Obesity Treatment Bydgoszcz

In its 2024 guidelines the Polish Society for the Treatment of Obesity (PTLO) describes obesity as a chronic disease, listed in ICD-10 under code E66, which does not clear up on its own and comes back once treatment stops. What drives that return is hormonal. When the fat stores are large, the hypothalamus stops responding to leptin, the hormone that tells the brain how big those stores are. After every diet the body reacts to the fall in weight by slowing the metabolism and releasing more ghrelin, the hunger hormone. That is why a man who has lost 12 kg on his own is eating more six months later than he did before the diet, and weighs what he weighed at the start or a few kilograms more.

Adipose tissue also behaves like an endocrine organ. It raises the levels of insulin and of insulin-like growth factor, produces oestrogens, keeps chronic inflammation going and changes the make-up of the gut bacteria. The same mechanisms that lead to type 2 diabetes and high blood pressure explain the link between obesity and some malignant tumours as well. The PTLO estimates that 4 to 8 percent of all cancer cases are attributed to obesity, and among the cancers linked with it lists bowel, kidney, oesophageal, pancreatic, liver and gallbladder cancer. We come back to this separately below.

We treat obesity the way high blood pressure is treated. We make the diagnosis, choose a drug, check the effect every month, change the drug when it stops working, and spread the whole thing over years. The doctor assesses whether the patient is eligible for drug treatment and keeps track of the tests, the dietitian draws up a meal plan, and the specialist in the psychology of eating deals with eating under the influence of emotion. We see patients at ul. Cieszkowskiego 5 and online, with no referral and no waiting list.

The scales alone are not enough for a diagnosis. We work out the BMI at the appointment, body weight in kilograms divided by height in metres squared, so a man 178 cm tall who weighs 108 kg has a BMI of 34. The thresholds set by the World Health Organization (WHO) and adopted by the PTLO are the same for women and men. Overweight begins at 25, class I obesity at 30, class II at 35 and class III at 40. The same index fails in people with a lot of muscle, and it says nothing about where the fat sits.

So we also measure the waist, with a tape measure halfway between the lowest rib and the top of the hip bone, on the out-breath. The International Diabetes Federation puts the limit for abdominal obesity at 94 cm in men and 80 cm in women, including when the BMI is within the normal range. Visceral fat, the fat around the organs of the abdomen, releases inflammatory substances and pushes insulin up more strongly than the fat under the skin of the thighs. A man with a BMI of 28 and a waist of 106 cm is therefore at greater risk of diabetes and a heart attack than someone of the same age with the same BMI and a waist of 92 cm. Finally we ask about the weight history: what the patient weighed in the army or at university, when he began to put weight on, after what event, how many times he has lost weight and how much of it came back. We also ask about snoring and daytime sleepiness, about alcohol, about shift work and about when someone last ordered blood tests for him.

The BMI at which we issue a prescription at the practice on Cieszkowskiego

A BMI of 30 on its own is enough for a prescription. Below that, from 27, a prescription may be issued only once the obesity has already caused a complication, that is prediabetes or type 2 diabetes, high blood pressure, lipid disorders or obstructive sleep apnoea. A patient with a BMI of 28, a waist of 104 cm and a fasting glucose of 108 mg/dl meets that criterion. Between a BMI of 25 and 27 we stay with diet and exercise, and we consider drug treatment only when the tests show insulin resistance alongside abdominal obesity. Age does not rule treatment out, but it changes how we go about it. After the age of 75 we do not give liraglutide, and we start the other drugs more cautiously, because there is little data from that age group. Treatment here is run by internal medicine specialists certified by the PTLO.

The first medical appointment, at the practice or online, costs PLN 250 and usually lasts about an hour. The doctor asks about the weight history, goes through the list of medicines the patient takes, weighs the patient, measures the waist and the blood pressure, looks at the test results and orders the ones that are missing. He also asks about screening, about colonoscopy, about mammography in women, about blood in the stool and about any unexplained abdominal symptoms, because that decides whether we begin with a prescription or with a referral. A patient who has the full set of results and meets the criteria leaves with an e-prescription (Poland's electronic prescription) for the starting dose, training in how to use the injection pen and an appointment with the dietitian.

