Weight-loss medications have transformed obesity treatment. Wegovy and Zepbound can produce remarkable results, and for many patients they are excellent treatment options. As a bariatric surgeon, I consider these medications among the most important advances in obesity treatment during my career.

But when patients ask whether they should try medication or consider surgery, I encourage them to think beyond one question: How much weight can I lose?

The more important question is how much weight you can keep off five or ten years from now, and what treatment will be required to maintain those results.

There is another consideration that frequently gets overlooked: there is no single “weight-loss drug” or single “bariatric operation.” The specific medication and the specific surgery can change the answer substantially.

How Much Weight Can You Actually Lose?

In clinical trials, patients taking semaglutide (Wegovy) lost an average of 14.9% of their body weight over 68 weeks in STEP 1. Patients receiving the highest studied dose of tirzepatide (Zepbound) lost an average of 20.9% over 72 weeks in SURMOUNT-1. For a person weighing 250 pounds, that represents about 37 to 52 pounds without surgery.

Those results are impressive. Tirzepatide at higher doses can approach the weight loss achieved by sleeve gastrectomy in some patients. But clinical trials do not always reflect everyday treatment.

A June 2026 study in Obesity compared 44,025 patients treated with semaglutide, tirzepatide, sleeve gastrectomy, or gastric bypass. Average total body weight loss at two years was:

Treatment	Average weight loss
Semaglutide	6.5%
Tirzepatide	10.8%
Sleeve gastrectomy	22.4%
Gastric bypass	28.1%

For a 250-pound person, those averages equal approximately 16, 27, 56, and 70 pounds, respectively.

This was an observational study, not a randomized trial. Patients receiving prescriptions were different from those undergoing operations, and medication use varied by dose and duration. Still, the findings are relevant to what patients often experience outside the structured support of a clinical trial.

What Happens When You Stop Taking the Medication?

The question of long-term treatment becomes especially important when a medication is stopped.

In the SURMOUNT-4 trial, participants initially lost an average of 20.9% of their body weight while taking tirzepatide. During the following year, those switched to placebo regained an average of 14% of body weight, while participants who continued tirzepatide lost additional weight.

The STEP 1 extension study found a similar pattern with semaglutide: participants regained approximately two-thirds of their previous weight loss during the year after medication and structured lifestyle support were stopped.

This does not mean every patient regains all the weight. It means that for many patients, sustaining the medication’s benefits requires ongoing treatment.

And remaining on treatment can be difficult. In a 2025 study of more than 125,000 adults, 64.8% of those without diabetes discontinued GLP-1 treatment within the first year, although some later restarted. Side effects, cost, access, and treatment response can all affect whether a patient continues.

A medication may work extremely well, only for a change in insurance coverage to make continued treatment unaffordable. That possibility deserves discussion before starting a treatment expected to continue for years.

How Long Does Weight Loss Last After Bariatric Surgery?

Bariatric surgery has an important advantage: decades of long-term outcomes research.

In the American PCORnet study of more than 65,000 bariatric patients, average total body weight loss five years after surgery was 18.8% after sleeve gastrectomy and 25.5% after gastric bypass.

For an even longer view, the Swedish Obese Subjects study followed surgical patients for up to 20 years. Across a group that included several older operations, average weight loss was about 17% at ten years and 18% at twenty years. Gastric bypass patients maintained approximately 25% weight loss at ten years.

These outcomes do not mean surgery makes weight regain impossible. Some regain is common, and patients still need appropriate nutrition, exercise, vitamins, and follow-up. Some eventually benefit from medication or additional intervention.

The difference is that surgery can provide substantial, durable weight reduction without relying on an ongoing weekly weight-loss injection.

What About Diabetes, Heart Disease, and Living Longer?

For many patients, the medical benefits of treatment matter more than the number on the scale.

Type 2 Diabetes

In the five-year STAMPEDE randomized trial, an HbA1c of 6.0% or lower was achieved by 5% of patients receiving intensive medical therapy alone, compared with 23% after sleeve gastrectomy and 29% after gastric bypass. Surgical patients also generally needed fewer diabetes medications. These numbers measure blood sugar control, not necessarily medication-free remission.

A 2024 JAMA analysis of four randomized trials found that, at twelve years, 12.7% of evaluated surgical patients were in diabetes remission, compared with none of the evaluated medical-treatment patients. Those original trials predated today’s most potent obesity medications, which can also improve diabetes substantially and sometimes produce remission.

Heart Disease and Mortality

The cardiovascular evidence after bariatric surgery is compelling. A 2022 European Heart Journal meta-analysis of 39 studies found that, compared with nonsurgical care, bariatric surgery was associated with a 41% lower relative risk of cardiovascular death, 50% lower relative risk of heart failure, 42% lower relative risk of heart attack, 36% lower relative risk of stroke, and 45% lower relative risk of death from any cause.

These are observational associations, not proof that surgery caused the entire difference. Nevertheless, the findings are remarkably consistent across large patient populations and long follow-up periods.

Modern medications also have demonstrated cardiovascular benefits. In the randomized SELECT trial, major cardiovascular events occurred in 6.5% of participants receiving semaglutide versus 8.0% receiving placebo, a 20% relative reduction among adults with established cardiovascular disease and overweight or obesity but without diabetes.

We should not directly compare the percentages across studies with different populations and designs. Both approaches can improve health beyond weight loss, and the right choice depends on the conditions being treated.

