Weight loss options: how to compare all of them

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There is no single best option. There are real differences between the options, and the right one depends on your health, your history and what you are willing to do over the long term. Some options remove part of the stomach and some remove nothing. Some can be taken out or stopped, and some cannot. Some end on a set date, and some last for life.

Who wrote this. This guide comes from the practice of a bariatric surgeon. The practice earns money from the procedures it offers, so it has a financial interest in what you choose. To limit that bias, the figures here come from outside sources: FDA documents, drug labels, national health agencies, professional societies and named trials. You can open each one from the links on this page and in the source list.

How to read the numbers. Trials studied different people, for different lengths of time, and often measured results in different ways. Except where a trial directly compared two options, you cannot line up two numbers and conclude that one option is better. Individual results vary, and no option is sure to work or to last.

BMI (body mass index) is a measure of weight in relation to height, and many of the rules below use it. You can check your BMI with the calculator. For background on the operations, read the practice's overviews of types of bariatric surgery and different types of weight loss surgery. National references are ASMBS and NIDDK, a part of the National Institutes of Health.

Questions that decide between them

A handful of questions do most of the sorting. None has a universal answer, but knowing your own answer before a consultation makes it more useful.

Do you have reflux or heartburn?

This is often a deciding fact between a sleeve and a bypass. ASMBS notes that the sleeve may worsen reflux or cause it for the first time. In the SM-BOSS trial, reflux got worse in 31.8% of people with a sleeve and 6.3% with a bypass. Mention reflux, heartburn medicine and any hiatal hernia at your first visit. See gastric bypass vs gastric sleeve.

Do you have type 2 diabetes?

Diabetes and other weight-related conditions shape the recommendation as much as weight does, and they are a main reason gastric bypass is discussed. Read gastric bypass and diabetes and bariatric surgery for diabetes, sleep apnea and blood pressure. For the conditions themselves, see obesity and related health conditions.

How much does permanence matter to you?

Some people want an option that removes nothing and can be changed later. Others would rather make one decision that does not need revisiting. The band is adjustable and removable, balloons are temporary, and ESG and plication remove no tissue. The sleeve cannot be reversed and the bypass is difficult to reverse (NIDDK). Both ASMBS and NIDDK also note that the band is used less often in the United States than it once was, which is worth asking about directly.

• How Lap-Band adjustments work
• Can ESG be reversed or redone?
• How long a gastric balloon stays in, and what happens after removal

Have you had weight loss surgery before?

If so, you are choosing a revision, not a first procedure, and the options depend on what was done originally. Start with the revision and weight regain hub, or go straight to Lap-Band revision or gastric bypass revision. Medication after surgery is covered in GLP-1 medications after bariatric surgery.

Are you planning a pregnancy?

Timing matters more than the choice of procedure, but the two interact. See Lap-Band vs gastric sleeve for a future pregnancy and pregnancy and fertility after bariatric surgery.

Medication, a procedure, or both?

These are not opposites. Some people try medication first, some use it before or after surgery, and some decide on a procedure instead. Read weight loss medications and GLP-1s before bariatric surgery: bridge or alternative?

What follow-up can you realistically commit to?

Band adjustments, a balloon's fixed treatment period, lifelong vitamins after a bypass, and an ongoing prescription are very different commitments. Be honest with yourself about which one fits your life.

Medical weight loss

What it is. A program supervised by a doctor. It usually starts with a health history, an exam and lab tests, followed by a plan that may include diet, activity, medication and regular visits. The term has no single standard meaning, so programs differ widely. Some pages on this website also use the phrase “medical weight loss surgery” for surgical care. That is a different topic.

Who guidelines or labels say it may suit. NIDDK says your health care professional may refer you to a specialist or team trained in weight management. NIDDK says prescription medication may be considered at a BMI of 30 or more, or 27 or more with a weight-related health problem.

Who it may not suit. Be careful with any program that promises a set number of pounds or fast results. NIDDK lists too many promises as a warning sign.

Evidence and its limits. There is no single figure because programs differ. For the medication part, NIDDK says adults on prescription medication in a lifestyle program lose on average 3% to 12% more of their starting weight after 1 year than those in the program without medication.

Main risks. These depend on what the program uses. Medication carries the risks on its label.

What it asks of you. Regular visits, lab work and keeping up with the plan. Ask how often you would be seen, by whom, and for how long.

Cost and coverage. Varies. Ask for a list of what is included, what is billed separately, and whether your plan pays for any part of it.

