Weighing In: Making Obesity Treatment More Effective and Accessible by 2030

Endocrine News speaks to the participants of the ENDO 2025 symposium “Future Developments and Challenges in Obesity Treatment: Where Will We Stand at ENDO 2030?” who discuss the future of treating this formidable condition.   

This July, the year’s biggest event in endocrinology happens in San Francisco, Calif. Although every ENDO is special, ENDO 2025 holds special importance. With advances in science happening at possibly the fastest rate in history, this meeting is endocrinologists’ one-stop shop for keeping up with progress and understanding how it will shape the future of endocrinology, an otherwise daunting task.

One session in particular, “Future Developments and Challenges in Obesity Treatment: Where Will We Stand at ENDO 2030?” happening on Sunday, July 13, addresses this dual challenge head on, as the title suggests.

Satya Dash, MD, PhD, FRCPC, of the University of Toronto and Senior Scientist at the Toronto General Hospital Research Institute (TGHRI), both in Ontario, Canada, will present a talk on “Bariatric Surgery: Will it have a role in 2030 and Beyond?” and Diana Lucia Alba, MD, of the University Of California San Francisco, will present “How Can We Overcome Socioeconomic Contributors of Obesity?” This session is co-chaired by Sam Pabich, MD, MPH, of the University of Wisconsin in Madison and clinician at the Madison U.S. Department of Veterans Affairs Hospital, and by Marcelo Correia, MD, MSc, PhD, clinical assistant professor of internal medicine-endocrinology and metabolism at the University of Iowa, in Iowa City.

Their 90-minute session focusing on obesity is timely to say the least. As obesity rates skyrocketed in the last few decades of the 20th century, the associated morbidity and mortality led to the public health crisis we now live with. According to data from the National Health and Nutrition Examination Survey (NHANES), obesity rates reached an estimated 41.9% of adults in the United States by 2020; fortunately, that rate may have been the peak. The most recent NHANES data reveal that the rate did not change significantly from 2020 to 2023, even decreasing slightly to 40.3%, the first such reversal in almost 50 years. Some of this decline can be attributed to recent advances in treatment.

We may well be on the brink of what might be considered a revolution in obesity healthcare. For decades, obesity felt unconquerable. Now, with the emergence of new treatments and more treatment options, we’re making modest gains against the enemy. The session at ENDO 2025 aims to make sure we get this revolutionary opportunity right, including by considering the interplay of factors that led to the obesity epidemic. Despite the promise that the next five years hold in terms of treatment, there is no magic bullet. Any transformation in the field we can make will be complex and multifaceted, as the four participants in the ENDO 2025 obesity session make clear.

Future Role of Surgery

The “elephant in the room” is obesity pharmacotherapy. The newest to be approved by the U.S. Food and Drug Administration are the GLP-1 receptor agonists originally indicated to treat type 2 diabetes. These drugs are helping millions of people with obesity lose weight and achieve better health. Based on their success, do they stand to supplant other obesity treatments?

Not at all, says Dash. In his talk on bariatric surgery, he plans to show how the role of surgery is evolving but not diminishing, as part of a shift toward a multimodal approach. This approach should resemble how other complex, chronic conditions are managed, such as diabetes and hypertension, with multiple treatment options that can be used alone or in combination, guided by individual patient factors and responses.

“It’s always good to have options for effective treatment like pharmacotherapy and bariatric surgery,” he explains. “Frequently we tend to think of treatment as one or the other, but in my practice, many patients end up needing both. Different people have different circumstances that determine which one is better for them, and this can vary from patient to patient and from time to time.”

Dash says that even before specifics of treatment should be addressed, we should back up to consider two questions. The first is, why do we need these types of treatment for obesity? He explains: “This is a highly heritable trait disease, and it’s a lifelong condition. Many people will have had success at some point with a dietary strategy or lifestyle change, but, statistically, it’s very difficult to control weight with lifestyle factors alone. When weight is lost, adaptive changes occur in the body. For example, leptin decreases, so the brain signals the need to eat more and replenish that level. Decreases in leptin also lead to reduced energy expenditure.”

