Obesity Treatment Gdańsk

Obesity appears in the ICD-10 classification of diseases under code E66, and in its 2024 guidelines the Polish Society for the Treatment of Obesity (PTLO) describes it as a chronic, relapsing disease that has to be treated for years. Someone who comes to us for the first time has usually lost a dozen or more kilograms at some point and put them back on, with interest, a year or two later. The reason lies in physiology. Once body fat has gone, the body burns less energy than its new weight would suggest, levels of ghrelin, which drives appetite, go up, and levels of leptin, which tells the brain how much energy is stored, go down, because leptin disappears along with the fat. This state lasts for months after the diet ends, and it is this, not a lack of discipline, that brings the old weight back.

Adipose tissue does more than store energy. The fat that gathers around the organs in the abdomen releases substances that keep up a low-grade chronic inflammation and blunts the sensitivity of the tissues to insulin, so the pancreas secretes more and more of it. Blood pressure, blood glucose and triglycerides all rise, and fat is laid down in the liver. That same inflammation reaches the skin as well, which is why psoriasis and hidradenitis suppurativa flare more often in people with obesity, and why wounds heal more slowly.

In a cross-sectional study of a hundred people with a BMI above 30, skin changes were found in 60 to 70 percent of those examined, most often in the folds, where skin rubs against skin and stays damp. Some of them do not hurt, so the patient rarely connects them with body weight, and they show up earlier than an abnormal blood test. This is why at the first appointment we look at the neck, the armpits and the groin, and ask about changes patients rarely mention of their own accord.

We also ask about things that have little to do with food. Body weight is pushed up by glucocorticoids, the anti-inflammatory steroids taken by mouth, by some antidepressants and antipsychotics, by night work and by alcohol, whose calories almost nobody counts. We ask about an underactive thyroid too, which does not explain obesity on its own but makes losing weight harder when it goes untreated. We plan treatment as we would for any chronic disease, over years, with regular monitoring and with a change of plan when the current one stops working. We say at the outset that there will be weeks in it when the scales do not move.

The diagnosis rests on four things, body weight, height, waist circumference and the history of the patient's weight. A man who is 178 cm tall and weighs 108 kg has a BMI of 34.1, that is class I obesity by the thresholds the World Health Organization uses for both sexes, where 25 marks overweight and 30, 35 and 40 mark the successive classes of obesity. BMI on its own is not enough, because at the same value the risk of complications differs between someone who carries fat on the hips and someone who carries it on the abdomen.

To the scales we add a tape measure. We measure the waist midway between the lowest rib and the iliac crest, the ridge of bone that can be felt above the hip, at the end of a quiet breath out, and we read the result against two sets of thresholds. The International Diabetes Federation takes 94 cm in men and 80 cm in women of European descent, and the World Health Organization takes 102 cm and 88 cm, the point above which it regards the metabolic risk as substantially increased. A result between the two thresholds we treat as a warning, and above the higher one we widen the investigations. For a remote appointment we ask for the measurement to be taken in the morning against bare skin, and we warn that a self-taken measurement usually comes out a few centimetres smaller, because the tape slides up to the narrower point above the abdomen.

To the measurements we add the history of the patient's weight. We ask what they weighed at around the age of twenty, in which year the weight started to climb, what was happening in their life at the time, what diets and drugs they tried, how many kilograms came back and how quickly. This conversation takes a quarter of an hour or so and shows what to expect from another attempt at treatment. On top of that comes a look at the skin, because dark patches in the folds can point to a high insulin level before a blood test picks it up.

When an obesity drug may be prescribed and when diet is all that is left

The limits follow from the marketing authorisations of the drugs and there are no exceptions to them. From a BMI of 30 the index alone is enough. At a BMI of 27 to 29.9 a prescription may be issued only once the patient has one of the conditions listed in the summary of product characteristics, the official description of the product, namely prediabetes or type 2 diabetes, high blood pressure, lipid disorders, obstructive sleep apnoea or cardiovascular disease. The lists differ slightly between products, and the one given above comes from the summary for semaglutide. Below a BMI of 27 we do not issue a prescription, even if the waist circumference and the test results are abnormal; what remains then is work with a dietitian. For orlistat the thresholds are different, a BMI of 30, or 28 with additional risk factors.

