GLP-⁠1 and endoscopic procedures: a new era of obesity therapy

• In SURMOUNT-1, 9 out of 10 people treated lost weight; more than half lost at least 20% of their weight at the highest dose.
• In a direct comparison over 72 weeks (SURMOUNT-5), participants lost on average 22.8 kg (20.2% of body weight) with the dual agent and 15.0 kg (13.7%) with the pure GLP-⁠1 preparation.
• 31.6% of the group on the dual agent achieved at least 25% weight loss, compared with 16.1% on the pure GLP-⁠1 preparation.
• Older, daily injected GLP-⁠1 preparations achieved around 8% weight loss (~8 kg) by comparison.

Study values are averages. Results vary from person to person.

1. 01SCOPE registry (USA)After 6 months on the weekly GLP-⁠1 preparation, an average weight loss of 10.5 kg (≈ 10%); 48% lost at least 10% of their starting weight.
2. 02Truveta analysis (2022/23)After 12 months: dual agent −15.3%, pure GLP-⁠1 preparation −8.3%. At least 5% weight loss was achieved by 82% (dual; 51% even at least 15%) and 67% (GLP-⁠1; 26% at least 15%) respectively.

Important on adherence: more than half (54%) stopped therapy within 12 months – because of side effects, cost or limited availability.

1. 01With or without diabetesPeople without diabetes lose markedly more weight in percentage terms (typically around 12–15 percentage points more). The lower weight loss with diabetes is attributed to differences in metabolism and to accompanying medications. Even so, the weight losses are considerable with diabetes too (9–16 kg depending on the agent).
2. 02By BMIThe percentages mostly come from participants with obesity: the average BMI was often 37–38 (class II obesity), in STEP-1 with a starting weight of around 105 kg. Two thirds of participants in one large study had a BMI of 35 or above.
3. 03With a BMI of 40 or aboveSimilar weight losses in kilograms as with lower obesity, but very high losses of over 15% are less common in percentage terms. The health benefit of double-digit kilogram losses nevertheless remains high.

• Without continued therapy, the risk of a yo-yo effect is high.
• The effect varies greatly from person to person.
• Adherence and uninterrupted supply are decisive – as is medical guidance on the dose.

1. 01MethodDuration about 1 hour, purely endoscopic via the mouth, as a day case or with a short inpatient stay. The greater curvature of the stomach is folded and sutured.
2. 02Weight reductionMeta-analyses: 13–16% weight loss after 1 year. In a model study over 5 years, 18% was maintained in the long term, in some groups more than 20% after 1–2 years. Suitable for a BMI of 30–40, for example.
3. 03SafetySerious complications in fewer than 1% of cases (0.2% in a large series). The risk is markedly lower than with an operation; the passage through the gut remains unchanged.
4. 04Related conditionsMetabolic related conditions can improve: diabetes in up to 92%, high blood pressure in around 50% of those treated.

1. 01Weight reductionBalloons for 6 months: 7–15 kg (around 10% of body weight). Balloons for 12 months: median 15.9 kg (≈ 15.4%), with wide variation (middle half 10–22 kg).
2. 02SafetyIn a 12-month study, around 5% of balloons were removed early because of intolerance; serious complications: 0.17%. Most common at first are nausea and a feeling of fullness.

Lifestyle measures

limited (under 10%)

GLP-⁠1 analogues

double-digit (8–20%)

Endoscopic procedures

mid-range (10–16%)

Bariatric surgery

highest (over 25%)

1. 01Endo sleeve + GLP-⁠1: US multicentre study (n = 1,506)Those who additionally received GLP-⁠1 therapy after the endo sleeve had markedly higher weight losses after 24 months. The right timing of the added medication is decisive.
2. 02Endo sleeve + GLP-⁠1 with fatty liver (BMI ~41)18.2% weight loss after 12 months with the combination, 9.6% with the endo sleeve alone. Also better metabolic values: liver stiffness −54% compared with −14% (p = 0.05), better HbA1c and insulin resistance values.
3. 03Endo sleeve + older GLP-⁠1 preparation (Taiwan, n = 18)24.7% compared with 20.5% weight loss after 7 months, without additional side effects.
4. 04Swallowable balloon + GLP-⁠1 (randomised, n = 115)17.6% weight loss after 4 months with balloon and GLP-⁠1 preparation, 13.7% with balloon and placebo – plus more frequent improvement in diabetes, high blood pressure and sleep apnoea.
5. 05Balloon, then GLP-⁠1 (n = 181)14% weight loss after 4 months of balloon; with a subsequent older GLP-⁠1 preparation up to 19% overall, with 99% loss of excess weight (EWL).

Study values are averages. Results vary from person to person.

• Different mechanisms of actionEndoscopic procedures reduce the stomach mechanically or fill it as a placeholder; GLP-⁠1 analogues regulate appetite centrally and delay stomach emptying. The two complement each other.
• Overcoming plateausIf weight stalls a year after the endo sleeve, GLP-⁠1 can enable further loss; if it stalls on GLP-⁠1, an endoscopic procedure can give new momentum. After a balloon is removed, continuing with medication can help to maintain weight.
• Avoiding relapseAfter a balloon is removed, the risk of a yo-yo effect is high. Continued GLP-⁠1 therapy can stabilise weight, while the lasting change to the stomach from the endo sleeve provides satiety in the long term.

1. 01GLP-⁠1 before the endo sleeve4 months of pre-treatment, then the endo sleeve – in studies with up to 29% weight loss.
2. 02Endo sleeve before GLP-⁠1The endoscopic procedure first, then medication as a supplement if there is a plateau.
3. 03Balloon, then GLP-⁠14–6 months of gastric balloon, then GLP-⁠1 therapy as a continuation.
4. 04At the same timeA lower GLP-⁠1 dose may be enough – with fewer side effects. This includes intensive nutritional support within the multimodal programme and close aftercare.

