While both metabolic surgery and glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) are known to improve cardiometabolic health, direct long-term comparisons of their macrovascular and microvascular outcomes have been lacking. A new study published in Nature Medicine has addressed this gap by comparing these two major treatment strategies in patients with type 2 diabetes and obesity.¹

This retrospective cohort study analysed data from 1,657 patients with type 2 diabetes and obesity who underwent metabolic surgery and 2,275 similar patients who received treatment with GLP-1 RAs. Baseline characteristics between the groups were balanced using a doubly robust estimation method.

The primary endpoint was all-cause mortality. Secondary endpoints included incident major adverse cardiovascular events (MACE), nephropathy, and retinopathy. The median follow-up period for the study was 5.9 years.

Over the follow-up period, metabolic surgery was associated with significantly better outcomes across all endpoints compared to treatment with GLP-1 RAs. The 10-year cumulative incidence of all-cause mortality was 9.0% (95% CI 6.8–10.8%) in the metabolic surgery group versus 12.4% (95% CI 9.9–15.2%) in the GLP-1 RA group (adjusted HR 0.68; 95% CI 0.48–0.96; p=0.028).

Compared with the GLP-1 RA group, the metabolic surgery group also had a significantly lower risk of:

• MACE (adjusted HR 0.65; 95% CI 0.51–0.82; p<0.001)
• Nephropathy (adjusted HR 0.53; 95% CI 0.43–0.67; p<0.001)
• Retinopathy (adjusted HR 0.46; 95% CI 0.29–0.75; p=0.002)

The results of this study demonstrate that metabolic surgery is associated with a lower long-term risk of all-cause mortality, as well as major macrovascular and microvascular complications, when compared to treatment with GLP-1 RAs in patients with type 2 diabetes and obesity. The study authors concluded that "these findings indicate that even with the availability of GLP-1 RAs, metabolic surgery remains superior to medical treatment."

The investigators suggest that "future studies should compare the cardiometabolic outcomes of metabolic surgery with newer GLP-1 RAs that are more effective for weight reduction."

References

1. Gasoyan H, Alavi MH, Zajichek A, et al. Macrovascular and microvascular outcomes of metabolic surgery versus GLP-1 receptor agonists in patients with diabetes and obesity. Nat Med (2025). https://doi.org/10.1038/s41591-025-03893-3

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