For the first three months we raise the dose. Every 4 weeks we meet by video: the patient gives the weight and the blood pressure measured at home and describes how he is tolerating the drug, and the doctor either raises the dose or keeps the current one and sends the code for the next e-prescription. Resistance training starts in the first week, because weight loss is fastest in the early months and that is when muscle is most easily lost instead of fat. In the fourth month, on the full dose, we repeat the blood tests. In the sixth month we check whether the drug is working. The PTLO counts it as effective if body weight has fallen by at least 5 percent, and anyone who has not passed that threshold is given a different product. In the second half of the year we no longer change the dose, follow-up appointments take place every 4 to 8 weeks, and once a quarter the patient comes to the practice to have the waist measured and to be examined. After a year we decide together whether the drug stays or we begin to withdraw it.

What we do not do at Nasz Gabinet Bydgoszcz when treating obesity

• We do not start drug treatment in a patient who is having chemotherapy, radiotherapy or hormone therapy without the agreement of the oncologist looking after him. Once cancer treatment has finished we treat obesity as normal, but we agree the plan with the oncologist in writing.
• We do not treat unexplained weight loss as a sign that a diet is working. A patient who is losing weight without trying, especially after the age of fifty, is sent for investigation first, because the PTLO requires diabetes or cancer to be looked for in that situation.
• We do not put screening off until after the weight has come down. Colonoscopy, mammography and cervical screening have their own schedules regardless of weight, and an obesity drug is no reason to move them.

Before the first prescription we ask for eight blood tests. Fasting glucose and glycated haemoglobin, the average blood glucose over the last 3 months, settle whether the patient already has prediabetes or diabetes, and that decides both the BMI criterion and the choice of drug. The lipid profile shows the triglycerides and the cholesterol. Creatinine with a calculated eGFR shows how the kidneys are working; at an eGFR below 30 ml/min liraglutide is out. TSH rules out an underactive thyroid, which produces symptoms deceptively similar to obesity, weight gain, tiredness and feeling the cold. The liver enzymes ALT and AST show whether fat is building up in the liver, we check uric acid for gout, and the full blood count sometimes reveals the anaemia we describe below. Results older than six months we ask to have repeated; newer ones we accept, whoever ordered them. The patient has any missing tests done at any laboratory in Bydgoszcz and sends us a photograph of the result before the appointment.

We also go through the list of medicines and supplements the patient takes, ideally with the packs themselves or photographs of them. Several groups of drugs promote weight gain in their own right: glucocorticoids, insulin, the older diabetes drugs from the sulfonylurea group, and some antiepileptic, antidepressant and antipsychotic medicines. We do not stop any of them on our own. If a drug taken for another condition gets in the way of obesity treatment, we write to the doctor who prescribed it and ask about an alternative from the same group with a weaker effect on body weight. We look separately at the blood pressure and diabetes medicines, because their doses usually have to come down once the patient has lost weight.

When we issue a referral for investigation instead of a prescription

In a few situations we hold the prescription for an obesity drug back until the symptoms have been explained. The first is weight loss the patient did not plan; a few kilograms over 2 or 3 months with no change in diet has to be explained before we call it a success. The second is iron-deficiency anaemia in a man or in a woman past the menopause, because in that group the commonest cause is bleeding from the gut. The third is a change in bowel habit lasting several weeks, blood in the stool, difficulty swallowing, pain in the upper abdomen radiating to the back, or blood in the urine. With any of these symptoms we refer the patient to the right specialist, and we come back to obesity treatment once the investigation is finished. We do not leave him on his own with it; we issue the referral straight away and go through the results with him.

