GLP-1s beat by bariatric surgery on cardio outcomes

Clinical takeaway: Advanced age alone should not exclude patients from bariatric surgery, particularly when serious cardiometabolic complications are the primary concern.

Older adults with obesity and diabetes are often steered toward medication rather than surgery, despite carrying the highest cardiometabolic risk. This real-world analysis compared five-year cardiovascular and microvascular outcomes between bariatric surgery and GLP-1 receptor agonists in patients 65 and older.

Surgery was associated with lower risk across every endpoint examined. After five years, the rate of major adverse cardiovascular events was 11.5% with surgery versus 13.6% with GLP-1 therapy, a relative reduction of nearly 16%. Severe kidney disease occurred in 9.1% of surgical patients versus 12.4% on medication, and diabetic retinopathy in 5.8% versus 9.0%, a 35% lower rate.

The weight-loss gap likely explains much of the outcome difference. Surgical patients lost 17.3% of body weight in the first year compared with 4.2% among GLP-1 users. Notably, HbA1c improvement was similar between groups.

The analysis drew on electronic medical records for more than 200,000 older adults treated between 2017 and 2025. After matching, about 2,800 surgical patients were compared with roughly 104,000 receiving GLP-1 therapy. The study has not yet undergone full peer review.

The findings reinforce a growing case that bariatric surgery functions as a metabolic intervention rather than a weight-loss procedure, with effects on chronic disease trajectory that medication does not consistently match. They also push back on the common practice of treating advanced age as a contraindication to surgery, since older patients carry the highest absolute risk of cardiometabolic events and may stand to benefit most.

Current American Society for Metabolic and Bariatric Surgery/International Federation for the Surgery of Obesity and Metabolic Disorders guidelines, updated in 2022, do not set an upper age limit for metabolic and bariatric surgery. For older adults, they recommend basing decisions on overall health, frailty, cognitive capacity, smoking status, and organ function rather than age alone.

"While GLP-1 agonists have transformed the treatment landscape for obesity and diabetes, our findings show metabolic and bariatric surgery delivers even greater protection against serious complications including heart attacks, kidney failure and vision loss," said lead author Thomas Shin, MD, PhD, assistant professor of surgery at UVA Health in Charlottesville, Virginia. "What's more, this study showed advanced age alone should not exclude patients from surgery. In fact, older adults may have the most to gain."

Source: Gillikin A. ASMBS 2026 Annual Scientific Meeting Abstract 4719. Cardiometabolic outcomes of metabolic surgery versus GLP-1 receptor agonists in older adults with diabetes and obesity