The number of bariatric surgical procedures performed has plateaued over the last few years in Europe and the USA. Even though bariatric surgery has been shown to be superior to medical therapy in terms of glycaemic control and weight reduction, non-surgical therapies are continually improving. The appropriate use of bariatric surgery remains a subject of debate, with many physicians in the field remaining sceptical about it, in view of the risks associated with surgery. Ultimately, surgery can be enhanced by the appropriate use of medication to give patients the best possible outcome as regards their obesity and type 2 diabetes (T2D).
A combination of therapies will be required to optimize the benefits of bariatric surgery, but will certainly be worthwhile in obese patients who are otherwise unable to achieve lasting health benefits. Ongoing head-to-head trials of surgical and surgery enhanced by medication are warranted to determine the best route to obesity management, and to identify the patient populations most likely to benefit from each strategy. Using the currently available treatment options we would suggest that the effect of bariatric surgery on reducing hepatic insulin resistance can be enhanced by adding metformin and the effect on blood pressure and glycaemic control can be enhanced by sodium glucose co-transporter 2 inhibitors. The major benefit of bariatric surgery is the weight loss maintenance and this may be enhanced by using high-protein low-glycaemic index (GI) diets more effectively in the future. Thus not only can most of the beneficial effects of bariatric surgery potentially be mimicked, but this may also be enhanced to achieved at a much reduced cost while improving morbidity and mortality.