In 2016 the International Agency for Research on Cancer (IARC), part of the WHO, summarised the evidence linking excess body fat with the development of cancer. It judged the evidence sufficient for thirteen cancers: colon and rectum, adenocarcinoma of the oesophagus, gastric cardia, liver, gallbladder, pancreas, kidney, ovary, the body of the uterus, breast in women past the menopause, thyroid, and also meningioma and multiple myeloma. Eight of those thirteen entries were added only then, after a review of more than a thousand studies. This does not mean that everyone with obesity will develop cancer. Across large groups of people, though, the risk rises along with body weight, and after smoking, obesity is the second risk factor a patient can change.

How much the risk rises for every 5 BMI points

Meta-analyses show that every 5 kg/m2 above the normal range raises the risk of cancer of the body of the uterus, of adenocarcinoma of the oesophagus and of kidney cancer by 30 to 60 percent, and the risk of bowel cancer, pancreatic cancer and breast cancer in women past the menopause by 13 to 18 percent. For a man 178 cm tall, 5 BMI points come to about 16 kg. In the table we set these figures against the question we ask at the appointment for each of these cancers.

Where the link between obesity and cancer comes from

Visceral fat raises the levels of insulin and of insulin-like growth factor, and both push cells to divide and hold back their death. Adipose tissue also carries aromatase, the enzyme that converts androgens into oestrogens, which is why a woman past the menopause who has obesity keeps a higher oestrogen level than a slim woman of the same age, and oestrogens drive the growth of the lining of the womb and of breast tissue. On top of that comes a low-grade chronic inflammation that damages the genetic material of cells, and a shift in the make-up of the gut bacteria. Gastro-oesophageal reflux, commoner with a large abdomen, in turn damages the lining of the oesophagus, and over time that can lead to adenocarcinoma. None of these mechanisms works overnight; they all develop over years, which is why we ask about the class of obesity and about how long it has lasted.

Whether losing weight lowers the risk of developing cancer

The strongest data come from following patients after bariatric surgery. The American SPLENDID study compared 5,053 people who had bariatric surgery with 25,265 people of the same class of obesity who did not. After 10 years an obesity-related cancer had been diagnosed in 2.9 percent of those operated on and in 4.9 percent of those who were not, and death from cancer was recorded in 0.8 percent against 1.4 percent. The difference in body weight between the groups after 10 years was about 25 kg. This is an observational study, with no random allocation to groups, so it shows an association rather than a proven cause, but it is the largest study of its kind. For the drugs the follow-up is shorter. In an analysis from 2025 covering 86,632 adults with obesity, cancers from the obesity-related list were diagnosed less often in those taking GLP-1 analogues than in those who were not, 13.6 against 16.4 cases a year per thousand people followed. For kidney cancer the result went the other way: the risk in treated patients was higher, though at the edge of statistical significance, and further studies have not settled it. So we treat these findings as an indication, and we do not offer an obesity drug as a way of avoiding cancer.

Whether obesity drugs can cause cancer

This question comes up at appointments more often than any other question about safety. The worry comes from studies in rodents. In rats and mice semaglutide produced benign tumours of the C cells of the thyroid, which the European summary of product characteristics describes as an effect of the whole GLP-1 analogue class, arising from a mechanism to which rodents are particularly sensitive. Its significance for humans was judged to be low, although it could not be ruled out entirely. In humans no such effect has been confirmed so far. A study published in 2025, covering 98,147 people taking GLP-1 analogues and nearly 2.5 million taking comparator drugs in six countries, found no increased risk of thyroid cancer. The follow-up, though, ran from 1.8 to 3 years, and that is too short to settle what ten years of taking the drug does. We tell patients about this at the appointment, and when we examine them we look at the neck and feel it; if a lump can be felt we refer them for a thyroid ultrasound.

What these findings mean for the way we work

We ask about screening at the first appointment and come back to it at the follow-ups, because people with obesity turn up for colonoscopy and mammography less often, while they stand to gain more from them than a slim person does. We clear up red-flag symptoms before the prescription, which we describe in the section on tests. Losing weight does not remove the risk, but it lowers it, in the same way as giving up smoking, and it does most when it holds for years.

