Obesity treatment Wałbrzych

Obesity has its own code, E66, in the ICD-10 classification, and the Polish Society for the Treatment of Obesity describes it as a chronic, relapsing disease in its 2024 recommendations. This is reflected in the histories of patients returning to us: they once lost twenty kilograms, then returned to their previous weight within two or three years. After losing body fat, the body uses less energy than would be expected from its new weight, levels of the appetite-stimulating hormone ghrelin rise, and levels of leptin, which tells the brain about energy stores, fall. This adjustment persists for at least a year after weight loss ends, and longer in some people, and it drives weight regain.

Fat accumulated in the abdomen behaves like an active organ. It releases substances that sustain low-grade but constant inflammation, reduces tissue sensitivity to insulin, and makes the pancreas secrete ever more insulin. Blood pressure, glucose and triglycerides then rise, while fat accumulates in the liver. The heart works harder because a larger body has more circulating blood, which the heart muscle pumps under a greater load for years.

The scale of this effect was shown in the Framingham study, which followed 5881 people for an average of 14 years. Each additional BMI point increased the risk of developing heart failure by 5 percent in men and 7 percent in women, and people with obesity had roughly twice the risk of those of normal weight. The disease develops over years and, for a long time, produces no symptoms that the patient would associate with weight. The first sign is usually breathlessness when walking uphill, and in Wałbrzych, spread across a basin between hills, walking uphill is a daily occurrence.

A substantial part of the first appointment is spent taking a history that is not about diet. We review the complete medication list because oral glucocorticoids and some antidepressants and antipsychotics increase weight independently of diet, while beta-blockers prescribed after a heart attack add roughly a kilogram. We ask about work schedules because night shifts disrupt the body clock, and about alcohol, whose calories almost nobody counts. We check the thyroid, although an underactive thyroid does not explain obesity and only makes weight reduction harder. Only this full picture reveals what sustains excess weight in each person. We plan treatment over years, with regular monitoring and a change of plan when the current one stops working. We also explain from the outset that there will be weeks when weight stays the same.

We start with weight and height, which are used to calculate BMI. A woman who is 165 cm tall and weighs 96 kg has a BMI of 35.3, meaning class II obesity under the World Health Organization thresholds, which are the same for both sexes: 25 indicates overweight, while 30, 35 and 40 mark successive classes of obesity. Diagnosis does not end there, however, because at the same BMI, the risk of complications differs greatly between someone whose fat is stored on their hips and someone whose fat is stored in their abdomen.

Waist circumference tells us more than weight and requires only a tape measure. We position it halfway between the lowest rib and the palpable edge of the hip bone, read the measurement after a gentle exhalation, and compare it with two thresholds. The lower one, 94 cm for men and 80 cm for women, comes from the International Diabetes Federation criteria for people of European origin. The higher one, 102 and 88 cm, is the World Health Organization threshold for substantially increased metabolic risk. A result between the thresholds is a warning; above the higher threshold, we extend the investigations. We warn patients measuring themselves before a video consultation that the tape tends to slip into a narrower area above the abdomen, making the result a few centimetres too small.

Before measuring blood pressure, we measure upper arm circumference. This determines cuff size, and the cuff determines the reading on which years of hypertension treatment may be based. We also discuss weight history: what the patient weighed around the age of twenty, when their weight began to rise, what was happening then, which diets and medicines they have tried, and how many kilograms returned and after how long. This takes around fifteen minutes and reveals which previous weight-loss attempts failed and why.

Who can be prescribed an obesity medicine, and what BMI thresholds, age and organ function decide

Eligibility for a prescription is determined by the medicine's approved indication, not our discretion. A BMI of 30 or above is sufficient on its own. With a BMI of 27 to 29.9, we prescribe only if the patient has a condition listed in the summary of product characteristics, the official description of the medicine. For semaglutide, these are prediabetes or type 2 diabetes, hypertension, lipid disorders, obstructive sleep apnoea and cardiovascular disease. The list differs slightly for other medicines, while orlistat has its own thresholds: 30, or 28 with additional risk factors. Below 27, we do not issue a prescription, even if waist circumference and test results are concerning; we then explain that working with a dietitian remains the option.

