Obesity Treatment Elbląg

Obesity appears in the ICD-10 classification under code E66, and in its 2024 guidelines the Polish Society for the Treatment of Obesity (PTLO) describes it as a chronic disease that does not go away on its own and returns once treatment stops. Adipose tissue releases leptin, the satiety hormone, but in a woman with obesity the hypothalamus gradually stops responding to it and keeps signalling hunger despite large stores of fat. After every diet the body slows its metabolism and raises levels of ghrelin, the hunger hormone, which is why someone who has lost weight on a diet eats more a few months later than she did before it and returns to her old weight.

Oestrogen decides where in the body a woman stores fat. As long as the ovaries produce it, fat is laid down mainly on the hips and thighs, under the skin, where it releases fewer inflammatory substances. When oestrogen levels fall during the menopause, the body lays down the same excess calories to a greater extent as visceral fat, between the organs in the abdomen. The American SWAN study, which we describe below, showed that from the start of the menopause transition fat is gained twice as fast, while muscle begins to be lost. Weight then rises at the same rate as before the menopause, but body composition changes. This is why a patient in her fifties often tells us that she weighs the same as she did ten years ago, but her trousers no longer do up at the waist.

We treat this disease the way high blood pressure is treated: we make the diagnosis, choose a drug, review progress every month, change the drug when it stops working, and plan in terms of years. The doctor assesses whether the patient is eligible for drug treatment and keeps an eye on her test results, the dietitian plans her meals, and the specialist in the psychology of eating works with her on comfort eating. In patients going through the menopause and beyond, protecting muscle and bone and keeping breast screening up to date are added to this; we write about it in a separate section.

The first measurement is BMI, body weight in kilograms divided by height in metres squared. A woman who is 162 cm tall and weighs 84 kg has a BMI of 32. Under the WHO thresholds adopted by the PTLO, overweight begins at 25, class I obesity at 30, class II at 35 and class III at 40. The thresholds do not depend on sex or age. BMI does not tell us where the fat is stored, though, and after the menopause that is precisely what the risk depends on.

The second measurement is waist circumference, taken with a tape measure halfway between the lowest rib and the top of the hip bone, at the end of a breath out. Under the criteria of the International Diabetes Federation, abdominal obesity is diagnosed from 80 cm in women and from 94 cm in men, even when BMI is normal. Visceral fat releases inflammatory substances, pushes up insulin and leads to diabetes, high blood pressure and heart disease faster than fat on the thighs. A woman whose BMI was 24 all her life and who after the menopause has a BMI of 27 and a waist of 92 cm is at greater risk of diabetes and a heart attack than those three BMI points would suggest. The third element is the questions about how her weight has changed: what she weighed at the age of 20, how much she gained during pregnancies, how much after her forties, when her last period was and whether the weight gain sped up after it or earlier. We also ask about sleep, snoring, hot flushes, medicines, alcohol and binge eating.

The BMI at which we prescribe a drug at our practice on Grobla Świętego Jerzego

From a BMI of 30 the index alone is enough for drug treatment. From a BMI of 27 a drug may be prescribed once obesity has already caused a complication: prediabetes or type 2 diabetes, high blood pressure, lipid disorders or sleep apnoea. In women after the menopause such a complication is more common than in women in their thirties, because visceral fat pushes up blood glucose and blood pressure faster. A patient with a BMI of 28, a waist of 95 cm and an abnormal fasting glucose therefore meets the criterion. Between a BMI of 25 and 27 we treat with diet and exercise, and consider a drug only where there is abdominal obesity with insulin resistance in the test results. Age in itself does not rule out a drug, but it changes the way we treat: in a woman in her fifties we protect muscle and bone from the first day, while a woman over 75 is not given liraglutide, and we start the other injections more cautiously, because experience with them at that age is limited. Treatment here is run by internal medicine specialists certified by the PTLO.