We treat adults only and we set no upper age limit, but age narrows the choice of drug. In people over 75 the summary of product characteristics advises against liraglutide, and there is less data on the other products in this group, so we decide more cautiously and see the patient more often. We look separately at the kidneys and the liver. In end-stage kidney failure liraglutide and the naltrexone-with-bupropion tablets are ruled out, and in severe liver failure there is next to no experience with the incretin drugs. The naltrexone-with-bupropion tablets are also ruled out in people with epilepsy, with a history of an eating disorder and in those taking opioids.

Treatment is run by internal medicine specialists certified by the PTLO. In Gdańsk we have no practice of our own, so the first consultation takes place either by video call or at our practice in Gdynia, at ul. Sokoła 28. It lasts about an hour and costs PLN 250, the same online as in person. We start by going through every drug and supplement the patient is taking, then discuss the test results and add any that are missing, then move on to the measurements and to looking at the skin, and at the end we decide on treatment. A patient who comes with a complete set of results and meets the criteria leaves the consultation with a code for an e-prescription, Poland's electronic prescription, for the starting dose and an appointment booked with the dietitian.

Reaching the target dose takes months. With semaglutide it takes 16 weeks, because we raise the dose four times, every 4 weeks. With tirzepatide we increase the dose in five steps, so the patient reaches the target after about 20 weeks. Liraglutide, which is given daily, is increased every week from 0.6 mg to 3.0 mg, which takes five weeks. We teach the patient to use the injection pen during a video call, together with the rule about changing the injection site, because that is what decides whether hard lumps form where the injections are given.

Every dose increase is preceded by a short follow-up. The patient reports body weight and blood pressure from measurements taken at home, says how they are tolerating the drug and how much they are drinking, and the doctor sets the dose and sends the prescription code. We ask for about two litres of fluid a day, and more if there is vomiting or diarrhoea. From the first week the patient walks and does resistance training, because the largest fall in body weight comes in the first months and that is when muscle is easiest to lose along with fat. We plan 1.2 to 1.5 g of protein per kilogram of target body weight and two resistance sessions a week. We repeat the blood tests in the fourth month.

We judge how well the treatment is working at around the seventh month, after three months on the full dose. We check one thing, whether body weight has fallen by at least 5 percent of the starting value. The individual products set different thresholds. Liraglutide has to be stopped if after 12 weeks on 3.0 mg the loss does not reach 4 percent, the naltrexone-with-bupropion tablets if after 16 weeks the loss does not reach 5 percent, and orlistat if it does not reach 5 percent after 12 weeks. We therefore keep to one common review point, in line with the PTLO guidelines. If the result falls below the threshold we change to another drug, and treatment carries on. After the review the dose stays the same, follow-ups take place every 8 weeks, and after a year we talk about whether the drug stays, whether we start coming down off it and how we will know it is time to go back to it.

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

• We do not treat chronic skin diseases. A patient with hidradenitis suppurativa or with psoriasis is looked after by a dermatologist, and a straightforward yeast infection in the folds is treated by the GP. What we are responsible for is the part of those diseases that depends on body weight, and we write to the dermatologist about how the weight loss is going.
• We do not remove excess skin and we do not carry out aesthetic medicine procedures. An abdominoplasty is performed by a plastic surgeon once body weight has stabilised, and we hand over the records of the treatment, which are needed for the assessment.
• We do not assess skin changes from a description over the telephone alone. We ask for a photograph in daylight, and when that is not enough we arrange an examination in Gdynia or refer the patient to a dermatologist, writing down what concerned us.

We issue a prescription to nobody without test results, and the set is fixed and made up of tests the GP can order free of charge. It consists of a full blood count, fasting glucose or glycated haemoglobin, a lipid profile, liver enzymes, TSH and creatinine with the estimated glomerular filtration rate, reported as eGFR. We ask for results older than three months to be repeated before the appointment. Each item answers a different question. Glucose and glycated haemoglobin show whether diabetes is already in play, because that changes the product and how often we review the patient. If the liver enzymes are above the normal range we order an ultrasound scan to look for fatty liver disease; normal liver enzymes do not rule it out. If TSH is outside the range we measure FT4, because an untreated underactive thyroid makes losing weight harder. Creatinine with eGFR settles which products can be considered at all. In women of childbearing age we rule out pregnancy before the first prescription, and before the naltrexone-with-bupropion tablets we measure blood pressure and pulse, because bupropion raises both.