Offered here?. Ask the office whether the practice runs this program now, and what it includes.

Read next. Benefits of a personalized medical weight loss program (an older article) and gastric balloon vs medical weight loss.

Gastric balloons

What it is. A soft balloon filled with fluid sits in your stomach for a limited time and takes up space. Two are covered here. The Allurion balloon is swallowed as a capsule and needs no endoscopy or anesthesia. It empties itself after about 16 weeks and passes through the body. The Orbera balloon is placed and removed by endoscopy (a flexible camera through the mouth) and can stay for up to 6 months.

Who guidelines or labels say it may suit. FDA says Allurion is indicated to promote short-term limited weight loss in adults aged 22 to 65 with a BMI of 30 to 40 who have had at least one unsuccessful attempt at a weight loss program, used with a lifestyle program. Orbera is for adults with a BMI of 30 to 40 who have tried more conservative approaches, used with a long-term supervised diet and behavior program.

Who it may not suit. Each label has its own list of conditions that rule a balloon out. Examples include prior stomach or bariatric surgery and Crohn's disease. The Allurion list also includes some swallowing disorders, a history of bowel obstruction, taking blood thinners, and being unable to stop NSAID pain relievers.

Evidence and its limits. In the Allurion study, weight loss was 6.87% at 48 weeks vs 3.09% with lifestyle therapy alone, with up to two balloons placed over about 10 months. That is why FDA uses the words “short-term limited.” In the Orbera study, the balloon group had lost 10.2% at removal at 6 months and 7.6% at 12 months, compared with 3.3% and 3.1% in the control group. These are different trials and not a direct comparison. NIDDK says researchers have not studied weight loss devices over long periods.

Main risks. FDA has written to health care providers about liquid-filled balloons, reporting deaths, stomach perforation, pancreatitis and balloons enlarging on their own. Nausea and vomiting are very common at first. In the Orbera study, 86.9% reported nausea, and 18.8% had the balloon removed early. If you have severe belly pain, trouble breathing or repeated vomiting with a balloon, seek care right away.

What it asks of you. A diet and lifestyle program during treatment and afterward. Orbera also needs a second endoscopy for removal. Weight can return, so ask what the plan is once the balloon is gone.

Cost and coverage. Medicare does not cover a gastric balloon for treating obesity. Ask other plans directly. The FDA-labeled Allurion program can include up to two balloons over 10 months, so ask what your quote covers.

Offered here?. Yes. The practice offers gastric balloons. Ask the office which balloons are available now and which fits your history.

Read next. Gastric balloons: an overview, Allurion vs Orbera and Allurion vs Ozempic and Wegovy.

Gastric plication

What it is. A surgeon folds the stomach inward and stitches it so that it holds less. This is done through small incisions under general anesthesia. Nothing is removed or rerouted, and no device is left except the stitches.

Who guidelines or labels say it may suit. Gastric plication is not on the ASMBS list of endorsed procedures. ASMBS says a procedure not on its list needs review by an ethics board (an IRB) before use as a primary treatment at accredited centers, and that unlisted procedures either have not been endorsed or have not finished its review. This guide found no guideline naming who it suits.

Who it may not suit. If you want an option with a strong evidence base and a place on national lists, ask about listed procedures first.

Evidence and its limits. This guide gives no figure, because we did not open a study we could rely on for one. Ask any surgeon who offers it which studies apply, how many patients they followed, and for how long.

Main risks. It is surgery, so it carries surgical risks. Ask for the complications the surgeon has seen, and how often. Also ask what happens if it does not work.

What it asks of you. A staged diet, nutrition follow-up and lasting changes in eating.

Cost and coverage. Ask for a written quote, and ask your plan in writing. Do not assume coverage.

Offered here?. Ask the office whether this is still offered.

Read next. Gastric plication: what happens in your body and plication vs sleeve vs balloon.

Gastric sleeve

What it is. A surgeon removes about 80% of the stomach and leaves a banana-shaped tube (ASMBS). It holds less and changes hunger hormones. The small intestine is not rerouted, and no device is left behind.

Who guidelines or labels say it may suit. The 2022 ASMBS and IFSO statement recommends surgery at a BMI of 35 or more, with or without other conditions, and says it should be considered at 30 to 34.9 with metabolic disease. For people of Asian ancestry it should be offered at 27.5 or more. It found no evidence for an upper age limit, but advises careful selection, including a check for frailty. Your insurer may use different rules.

