A new meta-analysis suggests that metabolic and bariatric surgery (MBS) may offer stronger long-term cardiovascular protection than widely used glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in people living with type 2 diabetes and obesity. The findings were published in the journal Obesity Surgery.
Researchers noted that while both approaches are proven to improve metabolic health and reduce cardiovascular risk, direct comparisons of their long-term impact on major adverse cardiovascular events (MACEs) and overall mortality have been limited.
“Although both MBS and GLP-1 RAs are effective strategies for improving metabolic outcomes and reducing cardiovascular risk in individuals with obesity and type 2 diabetes, their risk-benefit profiles differ,” wrote lead author Joshua Chadwick of the Indian Council of Medical Research and colleagues.
Large, International Patient Analysis
The research team analyzed data from 11 studies involving nearly 20,000 patients across several countries, including the United States, China, Italy, Sweden, Israel, Australia and Taiwan. The analysis incorporated a range of study designs, including randomized controlled trials, propensity score-matched cohorts and nationwide matched cohort studies.
Among surgical interventions, the most frequently studied procedures were Roux-en-Y gastric bypass and sleeve gastrectomy—two of the most common forms of bariatric surgery.
The GLP-1 medications evaluated included semaglutide (marketed as Wegovy and Ozempic), liraglutide (Saxenda and Victoza) and dulaglutide (Trulicity), all widely prescribed to improve blood sugar control and promote weight loss.
Surgery Associated With Greater Risk Reduction
Across the pooled data, bariatric surgery was associated with a 52% relative reduction in the risk of major cardiovascular events and all-cause mortality compared with GLP-1 therapy.
Subgroup analyses showed that the advantage of surgery remained consistent across both randomized trials and observational studies. Despite variations among study populations and methodologies, additional sensitivity testing confirmed the robustness of the findings.
According to the authors, the benefits of surgery likely extend beyond weight loss and glucose control.
“The observed benefits of MBS extend beyond glycemic control and weight loss, likely reflecting the multifactorial impact of surgical interventions on metabolic and cardiovascular risk factors,” the researchers wrote.
GLP-1 Drugs Still Play a Key Role
The investigators emphasized that GLP-1 receptor agonists remain highly effective and should not be viewed as inferior or unsafe. These medications have demonstrated meaningful reductions in cardiovascular events and improved metabolic outcomes, particularly for patients who are not candidates for surgery or who prefer non-surgical treatment.
However, the study noted that the magnitude of long-term benefit appears greater with surgical intervention, especially over extended follow-up periods. Concerns such as weight regain and uncertain long-term cardiovascular outcomes may require ongoing evaluation in patients treated exclusively with medication.
“GLP-1 RAs remain an essential therapeutic option for patients ineligible for surgery or seeking non-surgical management,” the authors wrote.
Individualized Treatment Decisions Recommended
The researchers concluded that treatment decisions should be tailored to each patient’s clinical profile, preferences, and access to care. They also called for further research to clarify how best to sequence or combine medical and surgical therapies, as well as to evaluate long-term safety and cost-effectiveness in real-world settings.
As obesity and type 2 diabetes continue to drive cardiovascular disease globally, the findings add to growing evidence that both advanced pharmacotherapy and surgical approaches have important—but potentially different—roles in long-term risk reduction.