After a meal the gut releases the hormone GLP-1, which for a few minutes damps down appetite and slows the emptying of the stomach. GLP-1 analogues, or GLP-1 receptor agonists, are versions of it that resist breakdown and go on working for several days. The patient feels full after a smaller portion and stops thinking about food between meals. Many of our patients say that it was exactly this constant thinking about food that wore them down most. Tirzepatide also acts on the receptor for a second gut hormone, GIP, and in the trials it produces a larger fall in body weight. Semaglutide and tirzepatide are injected once a week into the skin of the abdomen, the thigh or the upper arm, liraglutide daily, and we raise the dose every 4 weeks so that the stomach has time to get used to it.

How much weight comes off in the trials and how wide the spread of results is

A man who weighs 120 kg usually weighs about 18 kg less after a year on semaglutide, and about 25 kg less after tirzepatide. These estimates rest on three trials. In the STEP 1 trial participants on semaglutide at a dose of 2.4 mg lost an average of 14.9 percent of their body weight after 68 weeks, against 2.4 percent on placebo. In the SURMOUNT-1 trial tirzepatide at a dose of 15 mg produced a fall of 20.9 percent after 72 weeks, against 3.1 percent on placebo. Liraglutide at a dose of 3 mg does less well: in the SCALE trial 8.4 kg came off on it after 56 weeks, against 2.8 kg on placebo. The spread of results is wide, because some participants lost twice as much as the average and some almost nothing. If body weight has not fallen by 5 percent after 3 months on the full dose, we count the drug as ineffective in that patient and change it for another.

How we plan coming off the drug so that the weight does not return

Participants in the STEP 1 trial who came off the drug once it ended and were left without further care regained two thirds of the weight they had lost within a year, and their blood glucose and blood pressure went back to the values from before treatment. So we plan the withdrawal as a separate stage of treatment. We begin to reduce the dose only once the weight has been steady for several months, the patient has a settled way of eating and trains regularly, and we carry on with follow-up appointments for six months after the last injection. Anyone who puts 5 percent of their body weight back on after stopping goes back on the drug. The PTLO describes relapse as part of the course of a chronic disease, not as a failure on the patient's part.

Patients come to us with brand names read off the internet and ask which drug to choose. Not every product containing the same active substance may be prescribed for obesity. In Poland the ones with a marketing authorisation in that indication are Wegovy, Mounjaro, Saxenda, Mysimba and Xenical. Ozempic, Rybelsus and Victoza contain semaglutide or liraglutide, the same substances as Wegovy and Saxenda, but their indication covers type 2 diabetes only. What may be prescribed is settled by the summary of product characteristics, not by the active substance alone or by the price of the pack.

Why we prescribe Wegovy and not Ozempic

A patient without diabetes gets a prescription from us for Wegovy or Mounjaro, and a patient with type 2 diabetes gets the drug agreed with his diabetes specialist. Wegovy and Ozempic are the same semaglutide, but Ozempic comes in doses up to 2 mg and is authorised in diabetes, while Wegovy comes in doses up to 2.4 mg and is authorised in obesity, on the strength of the STEP programme of trials. Rybelsus is semaglutide in tablet form, also authorised in diabetes only. Liraglutide splits the same way: Saxenda at a dose of 3 mg treats obesity, Victoza at doses up to 1.8 mg treats diabetes. Mounjaro, that is tirzepatide, is the only one authorised in both diseases. A person without diabetes who takes Ozempic is taking a drug outside its indication and at a dose that has never been studied in obesity, and if the prescription was reimbursed, the National Health Fund (NFZ) can demand the cost back from the doctor. Ozempic did in fact end up on Poland's list of medicines at risk of running short, precisely because people without diabetes were buying it.