What Are the Risks?

GLP-1 and related medications commonly cause nausea, vomiting, diarrhea, constipation, or abdominal discomfort. Less common serious problems include pancreatitis, gallbladder disease, and dehydration. Certain medical histories make these drugs unsuitable.

Modern bariatric surgery is considerably safer than it was decades ago. Commonly cited national estimates are approximately 0.1% mortality and 4% major complications, though risks vary by operation and patient. Potential complications include bleeding, infection, blood clots, leaks, and additional operations. Sleeve gastrectomy can worsen reflux; bypass carries different long-term risks. Surgery also requires lifelong vitamins and monitoring.

The comparison must include another risk: leaving severe obesity and its associated medical conditions inadequately treated.

Which Treatment Costs More Over Time?

Medication expenses may continue for years. Surgery generally has a larger upfront cost, along with ongoing follow-up costs.

In a 2025 JAMA Surgery study of more than 30,000 patients, average two-year total healthcare expenditures were $63,483 for GLP-1 therapy and $51,794 for bariatric surgery, approximately $11,700 less in the surgical group. The study estimated a break-even point around 15 months.

These were total healthcare expenditures, not the price of surgery or a patient’s out-of-pocket costs. The medication group included older GLP-1 drugs, and prices and insurance benefits continue to change.

Arkansas Insurance Coverage Has Changed

Arkansas Act 628, effective January 1, 2026, requires qualifying state-regulated commercial plans to cover medically necessary bariatric surgery for eligible adults, generally those with BMI 40 or greater, or BMI 35 or greater with an associated condition such as diabetes, hypertension, or sleep apnea.

The law does not require insurance coverage for weight-loss medications. Consequently, a patient whose plan does not cover Wegovy or Zepbound may still have bariatric surgery benefits. Self-funded employer plans generally fall outside the commercial mandate, and deductibles, prior authorization, and other requirements still apply.

I participated in the legislative effort behind Act 628 because patients should have access to medically appropriate obesity treatment. For details, read Does Insurance Cover Bariatric Surgery in Arkansas? Act 628 Explained.

Which Drug, Which Surgery, and Which Patient?

Comparing “medication versus surgery” as though each were a single treatment oversimplifies the decision.

Semaglutide and tirzepatide differ in effectiveness, dosing, tolerability, and cost. Sleeve gastrectomy and gastric bypass also differ in expected weight loss, reflux effects, metabolic outcomes, and potential complications.

Someone doing well on tirzepatide with a BMI of 32 may have good reasons to continue medication. Someone with a BMI of 45, difficult-to-control diabetes, and repeated weight regain may benefit more from discussing surgery. For a patient with significant acid reflux, gastric bypass may be more appropriate than sleeve gastrectomy.

Medications and surgery can also work together. Some patients use medication before surgery; others benefit from medication years afterward to address inadequate weight loss or weight recurrence.

This is why the decision should not be made by a chart alone. During a surgical evaluation, we can review your BMI, medical history, prior treatment, health goals, and the relative advantages of specific medications and specific procedures. For more on candidacy, see Do I Qualify for Bariatric Surgery in Arkansas?.

Considering Bariatric Surgery?

The most important question is not simply how much weight you can lose, but how much you can maintain over time. Modern medications are powerful options. Bariatric surgery offers substantial and often durable benefits, particularly for appropriate patients with severe obesity and obesity-related disease.

If you are considering surgery, an individualized evaluation can help determine whether sleeve gastrectomy, gastric bypass, or continued medical treatment may be appropriate.

Dr. Samuel Bledsoe is a board-certified general surgeon and Medical Director of Bariatric & Metabolic Surgery at UAMS Health in Bryant, Arkansas.

Learn more about bariatric surgery services with Dr. Bledsoe.

 

Our UAMS insurance verification specialist will review your benefits, and our team aims to contact you within approximately 72 hours to discuss coverage and next steps. Submission does not guarantee coverage or an appointment.

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Prefer to call? (501) 252-6650.

References

1. STEP 1: Semaglutide treatment for obesity. New England Journal of Medicine, 2021.
2. SURMOUNT-1: Tirzepatide once weekly for obesity. New England Journal of Medicine, 2022.
3. Brown et al. Real-world semaglutide and tirzepatide compared with bariatric surgery. Obesity, 2026.
4. SURMOUNT-4: Tirzepatide continuation versus withdrawal. JAMA, 2024.
5. STEP 1 extension: Weight regain after semaglutide withdrawal. Diabetes, Obesity and Metabolism, 2022.
6. Rodriguez et al. Discontinuation and reinitiation of GLP-1 therapy. JAMA Network Open, 2025.
7. Arterburn et al. PCORnet comparison of bariatric procedures. Annals of Internal Medicine, 2018.
8. Sjöström. Swedish Obese Subjects long-term outcomes. Journal of Internal Medicine, 2013.
9. STAMPEDE five-year diabetes outcomes. New England Journal of Medicine, 2017.
10. Courcoulas et al. Long-term surgery versus medical therapy for diabetes. JAMA, 2024.
11. van Veldhuisen et al. Bariatric surgery and cardiovascular disease meta-analysis. European Heart Journal, 2022.
12. SELECT: Semaglutide and cardiovascular outcomes. New England Journal of Medicine, 2023.
13. Barrett et al. Obesity treatment with surgery versus GLP-1 therapy. JAMA Surgery, 2025.