The second question is, how much weight loss is needed to see improvements in health?

“For most people, losing 5% to 10% of their starting weight can improve sleep apnea, insulin sensitivity, blood glucose control, and blood pressure,” Dash says. “A 10% to 15% reduction can potentially start to reverse certain recently diagnosed conditions like type 2 diabetes. What we don’t know, because we haven’t had the tools, is how much additional benefit comes with weight loss beyond 20% to 25% — do you accrue additional health benefits?”

The answers to these questions will help guide treatment decisions in conjunction with how the patient responds to a given therapy. For example, the GLP-1 inhibitor tirzepatide induces an average weight loss of 21% of starting weight in people without type 2 diabetes, but some people lose less than 10% and some do not respond at all. For people with type 2 diabetes, the average weight loss is about 15%. Bariatric surgery induces weight loss of about 25% to 30%, depending on the procedure, with some data suggesting that this percentage is slightly less in the setting of type 2 diabetes.

“Because of this heterogeneity in response to pharmacotherapy,” Dash says, “having another treatment that’s potentially more efficacious and more affordable is good. Some people will have gastrointestinal side effects with the medications, and they are very expensive in the United States. Many people end up having to stop them for these reasons.”

Then, too, back to the second question; some of the newer medications, like albiglutide, may have weight-independent benefits, especially for cardiovascular health (including major cardiovascular events [MACEs]), potentially meaning that people can achieve better health status even without losing weight. Publication of these data is pending, but semaglutide showed similar results in the SELECT trial from 2023. Dash says, “There’s evidence this mechanism works through central nervous system pathways, which then have downstream effects on the body to reduce inflammation, particularly in blood vessels.”

Looking ahead to 2030, Dash can imagine what the field of obesity will look like — “guided by pertinent facts.” In addition to the variation in response to medication already mentioned, these facts include that many people who are eligible for surgery change their minds about having an invasive, irreversible procedure. This is true even in Canada, where Dash practices and where the cost of bariatric surgery is covered by insurance, unlike in the United States. Another consideration is that some people regain the weight they lost from surgery because of endocrine system adaptations.

All of these factors will demand an algorithmic approach to treatment. Says Dash: “We’ll discuss health goals with the patient and try medication first. If they get to where they need to be, we continue. If they can’t tolerate it or don’t get where they need to be, we can switch classes or use combinations. For the subsection of people who may not get to where they need to be, surgery will still be an option. If they’ve already had surgery, we may reintroduce medications. They’re just as effective in people who’ve had surgery as those who haven’t.”

“It’s always good to have options for effective treatment like pharmacotherapy and bariatric surgery. Frequently we tend to think of treatment as one or the other, but in my practice, many patients end up needing both. Different people have different circumstances that determine which one is better for them, and this can vary from patient to patient and from time to time.”  —Satya Dash, MD, PhD, FRCPC, associate professor, University of Toronto; Senior Scientist, Toronto General Hospital Research Institute (TGHRI), Toronto, Ontario, Canada

He also hopes that increased messaging about the effectiveness of surgery will sway some otherwise hesitant patients who could see major cardiovascular and renal health improvements among other areas of improvement. In addition, counseling on dietary changes, mental health support, behavioral changes, and lifestyle changes should still have a role.

Other changes transforming the landscape include less stigma regarding obesity. “The attitudes among healthcare providers toward chronic conditions like diabetes and hypertension have paralleled how easily we can now treat them. Because it’s easier to treat these conditions with medications, and now that we know so much about their biology, this has affected how healthcare providers think of these conditions. Etiologically, these and many other conditions are similar to obesity — highly heritable, modulated by the environment — and this has helped reduce bias,” Dash says. In addition to clinicians becoming more open to prescribing pharmacotherapy (as well as more pharmaceutical options becoming available, as happened with diabetes and hypertension), continuing therapy even after certain end points are reached may become more widespread, if data bear out the potential accrual of other health benefits (e.g., cardiovascular and renal).