Age does not rule out treatment, but changes the choice of medicine. We treat adults only. Above the age of 75, the product information advises against liraglutide, and less is known about the other medicines in this age group, so we increase doses more slowly and schedule more frequent appointments. Organ function sets another limit. Product information does not recommend a GLP-1 analogue for NYHA class IV congestive heart failure, with breathlessness at rest; treatment is possible in classes II and III, the groups covered by the studies discussed later on this page. Liraglutide is ruled out when kidney function is reduced, with creatinine clearance below 30 ml/min, and naltrexone/bupropion tablets in end-stage kidney failure. Evidence in severe liver failure is lacking, so we do not start the medicine. We also do not start a GLP-1 analogue in someone with a history of acute pancreatitis, while naltrexone/bupropion tablets are ruled out in epilepsy, a history of eating disorders and opioid use.

Treatment is provided by internal medicine specialists certified by the Polish Society for the Treatment of Obesity. The first consultation lasts about an hour, costs PLN 250, and takes place at Młynarska 24 or by video call for the same price. We begin by reviewing all medicines, including those for the heart and blood pressure, then discuss test results and request any missing tests, carry out measurements and an examination, and finally decide on treatment. A patient with a complete set of results who meets the criteria leaves with an e-prescription code for the starting dose and an appointment with a dietitian.

We do not give the full dose immediately, but build up gradually so that the digestive tract can adapt. Semaglutide starts at 0.25 mg weekly, increasing every 4 weeks until the target dose is reached after 16 weeks. Tirzepatide has five dose steps, so the full dose is reached after roughly 20 weeks. Liraglutide differs from both because it is given daily and its dose increases weekly, from 0.6 mg to 3.0 mg. We practise the first injection together with the patient, in person or on camera, and agree a rotation of injection sites straight away, because injecting repeatedly into one spot causes hard lumps.

We have a short follow-up before every dose change. The patient reports weight, blood pressure and pulse measured at home, describes how they tolerate the medicine and how much fluid they drink daily, and the doctor decides the dose and sends a prescription code. We particularly emphasise drinking fluids because dehydration from vomiting or diarrhoea is more dangerous in someone taking diuretics: we ask for about two litres daily and more on days with symptoms, unless a cardiologist or nephrologist has advised fluid restriction, in which case we follow that advice. From the first week, the patient walks and does resistance exercise, because the greatest weight loss occurs in the first months, when muscle is most easily lost along with fat. We plan 1.2 to 1.5 g of protein per kilogram of ideal body weight, roughly 70 to 90 g daily for a woman 165 cm tall, and two resistance training sessions weekly; with reduced eGFR, we set a lower protein intake in consultation with a nephrologist. In the fourth month, we repeat glucose, lipid profile, liver function tests and creatinine.

We first assess effectiveness after three months on the full dose, in the seventh or eighth month after the first injection, depending on the medicine. We check whether at least 5 percent of starting weight has been lost. Individual product information documents also set their own assessment times. Liraglutide is stopped if weight loss is below 4 percent after 12 weeks at 3.0 mg, naltrexone/bupropion after 16 weeks without 5 percent loss, and orlistat after 12 weeks without 5 percent loss. We set a common assessment time in line with Polish Society for the Treatment of Obesity recommendations. A result below the threshold means changing the medicine, not ending treatment. The dose then remains stable, with follow-ups every 8 weeks. We return to discussing dose reduction and signs of relapse after a year, although we first discuss them before the first prescription.

What we do not do in obesity treatment at Nasz Gabinet Wałbrzych

• We do not treat heart disease. A cardiologist manages heart failure, arrhythmia and coronary artery disease, and we do not change their recommendations. We manage body weight and provide the cardiologist with written information about weight-loss progress.
• We do not change cardiac medication doses on our own. When blood pressure falls too low after losing a dozen or more kilograms, we describe this in our recommendations and ask the patient to contact the doctor managing those medicines.
• We do not perform cardiac imaging. We do not offer echocardiography, exercise stress testing or Holter monitoring; we refer patients to diagnostic facilities and review the results together.

We ask for results no more than six months old: full blood count, fasting glucose or glycated haemoglobin, lipid profile, liver function tests, creatinine with calculated eGFR, and TSH. Each test answers a different question. Glucose and glycated haemoglobin show whether diabetes or prediabetes is already present, which changes the choice of medicine and justifies a prescription at a BMI of 27 to 29.9. Lipid profile and liver function tests show how far metabolic changes have progressed. Creatinine and eGFR determine which medicine can be given. A normal TSH rules out the underactive thyroid that almost every patient asks about.