Which tests we add when the skin points to a high insulin level

In a patient with dark, velvety patches on the neck, in the armpits or in the groin we widen the set of tests, because this change goes with a high insulin level and makes disturbed glucose metabolism more likely. We start with glycated haemoglobin, and at a result of 5.7 to 6.4 percent, that is within the prediabetes range, we order a 75 g oral glucose tolerance test, because only that shows the blood glucose two hours after the load. We do not measure fasting insulin, though, nor the insulin resistance indices calculated from it, because the result would not change the treatment anyway.

The second set we order when hair starts falling out, which some people report after a few months of rapid weight loss. We then check ferritin together with a full blood count and C-reactive protein, because in obesity ferritin is often pushed up by inflammation, and on top of that vitamin B12 and TSH again. Hair loss most often comes from a shortage of nutrients rather than from the drug itself. With chronic, recurring pus-filled lesions in the folds we order a full blood count with a differential and C-reactive protein, which shows how severe the inflammation is, and we refer the patient to a dermatologist.

Beyond that we do not order further tests. We arrange an abdominal ultrasound scan when the liver enzymes are abnormal and when gallstones are suspected, and we suggest an ECG together with a cardiology opinion for palpitations and breathlessness on exertion. A patient with chest pain or with breathlessness at rest should seek urgent medical help the same day rather than wait for a planned test. We repeat the basic set in the fourth month, then once a year, and more often only when the previous result was outside the normal range.

Skin changes are visible without any test, while what is happening at the same time in the liver and the kidneys cannot be seen at all. Three mechanisms lie behind them. Folds of skin rub against each other and trap moisture, which produces intertrigo and yeast infections. A high insulin level drives the cells of the epidermis to divide through receptors for the growth factor IGF-1, and the result is dark, thickened patches in the flexures. The third mechanism is low-grade inflammation, kept up by adipose tissue, which makes inflammatory skin diseases worse and delays healing.

That last mechanism shows itself best on the lower legs. In an American analysis of medical records from 2026, the strongest risk factors for bacterial cellulitis of the lower leg, a condition related to erysipelas, turned out to be a leg ulcer, which raised that risk 2.67-fold, and lymphoedema, which raised it 1.63-fold. Obesity, diabetes, venous insufficiency and athlete's foot also mattered. This is why in a patient with swollen lower legs and cracked skin between the toes we deal with the fungal infection and with leg care alongside the obesity treatment. The table below sets out the changes we ask about and look at during the appointment.

Dark patches on the neck, or acanthosis nigricans

Acanthosis nigricans consists of symmetrical, brownish thickenings of the skin with a velvety surface, most often on the neck, in the armpits and in the groin. The changes are easily mistaken for dirt, and scrubbing does not remove them and irritates the skin further. In a paper published in 1992 in Archives of Dermatology it was found in 74 percent of 34 consecutive adult patients at an American obesity clinic, and their fasting insulin levels were clearly higher than in the rest. The severity of the changes rose with the class of obesity. In a prospective follow-up of 319 people who had bariatric surgery, described in 2023, the patches faded after weight loss in some of them, and the chance of them clearing depended on how far the metabolic measures improved.

This change is a signal, visible to the naked eye, that the insulin level may be high, so in such a patient we widen the investigation of glucose metabolism instead of waiting a year to do it. In that study fasting insulin was measured; we do not do that today, because the result does not change what we do. The skin itself usually needs no topical treatment, and where the changes are marked a dermatologist will suggest it. One situation we treat differently, and that is acanthosis nigricans appearing quickly in someone who is slim or who is losing weight without trying: that calls for investigation for cancer, and we then refer the patient to the GP without delay.

Painful lumps in the armpits and the groin, or hidradenitis suppurativa

Hidradenitis suppurativa is a chronic inflammatory disease of the hair follicles that produces painful lumps, abscesses and sinus tracts where skin meets skin. Patients treat it themselves for years as recurrent boils, and because the lesions are in intimate places they rarely raise them of their own accord. In a study published in JAMA Dermatology and based on Mendelian randomisation, a method that compares people differing in their genetic tendency towards a higher BMI, every additional point of the index raised the risk of hidradenitis suppurativa by 20 percent. It covered 4,814 patients and over 1.2 million people without the disease, and a study built this way tells a cause apart from a coincidence. Additional analyses in the same paper did not confirm a similar result for smoking.

This disease is treated by a dermatologist, and it is the dermatologist who decides on an antibiotic, on biological treatment or on surgery. We deal with body weight and with smoking, because clinical observation shows that losing weight and stopping smoking reduce the number of flares. Reports of improvement in patients taking GLP-1 analogues come so far from small observational studies and a dozen or so case reports, so we tell the patient that these are preliminary data and not yet an indication for treatment.

