Obesity has long been described as a chronic disease. Yet in clinical practice, we still treat it as two separate conditions: one affecting children, and the other adults. This artificial divide fragments care and overlooks the reality that obesity unfolds across a lifetime. Nowhere is this more evident than in the recent and surprising trend we documented in adolescent metabolic and bariatric surgery (MBS). Despite the approval of powerful new obesity medications for teens, rates of MBS in U.S. adolescents rose nearly 15% from 2021 to 2023. During the same period, adult surgery rates declined.
These findings, published in The Journal of Pediatrics, highlight a critical need to reframe obesity care as a life-course issue, and to rethink the notion that newer medications will replace MBS. Instead, we should consider how these tools work together across different stages of life.
Why Are More Teens Choosing Surgery?
When glucagon-like peptide-1 receptor agonists (GLP-1s) like semaglutide (Wegovy) and liraglutide (Saxenda) were approved for adolescents, many predicted they would dramatically reduce the need for MBS. These medications can lead to weight loss of 15% to 20% of body weight, making them a meaningful alternative to surgery.
But the reality is more complex. First, access remains a significant barrier. Insurance coverage for GLP-1 medications is inconsistent, and out-of-pocket costs are prohibitive for many families. Even when covered, high out-of-pocket costs can make long-term treatment unaffordable. In contrast, MBS, though costly up front, is often covered by insurance as a one-time intervention for adolescents with severe obesity.
Second, the long-term durability of GLP-1 medication-induced weight loss is unknown when used in younger populations. Although these medications are highly effective for weight reduction, research shows significant weight regain if treatment is discontinued. This reality poses a challenge for adolescents and their families, who must weigh the idea of potentially lifelong treatment and medication costs. Meanwhile, MBS has a well-established track record of sustaining weight loss and improvements in type 2 diabetes and sleep apnea and other obesity-related complications. Sustained weight loss is especially important in these populations. In our study, most adolescents who underwent MBS had severe obesity, with almost 40% presenting with a BMI over 50 kg/m², underscoring the severity of disease in these young patients.
Side effects also influence decision-making. Nausea, vomiting, and gastrointestinal issues are common adverse effects that can lead to GLP-1 medication discontinuation. Some adolescents and families may prefer surgery as a more definitive solution, despite its own risks. This may help explain why, despite new medications, more teens — particularly Hispanic and non-Hispanic Black adolescents — are pursuing MBS. Encouragingly, it suggests that historically underserved populations are gaining access to surgical obesity care. Yet, it also underscores that one size will never fit all when treating obesity.
Why the Pediatric-Adult Divide Holds Us Back
Our current healthcare systems draw a sharp line between pediatric and adult obesity care. Pediatric clinicians often focus on growth, family dynamics, and developmental concerns. Adult providers prioritize cardiometabolic risk and individual decision-making. But obesity does not reset at age 18. In fact, nearly 80% of adolescents with severe obesity continue to live with obesity as adults. Many carry forward years of metabolic risk, mental health challenges, and stigma. When they transition to adult care, it is often without a clear history of their prior weight, exposures, or previous treatments. That missing context limits adult providers’ ability to deliver truly personalized, effective obesity care.
It is as if we are treating two different diseases — childhood obesity and adult obesity — when in fact, it is the same disease progressing over time. We need to break out of these silos and adopt a life course model that recognizes obesity as a single chronic disease whose roots often lie early in life and acknowledges that effective interventions may need to span decades.
Combining Medications and Surgery: The Future of Obesity Care
It is time to move beyond viewing pharmacotherapy and MBS as separate or competing strategies. In many cases, they work best together. Some patients who plateau on medication may benefit from surgery; others who regain weight after surgery might benefit from medications to help maintain their progress. This flexibility is crucial for tailoring treatment to each patient’s unique health profile, social circumstances, and preferences.
In our study we emphasize the importance of a precision obesity medicine approach: one that considers not just weight, but also a patient’s comorbidities, psychosocial environment, and long-term risk. That same approach should guide care in adolescents and adults and demand better communication and coordination across the lifespan.
Of course, even the most precise treatment strategy can be derailed by costs. A lifetime of GLP-1 therapy (50 years, for example) could exceed $600,000 per patient. In contrast, MBS surgical costs range on average from $17,000 to $26,000, and are more likely to be covered by insurance. Until medication prices decrease, financial realities will inevitably continue to influence both treatment choices and risks, widening disparities in access and outcomes for vulnerable populations.
Bridging the Gap for Better Outcomes
The rise in adolescent MBS utilization does not mean new medications have failed. Instead, it highlights that obesity is a complex, chronic disease requiring a comprehensive and coordinated approach. Medications, surgery, and behavioral interventions each play a role, but their greatest impact comes when they are integrated across the patient’s life course.
The next step in obesity care is to bridge the gap between pediatric and adult systems, ensure seamless transitions as patients age, and deliver lifelong, individualized treatment. Only then can we offer patients care that reflects the true, lifelong nature of obesity and support healthier futures.
Sarah E. Messiah, PhD, MPH, is a professor at the Peter O’Donnell Jr. School of Public Health and the Department of Pediatrics at UT Southwestern Medical Center in Dallas. She directs research on obesity and cardiometabolic health across the lifespan. Jaime Almandoz, MD, MBA, is an associate professor in the Division of Endocrinology and director of the Weight Wellness Program at UT Southwestern Medical Center in Dallas. His research and clinical interests focus on medical and surgical obesity care.
Disclosures
Almandoz is an advisor/consultant to AbbVie, Amgen, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, and Rhythm.