The first appointment, at the practice or online, costs PLN 250. The doctor asks how the patient's weight has changed, goes through her list of drugs, weighs her, measures her waist and blood pressure, looks at her test results and orders the ones that are missing. A woman in her forties is asked about the date of her last period, about hot flushes, about menopausal hormone therapy (HRT), about her last mammogram and about whether she leaks urine when she coughs or laughs, because each of these answers shapes the treatment plan. Anyone who has a complete set of results and meets the criteria leaves with an e-prescription, Poland's electronic prescription, for the starting dose, instructions on how to inject and a date with the dietitian.

Over the first three months we build the dose up: every 4 weeks there is a video call in which the patient gives her weight and her blood pressure from measurements taken at home and describes how she is tolerating the drug, and the doctor either raises the dose or keeps the current one and sends the e-prescription code. At the same time she starts strength training, because in a woman in her fifties the first kilograms come off fastest and that is when muscle is easiest to lose. In the fourth month, on the full dose, we repeat the blood tests, and in the sixth we look at her weight: the PTLO considers a drug effective when body weight has fallen by at least 5 percent, and anyone who has not reached that threshold is given a different drug. In the second half of the year the dose no longer changes; follow-ups take place every 4 to 8 weeks, once a quarter the patient comes to the practice to have her waist measured, and a woman with risk factors for osteoporosis repeats her bone density scan at the end of the year. After twelve months we decide together whether the drug stays for longer or whether we start coming down off it gradually.

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

• We do not prescribe HRT and we do not stop it. Hormones for hot flushes are the gynaecologist's decision, and we fit obesity treatment around it. We do not offer hormone therapy as a way of losing weight, because the PTLO does not recommend it.
• We do not start a drug in a woman who has bleeding after the menopause, a lump she can feel in her breast or a mammogram several years overdue, until a gynaecologist has examined her. An obesity drug treats neither bleeding nor a lump, and overweight and obesity raise the risk of breast cancer and womb cancer, so that has to be looked into first.
• We do not prescribe obesity drugs to women who are pregnant or breastfeeding, or to anyone under 18. A woman who is not yet fifty and still has periods, even irregular ones, uses contraception during treatment, because semaglutide has to be stopped 2 months before trying to conceive.

We need eight blood test results before the first prescription. Fasting glucose and glycated haemoglobin, the average blood glucose over 3 months, settle whether the patient already has prediabetes or diabetes, and that changes both the BMI criterion and the choice of drug. From the lipid profile we read the triglycerides and cholesterol, which rise of their own accord after the menopause. Creatinine and eGFR show how the kidneys are filtering the blood; below an eGFR of 30 ml/min liraglutide must not be given. TSH rules out an underactive thyroid, which is common in women in their fifties and misleading, because it causes the same symptoms as obesity: weight gain, tiredness and feeling cold. The liver enzymes ALT and AST tell us whether fat is damaging the liver; we check uric acid for gout and a full blood count for anaemia, which is common in women with heavy periods before the menopause. Results no more than six months old, from a GP surgery or from an occupational health check, we accept without repeating. The patient has any missing tests done at any laboratory in Elbląg and sends us a photograph before the appointment.

The second document is the list of drugs, with the packs or photographs of them, together with supplements, hormone tablets and patches. Several groups of drugs cause weight gain in themselves: steroids, insulin, older diabetes tablets containing sulfonylureas, and some epilepsy and antidepressant medicines. A woman in her fifties usually takes more drugs than a woman in her thirties, and with a GLP-1 analogue we look separately at two of them: at levothyroxine, because semaglutide raises its level in the blood, and at blood pressure drugs, because their doses usually have to be lowered once she loses weight. We describe both situations in the section on safety.