Psoriasis in a person with obesity and how losing weight affects its course

People with obesity get psoriasis more often, have a more severe course and respond less well to treatment. This was tested in two randomised trials. In an Italian trial from 2008, 61 people with psoriasis and obesity were given a low dose of ciclosporin, and half of them also followed a reduced-calorie diet. After 24 weeks the lesions had cleared by at least three quarters in 66.7 percent of those on the diet and in 29.0 percent of those treated with the drug alone, with a mean weight loss of 7.0 percent in the diet group. In a Danish trial from 2013, in which 60 people followed a very-low-calorie diet for 16 weeks, the difference in the severity of psoriasis turned out to be statistically non-significant despite a loss of 15.4 kg, though a follow-up that short does not settle the matter; quality of life improved significantly.

Losing weight does not cure psoriasis and does not replace dermatological treatment, but it improves the chance that this treatment will work, and it clearly improves day-to-day life. The dose of some biological drugs depends on body weight, so we tell the dermatologist in charge that weight loss is beginning.

Hair loss during rapid weight loss and what we do about it

Hair loss follows above all from the rate at which the body is losing weight and from the deficiencies that go with it, although the drug itself raises the risk slightly. The mechanism is called telogen effluvium: a sudden metabolic change pushes some of the follicles into a resting phase, and the hair falls out two to three months later, in handfuls when washing. In the summary of product characteristics for semaglutide, hair loss was recorded in 2.5 percent of those treated against 1.0 percent of those on placebo. It was reported more often in people who had lost at least 20 percent of their body weight, the symptoms were usually mild and in most people they settled while treatment continued. After bariatric surgery the phenomenon is far more common, and a review of 41 papers covering 7,044 operated patients gives 47 percent.

In a meta-analysis from 2026 covering 17 studies and more than a million people, the risk of non-scarring hair loss was 40 percent higher in people taking GLP-1 analogues than in those not taking them, and the authors put it down mainly to deficiencies after rapid weight loss. So instead of stopping the drug we check ferritin, vitamin B12 and TSH, count the protein in the meal plan, and where weight is coming off very fast we increase calories and protein or hold off raising the dose. Hair usually grows back, though it takes several months; if the loss goes on for more than half a year or bald patches appear, we refer the patient to a dermatologist. Stopping the drug without these investigations usually means the weight returns, and it does not help the hair either.

Excess skin after a large weight loss

After losing tens of kilograms the skin does not return to its former shape, because it loses collagen. In a paper from 2024 comparing 80 skin samples taken during plastic surgery, the loss of collagen was the same in people who had lost weight after bariatric surgery as in those who had lost it without surgery; the difference lay in the elastic fibres in the skin of the abdomen, of which there were fewer after bariatric surgery. Excess skin therefore follows from the scale of the weight loss and not from the operation itself. Swedish work on excess skin shows that between 68 and 90 percent of people would like body-contouring surgery after bariatric treatment, and that about 20 percent go through with it.

A fold of skin on the abdomen causes chafing, chronic intertrigo and recurrent infections, and when it is large it makes hygiene and movement difficult. In such cases public funding for the operation can be applied for, but it is the plastic surgery centre that carries out the assessment, documented complications are required, and the wait is measured in years. The appearance of the abdomen alone is not grounds for funding. The assessment is carried out once body weight has stabilised, usually after at least a year, and some centres expect the patient to get below a BMI of 30. While we are looking after a patient we document the course of the weight loss and the state of the skin, because the plastic surgeon needs this information for the assessment.

The skin at the injection site and the rule about rotating it

Reactions at the injection site are common and usually trivial. In trials of tirzepatide used for weight management they occurred in 8.0 percent of those treated against 1.8 percent of those on placebo, most often as redness and itching; 91 percent of the reactions were mild and none was severe. For liraglutide, the summary of product characteristics describes rare cases of cutaneous amyloidosis at the injection site, a hard lump from which the drug is absorbed less well. Hence the rule we go through at the first appointment: inject into the abdomen, the thigh or the upper arm, change the site with every dose and never inject into a lump or into changed skin. Redness lasting more than a few days, a painful swelling or a fever call for contact with us. Unopened pens are kept in the fridge, at 2 to 8 degrees; a semaglutide pen that has been started may be kept outside it, below 30 degrees, for six weeks. Used needles are collected in a hard container and handed in at a pharmacy.