With all of these exciting, if still hypothetical, developments to look forward to, Dash offers a tempering word of advice: “There’s a lot of misinformation around now, reducing complex topics into simple answers. The challenge going forward for public health in all domains will be fighting this potential for misinformation. You can have the best treatments available, but across chronic disease spectra, the big challenge isn’t lack of effective treatment, it’s that many people aren’t taking the treatments or are hesitant because of misinformation. That will be another big factor to counter in coming years.”

Addressing Socioeconomic Contributors to Obesity

Even as the field of obesity makes positive strides toward the more personalized, multifaceted approach to treatment Dash describes, Alba emphasizes the complementary need to address the socioeconomic aspect. “There are many things we need to tackle, like structural inequities. We have to promote equal access to resources, find out how we can support each patient, but also have community-level health improvements,” she says.

In her talk on the socioeconomic contributors to obesity, she plans to promote the community aspect very strongly. “I’ll touch on promoting physical activity and improving access to healthy foods since there’s a lot of great research we can review, but I will focus more on fostering community engagement, thinking about grassroots initiatives and what we do in our clinics,” she explains. “I’m deeply committed to addressing health disparities with a focus on vulnerable populations. My clinical work at a safety net hospital has allowed me to witness firsthand the impact of socioeconomic contributors to obesity and other metabolic diseases.”

This work has helped shape her perspective on this topic: “It’s really easy to tell someone they need to eat better and exercise, and here are some medications to help, but when it comes to the type of population I see here, it’s not that easy.” Some of the barriers to eating better and being more physically active — even just taking a walk — include living in unsafe neighborhoods, lack of access to a park, very limited free time due to work and childcare demands, and lack of access to healthy foods. Often the employment options open to her patients do not include paid time off, so even keeping healthcare appointments can present a hardship. Getting transportation to and from can likewise be a barrier. “As clinicians or researchers, we don’t always think about what’s required for our patients to comply and do everything we want them to do,” she says.

Alba sees “culturally tailored approaches” as a way forward. “We need programs tailored to specific populations instead of putting everyone in the same category,” she says. “One thing I want to highlight is getting communities involved in designing solutions that actually work for them and are more likely to succeed.” At her hospital, for example, despite offering patient education and resources in multiple languages, this does not cover every population in the area. She points to the large Mayan population her hospital serves, whose native languages include Mam and Yucatec Maya. Although they might speak Spanish as a second language, they do not necessarily understand complex medical directions presented in Spanish.

Education is part of the community component, and local clinics and hospitals can often help set up programs at the local level. Alba points to examples like diabetes-prevention programs that provide low-cost gym memberships or free community fitness classes that are proven effective.

“I’m a physician scientist, and my research since my fellowship days focuses on transcriptional pathways that regulate adipose tissue function. I study high-risk populations — people at high risk of developing obesity, type 2 diabetes, or metabolic complications. Hispanic, Latino, and Chinese American groups, for example, don’t need to gain much weight to develop these conditions.”  — Diana Lucia Alba, MD, assistant professor of medicine, Division of Endocrinology University of California San Francisco, San Francisco, California

Another missing piece is representation, often due to costs and logistics. “I want to emphasize our need to continue research for these particular populations. It’s not only research on socioeconomic factors that drive obesity that will help us understand the most effective interventions, but it’s also making sure we have these vulnerable populations in our research projects and studies,” Alba says. “It’s harder to enroll participants who have to take time from work or might not have transportation to come to research visits. It also gets more expensive to enroll these participants because you have to translate everything to their language.” Although her institution focuses on hiring research coordinators who either speak the language or look like the participants, making connection easier, she says these aspects are not always considered in the design of research projects elsewhere. “This has long been near and dear to my heart,” she says. “I’m a physician scientist, and my research since my fellowship days focuses on transcriptional pathways that regulate adipose tissue function. I study high-risk populations — people at high risk of developing obesity, type 2 diabetes, or metabolic complications. Hispanic, Latino, and Chinese American groups, for example, don’t need to gain much weight to develop these conditions.”