When we send a patient for a bone density scan, a mammogram or to a gynaecologist before starting a drug

The PTLO does not recommend testing hormones in every patient with obesity, because mild hormonal disturbances are usually a consequence of obesity and settle once weight is lost. The exceptions are Cushing's syndrome, which we suspect when a young person has purple stretch marks, a rounded face and high blood pressure, and an underactive thyroid, which TSH picks up. In a woman after the menopause we add three questions. The first is about her last mammogram: the National Health Fund (NFZ) provides one free of charge every 2 years for women aged 45 to 74, with no referral, and if more than 2 years have passed since the last one, we ask her to have it done in the first weeks of treatment. The second is about bleeding: a patient who has any spotting at all a year after her last period is referred to a gynaecologist before we start the drug, because according to the PTLO the excess oestrogen produced in adipose tissue drives thickening of the womb lining. The third is about bone: a patient who has broken a bone after a minor injury, has taken steroids long term, has osteoporosis in the family or went through the menopause before the age of 45 is sent for a bone density scan before treatment, because bone loses density as weight comes off, and the result of that scan decides how much strength training and which supplements we add to the drug.

The menopause does not cause obesity, but it changes the way it runs: fat is laid down around the abdomen instead of on the hips, muscle and bone are lost, and the risk of breast cancer and womb cancer rises along with BMI. For this group of patients we have separate rules.

What the menopause changes in body composition and why weight alone is not enough

In the SWAN study, in which American researchers used DXA scans to measure body composition in the same women over a number of years, fat was gained twice as fast from the start of the menopause transition, muscle began to be lost, and both changes carried on until 2 years after the last period and only then slowed down. Weight itself was rising at the same rate as before the menopause. A woman sees the same gain on the scales as she did before, but this time it is fat around the abdomen, and muscle is being lost at the same time. The PTLO writes that fat is gained more easily during the menopause, and in the few studies available women who changed their habits at that point did not put on weight over 5 years. This is why we do not tell a patient who comes to us at the age of 48 with a BMI of 26 and a waist of 88 cm to come back when her BMI goes above 30. We start with the dietitian and strength training, and add a drug once she meets the criteria.

Whether HRT causes weight loss and whether it can be combined with semaglutide

HRT does shift where fat is stored in a favourable direction, but the PTLO states that it should not be recommended as a treatment for abdominal obesity; today it is used mainly to ease hot flushes and the other troublesome symptoms of the menopause transition. An American analysis from the Mayo Clinic published in 2024 compared 106 women after the menopause treated with semaglutide: 16 were taking hormones at the same time, 90 were not. The women on hormones lost an average of 16 percent of their body weight over a year, the rest 12 percent, and they crossed the 5 and 10 percent thresholds more often. This was a retrospective study, one based on medical records, in a small group, and in a position statement from 2026 the Spanish Menopause Society treated the link as a hypothesis that does not justify starting hormones in order to lose more weight. We take the same line: a woman who has been given hormones by her gynaecologist because of hot flushes carries on taking them and can take semaglutide alongside, while a woman without those symptoms is not offered hormones as an aid to weight loss. We ask a patient on hormones to tell us if her hot flushes worsen after a change in the dose of her drug, and if there is any doubt we write to her gynaecologist.

How to lose weight after the menopause without losing muscle and bone density

Bone loses density with every large fall in body weight, because the skeleton no longer carries the old load, and after the menopause bone loss speeds up in any case. In the same SWAN study, the more muscle a woman lost during the menopause transition, the higher her later risk of fracture, by 63 percent for each unit of loss used in the study, and the more fat she gained, the more that risk rose, by 28 percent per unit. In a Danish randomised trial published in 2024, 195 people with obesity first lost weight on an 800 kcal diet and then spent a year on liraglutide, on an exercise programme, on both, or on placebo. Those on liraglutide alone lost markedly more bone density at the hip and spine than those who only exercised, despite a similar fall in weight, while the group that combined the drug with exercise lost the most weight and kept the same bone density as the placebo group. On that basis we put together a programme for women in their fifties: strength training twice a week from the first month, 1 to 1.5 g of protein per kilogram of ideal body weight spread over three meals, vitamin D and calcium at doses agreed with the dietitian, and, where there are risk factors, a bone density scan before treatment and after a year.