GLP-1 is a hormone released by the gut after a meal. It prompts the secretion of insulin when blood glucose is high, holds back the secretion of glucagon, slows the emptying of the stomach and acts on the satiety centres in the hypothalamus. The drugs in this group, the GLP-1 analogues or GLP-1 receptor agonists, are longer-lasting versions of it, which is why one injection a week is enough, or one a day with liraglutide. The patient feels this as fullness arriving sooner, smaller portions and fewer thoughts about food between meals. Tirzepatide acts in addition on the receptor for a second gut hormone, GIP, and in comparative trials it produced a larger fall in body weight.

In the STEP 1 trial, semaglutide at 2.4 mg a week, given for 68 weeks to 1,961 people without diabetes, brought body weight down by an average of 14.9 percent against 2.4 percent in the placebo group; both groups received dietary advice and recommendations on exercise. In the SURMOUNT-1 trial, tirzepatide given for 72 weeks to 2,539 people produced a loss of 15.0 percent at 5 mg, 19.5 percent at 10 mg and 20.9 percent at 15 mg, against 3.1 percent on placebo. The average hides sizeable differences, though. Some participants lost more than a quarter of their body weight, and some did not respond to treatment at all, which is precisely why we judge how well it is working after three months on the full dose.

Why we plan treatment over years rather than over a quarter

Once the drug is stopped the appetite comes back, because the mechanism that was damping it down disappears. In the extension of the STEP 1 trial, participants who stopped taking semaglutide regained about two thirds of the weight they had lost within a year, and their metabolic measures drifted back towards the starting values. This is why we plan treatment over years and work on the meal plan, on protein and on resistance exercise from the first appointment. Coming down off the dose, where that happens, we spread over months, and we agree with the patient at what weight gain we go back to the drug; usually it is 5 percent of the weight on the day it was stopped.

Five substances are used in Poland to treat obesity in adults, sold under several brand names. Wegovy contains semaglutide, is given once a week, and the dose is raised from 0.25 mg to 2.4 mg. Mounjaro contains tirzepatide, also as a weekly injection, at doses from 2.5 mg to 15 mg. Saxenda contains liraglutide and has to be injected daily, with a target dose of 3 mg. Mysimba is a tablet combining naltrexone with bupropion, which act on the appetite centres in the brain; it must not be used in epilepsy, in uncontrolled high blood pressure, with a history of an eating disorder, during alcohol withdrawal or in people taking opioids. Xenical contains orlistat, which blocks the absorption of about one third of the fat in a meal; it calls for a diet low in fat, because otherwise oily stools that are hard to control appear, and for vitamin A, D, E and K supplements. Ozempic, which contains the same semaglutide at lower doses, is authorised only in type 2 diabetes, so we do not use it to treat obesity on its own.

We checked prices in September 2026 and they vary between pharmacies more than the patient expects. A month of treatment with Wegovy costs from about PLN 550 to 890 and with Mounjaro from about PLN 800 to 1900, in both cases depending on the dose, so the cost is lowest at the start of treatment. Saxenda at the full dose works out at about PLN 500 to 1250, because at 3 mg a patient uses several pens a month and their prices in pharmacies differ widely. The tablets are cheaper, Mysimba from about PLN 370 to 600 and Xenical from about PLN 160 to 350 a month. None of them is reimbursed, and the spread of prices runs into several hundred zloty, so it pays to compare a few pharmacies before buying. A price clearly lower than the rest, especially in an online offer, is a warning sign. Poland's Chief Pharmaceutical Inspectorate (GIF) has warned many times about counterfeit semaglutide pens, and prescription-only medicines are not bought outside a pharmacy or as preparations brought in on one's own initiative.

What the patient's skin changes about the choice of product

The skin rarely decides the choice of drug, but we take it into account. The summary of product characteristics for Mysimba lists itching, rash, increased sweating and hair loss among the common side effects and warns about severe skin reactions that require treatment to be stopped immediately, so in a person with a diagnosed autoimmune skin disease we reach for this product cautiously. Orlistat can cause hypersensitivity reactions with itching, urticaria and blistering eruptions. Liraglutide has to be injected daily, that is thirty injections a month instead of four, which matters in someone prone to local reactions. Semaglutide and tirzepatide differ little from each other in terms of skin reactions, and hair loss has been described with both.

