Weight Loss Surgery or Weight Loss Medication?

An Honest Look at Your Options

Five years ago, most people who came to see Dr. Hesham Atwa and his team about weight loss surgery had already decided on surgery. Today, the conversation is very different. Patients often arrive already taking a GLP-1 medication, or wondering whether they should try one first, or asking him outright: “With all these new weight loss shots, is surgery even worth it anymore?”

It is a great question, and Dr. Hesham Atwa gives an honest answer. In his view, these are not competing options. They are different tools for treating the same disease, and for many people, the best results come from using the right tool at the right time.

Does the rise of weight loss medications worry surgeons?

Not Dr. Hesham Atwa. In fact, he sees one very big benefit. These medications have helped people finally understand that obesity is a medical problem, just like diabetes, high blood pressure, or cancer. It needs medical treatment, and if one treatment does not work, there are others.

And it does need treatment. More than four in ten American adults now live with obesity (Centers for Disease Control and Prevention). It shortens lives and affects nearly every organ in the body. It is linked to heart attacks, strokes, type 2 diabetes, sleep apnea, fatty liver disease, joint pain, polycystic ovary syndrome, and a number of cancers.

It also wears down quality of life day by day: the fatigue, the poor sleep, the aching knees and back. Yet only about one percent of people who qualify for weight loss surgery ever have it. Dr. Hesham Atwa’s view is simple. It matters less how obesity is treated than that it is treated.

It’s Not Your Fault

When new patients sit down with Dr. Hesham Atwa, he often asks them, “Why do you think you are overweight?” Most of them say some version of the same thing: “It’s my fault. I eat too much. I don’t exercise enough.”

He then explains that there are many reasons people carry extra weight, and genetics is one of the biggest. Two people can eat exactly the same food, and one gains weight while the other does not. Certain medications increase appetite. Stress and depression play a role as well as living in a world where unhealthy food is everywhere.

Many patients have cried in his office when they hear this. They tell him, “My whole life, I thought this was my fault. Everyone told me to just eat less and exercise more.” Obesity is a medical condition, not a character flaw, and it deserves real medical treatment.

Why Dieting Alone Often Fails

Most patients have tried dieting many times. They lose 10 or 20 pounds, gain it back, and feel like a failure. Up and down, the classic yo-yo. Dr. Hesham Atwa has seen a few people lose 50 to 100 pounds with diet and exercise alone, but for most people, the results do not last.

The reason is that the brain fights back. Dr. Hesham Atwa describes it as an alarm going off in your head: I’m hungry, I’m hungry, I can’t do this. The body also has somewhat of a thermostat for its weight. If someone who weighs 200 pounds diets down to 160, the body essentially says, “We are not supposed to be at 160. We are supposed to be at 200,” and turns up the appetite to pull the weight back.

What medications and surgery both do, in different ways, is turn that thermostat down. The brain accepts the new weight as normal, and the constant “food noise” quiets down. That is what makes lasting weight loss possible.

How GLP-1 Medications Work

Anti-obesity medications like the GLP-1 drugs come as weekly injections or, for some, a daily pill. They work in several ways. They act on the appetite centers in the brain to quiet food noise, help people feel full sooner, and slow how quickly the stomach empties. Some people feel a little nauseated or tired for a day or two after a dose, especially early on.

With medication, most people lose somewhere between 10 and 25 percent of their body weight, depending on the medication and how well they tolerate it. That is a real, meaningful result.

How the Gastric Sleeve Works

Dr. Hesham Atwa asks patients to picture their stomach shaped something like a pineapple.

During a sleeve gastrectomy, about 80 percent of it is removed, leaving a narrow tube about the shape of a banana. After surgery, a few bites bring a feeling of fullness.

But the smaller size is only half the story. The part of the stomach that is removed produces most of a hormone called ghrelin, the “hunger hormone” that makes the stomach growl. Once it is gone, the hunger largely goes with it. Many of Dr. Hesham Atwa’s patients say they have to remind themselves to eat, which is important, because they need enough protein to protect their muscle.

With the sleeve, patients typically lose about 25 to 30 percent of their body weight, reaching their lowest weight around nine to twelve months after surgery. In Dr. Hesham Atwa’s experience, surgery gives a more durable, longer-lasting result. Muscle loss is a concern with any significant weight loss, and some of the weight lost on medication can be muscle, which is why protein and strength training matter so much no matter which path a patient chooses.