Who it may not suit. Significant reflux is the main concern to raise. It also may not suit you if you want something that can be reversed. Ask how it fits your diabetes, your stomach history and any plans for pregnancy.

Evidence and its limits. Two trials randomly assigned people to a sleeve or bypass and followed them for 5 years. In SLEEVEPASS (Finland, 240 people, average BMI 45.9), excess weight loss was 49% with a sleeve and 57% with a bypass. The authors reported that the two did not meet their test for being equivalent, and that the difference was not statistically significant under the limits they set in advance. In SM-BOSS (Switzerland, 217 people, average BMI 43.9), excess BMI loss was 61.1% and 68.3%, and that difference was not statistically significant. NIDDK says no method, including surgery, is sure to produce and maintain weight loss, and some people regain some weight.

Main risks. Leak, bleeding, blood clots, narrowing, hernia and low vitamin and iron levels (NIDDK). Reflux may worsen or start. In SM-BOSS, 15.8% of sleeve patients had a further operation or procedure by 5 years. It cannot be undone.

What it asks of you. Tests and preparation before surgery, a staged diet afterward, lifelong vitamins and lab checks, and lasting changes in eating and activity.

Cost and coverage. See the cost table. Medicare contractors decide on a stand-alone sleeve at a BMI of 35 or more, with a related condition, after unsuccessful medical treatment. The practice accepts PPO and HMO plans that allow it, so ask whether you can be seen on your plan. Ask for a written quote if you are paying yourself.

Offered here?. Yes. Surgery takes place at hospitals where Dr. Davtyan has privileges. Ask the office which hospital would apply to you.

Read next. The worked example below, gastric sleeve overview, sleeve risks and Lap-Band vs sleeve.

Duodenal switch and SADI-S

What it is. Both begin with a sleeve-shaped stomach, then reroute the small intestine. In a biliopancreatic diversion with duodenal switch (BPD/DS), food bypasses about 75% of the small intestine (ASMBS). SADI-S is a simpler version with only one bowel connection. Both reduce how many calories and nutrients your body absorbs.

Who guidelines or labels say it may suit. ASMBS lists both among its endorsed procedures. NIDDK says a surgeon may recommend a duodenal switch for people with severe obesity and certain health conditions. ASMBS also describes SADI-S as an option after an earlier sleeve when someone is seeking further weight loss.

Who it may not suit. These may not suit you if you cannot commit to close, lifelong nutrition follow-up. Frequent loose stools can also be hard to live with. Tell the surgeon about any reflux.

Evidence and its limits. NIDDK says a duodenal switch allows more weight loss than the other common operations, and that it is the most likely to cause surgery-related problems and shortages of vitamins, minerals and protein. That is why surgeons do not perform it often. ASMBS (2021) calls SADI-S a newer operation with only short-term outcome data. This guide does not give a percentage for either.

Main risks. The highest risk of poor nutrient absorption, slightly higher complication rates than other procedures according to ASMBS, looser and more frequent bowel movements, and new or worse reflux.

What it asks of you. Longer, more complex surgery, and strict lifelong vitamins and lab checks.

Cost and coverage. Medicare covers BPD/DS at a BMI of 35 or more, with a related condition, after unsuccessful medical treatment. SADI-S is not named in that decision, which leaves unnamed procedures to local contractors. Ask your plan in writing.

Offered here?. Ask the office whether Dr. Davtyan performs these procedures. If not, ask for a referral to a center that does.

Read next. This website has no dedicated page for these operations yet. Read ASMBS and NIDDK, and compare them with the sleeve and bypass chapters.

When another route is the better fit

This practice cannot be the right place for everyone. Please look elsewhere in these situations.

• Your BMI or health does not call for a procedure. Start with lifestyle care and your primary care doctor.
• Your medication is working. Stay with the doctor who prescribes it, and keep that follow-up going.
• You want a procedure this practice does not perform. Ask the office, and ask for a referral to a center that performs it. ASMBS has a surgeon finder.
• Your plan requires a certain hospital or network. A plan may need you to use its own program. Ask us whether we can see patients on your plan. If the answer is no, an in-network program may be the more direct route to coverage.
• You are under 18. NIDDK and the 2022 statement point to a team with expertise in young people, in a specialty center. Start with a pediatrician or a pediatric obesity program.
• You have an eating disorder, or you are not sure. Get mental health or eating disorder care first. FDA notes that some weight loss devices are not for people with a history of eating disorders.
• You have urgent symptoms. Call 911 or go to the emergency room. This guide is not for that.