We also take measurements that no laboratory can provide. We measure blood pressure with the correct cuff, count the resting pulse and record it as a reference for later, because GLP-1 analogues slightly increase it. We examine the abdomen, inspect the skin on the back of the neck and in the armpits, where dark, velvety patches suggest insulin resistance, and check the lower legs for swelling. We ask about breathlessness on exertion and palpitations.

We request an electrocardiogram when the history includes an irregular pulse, palpitations, near-fainting or breathlessness disproportionate to exertion. If the tracing is abnormal or symptoms suggest heart failure, we refer to a cardiologist for echocardiography before issuing a prescription. Chest pain, breathlessness at rest and fainting are urgent situations: we do not arrange a routine test, but ask the patient to seek urgent medical care immediately.

A GP can usually request the basic tests free of charge and does not need a referral from us. Patients who prefer to obtain all results immediately can pay for testing at any local blood collection point and bring the results to their appointment. We do not order fasting insulin, HOMA-IR or a hormone panel without an indication, because these results do not change the treatment decision.

The heart is what patients with obesity ask about most often, yet it receives the least discussion at weight-loss appointments. Heart function determines decisions that change the entire treatment plan: whether breathlessness needs investigating before the first prescription, whether a normal blood test can be considered reassuring, and whether the patient has time to lose weight before a cardiac procedure.

What causes breathlessness in obesity and why it is not always poor fitness

Excess body fat increases circulating blood volume. This was measured using a catheter inserted into the heart during exercise. The study included 99 people with obesity and heart failure, 96 with heart failure without obesity, and 71 healthy people. Plasma volume averaged 3907 ml in people with obesity and 2772 ml in the other patients, roughly 40 percent more. Fat also accumulates around the heart, in the pericardial sac, restricting the ventricles' ability to fill freely. The heart therefore has more blood to pump and less space to receive it, which the patient experiences as breathlessness during exertion that went unnoticed a year earlier.

Sometimes the same breathlessness simply results from years of inactivity. Weight loss helps in both cases, but heart failure requires cardiac treatment that losing weight cannot replace. This is why we do not just ask whether the patient gets breathless, but after how many stairs they must stop, whether they sleep on one pillow, whether their legs swell by evening, and whether they wake at night short of breath. These answers determine whether we refer for an echocardiogram before prescribing.

Heart failure with preserved ejection fraction and obesity treatment

In some patients, the heart contracts normally but still does not pump enough blood because it relaxes and fills poorly. This is called heart failure with preserved ejection fraction and is the most common form of heart failure in obesity. For years, the choice of medicines was very limited. Today, SGLT2 inhibitors are the foundation of treatment, reducing hospitalisation risk. What weight-loss medicines could offer in this condition, however, was unknown.

Two randomised trials clarified this. In STEP-HFpEF, 529 people with obesity and this form of heart failure took semaglutide 2.4 mg or placebo for a year. Their Kansas City questionnaire score, in which patients assess symptoms and physical functioning and a higher score means fewer symptoms, improved by 16.6 points versus 8.7 points, body weight fell by 13.3 percent versus 2.6 percent, and six-minute walking distance increased by 21.5 metres versus 1.2 metres. In SUMMIT, 731 people with obesity and heart failure took tirzepatide or placebo, with a median follow-up of two years. Cardiovascular death or worsening heart failure occurred in 9.9 percent of treated patients versus 15.3 percent in the placebo group, a 38 percent relative reduction.

Both studies were published in peer-reviewed medical journals, and their results were included in both medicines' product information. Neither medicine is approved for treating heart failure, and we do not prescribe it for that purpose. We treat obesity, with improved functional capacity resulting from that treatment. Cardiac medicines are decided on by the cardiologist, and obesity treatment does not replace them.

Atrial fibrillation and weight reduction before ablation

Obesity is one of the reversible risk factors for atrial fibrillation, alongside alcohol, sleep apnoea and hypertension. In a meta-analysis of 51 studies involving 626 603 people, every 5 BMI points increased the risk of developing atrial fibrillation by 29 percent and the risk of arrhythmia after cardiac surgery by 19 percent. The effect of weight is also visible in ablation outcomes, which is why cardiologists increasingly ask patients to lose weight before the procedure, although many patients interpret this as postponing it.

The Australian observational LEGACY study followed 355 people with atrial fibrillation and excess weight for five years. There was no random allocation to groups, so we describe a strong association rather than conclusive proof. Those who lost at least 10 percent of their weight were six times more likely than the others to maintain sinus rhythm without recurrent arrhythmia. Maintaining the lower weight matters: fluctuations above 5 percent doubled the risk of recurrent arrhythmia and partly cancelled out the benefit. We therefore tell patients with an ablation date that losing weight before the procedure and keeping it off afterwards increases the chance of avoiding a repeat procedure.

