Impact of Sleeve Gastrectomy Versus Intensive Lifestyle Modifications With Obesity Management Medications on BMI Trajectory and Target Attainment: A Prospective Matched Cohort Study

Aims To compare sleeve gastrectomy (SG) with intensive lifestyle modification combined with obesity management medications (ILM/OMMs) in adults with severe obesity, focusing on BMI trajectory, time to achieving clinically meaningful weight loss, and metabolic outcomes in a real‐world clinical setting. Materials and Methods This prospective matched cohort study included 190 patients (BMI ≥ 35 kg/m 2 , obesity‐related comorbidities) assigned to SG or ILM/OMM in a 1:1 ratio, matched for age, sex, BMI, and diabetes duration. The primary outcomes were change in BMI at 12 months and time to achieving ≥ 25% total weight loss (TWL). Secondary outcomes included changes in weight and obesity‐related comorbidities (hypertension, dyslipidemia, type 2 diabetes) ( clinicalTrials.gov , NCT06820047). Results At 12 months, model‐based BMI was lower after SG than after ILM/OMM (28.4 kg/m 2 , 95% CI 27.2 to 29.6 vs. 31.6 kg/m 2 , 95% CI 30.5 to 32.8; between‐group difference −3.2 kg/m 2 , 95% CI −4.9 to −1.5; p < 0.001). Estimated %TWL was greater after SG than after ILM/OMM at 12 months (37.6%, 95% CI 36.5 to 38.7 vs. 18.0%, 95% CI 16.9 to 19.1; difference 19.6 percentage points, 95% CI 18.1 to 21.1; p < 0.001). Time to achieving ≥ 25% TWL was shorter after SG; the median time was 6 months in the SG group, whereas the median was not reached by 12 months in the ILM/OMM group (log‐rank p < 0.001; HR 13.85, 95% CI 7.81–24.58). Both groups showed metabolic improvement, although between‐group differences were limited. Conclusions SG was associated with greater and more rapid weight loss than ILM/OMM over 1 year, with earlier achievement of ≥ 25% TWL. Both approaches produced clinically meaningful metabolic improvements, supporting individualized treatment selection.