We start the choice, though, from other things, from the conditions the patient also has, from whether they will accept injections, from kidney and liver function and from the budget they intend to put towards treatment over the coming year. We suggest an oral product to someone who will not take injections, and we warn them that the average weight loss with it is smaller. In the licensing trial of naltrexone with bupropion it came to 6.1 percent of body weight after 56 weeks against 1.3 percent on placebo, and orlistat gives about 2 to 3 kg more than placebo over a year.

Pregnancy is an absolute contraindication, and breastfeeding and planning a pregnancy in the coming months also rule treatment out. We advise a woman of childbearing age to use effective contraception throughout the time she is taking the drug, and to stop semaglutide at least two months before a planned conception and tirzepatide a month before. To a woman on oral contraception who is starting tirzepatide we also advise a barrier method for four weeks from the start of treatment and after every increase in dose, because slower emptying of the stomach can reduce the absorption of the tablet. If a pregnancy occurs during treatment, we stop the drug immediately and ask the patient to contact us urgently. We do not start these drugs ourselves after an episode of acute pancreatitis, or where there is medullary thyroid cancer or multiple endocrine neoplasia type 2 in the family; those last two reservations come from the American product information, the European one does not list them as contraindications, though it warns about the thyroid C-cell tumours seen in rodents, and we take the more cautious line.

The commonest symptoms of the first weeks affect the digestive tract. In a pooled analysis of the STEP 1 to 4 trials, nausea was reported by 43.9 percent of those treated with semaglutide against 16.1 percent of those on placebo, diarrhoea by 29.7 against 15.9 percent, vomiting by 24.5 against 6.3 percent and constipation by 24.2 against 11.1 percent. Most of these complaints pass within a few weeks, and a slower increase in dose eases them. Gallstones were recorded in 1.6 percent of those treated, more often with rapid weight loss, and confirmed acute pancreatitis in 0.2 percent; we ask to be told at once about pain under the right costal margin, fever or yellowing of the skin. With severe vomiting and diarrhoea we ask the patient to get in touch before the next dose, because dehydration is the commonest cause of worsening kidney function during this treatment. Persistent vomiting with increasing bloating and no passage of wind may mean markedly delayed emptying of the stomach or bowel obstruction, and calls for contact the same day. In a patient with diabetes and retinopathy, a rapid improvement in blood glucose control can make the retinopathy temporarily worse, so we ask for the back of the eye to be checked before treatment and during it.

A GLP-1 analogue added to insulin or to a sulfonylurea carries a risk of hypoglycaemia, so their doses usually have to be lowered. That is for the diabetes specialist to decide, so in a patient on insulin we write to the doctor in charge before starting the drug and ask for an appointment with them within two weeks, and we ask the patient to measure their blood glucose more often. Once someone has lost a dozen or more kilograms, the existing doses of their blood pressure drugs usually turn out to be too high, and dizziness on standing up is a signal to measure the blood pressure and tell us.

Which skin symptoms call for an immediate response

A widespread rash with a fever, blisters on the skin or erosions on the lips, in the mouth and around the genitals mean the drug is stopped and the patient contacts a doctor urgently, because this is how severe drug reactions begin, among them Stevens-Johnson syndrome; they have been described above all after the naltrexone-with-bupropion tablets. The same goes for sudden swelling of the lips, the tongue or the throat and for breathlessness, which point to angioedema. Spreading redness and warmth of the lower leg with a fever, that is the picture of erysipelas, and a wound on the foot in someone with diabetes that has not healed for more than two weeks are also a signal to get in touch the same day. Severe encircling abdominal pain with vomiting calls for going to a hospital emergency department without waiting to contact us; the same applies to complete inability to pass urine, and where consciousness is disturbed those close to the patient should arrange help.

The drug reduces appetite, but it does not decide what the patient eats. The dietitian draws up a meal plan with a deficit of 500 to 750 kcal a day, counted from the calculated energy requirement, and makes sure that smaller portions still leave room for protein, vegetables and fluids. With diet alone, half a kilogram to a kilogram a week is regarded as a safe rate. With the incretin drugs the loss in the first months is often larger, and that in itself is not a complication, but we then watch the protein, the test results and the symptoms all the more closely. Very rapid weight loss means a greater loss of muscle, more frequent deficiencies and a higher risk of gallstones, and it is also what lies behind the hair loss described above.