Breast cancer, womb cancer and incontinence, or what losing weight after the menopause helps with

A patient with spotting after the menopause is examined here by a gynaecologist before we start a drug, and the mammogram, free on the NFZ every 2 years, we treat as part of obesity treatment, because the risk of both cancers rises along with BMI. In a meta-analysis of 141 studies from 2008, every 5 BMI points raised a woman's risk of womb cancer by 59 percent, and her risk of breast cancer after the menopause to a lesser degree, by under 20 percent. The PTLO quotes an analysis by the American Cancer Society under which womb cancer is twice as common in women who are overweight and more than three times as common in women with obesity, and in more than half of those affected the cause is obesity. Here too oestrogen is to blame: adipose tissue produces it after the menopause as well, and progesterone no longer balances it, so it drives thickening of the womb lining. There are no randomised trials that have tested whether losing weight lowers the risk of these cancers; what is known is that it lowers oestrogen and insulin levels, and both hormones help them develop.

The evidence on the bladder is firmer. According to the PTLO, stress urinary incontinence depends on age, the number of births, genes and body weight, and body weight is the only one of these factors that can be changed. Obesity also makes prolapse of the vaginal walls more likely: 40 percent of women with a BMI between 30 and 40 have it, and 57 percent of women with a BMI above 40. In the American PRIDE trial, 338 women who were overweight or obese, average age 53, and who leaked urine at least 10 times a week, were randomly assigned either to a six-month weight-loss programme or to information sessions alone. The women in the programme lost 8 percent of their weight and leaked urine 47 percent less often, the control group 28 percent less often, and the difference lay in leaking with coughing and exertion, not with a sudden urge. The PTLO sets a fall in body weight of 5 to 10 percent as a goal of treatment in incontinence, which is why we ask about this symptom at the first appointment and check at follow-ups whether it is settling.

After a meal the gut releases the hormone GLP-1, which tells the brain that enough has been eaten and damps down appetite for a few minutes. A GLP-1 analogue, or GLP-1 receptor agonist, is a longer-lasting version of it that works for several days: it slows the emptying of the stomach and strengthens the satiety signal in the hypothalamus. In practice the patient puts her fork down halfway through the plate and stops thinking about food between meals. Tirzepatide also acts on the receptor for a second gut hormone, GIP, and in trials it produces greater weight loss. Semaglutide and tirzepatide are given once a week under the skin of the abdomen or the thigh, liraglutide daily, and we raise the dose every 4 weeks so that the stomach gets used to working more slowly.

How many kilograms a woman weighing 90 kg can lose and when we change to a different drug

In the STEP 1 trial semaglutide 2.4 mg brought body weight down over 68 weeks by an average of 14.9 percent, against 2.4 percent on placebo. Tirzepatide 15 mg brought it down in SURMOUNT-1 over 72 weeks by 20.9 percent, against 3.1 percent on placebo. Liraglutide 3 mg came off worst: participants in the SCALE trial lost 8.4 kg on it over 56 weeks, and 2.8 kg on placebo. A woman weighing 90 kg can therefore expect to be about 13 kg lighter on semaglutide and about 19 kg lighter on tirzepatide, with a wide spread: some participants lost twice as much, others almost nothing. There are few separate trials of these drugs in women after the menopause, and they are mostly observational rather than randomised, so in this group we treat the figures from STEP and SURMOUNT as an approximation. If body weight has not fallen by 5 percent after 3 months on the full dose, we conclude that the drug is not working and change it for another.

What we do after a year so that the weight does not return once the drug stops

Participants in STEP 1 who had the drug stopped and their care ended when the trial finished put two thirds of the weight they had lost back on within a year, and their blood glucose and blood pressure returned to the values from before treatment. We therefore treat coming off the drug as a separate stage: we reduce the dose gradually, and only once weight has stood still for several months, the patient has a meal plan in place and a settled training routine, and follow-ups carry on for a further six months after the last injection. In a woman after the menopause, keeping the weight off without a drug depends in our view above all on whether she has stayed with strength training, because that is what maintains muscle mass and with it the rate at which she burns energy. Anyone who puts 5 percent back on returns to the drug; the PTLO describes relapse as part of the course of a chronic disease.

