GLP-1 Use in Youth Climbs as Bariatric Surgery Rates Fall

Pharmacotherapy has become the default entry point into obesity care for young people, with exclusive use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) among treated adolescents and young adults (AYAs) rising from 88.2% to 96.1% in less than 4 years while metabolic and bariatric surgery (MBS) fell by more than two-thirds, according to a research letter published in JAMA Pediatrics.¹ The shift happened faster than the evidence base guiding it, leaving clinicians and payers without clear guidance on when or whether to sequence the 2 modalities.

Researchers at UT Southwestern Medical Center analyzed records for 204,148 patients aged 13 to 25 years treated for obesity between May 2022 and January 2026 in Epic Cosmos, an electronic health record database drawn from more than 300 million patients. The mean (SD) age was 21.3 (3.3) years; 73.5% were female, and nearly half (48.2%) had class III obesity. Across the full cohort, 94.1% received GLP-1 RAs alone, 4.4% underwent MBS alone, and 1.5% received both.

How Treatment Patterns Shifted Between 2022 and 2026

The trend data show a steady, one-directional migration. Exclusive GLP-1 RA use climbed from 88.2% in the May-November 2022 window to 96.1% in June 2025-January 2026 (P < .001), while MBS completion dropped from 11.6% to 3.7% (P for trend < .001).

Combination therapy, by contrast, held at 0.2% of patients in every interval studied. Among the 3075 patients who received both, 2106 (72.3%) started a GLP-1 RA before surgery and 808 (27.7%) started after. Median (IQR) time from GLP-1 RA initiation to surgery was 339 (185.0-561.8) days, shorter than the 434 (206.2-685.2) days from surgery to GLP-1 RA initiation.

Investigators were explicit about what the data cannot answer. They could not determine whether the decline in MBS reflected substitution by pharmacotherapy, shifts in insurance coverage, changes in referral practices, or evolving patient preference.¹

Why Adherence Data Complicate the Substitution Story

Roughly two-thirds of AYAs receiving GLP-1 RAs (131,818 patients) met the 80% proportion-of-days-covered threshold for adherence, with males more adherent than females (72.5% vs 65.8%; P for trend < .001). That leaves nearly a third of young patients below the adherence threshold on what is, for this cohort, an open-ended course of treatment.

The finding echoes earlier research on real-world GLP-1 persistence, which found only 34% of patients remained on therapy at 365 days and out-of-pocket costs of $150 or more predicted discontinuation.² A treatment pathway that increasingly routes young patients toward a chronic medication with documented drop-off and away from a durable procedure carries long-term cost and outcome implications that this study was not designed to measure.

What the Disparity Signals Mean for Access

Utilization diverged sharply by race and ethnicity. MBS completion was highest among Hispanic or Latino (8.8%) and non-Hispanic Black (4.7%) patients compared with non-Hispanic White patients (2.5%), while exclusive GLP-1 RA use was highest among non-Hispanic Asian (97.3%) and non-Hispanic White (96.4%) individuals (P for trend < .001).¹ Combination therapy was likewise more common among Hispanic or Latino and non-Hispanic Black patients (both 2.1%) than non-Hispanic White patients (1.2%).

The authors framed these gaps as heterogeneity in treatment pathways rather than uniform disparities in access. This distinction matters for payers evaluating whether coverage design is steering patients by demographic group. Adolescents were also far less likely than young adults to undergo surgery (1.7% vs 5.1%) and correspondingly more likely to receive GLP-1 RAs alone (97.2% vs 93.3%).

What This Means for Coverage and Guideline Development

The evidence gap the study identifies is not new to adult populations. Previous research examining GLP-1 initiation after bariatric surgery in US adults concluded that optimal timing remains unclear and that any causal link between GLP-1 uptake and falling surgery rates is not established.³ Separately, a JAMA Surgery analysis found bariatric surgery both more effective and more cost-effective than GLP-1 RAs for weight loss in adults.⁴

Study limitations include the exclusion of the obesity medications, such as phentermine and topiramate, which may understate total pharmacologic treatment. The authors called for evidence-based guidance on sequencing and long-term outcomes—the questions payers will need answered as this cohort ages into decades of coverage decisions.

References

1. Messiah SE, Ernest DK, Elnakieb Y, et al. GLP-1 receptor agonist and bariatric surgery utilization among adolescents and young adults. JAMA Pediatr. Published online July 20, 2026. doi:10.1001/jamapediatrics.2026.2828
2. McCormick B. Gaps in persistence, coverage limit GLP-1 impact in obesity. AJMC. June 2, 2026. Accessed July 20, 2026. https://www.ajmc.com/view/gaps-in-persistence-coverage-limit-glp-1-impact-in-obesity
3. McCrear S. GLP-1 usage post bariatric surgery requires more research. AJMC. August 28, 2025. Accessed July 20, 2026. https://www.ajmc.com/view/glp-1-usage-post-bariatric-surgery-requires-more-research
4. McCrear S. Bariatric surgery potentially superior to GLP-1 RA treatment for obesity. AJMC. September 17, 2025. Accessed July 20, 2026. https://www.ajmc.com/view/bariatric-surgery-potentially-superior-to-glp-1ra-treatment-for-obesity