Finally, Alba sees government policy playing a crucial role in obesity treatment and mitigating challenges. One policy in particular she hopes to see implemented is clearer food labeling, an initiative that has had positive impacts in Latin American countries recently, with Brazil famously leading the charge. This and efforts to regulate “junk food” can help consumers make better choices at the grocery store, she explains.

Even with all her powerful suggestions for improving the obesity landscape for vulnerable populations over the next five years, Alba remains a realist. “I tell my patients, ‘We have more resources now, we understand more about the biology, we know that what you’re doing to lose weight might not be what you need to do to keep that weight off, and we know that your brain is fighting really hard to take you back to the previous weight.’ Switching to that idea of obesity as a chronic condition with chronic inflammation and complications helps us and our patients understand that this is something they’re going to have to deal with for a long time.”

Perspectives from the Co-Chairs

Although they are not presenting a talk, facilitators Pabich and Correia are equally inspired by and passionate about the topic of future developments and challenges in obesity treatment — and therefore excited and honored to be co-chairing the session.

Pabich says she has been involved in advancing obesity medicine in her home state of Wisconsin and helping educate clinicians to feel comfortable treating obesity as a disease. This includes giving lectures and education seminars on using obesity pharmaceuticals or lifestyle-based obesity medicine therapies as well as when and when not to refer people for bariatric surgery procedures.

“For so long my mission in obesity medicine has been to get the world to appreciate obesity as a disease and to prevent and treat it with evidence-based strategies the way we do with any other disease,” she explains. “Finally, we’ve seen a significant acceleration in this movement. In facilitating this session, I want to probe the presenters about how obesity medicine is going to change and adapt now that the world is starting to see it the same way that we have for years.”

“For so long my mission in obesity medicine has been to get the world to appreciate obesity as a disease and to prevent and treat it with evidence-based strategies the way we do with any other disease. Finally, we’ve seen a significant acceleration in this movement. In facilitating this session, I want to probe the presenters about how obesity medicine is going to change and adapt now that the world is starting to see it the same way that we have for years.” —  Sam Pabich, MD, MPH, assistant professor, University of Wisconsin; clinician, Madison U.S. Department of Veterans Affairs Hospital, Madison, Wisconsin

She also has experience with all of the FDA-approved medications, old and new. “GLP-1s and GLP-1/GIP-1s are the newest players in the field,” she says, “and they’re also the most effective and therefore the most exciting.” Because endocrinologists have been using these medications for almost 20 years with diabetes, Pabich says, “we have this benefit compared to a lot of other specialists of feeling extremely comfortable with them, knowing how they work, and knowing how to help our patients navigate the side effects. We should be really ready to help patients get access to these medicines and help other clinicians feel that same comfort that we’ve developed over time.”

A future date she anticipates will be very significant will likely come in the early 2030s, when the more potent GLP-1s will start to go off-patent and hopefully become more affordable (it’s also possible that lower prices can be negotiated before then). Because the current off-label (i.e., for obesity) price tag is often more than $1,000 a month, these medications are out of financial reach for many. So, when those prices come down, says Pabich, “that’s when we’re going to see significant changes in population health because of more widespread ability to get these medications affordably.”

Like Dash and Alba, Pabich also shares a word of caution: “What I really hope is that this unfortunate problem that now has a good treatment doesn’t just make people rely on the treatment. I hope it allows people to focus on prevention of these issues so that maybe the next generation won’t be dependent on these medications. We have made huge strides in treatment, but we haven’t made big strides in prevention of obesity.”