Protein, iron and zinc, what we watch during rapid weight loss

With markedly smaller portions it is easy to drop below the requirement for nutrients whose stores run down quickly. We plan protein in the range of 1.2 to 1.5 g per kilogram of target body weight, that is the weight the patient is aiming for, which we work out at the appointment, and we spread it across all the meals, because protein protects muscle and is the building material for hair and skin. We check the iron stores, measured as ferritin, and vitamin B12, and in people who eat very little meat we ask where the zinc in their diet comes from. We choose supplements on the basis of a test result rather than as a precaution, because too much of some nutrients also does harm; the exception is the period after bariatric surgery, where supplements are permanent. We also watch fluids, because with a reduced appetite patients drink less, and with vomiting after the drug it is easy to become dehydrated, which threatens the kidneys.

We bring in work on eating behaviour when food is serving a purpose other than nourishment. We invite patients who eat under stress, who describe binges with a sense of losing control, who eat at night or who have many failed diets behind them and a strong fear of failing again. The work consists of recognising the situations in which the patient reaches for food and of building a different response, and where there is binge eating we run it alongside drug treatment for obesity. Someone who after a large weight loss cannot accept the way they look because of excess skin should also talk to a specialist in the psychology of eating, because an operation to remove the fold does not change how the patient sees themselves.

A gram of pure alcohol supplies 7 kcal, more than a gram of sugar and less than a gram of fat, and the body burns it first, putting the burning of fat on hold for that time. Three half-litre beers come to about 700 kcal, which rarely find their way into a food diary. Alcohol makes psoriasis worse and weakens its response to treatment, impairs the healing of wounds and encourages fatty liver disease, which is common in obesity anyway. It also makes nausea and vomiting after an incretin drug worse, and through them dehydration. In someone who alongside an obesity drug is taking insulin or a sulfonylurea, alcohol drunk without food raises the risk of hypoglycaemia.

We do not use the naltrexone-with-bupropion tablets in people taking opioids or dependent on them, nor during alcohol withdrawal, because bupropion lowers the seizure threshold and seizures then become a risk. So we ask about drinking without judging, and we treat the answer as part of the assessment for the drug. Where the conversation reveals a problem with alcohol, we suggest dealing with the drinking first, because obesity treatment run alongside bouts of drinking has no chance of working. For patients from Gdańsk we run alcoholism treatment in Gdańsk and addiction therapy in the same remote format.

We have no premises in Gdańsk. Obesity can be treated remotely, because treatment rests mainly on test results, measurements and conversation rather than on procedures. The first consultation usually takes place by video call: the doctor goes through the results, takes the medical history, assesses the contraindications and issues an e-prescription, while the patient measures body weight, waist circumference and blood pressure and gives the figures at the appointment. We ask for weighing in the morning, after going to the toilet, and for two blood pressure readings one to two minutes apart, taken after five minutes of sitting quietly. The patient gives blood fasting at the nearest laboratory and sends the results in before the appointment.

There are three situations in which we ask the patient to come to the practice at ul. Sokoła 28 in Gdynia, about twenty kilometres from the centre of Gdańsk. The first is the absence of reliable measurements at home, because a waist circumference measured on one's own differs by as much as a few centimetres from one taken by our staff, and a home blood pressure monitor with a cuff too narrow for the arm gives a reading that is too high. The second is a sign that has to be felt with the hand or listened to: swelling, an enlarged liver, an irregular pulse. The third is a skin change that cannot be assessed through a camera.

Photographs of skin changes have rules of their own, because how much can be read from them depends on their quality. We ask for a photograph in daylight, from about 30 cm away, without a flash, for a second shot from further back so that the location can be seen, and for a ruler or a coin to be placed beside the change to give a scale. We accept photographs through the channel given when the appointment is booked, and they go into the medical records rather than onto a private messaging app. If the picture leaves any doubt, we arrange an examination in Gdynia or refer the patient straight to a dermatologist, because a video call is no substitute for looking at the skin close up and touching the change.

For a video call the patient pays exactly what they pay for a meeting at the practice, and it ends the same way, with a prescription or with a refusal to issue one and the reason explained. Over a year of treatment a patient from Gdańsk travels to Gdynia once or twice, and we hold the remaining appointments through a camera.

The National Health Fund (NFZ) funds only a small part of the cost of obesity treatment. Most of the tests on our list can be ordered by the GP free of charge. Someone between the ages of 35 and 65 who has not been diagnosed with cardiovascular disease, diabetes, chronic kidney disease or familial hypercholesterolaemia is entitled once every five years to the cardiovascular prevention programme, which covers measurements, a lipid profile, glucose and a risk assessment, with no referral. Since May 2025 there has also been an adult health check under the Moje Zdrowie programme, available from the age of 20, once every five years up to the age of 49 and once every three years from the age of 50.

