doubt about it that, you know, behavioral changes in combination with these different options like surgery and medications will definitely enhance weight loss and some of the resolution of the comorbidities that we see with these therapies.

 This is a total lifestyle change, regardless of which route you decide to go with medication or surgery. We are trying to make patients able to eat healthy, be more active, and live a full lifestyle.

Host: And then, in summary here, Doctor, having said all of the above, what's the best way for those joining us to decide inevitably which weight loss route is best for them?

Dr. John Scott: The best way to get on the path to this healthy lifestyle is to have a conversation with your physician. Physicians can prescribe GLP-1 therapies themselves, or they can refer you to a comprehensive center that has access to all of these treatment modalities, like surgery and medications.

Host: Well, Doc, no question, it's an area of medicine that's growing in terms of participation and a thirst for knowledge out there on the part of patients, so very important to discuss it right here. We appreciate all your expertise. Folks, we trust you are now more familiar with bariatric surgery in this GLP-1 era. Dr. Scott, keep up all your great work and thanks so much again.

Dr. John Scott: Appreciate it.

Host: Same here. And for more information, please visit prismahealth.org/flourish. If you enjoyed this podcast, please share it on your social channels and check out our entire podcast library for more topics of interest to you. I'm Joey Wahler. And thanks again for being part of Flourish, a podcast from Prisma Health.