Five products hold a marketing authorisation in Poland for the treatment of obesity: Wegovy, Mounjaro, Saxenda, Mysimba and Xenical. Three others, Ozempic, Rybelsus and Victoza, contain the same substances as Wegovy and Saxenda, but may be prescribed only in type 2 diabetes. Who a drug may be prescribed to is decided by the indication written into the summary of product characteristics, not by the active substance.

What separates Wegovy from Ozempic beyond the dose and why we prescribe Wegovy

A patient without diabetes is given a prescription here for Wegovy or Mounjaro, and a patient with type 2 diabetes the drug agreed with her diabetes specialist. Wegovy and Ozempic are the same semaglutide, but Ozempic comes in doses up to 2 mg and is authorised in type 2 diabetes, while Wegovy comes in doses up to 2.4 mg and is authorised in obesity, on the basis of the trials in the STEP programme; Rybelsus is semaglutide in tablet form, again only for diabetes. It is the same with liraglutide: Saxenda 3 mg is authorised in obesity, Victoza up to 1.8 mg in diabetes. Mounjaro, that is tirzepatide, is the only one authorised in both conditions. A woman without diabetes who takes Ozempic is receiving a drug outside its indication and at a dose that has not been studied in obesity, and if the prescription was issued with reimbursement, the NFZ can demand the money back from the doctor; Ozempic has in any case appeared on the Polish list of drugs at risk of shortage, because some packs were being bought by people without diabetes.

What the patient pays at the pharmacy each month for each of the five drugs

None of the five products is reimbursed in the treatment of obesity, so every month the patient pays the full price at the pharmacy. In September 2026 the figures look roughly like this: Xenical from PLN 160 to 350, Mysimba from PLN 370 to 600, Saxenda from PLN 500 to 1250, Wegovy from PLN 550 to 890, Mounjaro from PLN 800 to 1900. The lower figure matches the starting dose of the first weeks, the higher one the target dose after a few months. The spread in the price of Saxenda comes from the cheaper liraglutide generics now sold alongside the original. Between pharmacies in Elbląg the same pack differs in price by several dozen zloty, so it pays to check the price in a few of them before buying.

Which patients we give tablets to, Mysimba or Xenical, rather than a GLP-1 analogue

Mysimba, that is naltrexone with bupropion, acts on the satiety centre and the reward system in the brain. In the COR-I trial participants lost 6.1 percent of their weight over 56 weeks, against 1.3 percent on placebo, and the summary of product characteristics requires the drug to be stopped when body weight has not fallen by 5 percent after 16 weeks. We do not give Mysimba in uncontrolled high blood pressure, epilepsy, bipolar disorder, a history of bulimia or anorexia, during opioid treatment or during alcohol withdrawal. We offer it to a woman who does not want injections or who tolerates the nausea after a GLP-1 analogue badly, and the PTLO says it should be considered first in patients whose obesity comes mainly from what is known as emotional hunger, that is from eating to cope with stress. Xenical, that is orlistat, blocks the absorption of about one third of the fat in a meal in the gut; in trials people lost about 3 kg more on it over a year than on placebo. It calls for a diet low in fat, because otherwise it causes oily stools. We choose it for patients who are only mildly overweight and for those in whom the other drugs are contraindicated.

The most common complaints are nausea, vomiting, diarrhoea and constipation, reported by more than one woman in ten, almost always in the week after the dose goes up. The stomach empties more slowly, so a large or fatty meal sits there and comes back up. Smaller portions, a light main meal on the day of the injection, water between meals rather than with them and vegetables with every dish are enough for most women; anyone who tolerates a new dose badly stays on the previous one for longer; there is nothing to be gained by rushing the dose up. In the STEP 1 trial 4.5 percent of participants stopped treatment because of these complaints. If vomiting goes on for a whole day even though the patient is drinking, she rings us the same day, because she risks becoming dehydrated, and a woman on diuretics dehydrates faster than one who is not taking them.