A referral from the GP is needed to see a dermatologist under public insurance. So for a patient in whom we see changes that call for a dermatologist, we set down in the records exactly what is causing concern, so that the GP can issue the referral without another diagnostic appointment.

For the indication of obesity, no drug is reimbursed. Semaglutide is reimbursed only in type 2 diabetes, where the criteria set out in the reimbursement list are met, and it cannot be prescribed with reimbursement to a patient without diabetes. Bariatric surgery, after assessment at a centre, and the treatment of the complications of obesity are funded from public money. An operation to remove excess skin can be funded only where there are documented complications such as recurrent infections and chronic intertrigo in the fold; an assessment on aesthetic grounds is out of the question.

We refer patients to a bariatric centre in two situations. The first is a BMI of 40 or more that persists despite documented non-surgical treatment. The second is a BMI of 35 or more with a condition that depends on body weight, most often type 2 diabetes, sleep apnoea or high blood pressure that cannot be brought under control. In 2022 the international federation of metabolic surgery societies and the American society jointly lowered the thresholds for surgery and now allow an operation from a BMI of 35 with no accompanying conditions and from a BMI of 30 in metabolic disease. Who is operated on with public funding, however, is decided by the centre carrying out the assessment.

Many months usually pass between the referral and the operation, and we check the waiting time at the centre we are referring to. Losing weight before the operation reduces the volume of the fatty liver and the amount of visceral fat, which makes the procedure itself easier, and centres often require a documented loss before admission to the ward. We then keep an eye on diabetes control and on the state of the skin in the folds, because an infection in the operative field puts the date back. After the operation, vitamin and mineral supplements, regular follow-up and a diet of altered structure stay for good. Hair loss in the first six months affects close to half of those operated on, partly because of deficiencies and partly because of the sheer rate of weight loss, so we monitor ferritin and vitamin B12 at that time.

We discuss an abdominoplasty only once body weight has held steady for at least a year. An earlier operation gives a worse result, because the skin will stretch again after further weight loss. Before any general anaesthesia, including for a procedure that has nothing to do with obesity, one rule applies: the anaesthetist has to know about the incretin drug the patient is taking, because delayed emptying of the stomach increases the risk of aspiration of stomach contents. Joint guidance from five societies published in 2024 advises against routinely stopping the drug before a procedure and recommends instead a day of liquid diet before planned anaesthesia, and where there is doubt an ultrasound assessment of the stomach contents. The decision rests with the anaesthetist, so we ask the patient to get in touch as soon as they have a date for the operation, and not to skip a dose on their own initiative.

Since treatment rests on video calls, distance matters far less and we look after patients from across the region. People come to us from Pruszcz Gdański, Tczew and Starogard Gdański, and from smaller places in Kashubia, Żuławy and Powiśle. The pattern is the same for everyone: blood tests at a laboratory in their own town, measurements at home, follow-up through a camera and an e-prescription code sent after the appointment, with a reminder that the first pack has to be collected within 30 days of the prescription being issued.

We draw up separate plans for seafarers, port workers and drivers, whose schedules do not allow them to eat at fixed times or to attend appointments on working days. For shift work we choose a product given once a week, set a fixed injection day independent of the shift and plan follow-ups on days off. For someone going to sea for several weeks we issue a prescription with enough for the whole voyage and explain the storage rules: unopened pens need a fridge, while semaglutide that has been started may be kept below 30 degrees for six weeks. Before departure we also check how the dose is tolerated, so that an increase does not fall in the middle of the voyage.

In the Pomeranian province there are four metabolic clinics under the NFZ where an adult can be treated for obesity with a referral from the GP, two in Gdańsk, one in Gdynia and one in Chojnice. According to the NFZ waiting-times service, in July 2026 one of the Gdańsk clinics had 698 people waiting and an average wait of 126 days, the Gdynia clinic 742 people and 229 days, and the Chojnice clinic, in August, 165 people and 56 days. The second clinic in Gdańsk reports no figures. A referral is valid anywhere in the country, but for follow-ups the patient returns to the same clinic every few weeks.

A patient from Gdańsk who does not want to wait several months starts with us without a referral, by video call, and buys the drug at the pharmacy for the same price either way. At a BMI of 40 or more, Pomerania has six bariatric centres on the list of the Association of Polish Surgeons, three of them in Gdańsk, and that is where we refer patients, with the records of their non-surgical treatment.