Pharmacy prices, from orlistat to tirzepatide

Reimbursement in the treatment of obesity covers none of these products, so the patient pays the full price at the pharmacy. In September 2026 a month of treatment costs roughly this much: orlistat PLN 160 to 350, Mysimba PLN 370 to 600, Saxenda PLN 500 to 1250, Wegovy PLN 550 to 890, Mounjaro PLN 800 to 1900. The lower figure matches the dose used in the first weeks and the upper one the target dose, so the monthly outlay grows with the dose and after six months is higher than at the start. Saxenda has such a wide range because cheaper liraglutide generics now sit alongside the original. Prices for the same dose differ between pharmacies by several dozen zloty, so we ask patients to compare them before buying the first pack and to stay with the pharmacy that worked out cheaper.

Who is better off with tablets

Two of the products are taken by mouth. They work less strongly than the injections, but in some patients they do better. Mysimba combines naltrexone with bupropion and reduces appetite driven by emotion, because both substances weaken the sense of reward that food gives in the brain. In the COR-I trial it produced a fall in body weight of 6.1 percent after 56 weeks, against 1.3 percent on placebo, and the summary of product characteristics requires it to be stopped if body weight has not fallen by 5 percent after 16 weeks. We do not give it in uncontrolled high blood pressure, epilepsy, bipolar disorder, a history of bulimia or anorexia, in patients on opioid treatment or during alcohol withdrawal. We reach for it in people whose tension ends in eating and in those who do not want to inject themselves; the PTLO puts it first in that situation. Orlistat, sold as Xenical, keeps roughly one third of the fat from a meal in the gut, and over a year in the trials it produced a fall in body weight about 3 kg greater than placebo. Anyone taking it has to cut the fat in the diet, or they get oily stools. That leaves it for patients who are only mildly overweight and for those in whom the other drugs are contraindicated.

The European summary of product characteristics for semaglutide lists hypersensitivity to the active substance as its only contraindication. That does not mean the drug suits everyone. We do not give it in pregnancy or while breastfeeding, we are particularly careful in anyone who has had pancreatitis, and in patients with gastroparesis, a paralysis of the stomach, or with severe kidney failure we choose another form of treatment. In type 2 diabetes treated with insulin or with sulfonylureas we lower those doses together with the diabetes specialist, because otherwise the risk of hypoglycaemia goes up.

Which side effects we see most often

In the STEP 1 trial nausea was reported by 43.9 percent of those treated with semaglutide against 16.1 percent of those on placebo; in half of them it lasted no longer than 8 days. Vomiting occurred in 24.5 percent, diarrhoea in 29.7 percent and constipation in 24.2 percent, and 4.3 percent of participants stopped treatment because of gastrointestinal symptoms. In our patients the worst days are the first ones after each increase in dose. Smaller portions, eating more slowly and dropping fatty food while the body gets used to the drug all help. That is why we raise the dose every 4 weeks, and when a patient tolerates it badly we stay on the current dose a month longer. We keep a separate eye on the gallbladder: with semaglutide, gallstones were recorded in 1.6 percent of those treated, and in 0.6 percent the gallbladder became inflamed. Rapid weight loss encourages stones to form whatever the drug, so with severe pain under the right ribs we refer the patient for an abdominal ultrasound. Acute pancreatitis is rare, in about 0.2 percent of those treated, but pain in the upper abdomen radiating to the back together with vomiting needs urgent assessment in hospital.

Symptoms for which the patient rings us without waiting for the next appointment

We ask patients to ring when vomiting lasts more than a day and they cannot drink, when severe abdominal pain radiating to the back appears, when the skin or the whites of the eyes turn yellow, and when the weight falls by more than 2 kg in a week despite normal eating. We also ask them to get in touch if vision worsens quickly in someone with diabetes, because a sharp improvement in blood glucose can make retinopathy, damage to the retina, temporarily worse. We answer the practice telephone every day from 8.00 to 20.00, and outside those hours the out-of-hours health service takes over.

How to check that a pen from the pharmacy is genuine

Counterfeit semaglutide pens have turned up in Europe, Poland included, and reached people buying the drug outside a pharmacy. A pack from a pharmacy carries a batch number and a two-dimensional code, which the pharmacist scans against the European Medicines Verification System when dispensing it. We ask patients not to buy obesity drugs from small ads, from auction sites or from private individuals, even when the price looks attractive. Our prescription arrives as a code by text message and can be dispensed at any pharmacy in Bydgoszcz or nearby.

