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METABOLIC SURGERY VERSUS CLINICAL TREATMENT:

COMPARISON OF COSTS AND EFFICACY IN THE MANAGEMENT OF

MORBID OBESITY

João Pedro do Valle Varela1

Ana Clara Berzoini Albuquerque2

Fabio Sandoval Pickert3

Danielle Rezende4

Julia Bandeira Lima5

Yasmin Oliveira Gil de Almeida6

Luiza Lucindo Lakatos7

Jaqueline Carrara Folly Valente8

Vinicius Augusto Rocha Pompermayer9

Sidney Pereira Ramos Júnior10

Débora Guimarães Cunha11

Bárbara Wagmacker Barbosa12

Debora Wagmacker Barbosa13

1 Metropolitan College São Carlos

2 Federal University of Juiz de Fora

3 Brazilian Multivix Faculty Vitória

4 Metropolitan College São Carlos

5 Vila Velha University

6 Brazilian Multivix College of Cachoeiro de Itapemirim

7 University of Vassouras

8 Federal University of Espírito Santo

9 State University ofMontes Claros

10 State University of Montes Claros

11 State University of Montes Claros

12 Federal University of Espírito Santo

13 Brazilian Multivix Faculty Vitória

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Rebeca Seraphim Veronez14

Camila Teles Rodrigues15

Abstract: Morbid obesity is a chronic and progressive condition associated with various comorbidities,

such as type 2 diabetes, hypertension and cardiovascular diseases. In the management of this condition,

clinical treatments and surgical interventions have been widely debated, with metabolic surgery

standing out as an alternative for cases refractory to clinical treatment. To compare the costs and

ecacy of metabolic surgery and clinical treatment in the management of morbid obesity, assessing

the economic impacts and clinical outcomes in the medium and long term. This is a literature review

with a qualitative approach, based on studies available in the PubMed, Scopus and Web of Science

databases. Health descriptors such as “Bariatric Surgery,” “Obesity Management,” and “Type 2 Diabetes

Treatment” were used, covering the period from 2015 to 2023. The selection followed specic inclusion

and exclusion criteria to ensure the relevance and quality of the articles included. Studies show that

metabolic surgery is more eective in sustained weight loss and in controlling metabolic comorbidities,

with type 2 diabetes remission rates of over 70%. In terms of costs, although the initial investment for

the surgical procedure is high, there are savings in the long term due to the reduction in expenditure on

medication, hospitalizations and monitoring of complications. In contrast, clinical treatment has lower

initial costs, but often requires prolonged use of medication and interventions, with lower success rates

in weight maintenance and remission of comorbidities. Metabolic surgery stands out as an eective

and economically viable option for morbidly obese patients, especially those with severe comorbidities.

However, the choice of treatment must be individualized, taking into account the surgical risks, the

ability to adhere to lifestyle changes and the resources available in the health system.

Keywords: Metabolic Surgery; Diabetes Mellitus 2; Clinical Treatment; Metabolic Diseases.

14 Vila Velha University

15 Vila Velha University

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INTRODUCTION

Morbid obesity represents a global public health problem, associated with a series of

comorbidities, such as type 2 diabetes mellitus, hypertension, dyslipidemias, and obstructive sleep

apnea. These conditions not only compromise the quality of life of individuals, but also substantially

increase costs for health systems. In this context, the search for eective treatments that can control

weight and associated complications becomes a priority. Two widely used methods are intensive clinical

treatment, involving lifestyle changes, medications, and psychological support, and metabolic surgery,

which has shown signicant benets in several studies (NGUYEN and VARELA, 2022).

Metabolic surgery, initially developed to treat morbid obesity, has stood out for its eectiveness

in providing sustained weight loss and remission of metabolic diseases, especially type 2 diabetes.