For some patients, a gastric balloon is another option. It is placed in the stomach for about six months, where it helps people feel full and slows emptying. Patients often lose around 30 to 50 pounds.

What Life Looks Like in the First Few Months

With medication, the first few months usually mean feeling fuller on smaller portions and gradually adjusting to any side effects. With the sleeve, the first few weeks are spent on a liquid or pureed, baby-food consistency diet while the stomach heals. After that, patients eat regular food, just in much smaller portions.

Either way, the eating habits Dr. Hesham Atwa recommends are similar: focus on protein and healthy fats, and keep carbohydrates low, since they tend to drive appetite. After the sleeve, he asks patients to aim for about 60 grams of protein and 64 ounces of fluid a day. With either option, vitamins are essential to prevent deficiencies.

Dr. Hesham Atwa often reminds patients that you lose weight by changing how you eat, but you keep it off with exercise. He asks them to work toward at least an hour of activity five days a week, about half an hour of cardio and half an hour of strength training. The good news is that once the weight starts coming off, energy returns.

He encourages patients to put that energy into moving, and it becomes a wonderful cycle: better sleep, less joint pain, more exercise, and more confidence. When he asks patients what changed after treatment, the most common answer he hears is, “Everything got better. I should have done this years ago.”

What happens when you stop the medication?

This is something Dr. Hesham Atwa wants every patient to understand before they start. GLP-1 medications work while they are being taken. For most people, when the medication stops, the appetite and food noise return, and so does the weight. In one large clinical trial, people who stopped semaglutide regained about two-thirds of the weight they had lost within a year (Wilding et al., Diabetes, Obesity and Metabolism, 2022). Dr. Atwa has seen a few patients keep the weight off after stopping, usually with a lot of exercise, but they are the exception, not the rule.

That is not a reason to avoid medication. It simply means it should be thought of as a long-term treatment, much like medication for blood pressure or diabetes. As Dr. Hesham Atwa puts it, there is no magic pill and no magic surgery. If there are emotional or psychological reasons behind the weight, those need care too. The goal is to find the causes and address them from every direction: medication, surgery, food choices, activity, and support.

Treating Obesity Like the Chronic Disease It Is

While understandably different, Dr. Hesham Atwa likes to compare obesity treatment to cancer treatment. With cancer, there is no single answer. There is screening, there is follow-up, and there is chemotherapy, radiation, and surgery, often used together. Obesity is the same.

Medication and surgery are often used together. For a patient who weighs 400 or 500 pounds, medication beforehand can bring the weight down enough to make surgery safer. After surgery, most patients do well on their own, but some regain a bit of weight over time, and a small dose of medication can give them the extra help they need to stay on track.

Who is a good fit for which option?

Medication can be a good choice for people with a lower BMI, generally from about 27 up to 40, who tolerate it well. Some patients tell Dr. Atwa they only want to try the medication, and that is completely fine. They try it and see how it goes. But medication is not a fit for everyone. Some people do not respond to it, many have side effects, some cannot get it covered, and a large share of people stop taking it within the first year, often regaining the weight.

Surgery is generally recommended for adults with a BMI of 35 or higher, whether or not they have other health problems, and it should be considered for people with a BMI of 30 to 34.9 who have a metabolic disease such as type 2 diabetes (American Society for Metabolic and Bariatric Surgery and International Federation for the Surgery of Obesity and Metabolic Disorders, Surgery for Obesity and Related Diseases, 2022). Dr. Hesham Atwa has operated on patients weighing anywhere from 200 to more than 500 pounds.

Some patients have been told that surgery is “the easy way out.” Dr. Hesham Atwa disagrees. In his words, “It’s not the easy way out. It’s the healthy way out.” Choosing the treatment most likely to restore your health takes courage, not weakness.

And sometimes surgery is not the right choice, or not yet. If someone does not meet the criteria, or their health makes anesthesia too risky, Dr. Hesham Atwa starts with medication, structured meal replacements, or other options. What matters is finding the safest and healthiest path for each person.

Is the gastric sleeve dangerous?