The drug reduces appetite, but it does not change what the patient eats. The dietitian starts with a dietary history and with the shape of the day, because a driver on the road and someone on a three-shift rota eat at different times from a person working from home. We set the energy deficit at 500 to 750 kcal below requirements and insist on protein at every meal, 1 to 1.5 g per kilogram of ideal body weight, because when weight comes off quickly, muscle goes with the fat. We also recommend fibre from vegetables, groats and wholegrains, which protects against constipation while the stomach is working slowly, and at least a litre and a half of fluid a day. Red and processed meat we discuss separately, because eating a lot of it is linked with bowel cancer regardless of body weight, and in the meal plans our patients bring us, cured meat is often the basis of two meals a day.

We recommend resistance training twice a week and a daily walk. A gym is not necessary; bodyweight exercises and resistance bands at home are enough. The point of the exercise here is above all to hold on to muscle, which is what the metabolic rate depends on once treatment ends.

How the specialist in the psychology of eating helps when food is the reward after a shift

Some patients reach for food after tension rather than out of hunger: after a night shift, after an argument, after a day that went badly. A GLP-1 analogue reduces physical hunger, but it does not change eating driven by tension, so in the first weeks of treatment these patients still eat after a hard day even though they do not feel hungry. The specialist in the psychology of eating teaches them to recognise the moment before they reach for food, to plan meals so that the evening does not start on an empty stomach, and to find another way of releasing the tension. In binge eating disorder we work for longer and we then suggest a psychiatric consultation alongside. We run the first year of treatment together: the doctor, the dietitian and the specialist in the psychology of eating see the same notes and the same measurements.

A gram of pure alcohol delivers 7 kcal, almost as much as a gram of fat, and the body burns it first, because it has no way of storing it. While the liver is breaking the alcohol down, the fat from the meal is laid down in adipose tissue. Half a litre of beer comes to about 250 kcal and a shot of vodka to about 110, so after three beers in the evening nothing is left of the daily deficit the diet has built up. Alcohol also raises blood pressure, spoils sleep and weakens control over eating, so a second helping comes more easily after it. The IARC classes alcoholic drinks among the agents with a proven carcinogenic effect in humans, among them for the mouth, the oesophagus, the liver, the bowel and the breast. Obesity burdens some of the same organs, which we describe in the section on cancer.

A GLP-1 analogue slows the emptying of the stomach, so alcohol is absorbed unevenly and the patient judges how much he has drunk less well; the nausea after the injection also gets worse. In someone treated with insulin or with sulfonylureas, alcohol adds to the risk of hypoglycaemia. We do not set complete abstinence as a condition, but we do ask for an honest answer about how much and how often the patient drinks, because the rate of weight loss and the safety of the treatment depend on it.

Sometimes, during obesity treatment, alcohol turns out to be a bigger problem than the weight. We then suggest dealing with that first, because with daily drinking a diet produces nothing. At the same practice we run alcoholism treatment in Bydgoszcz and addiction therapy, and naltrexone, a component of one of the obesity drugs, is the same substance used in the treatment of alcohol addiction.

The first appointment can be held online, and many patients start that way, particularly when they work shifts. The doctor then takes the medical history and looks at the test results and the readings from the scales and the blood pressure monitor at home, and issues the prescription after the video call. We ask patients to come to the practice when they have to be examined in person: to assess the thyroid, to look at the skin under the arms and in the groin, where obesity brings on the dark, thickened patches known as acanthosis nigricans, to measure the waist with a tape measure and to check the blood pressure in both arms with a cuff matched to the circumference of the arm, because one that is too narrow reads too high in a person with obesity.

The monthly follow-ups while the dose is going up we run by video, because they come down to a conversation about how the drug is tolerated and to reading off the measurements. Once a quarter the patient comes to the practice at ul. Cieszkowskiego 5 for the measurements and an examination, and with any new symptom we would rather see him in person. The patient has the blood tests done at a laboratory close to home and sends the results before the appointment, and the e-prescription arrives as a code by text message whatever form the appointment takes.

