Bariatric surgery can be considered to help keep weight off

Dear Dr. Roach: I have had a BMI over 40 for the last 20 years, and I have not been able to lose weight or keep the weight off. My doctor prescribed Ozempic, which is helping, but as soon as I stop, in a few weeks, all the weight creeps back on. I was always wary of surgery for weight loss, but recent studies seem to indicate better long-term health outcomes. What are your thoughts? — S.O.

Dear S.O.: Medical or surgical treatment for weight loss is not right for every person who is overweight. Many people take medications in the class called glucagon-like peptide-1 agonists, which includes semaglutide (Ozempic and Wegovy), liraglutide (Saxenda and Victoza) and tirzepatide (Mounjaro). But these medicines have the potential for harm, and an individual’s risks, especially the presence of other conditions that can be affected by being severely overweight or obese, need to be carefully considered.

Surgery has far more risks than medication and requires the most careful consideration before receiving a recommendation of bariatric surgery, of which there are many types.

I am much more likely to refer a patient to one of my colleagues in bariatric surgery when a patient is very obese and when there are clear medical issues that I can expect to get better with surgery. These medical issues can include diabetes, obstructive sleep apnea or nonalcoholic fatty liver disease. Most of the time, these conditions can be managed well without bariatric surgery, but sometimes management is very difficult. And, in this case, consideration of bariatric surgery is worthwhile.

Bariatric surgery is never the first choice in weight management. A comprehensive lifestyle intervention — with an individualized diet (ideally recommended by an expert such as a registered dietician nutritionist), moderate exercise (with a goal of 150 minutes per week minimum), and regular meetings to help keep a person on track — is the right place to start. It is effective for many people if they maintain the behaviorial changes.

I have been prescribing some of my patients with the GLP-1 or GLP-1/GIP medications with good results, but as you mention, if you stop taking them, they stop working. Unless you make a dramatic change to your lifestyle that you can keep up, the weight will come back on.

Bariatric surgery does have very strong long-term weight loss data, as well as dramatic reductions in diabetes when used for the appropriate people.

Dear Dr. Roach: My shoulder pain seems to be getting worse (lack of cartilage), and it is interfering with sleep. I haven’t taken any pain medication for it, but I read that the best relief is from either aspirin or ibuprofen. I’d like to switch them back and forth — maybe two to three days with aspirin, then one day with ibuprofen (the most I can tolerate being 200 to 300 mg a day).

How much aspirin is OK to use this way? — J.B.

Dear J.B.: I recommend against the combination of a medicine like ibuprofen (or naproxen, like Aleve) and aspirin. They have similar toxicities and work nearly in the same way, so you don’t get much more, if any, pain relief and instead increase the risk of kidney and stomach damage. The combination of aspirin or an anti-inflammatory drug like ibuprofen with acetaminophen (Tylenol) is commonly used and can lead to improved pain relief without a big toxicity risk when taken in the recommended doses.