Metabolic and bariatric surgery in an era of anti-obesity medication

Abstract

The global obesity epidemic has been well described. In South Africa (SA) in 2017, 68% of women and 31% of men were overweight or obese, defined as having a body mass index (BMI) ≥ 25 kg/m². Obesity is a complex, chronic, and progressive disease with severe metabolic, mechanical, and mental complications, with a clearly associated increased risk for premature cardiovascular and cancer deaths. Lifestyle and behavioural modification (diet and exercise) form the basis of weight gain prevention. However, it is a sustainable treatment option for very few patients. Metabolic and bariatric surgery (MBS) has evolved into the cornerstone for long-term, durable treatment of obesity, with robust evidence supporting its cost-effectiveness and decreased mortality. There is increasing evidence of the efficacy of anti-obesity medications (AOMs) in achieving weight-loss outcomes comparable to those of surgery. Both highly effective treatment options remain underutilised by health insurers and the National Department of Health and are mostly inaccessible to South Africans. This review examines the evolving global and local relationship between surgical and pharmacological approaches to obesity treatment.