The NFZ reimburses none of the drugs licensed for the treatment of obesity, so the patient covers the monthly cost of the product. A GP can diagnose obesity, order basic tests and refer the patient to a specialist clinic. An appointment in primary care is too short, though, to run obesity treatment in; there are few metabolic clinics in the country and patients wait months for them. In the Kuyavian-Pomeranian province there is no separate obesity prevention programme for adults funded by the provincial authority.

Screening, on the other hand, is free and needs no referral, and in obesity it matters more than in a slim person. Screening colonoscopy is open to people aged 50 to 65, and from the age of 40 to 49 to those whose first-degree relative has been diagnosed with bowel cancer. Women aged 45 to 74 have a mammogram every 2 years, also without a referral. On the NFZ the patient will also have the blood tests ordered by the GP and an abdominal ultrasound with a referral, and, once the criteria are met, bariatric surgery. What the patient pays for is the appointments with us, the drug from the pharmacy and the consultations with the dietitian and the specialist in the psychology of eating; the prices are in our price list.

Guidelines adopted in 2022 by the surgical societies, among them the Association of Polish Surgeons, lowered the threshold for bariatric surgery. Today it is considered at a BMI of 35 and above with no accompanying illness, and at a BMI of 30 and above in people with type 2 diabetes, whatever the diabetes is treated with. The PTLO estimates that about half a million people in Poland meet the criteria. In 2024, 6,700 such operations were performed in Poland, more than twice as many as in 2017, and the value of their reimbursement rose fourfold over that time, to PLN 140 million. So each year one person in several dozen of those who qualify has the operation.

We refer a patient for a surgical consultation when he meets the criteria and non-surgical treatment, carried out properly over more than a year, has produced no lasting result, and also when class III obesity goes together with diabetes or with severe sleep apnoea. A hospital referral does not tie the patient to his own province. Before the operation the patient loses weight under our supervision, we bring his diabetes and his blood pressure under control, we test him for sleep apnoea and refer him for a psychological consultation. After the operation we carry on looking after him, because vitamin and trace element supplements go on for life, and a deficiency of vitamin B12, of iron and of vitamin D develops without symptoms.

In the SPLENDID study described above, obesity-related cancers were diagnosed less often in the operated group and death from cancer occurred less often. It is an observational study, so on its own it does not prove that the operation delayed the disease, but the result fits what we expect from a lasting fall in body weight. Bariatric surgery, though, lowers bone mineral density more than drug treatment does, so afterwards we keep an eye on calcium, vitamin D, protein and resistance training.

Patients come to the practice at ul. Cieszkowskiego 5 from across the region: from Solec Kujawski, Koronowo, Nakło nad Notecią, Inowrocław, Świecie, Toruń, Żnin, Chełmno and Tuchola. We arrange treatment so that the journey is needed rarely: the first appointment and the measurements once a quarter take place at the practice, the monthly follow-ups by video call, and the patient has the blood tests done at a laboratory close to home.

The patient has the screening colonoscopy and the mammogram at whichever centre nearest to home runs the programme, and all we ask is that the result is sent to us; we then put the date of the next test into the treatment plan.

All three NFZ metabolic clinics in the Kuyavian-Pomeranian province are in Bydgoszcz, one of them attached to the children's hospital. Toruń, Włocławek and Grudziądz have none, so a resident of Toruń travels to Bydgoszcz for NFZ care just as he does to us. None of these clinics has reported the number of people waiting or the waiting time in the NFZ waiting-times directory; the date has to be checked by telephone, and a referral from a GP is needed for the appointment.

The drug costs the same at the pharmacy whichever route the patient takes, because the NFZ reimburses no obesity drug, so the difference comes down to the fees for appointments and to who runs the treatment over the year. At Nasz Gabinet Bydgoszcz that is done by a doctor, a dietitian and a specialist in the psychology of eating in one team, while on the NFZ there is no dietitian for obesity on its own.