Correia offers another complementary yet unique perspective: the need for balanced innovation across multiple treatment approaches. Correia practices weight management at the University of Iowa Weight Management Clinic. He is also a practitioner at the MOVE! Weight Management program at the Iowa City VA Medical Center, where he has easier access to incretin-receptor agonists. He also researches dietary approaches to managing metabolic-associated fatty liver disease (MAFLD) and metabolic dysfunction-associated steatohepatitis (MASH). “I’m confident that with effort from the community, including pharmaceutical companies running important clinical trials now focusing more on comorbidities associated with obesity, like cardiovascular disease and MAFLD, these medicines will have an impact on these conditions as well,” he says.

Even so, Correia echoes the other session participants about the limitations of incretin-receptor agonists, citing accessibility and variable responses among others. Like Dash, he sees bariatric surgery’s importance growing as a treatment option when medications are not adequate. The flip side is that bariatric surgery in the United States is expensive so not affordable to everyone.

Limitations notwithstanding, Correia is hopeful about what the next five years may bring. “The pipeline of new compounds to tackle obesity and its complications is unprecedented,” he says. “We’re really living in a revolutionary time with medicines that have multiple benefits. The pipeline is very promising: in five years, we’ll have novelties with small molecules, which might impact affordability because the production processes are probably much less complicated.”

He is hopeful, but with caveats, just like his fellow session participants. “One thing we can never put on the back burner between now and 2030 is lifestyle modifications,” he says. “This aligns with my interest in dietary interventions, which goes far beyond this or that diet. It has to do with behavior, how people can live their lives, adding more physical activity, and adding more mental and spiritual elements to bring not only health but well-being.” This is not to be confused with the outdated approach to lifestyle changes and obesity — diet and exercise alone are not enough to tackle the chronic, lifelong nature of obesity. Instead, Correia feels more research in lifestyle modifications and integrative approaches is needed. In other words, he hopes to see the same energy devoted to innovating procedures and developing drugs directed to innovating new lifestyle change approaches. In his words: “We need to include innovation in lifestyle that aims at promoting health more than anything.”

And what of the processed and junk food special interest groups lobbying to potentially hamper such efforts? Correia says the industry will adapt, just as it has done in other domains, like energy. “It is, after all, in their long-term interest to be part of this conversation and hopefully the solutions. We need partnerships with the food industry, not constant fighting,” he says.

Also like his fellow participants, Correia is glad to see much wider acceptance of the classification of obesity as a disease (i.e., arising from biologic factors), referring to a recent Lancet Diabetes & Endocrinology publication. “My interpretation is that they’re now making distinctions similar to diabetes and pre-diabetes, so now we have ‘pre-clinical obesity’ and obesity,” he says. “They’re characterizing these people not only by dysfunction of certain organs but by functional aspects of obesity as a disease, such as problems with incontinence and self-care, things that need to be addressed. I think this definition will raise even more awareness of how this problem affects people’s lives.”

“One thing we can never put on the back burner between now and 2030 is lifestyle modifications. This aligns with my interest in dietary interventions, which goes far beyond this or that diet. It has to do with behavior, how people can live their lives, adding more physical activity, and adding more mental and spiritual elements to bring not only health but well-being.” — Marcelo Correia, MD, MSc, PhD, clinical assistant professor of internal medicine-endocrinology and metabolism, University of Iowa, Iowa City, Iowa 

It so happens that Correia was an investigator in the SELECT trial Dash mentioned. He says: “Interestingly, this was one of the very few studies that didn’t implement lifestyle modifications; it was just about the medicine. The results were incredible, especially considering these patients were being treated with statins and had high cardiovascular risk to begin with. I can’t imagine what the results would have been if they had added exercise, also known to have an impact on cardiovascular health.”

“We have some idea of what can be done to help these people, but the solutions, especially those associated with lifestyle changes, aren’t fully developed yet,” he says. He mentions nutritional and physical activity genetics as possibly allowing more personalization of interventions by predicting responses to dietary interventions based on genetic traits. “But my impression is that we need more advances. Again, we need the same type of innovation we see in bariatric surgery techniques and the pharmaceutical pipeline.”

Horvath is a freelance writer based in Baltimore, Md. In the January issue, she wrote about the medical students who created various outreach programs in their local communities in rural New Hampshire.