Who we do not give the injection to and whose TSH we check after 6 to 8 weeks

A woman who is pregnant or breastfeeding does not receive a GLP-1 analogue. We do not start treatment after an episode of pancreatitis, where there is medullary thyroid cancer in the family, or in heart failure with breathlessness at rest. We do not give liraglutide where kidney function is poor (an eGFR below 30 ml/min) or after the age of 75; with semaglutide and tirzepatide there is little data in these situations and we decide case by case. In a patient on insulin or a sulfonylurea we reduce those doses from the first injection to avoid hypoglycaemia, and in a patient on blood pressure drugs we check her blood pressure every week, because once she loses weight those doses usually have to be lowered. The thyroid we watch separately. According to the European summary of product characteristics for semaglutide, 33 percent more hormone is absorbed from the same levothyroxine tablet while it is being taken. This is why in a woman with an underactive thyroid we check TSH 6 to 8 weeks after the drug is started and after every larger fall in weight, and the levothyroxine dose is adjusted by her endocrinologist, or by us in agreement with them.

Symptoms that should not wait until the next follow-up

There are four symptoms with which the patient rings us or goes to the emergency department the same day. The first is severe pain in the upper abdomen, spreading to the back, with vomiting, because that is how pancreatitis begins. The second is pain under the right ribs with a fever or yellowing of the skin, which is what gallstones look like; in the semaglutide trials gallstones occurred in 1.6 percent of those treated, mainly in those who lost weight fastest. The third is a sudden deterioration of vision in one eye: in 2025 the European Medicines Agency added ischaemic damage to the optic nerve to the summary of product characteristics for semaglutide as a very rare side effect. With that symptom the patient goes to an eye specialist straight away. The fourth applies to women on levothyroxine: palpitations, trembling hands, sweating and insomnia after a few weeks of losing weight usually mean that the thyroid hormone dose taken so far is now too high; we then check TSH before the next follow-up.

How to tell that an injection pen is genuine

A pack from a pharmacy carries a batch number, and the pharmacist checks it in the European verification system before handing the drug over to the patient. A pen bought from a small ad goes through no such check. In October 2023 Poland's Chief Pharmaceutical Inspectorate withdrew a falsified batch of a semaglutide drug from the Polish market. In Austria at the same time several people were admitted to hospital with severe hypoglycaemia after a counterfeit pen that contained insulin instead of semaglutide. Vials advertised online as a peptide for research use are not drugs, and nobody answers for what is inside them or for whether they are sterile. Here the patient is given an e-prescription, has it dispensed at a pharmacy, and agrees every change of dose with the doctor.

The dietitian agrees with the patient that she will eat 500 to 750 kcal a day less than she uses, as the PTLO recommends. After the menopause the body uses less than it did twenty years earlier, so the same shortfall in calories means smaller portions than it once did. Protein matters most: 1 to 1.5 g per kilogram of ideal body weight, the weight the patient ought to be, spread over three meals. On a drug that takes appetite away it is easy to get through the whole day on one sandwich and to lose muscle instead of fat. Add to that calcium from dairy or from a supplement, vitamin D all year round, because even in summer there is not enough sun in Elbląg to build up a store for the rest of the year, and fluids, which a patient on the drug forgets about, because she drinks less when her meals are smaller. Strength training twice a week, even with resistance bands and dumbbells at home, is part of treatment here; we explain why in the section on the menopause.