• Those who want to avoid medicationthe endo sleeve as a route without drugs
• Those who like technologymodern balloon systems with app support
• Those who want to achieve as much as possiblecombinations in specialised centres

1. 01GLP-⁠1 analogues especially fortype 2 diabetes (double benefit for weight and blood sugar), moderate obesity (BMI 30–35), the wish for a route without a procedure and good adherence with regular injections.
2. 02Endoscopic procedures especially forintolerance of or contraindications to GLP-⁠1 analogues, the wish for a one-off treatment, a wish to have children (GLP-⁠1 analogues must be stopped before pregnancy) and a view to cost (cheaper in the long term).
3. 03Combination especially forsevere obesity (BMI over 40), insufficient response to a single therapy, a weight plateau and a history of repeated yo-yo effect.

1. 01GLP-⁠1 therapyFor weight reduction alone, German statutory health insurers currently do not pay; cost coverage is usually only available for diabetes.
2. 02Weight Doctors SLEEVE®Where there is a medical indication in line with the guidelines, there is a chance of cost coverage – more on German health insurance.
3. 03Gastric balloonThe gastric balloon is a self-pay service; private insurers decide differently.

1. 01CommonGastrointestinal complaints (49% higher risk than on placebo), above all nausea and a feeling of fullness at first, occasionally diarrhoea or constipation. Mostly mild to moderate and temporary.
2. 02Rare, but importantInflammation of the pancreas (very rare), gallstones (with rapid weight loss), delayed stomach emptying, a possible worsening of diabetic retinal disease.
3. 03Before an endoscopyThe American Society of Anesthesiologists (ASA) recommends a pause before planned endoscopies: stop daily preparations on the day of the procedure, weekly ones a week beforehand.

• Endo sleeveserious complications under 1% (0.2% in large series); rare bleeding, very rare perforation of the stomach wall; markedly lower risk than with an operation.
• Gastric balloonoften nausea and vomiting at first (first week); rarely irritation of the stomach lining or ulcers; very rarely a spontaneous deflation with passing of the balloon (~2%); early removal because of intolerance in ~5%.
• Combinationsso far no unexpected additional complications; gastrointestinal complaints can be more pronounced, so particular attention should be paid to drinking enough.
• AnaesthesiaMore recent experience shows that an endo sleeve is often safely possible on GLP-⁠1 analogues – 24 hours of liquid diet and at least 12 hours of fasting are important. In a series of 57 people treated, there was no inhalation of stomach contents.

• ESGE guideline 2022multimodal approach recommended; always combine endoscopic procedures with lifestyle measures; prefer holistic treatment concepts.
• AGA guidelines 2022medications as a supplement to lifestyle measures – they treat a biological condition that often does not respond to lifestyle change alone; promote interdisciplinary cooperation.

1. 01Dr. Andres Acosta (Mayo Clinic)Treatment is moving away from a pyramid in which patients choose a single measure towards interdisciplinary programmes that combine measures.
2. 02Dr. Aurora Pryor (Northwell Health)With all available tools together, the disease can be treated better – everyone is different and needs different approaches.
3. 03Dr. Thomas McCarty (Houston Methodist)GLP-⁠1 therapy typically begins about four months before the endoscopic procedure. This leads to lasting weight loss, which often allows the medication to be stopped once the goal is reached.

“The future of obesity therapy lies in personalised medicine. We see every day how differently patients respond to different therapies. A 45-year-old with diabetes may be best treated with a modern GLP-⁠1 analogue, while a 35-year-old woman without diabetes benefits from a combination of endo sleeve and low-dose medication. Our task is to recognise these individual needs and find the right combination for each patient.”

• New medicationsthe next generation with triple action (GLP-⁠1/GIP/glucagon), new forms of administration (as a tablet, taken less often), individually tailored dosing.
• Endoscopyimproved endo sleeve techniques with longer-lasting results, “smart” balloons with sensors and app connection, reversible procedures for greater acceptance.
• Combination conceptsfixed treatment pathways for different starting points, sequences timed to fit together (e.g. GLP-⁠1 → endo sleeve → low-dose maintenance), connected digital health platforms.
• Payersgrowing evidence for the cost-effectiveness of combined approaches, possible changes to reimbursement rules, more attention to health costs in the long run.
• Carespecialised obesity centres as the standard, interdisciplinary teams from gastroenterology, endocrinology and nutrition counselling, aftercare also via telemedicine.

• GLP-⁠1 analoguesInformation on the different agents and their properties, on the differences between diabetes and obesity treatment, on new developments – and a recommendation that suits your medical situation.
• Medical supportindividual therapy planning, information on how it works, side effects and expectations, support throughout the entire treatment with regular checks and adjustments.
• Multimodal programmesendoscopic procedures in our centres, a coordinated combination of different approaches, strategies to maintain weight in the long term.
• Personal careconsultations on the choice of therapy, information on costs and reimbursement, support with the decision, long-term medical support.

1. 01ExperienceSpecialists with extensive experience in obesity therapy.
2. 02Up to dateWe continuously follow the scientific findings.
3. 03NeutralObjective advice on all available therapies.
4. 04IndividualEvery patient receives their own treatment recommendation.
5. 05HolisticAll sides of modern obesity therapy are taken into account.

Sources: STEP-1/2 trials, SURMOUNT-1/2/5 trials, SCOPE registry, Truveta analysis, studies on the endo sleeve and on combination therapies, cost studies and expert voices (including pmc.ncbi.nlm.nih.gov, pubmed.ncbi.nlm.nih.gov, diabetes.org, worldobesity.org, news.harvard.edu, houstonmethodist.org), as of May 2025.