Procedures such as gastric bypass and sleeve gastrectomy not only reduce caloric intake but also

promote hormonal changes that regulate glucose homeostasis and appetite. On the other hand, intensive

clinical treatment depends on continuous interventions and strict adherence by patients, which often

results in limited long-term success rates (RUBINO et al., 2020).

The economic analysis of these approaches is also a crucial point in the debate. Metabolic

surgery, although it has high initial costs, can reduce future expenses related to the management of

comorbidities associated with obesity. Clinical treatment, on the other hand, due to its continuous nature,

implies cumulative costs that can become signicant over time. Thus, understanding the dierences in

terms of cost-eectiveness between these options is essential to support public policies and clinical

recommendations (FRIED et al., 2021).

This study seeks to compare metabolic surgery and clinical treatment in the management of

morbid obesity, analyzing not only the costs involved, but also the eectiveness of each approach in

terms of weight control, remission of comorbidities, and impact on quality of life. The relevance of this

topic lies in the need to optimize health resources and oer patients the best possible care, considering

both clinical outcomes and the economic sustainability of treatments (LAKDAWALLA et al., 2023).

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MATERIALS AND METHODS

This is a literature review, with a qualitative approach, based on studies available in the

PubMed, Scopus and Web of Science databases. Health descriptors such as “Bariatric Surgery,”

“Obesity Management,” and “Type 2 Diabetes Treatment” were used, covering the period from 2015 to

2023. The selection followed specic inclusion and exclusion criteria to ensure the relevance and quality

of the articles included.

1. Guiding Question

What is the current scientic evidence supporting the use of bariatric surgery as a management

strategy for severe obesity and its eectiveness compared to conventional treatments for obesity and

type 2 diabetes?

3. Health Descriptors and Boolean Markers

Health descriptors standardized by the DeCS/MeSH vocabularies were used:

-Descriptors:

- “Bariatric Surgery”

- “Obesity Management”

- “Type 2 Diabetes Treatment”

- “Metabolic Surgery”

- “Cost-eectiveness”

Boolean Markers:

- “Bariatric Surgery” AND “Type 2 Diabetes”

- “Obesity Management” OR “Pharmacological Treatment”

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- “Cost-eectiveness” AND NOT “Adolescents”

Inclusion Criteria:

- Publications between the years 2015 and 2023;

- Peer-reviewed articles available in full text;

- Comparative studies between bariatric surgery and conventional treatments;

- Works in English or Portuguese;

- Systematic reviews, meta-analyses, and clinical guidelines.

Exclusion Criteria:

- Studies exclusively related to pediatric or adolescent populations;

- Publications outside the dened time frame;

- Case reports with isolated samples;

- Studies focused on surgical complications with no correlation with ecacy.

THEORETICAL FOUNDATION

Morbid obesity is a multifactorial and complex problem that aects millions of people

around the world. Associated with a range of metabolic, cardiovascular, and orthopedic comorbidities,

obesity represents a signicant challenge for health systems. In the treatment of this condition, two

main approaches have been used: intensive clinical treatment and metabolic surgery. The theoretical

foundation of this work is based on the analysis of the characteristics, benets and limitations of these

approaches, highlighting relevant studies in the area.

The clinical treatment of morbid obesity is widely used as an initial approach and includes

interventions such as personalized diets, physical exercise, behavioral therapy, and the use of medications.

Despite its large-scale application, studies indicate that the success rates of clinical treatment are limited,

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especially in morbidly obese patients, due to the diculty of long-term adherence and the presence of

genetic and hormonal factors that hinder sustained weight loss (APOVIAN et al., 2015).

On the other hand, metabolic surgery has been shown to be an eective alternative for the

management of morbid obesity, especially in cases of clinical treatment failure. Procedures such as

Roux-en-Y gastric bypass and sleeve gastrectomy not only promote signicant weight loss, but are also

associated with remission of metabolic diseases such as type 2 diabetes mellitus. These surgeries act

through mechanisms that go beyond dietary restriction, including hormonal changes and changes in the

intestinal microbiota, which positively impact metabolism (SCHAUER et al., 2017).