What the specialist in the psychology of eating works on when a patient eats to cope with stress in the evening

The drug damps down physical hunger, but it does not unlearn comfort eating in the evening after work, or after an argument, or after a sleepless night. In women going through the menopause transition such nights come more often, because hot flushes wake them, and someone short of sleep eats more sweet things the next day. The specialist in the psychology of eating teaches the patient to recognise the moment when her hand reaches for food without hunger, and to settle in advance what she will do instead: go out for ten minutes, ring someone, or simply eat the supper she planned earlier. Comfort eating differs from a binge in that the patient stays in control of the amount and stops once she notices what she is doing. A woman who describes binges with a loss of control is assessed for binge eating disorder, because an obesity drug on its own is not enough in that case. The specialist in the psychology of eating also works with a woman who has lost weight and is afraid of putting it back on, because after two or three diets in her life she has reason to be.

A glass of wine holds about 120 kcal, a bottle about 600, and a gram of pure alcohol 7 kcal, almost twice as much as a gram of sugar, and alcohol does not satisfy hunger at all. A woman who drinks two glasses with dinner fills half the shortfall in calories agreed with the dietitian, and for the next few hours her liver burns alcohol instead of fat. On a GLP-1 analogue there is a second problem: the stomach empties more slowly, alcohol is absorbed with a delay, the patient cannot feel how much she has drunk, and the nausea after the injection gets worse. A woman on insulin can mistake hypoglycaemia after alcohol for being drunk. After the menopause, alcohol drunk in the evening ruins the sleep that hot flushes break up in any case.

One of the obesity drugs contains naltrexone, the same drug we give in the treatment of alcoholism, because it reduces the pleasure of drinking. In the obesity product the dose is lower, but the summary of product characteristics requires alcohol to be kept to a minimum, because combined with bupropion it raises the risk of seizures, and during alcohol withdrawal the drug is contraindicated. What is known so far about semaglutide in people with an addiction amounts to a phase two trial from 2025 in 48 participants: over 9 weeks those on the drug had less craving for alcohol and drank less on the days when they did drink. That is too little to treat addiction with semaglutide, and we do not do it. A woman who drinks every day, or who cannot stop after the first glass, comes to our clinic for alcoholism treatment in Elbląg, and we treat her obesity alongside addiction therapy, because for as long as she is drinking the obesity drug works only in part.

The first appointment takes place at our practice at Grobla Świętego Jerzego 14A in Elbląg, because the doctor wants to weigh the patient on scales built for a high body weight and to measure her waist and blood pressure, the latter with a cuff of the right width. The doctor also examines her abdomen and thyroid, looks at the skin on the back of her neck and under her arms, where dark patches can point to insulin resistance, and asks about symptoms patients rarely raise themselves: incontinence, hot flushes, joint pain. A patient who cannot travel to us books the first appointment online and sends her results and her own measurements in advance; the doctor then judges whether she still has to be examined in person before a prescription is issued. Follow-ups every 4 weeks take place by video call, and the patient comes to the practice every 3 months for measurements and an examination. The dietitian and the specialist in the psychology of eating see patients both at the practice and online. We plan an appointment at the practice rather than a video call whenever a new symptom appears, abdominal pain, spotting or dizziness for instance, because that cannot be assessed through a camera.

On the NFZ the patient has an appointment with her GP, basic blood tests, a mammogram every 2 years from the age of 45 to 74 with no referral, a bone density scan with a referral and bariatric surgery if she meets the criteria. An appointment at a metabolic clinic requires a referral, and in the whole of the Warmia and Masuria province there is only one such clinic on the NFZ, in Olsztyn (as at 1 September 2026). The NFZ reimburses semaglutide only in type 2 diabetes, in patients who meet the conditions on the reimbursement list; a woman without diabetes pays the full price whoever issued the prescription. A dietitian on the NFZ comes with the coordinated care programme at a GP surgery, but only in diabetes, high blood pressure, heart failure, thyroid disease and chronic kidney disease; obesity on its own, code E66, does not appear on that list, so a woman with obesity and none of those conditions does not get a dietitian on the NFZ. HRT is prescribed by a gynaecologist, on the NFZ or privately.

