[13.03.2025]

With the expanding range of options for managing obesity – such as medications like Ozempic or Mounjaro, lifestyle changes, and surgical interventions – what key factors should a patient consider to choose the most effective and sustainable approach?

We invited the leading experts of the Medical Center - University of Freiburg to analyze the benefits, potential risks, and long-term outcomes of each option, offering valuable insights for those seeking sustainable weight management solutions. 

We consider it very important that each patient with obesity who wants to lose weight and improve their health receives an in individually tailored long-term recommendation and counseling for the most effective and sustainable result. To have the most success, we strongly believe that interdisciplinary treatment involving all of the expertise present at the Medical Center - University of Freiburg, including Endocrinology and Diabetology, nutrition counseling, training expertise, medication and bariatric surgery is mandatory.

In our Division of Endocrinology and Diabetology, we have long-standing expertise to manage patients with obesity and associated disorders such as diabetes mellitus, hypertension, hypercholesterolemia, fatty liver disease and cardiovascular disease with all individually necessary interventions that lead to sustained weight reduction and improvement of comorbidities. These interventions include individual plans for education and counseling with respect to nutrition and diet plans, exercise plans, use of new medications such as Ozempic, Wegovy and Mounjaro for weight reduction, and planning approaches for bariatric surgery. 

Indeed, we are very experienced in helping patients to lose weight with novel medications such as Ozempic, Wegovy and Mounjaro over a long period of time, as we were personally involved in the development of these medications over years.

We oversee great success in most of our patients in reducing substantial amounts of body weight with the use of these medications. Our major goal, however, is to help our patients maintain the reduced body weight for long periods of time after the initial weight loss by long-term treatment including nonmedication interventions as indicated above. Initial treatment plans include uptitration of Ozempic, Wegovy or Mounjaro to the highest dose, if tolerated, and reducing the dose in the long run to maintain long-term weight reduction for many years, and eventually, when lifestyle interventions come into effect, maybe stop the medication.

To find the best individual treatment for each patient, we work closely together with the other institutions at the Medical Center - University of Freiberg.

If you are overweight, you should first have an individual risk assessment. Is your metabolism affected in the sense of developing diabetes mellitus, hypertension, a lipometabolic disorder, or non-alcoholic steatohepatitis (NASH)? Are there any other risk factors? This determines the urgency and extent of the necessary weight reduction.

If we do not see any secondary diseases and the fatty liver has not yet led to significant fibrosis, then a weight reduction of 5% of the total weight would be expedient. This can be achieved through a lifestyle modification. For this, a sports-medical examination including training advice and nutritional counseling is recommended. A weight reduction of 5% can be achieved over a few weeks. Weight is primarily reduced by changing your diet, but in the long term, success can only be maintained by making lasting changes to your physical activity.

If we do find effects of ectopic fat deposits on the metabolism in the sense of secondary diseases, then a weight reduction of 5% is not sufficient. With highly motivated individuals, a weight reduction of 10% can be achieved through a change in lifestyle, but only a few succeed in sustaining this. However, some individuals do manage it and also build up muscle accordingly, which is why the weight is no longer as reliable with regular training. In this case, it makes sense to monitor the effect of the therapy by analyzing body composition (i.e. measuring muscle and fat mass).

In cases of diabetes mellitus, coronary heart disease or fatty liver hepatitis with significant fibrosis, we want to achieve a higher weight loss (>15%). This can no longer be achieved with lifestyle measures alone. Here, medication or surgical intervention is required. With modern active ingredients, high weight losses are possible for the first time, but this should be accompanied by a doctor. According to current knowledge, long-term use is necessary; permanent “reprogramming” of the metabolism is not possible with the current active ingredients. However, more activity can often be achieved when weight is reduced, so this can be used as a supportive measure.

From a scientific point of view, the data on bariatric surgery and its effectiveness in the case of secondary diseases such as diabetes, cardiovascular diseases, etc. has been known for years and is impressive. However, it comes at the price of requiring lifelong supplementation and medical supervision.

Obesity is a chronic disease that cannot be cured by any single measure. Over the last 50 years, surgical therapy has been the most effective form of treating obesity, not only in the short term (1-2 years) but also in the long term (10-20 years). Surgical therapy continues to be by far the most effective treatment for obesity and many of its associated diseases. Surgical therapy not only significantly reduces weight in the long term, but also effectively improves other secondary diseases such as type 2 diabetes mellitus, high blood pressure, fatty liver, gastroesophageal reflux, sleep apnea and many musculoskeletal secondary diseases. In the case of type 2 diabetes mellitus in particular, it is possible to achieve long-term remission without patients having to take medication. We now even know that patients who have undergone bariatric metabolic surgery (gastric bypass, sleeve gastrectomy, etc.) have a significantly lower risk of developing various tumor diseases. 

There is growing scientific evidence from animal experiments that gastric bypass surgery, for example, cannot only lead to the individual developing fewer tumors, but also to these metastasizing less. Even if the anatomy of the gastrointestinal tract is altered by the surgery and patients can develop functional problems such as reflux or heartburn, the advantages are obvious in terms of long-term and multiple effects.

In contrast, the new medications have only been known for 2-3 years with scientifically good data in terms of weight reduction in the first 1-2 years. In some cases, the medication even manages to reduce body weight to such an extent that they have 40-50% of the effect of surgical therapy in the first year. This makes the current medications, such as Mounjaro or Wegovy, certainly the best that have ever been on the market. The advantages of the medications are of course obvious, since they can be quickly applied or quickly discontinued. The side effects, including nausea, diarrhea, abdominal pain, dizziness, headaches, etc. occur in a large number of patients, but in my view are negligible compared to the achievable effect.

The medication will not be able to cure chronic obesity any more than surgical measures have ever been able to cure this chronic disease. It should also be emphasized that the medication is particularly suitable for patients with lower BMI values (under 40) and whose obesity is not as advanced. Surgical treatments in particular are often used in patients with a BMI well over 40 kg/m² and very often in patients with a BMI well over 50 kg/m². In my opinion, medication therapy alone is not an option for these patient groups in particular, because despite weight loss at a very high initial weight, the weight ultimately achieved is still too high. In my opinion, the main disadvantage of medication therapy is that long-term data on effectiveness is not available and that an immediate weight gain occurs after discontinuing the therapy, in the sense of a yo-yo effect.

From a surgical point of view and from the point of view of an expert who has been dealing with the treatment of obesity for almost 20 years, the development of new medications in the last 2-3 years has been an extremely important step in getting the chronic disease of obesity even more under control. The way obesity is treated will change significantly in the future. Analogous to other chronic illnesses, such as tumor diseases, for example, it will be important in the future to provide individual treatment for each patient rather than the same treatment for everyone. This could mean that some patients, for example, take medication over a period of time to reduce their weight before they undergo bariatric surgery. It may even be that additional medication therapy will be necessary for certain patients after surgery. In oncology, this is referred to as neo-adjuvant, adjuvant or even additive. In oncology, we have been able to significantly improve long-term patient outcomes with these approaches. Based on my many years of experience with obesity treatment, I do not believe that any of the two options (medical treatment and bariatric metabolic surgery) will be able to cure obesity. Instead, the most important thing will be to implement an interdisciplinary and collaborative treatment approach in order to achieve better long-term patient outcomes using the best capability of each method in individual patients.

For this reason, an interdisciplinary and, in particular, university obesity center is certainly the best place for all patients with obesity who are seeking effective and long-term therapy.

• Division of Endocrinology and Diabetology
• Back to News