This may be the biggest misconception Dr. Hesham Atwa hears. Many people assume weight loss surgery is risky, but today the sleeve is a straightforward procedure. Dr. Hesham Atwa typically performs it robotically, and it usually takes 30 to 45 minutes. Serious complications are rare, and the safety of bariatric surgery today compares favorably with some of the most common operations, like removing a gallbladder.

Part of the reason is the careful preparation. Before surgery, patients meet with cardiology, pulmonary, a nutritionist, and a mental health professional to make sure they are ready and safe. Most go home the same day or within a day, feel sore for a couple of days, and are back to themselves within five to seven days.

Patients often tell Dr. Hesham Atwa it is the best thing they have ever done. Treating obesity can add years to life, but just as important, it adds life to those years: better sleep, more energy, and less pain in the back, neck, and knees.

Let’s Talk About Cost

Cost is a real concern, and few people like to talk about it openly. Here is how Dr. Hesham Atwa explains it to patients.

Coverage for GLP-1 medications depends heavily on insurance. Some plans cover them with a modest copay, and new programs are expanding coverage, including for Medicare patients. Without coverage, these medications once cost more than a thousand dollars a month.

Manufacturers now offer lower cash-pay prices, but because the medication usually needs to be taken long term, the costs add up over the years. The team at Long Island Laparoscopic Doctors can help patients understand their current options.

Weight loss surgery, on the other hand, is covered by insurance for most patients who qualify. For those paying out of pocket, the cost is typically in the range of $10,000 to $17,000, depending on location. The difference is that it is a one-time cost for a lifelong benefit. And when weighed against the cost of diabetes, heart disease, strokes, and everything else obesity can lead to, Dr. Hesham Atwa always asks patients to consider one question: how much is your health worth?

The Downsides Nobody Warns You About

Every treatment has risks, and patients deserve to know them. With GLP-1 medications, the most important side effects Dr. Hesham Atwa discusses are pancreatitis and gallbladder problems. Any rapid weight loss, whether from medication or surgery, can lead to gallstones, so a medication to help prevent them is often prescribed. Serious complications are uncommon, but they are watched for closely.

Then there is loose skin, including what people now call “Ozempic face.” Dr. Hesham Atwa is candid about this. For years, when patients asked about loose skin, he gently brushed it aside because he was focused on saving their lives and preventing heart attacks. But he came to understand how much it matters to people, so he looked into it more seriously.

Loose skin can happen with any rapid weight loss, on the face or the belly, and much of it depends on how much collagen the body naturally has, which is largely genetic. Some people barely notice it, while others do. To help, Dr. Hesham Atwa encourages plenty of protein, regular exercise, and collagen supplements. If loose skin remains once weight stabilizes, the practice offers two minimally invasive options right in the office.

The first is Morpheus8®, a radiofrequency microneedling treatment. Tiny needles deliver radiofrequency energy beneath the skin, which stimulates the body to make new collagen and tightens the skin of the face or belly. In Dr. Hesham Atwa’s experience, patients can see roughly 30 to 50 percent of the effect of a facelift, without the cost or the downtime of surgery. The treatment takes about 45 minutes, and patients go home the same day.

The second is FaceTite® for the face and BodyTite® for the body. A small radiofrequency probe is used beneath the skin to melt fat and tighten tissue, and the fat is then gently removed with liposuction. Downtime is minimal, the procedure is done in the office, and patients go home the same day.

The Bottom Line

So, is weight loss surgery still worth it in the age of weight loss drugs? For many people, absolutely. For many others, medication is the right place to start. Often, the best answer is a thoughtful combination of both, along with healthy eating and regular movement.

According to Dr. Hesham Atwa, the most important thing is not which treatment you choose. It is that you stop blaming yourself and get real treatment for a real medical condition. He and his team are ready to help you find the safest, healthiest path for you.

Ready to explore your options?

Contact our office to schedule a consultation with Dr. Atwa and the team at Long Island Laparoscopic. And, if you would like to hear Dr. Hesham Atwa sharing his experience and expert advice on weight loss and other surgery topics, visit his podcast at https://www.youtube.com/@LILAPDOC

References:

• Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. Surgery for Obesity and Related Diseases. 2022;18(12):1345-1356.
• Wilding JPH, Batterham RL, Davies M, et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes, Obesity and Metabolism. 2022;24(8):1553-1564.
• Centers for Disease Control and Prevention. Adult Obesity Facts.https://www.cdc.gov/obesity/adult-obesity-facts/index.html