In addition to clinical ecacy, cost-eectiveness analysis has gained prominence in the

literature. Although metabolic surgery involves high upfront costs, such as hospitalization and surgical

procedures, it substantially reduces long-term comorbid management expenditures. A study by

Lakdawalla et al. (2023) demonstrated that the cumulative costs of clinical treatment can exceed those

of metabolic surgery in a period of ve to ten years, due to the continuous need for medications and

medical follow-up.

Another relevant aspect of the discussion is the impact on the quality of life of patients.

Metabolic surgery has shown signicant benets in this regard, including improved mobility, reduced

depressive symptoms, and increased ability to participate in daily activities. Clinical treatment, although

less invasive, presents less expressive results in this regard, particularly in patients with long-standing

obesity (MINGRONE et al., 2015).

However, it is important to consider the limitations of both approaches. Metabolic surgery

is not without risks, such as surgical complications and malnutrition, while clinical treatment faces

challenges related to patient compliance and the need for constant multidisciplinary follow-up. Thus,

the choice of the ideal treatment should be based on an individualized analysis, considering the clinical

characteristics and preferences of the patient (RUBINO et al., 2020).

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CONCLUSION

The comparison between metabolic surgery and clinical treatment for the management of

morbid obesity reveals a complex and multifaceted panorama, in which each approach has specic

advantages and limitations. Metabolic surgery, with its proven benets in terms of sustained weight

loss, remission of metabolic comorbidities, and improved quality of life, emerges as an eective solution,

especially in cases of failure of conventional clinical treatment. In addition, their cost-eectiveness

analysis points to long-term savings due to the reduction of expenses associated with the ongoing

management of obesity complications.

On the other hand, clinical treatment, despite its less invasive approach, faces challenges

related to patient adherence and limited ecacy in morbidly obese populations. However, it remains an

essential alternative for patients who have no indication or choose not to undergo surgery, in addition to

serving as an initial strategy for weight management.

Advances in the understanding of the mechanisms involved in obesity, as well as the

development of new surgical technologies and pharmacological therapies, broaden the perspectives

of personalization of care. The choice between these approaches should consider factors such as the

patient’s clinical prole, individual preferences, associated risks, and economic viability.

Therefore, optimal management of morbid obesity requires a holistic and multidisciplinary

view, which integrates the best available scientic evidence with a patient-centered approach. The

promotion of preventive and educational strategies is equally crucial, aiming to reduce the prevalence of

obesity and the costs associated with its treatment. Based on joint eorts between health professionals,

researchers, and managers, it is possible to achieve better clinical and social outcomes in coping with

this challenging condition.

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REFERENCES

FRIED, M., YUMUK, V., OPPERT, J. M., SCOPINARO, N., & TORRES, A. (2021). Interdisciplinary

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LAKDAWALLA, D. N., BERTRAM, L., GOLDHABER-FIEBERT, J. D., & PONCE, N. A. (2023).

Cost-eectiveness of bariatric surgery versus conventional care for obesity. Health Aairs, 42(1), 30-40.

NGUYEN, N. T., & VARELA, J. E. (2022). Bariatric surgery versus intensive medical management in

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APOVIAN, C. M., ARONNE, L. J., BESSESEN, D. H., MCDONNELL, M. E., MURAD, M. H., &

PHUNG, O. J. (2015). Pharmacological management of obesity: An Endocrine Society clinical practice

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MINGRONE, G., PANUNZI, S., DE GAETANO, A., GUIDONE, C., IACONELLI, A., &

CASTAGNETO-GISSEY, L. (2015). Bariatric surgery versus conventional medical therapy for type 2

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SCHAUER, P. R., KASHYAP, S. R., WOLSKI, K., BRETHAUER, S. A., KIRWAN, J. P., & POTHIER,

C. E. (2017). Bariatric surgery versus intensive medical therapy in obese patients with diabetes. New

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