Privately, with us, the first medical appointment costs PLN 250 at the practice and the same online; the patient pays for follow-ups, the dietitian and the specialist in the psychology of eating according to our price list, and buys her drug at the pharmacy. In return she needs no referral, does not wait for a date at the only clinic in the province, speaks to the same doctor all year, and gets letters to her gynaecologist, her endocrinologist or a bariatric centre from us at no extra charge. She has the mammogram and the bone density scan on the NFZ, because there they are free.

We suggest surgery when BMI is at least 40, or at least 35 with a complication such as type 2 diabetes, high blood pressure or sleep apnoea, and when non-surgical treatment with diet, exercise and drugs is documented but has not been enough. Polish centres keep to these thresholds and usually to an upper age limit of 65, although in 2022 the international metabolic surgery societies lowered the criteria to a BMI of 35 without complications and 30 with diabetes. A psychological assessment, which the PTLO requires, is a further condition; where there is active addiction, untreated depression or uncontrolled binge eating, the centre postpones the operation. The Metabolic and Bariatric Surgery Section of the Association of Polish Surgeons lists one centre in the Warmia and Masuria province, in Olsztyn, and six in neighbouring Pomerania, three of them in Gdańsk. With a referral on the NFZ you can have surgery in any province, so a woman from Elbląg chooses between Olsztyn and Gdańsk herself, going by the date she is offered and by where it is easier for her to travel for check-ups after the operation. The NFZ does not currently pay for a year of care after surgery: the KOS-BAR pilot programme, which combined the operation with that kind of follow-up, ended on 30 June 2026 and was not taken into the list of guaranteed services.

Until the day of the operation the patient stays under our care: we document the non-surgical treatment, complete the tests and make sure she loses weight, because the liver then shrinks and the surgeon reaches the stomach more easily. Before the operation we tell a woman after the menopause that, according to reviews of the evidence, bone loses more density after bariatric surgery than it does with drugs; this is why we do a bone density scan before the operation and a year after it. After an operation that bypasses part of the bowel, calcium, vitamin D, vitamin B12 and iron are taken for life, and their levels are checked every year. To a woman not yet fifty who still has periods we repeat the advice of the Association of Polish Surgeons not to become pregnant sooner than 24 months after surgery. An obesity drug can still be used after the operation, when weight comes back after a few years; the PTLO quotes an observational study of 207 people with weight regain after surgery who over a year lost 12.9 percent on semaglutide and 8.8 percent on liraglutide.

Women and men come to the practice on Grobla Świętego Jerzego from Braniewo, Frombork, Tolkmicko, Pasłęk, Młynary, Morąg, Ostróda and Iława, and also from the Pomeranian side of the Vistula: from Malbork, Nowy Dwór Gdański, Sztum, Dzierzgoń, Prabuty and Kwidzyn, which is closer to Elbląg than to Gdańsk. The first appointment takes place in Elbląg, and after that treatment looks the same as it does for women from the city, except that the patient has her blood tests done where she lives. She has her mammogram in the mobile screening unit that tours the districts of the province, or at the unit nearest her home; we record the date and the result. A woman who sees a gynaecologist in Malbork or Braniewo gives us their details, and we pass on which drug she is taking and at what dose, so that we can look after her together, following the same plan.

The only metabolic clinic on the NFZ in the Warmia and Masuria province works in Olsztyn and gives neither the number of people waiting nor the waiting time in the NFZ waiting-times service, so you have to ring to ask about a date. With a referral from a GP you can also put your name down at a clinic in Gdańsk or in Gdynia; there, though, according to the same service, 698 and 742 people respectively were waiting in July 2026, and the average waiting time was 126 and 229 days. A woman with type 2 diabetes also has the diabetes clinic, which treats obesity together with the diabetes.

A woman from Elbląg who does not want to wait for a date or to travel to Olsztyn or the Tricity for follow-ups is treated here without a referral, and buys her drug at the pharmacy at the same price she would pay after an appointment on the NFZ.