Blood pressure, cuff size and medication doses during weight loss

Before treating hypertension, the doctor must be sure the measurement is reliable. In a study of 195 people with measurements taken in random order, the same device on the same arm gave different results depending on the cuff. In those needing the largest cuff, a standard cuff overestimated systolic pressure by an average of 19.5 mmHg; in those with a very slim arm, it underestimated it by 3.6 mmHg. Nineteen millimetres is the difference between a normal result and a hypertension diagnosis, and between observation and lifelong treatment.

Reliable measurements show that weight reduction alone lowers blood pressure. A meta-analysis of 25 randomised studies involving 4874 participants found that every kilogram lost lowered systolic pressure by an average of 1.05 mmHg and diastolic pressure by 0.92 mmHg. After losing a dozen or more kilograms, blood pressure sometimes falls enough for previous doses of blood pressure medicines to become too high. We therefore ask patients to keep a home measurement diary and contact us if systolic pressure falls below 110 mmHg with dizziness, weakness or near-fainting on standing. The doctor treating hypertension reduces the doses, and fewer blood pressure tablets are one of the first visible effects of obesity treatment.

Palpitations and a faster pulse while taking the medicine

GLP-1 analogues increase heart rate, and patients notice it. Semaglutide product information reports an average increase of 3 beats per minute from a baseline of 72, while an increase of at least 10 beats at any point during treatment occurred in 67 percent of treated patients versus 50.1 percent taking placebo. With tirzepatide, the mean maximum increase was 3 to 5 beats per minute. These figures alone are not alarming, but we take them more seriously in someone with atrial fibrillation or coronary artery disease, which is why we record the pulse before the first dose.

We distinguish three situations when palpitations are reported during treatment. With a regular, moderately increased pulse and no other symptoms, we observe and reassess at the next follow-up. With an irregular pulse and uneven intervals, we refer for an electrocardiogram because this is how atrial fibrillation can begin. Palpitations with chest pain, near-fainting or breathlessness at rest are treated as urgent, without waiting for the follow-up date. We also ask patients not to stop treatment on their own, because without knowing about this it is difficult to establish whether the medicine was the cause.

Cardiac medicines that make weight loss harder

Some heart medicines make obesity treatment harder. A systematic review of eight randomised studies lasting at least six months found that weight at the end of the study was higher in beta-blocker groups than in control groups, with a median difference of 1.2 kg; the gain occurred in the first months and did not continue to increase afterwards. This is small compared with the dozen or more kilograms that can be lost with obesity treatment, but it explains why weight started rising after a heart attack, so the patient need not suspect that cardiac treatment has harmed them.

We do not stop or replace these medicines. A beta-blocker after a heart attack or for atrial fibrillation protects against complications that no number of kilograms can outweigh. The same applies to diuretics, for which we monitor hydration on days with vomiting. The treating doctor reviews anticoagulant doses because some are dosed according to body weight and kidney function, both of which change during treatment. Before a planned procedure, including a cardiac procedure, the patient tells the anaesthetist about all these medicines and the GLP-1 analogue, because delayed stomach emptying changes preparation for anaesthesia.

The table below helps you review your own results: the test is on the left, factors that distort it in obesity are in the middle, and our approach is on the right.

Semaglutide and tirzepatide mimic gut hormones released after a meal. They slow stomach emptying, suppress the hunger centre in the hypothalamus and increase glucose-dependent insulin secretion. Patients describe this as appetite disappearing rather than having to fight it: food stops occupying their thoughts, and a portion that previously seemed normal becomes too large. Tirzepatide also stimulates the GIP receptor, for a second gut hormone, which probably accounts for its greater effectiveness.

In STEP 1, semaglutide 2.4 mg weekly produced a 14.9 percent weight loss after 68 weeks, compared with 2.4 percent in the placebo group; in SURMOUNT-1, tirzepatide produced 15 to 20.9 percent after 72 weeks, depending on dose. For someone starting at a hundred kilograms, that means fifteen to twenty kilograms, not just a few. Both studies also included dietary counselling and advice to exercise, so the injection alone without changing eating habits will not produce that result.

Weight returns after the medicine is stopped, and we explain this before the first prescription. A year after treatment ended, STEP 1 participants had regained two-thirds of the weight they had lost, and blood pressure, blood glucose and lipids had returned to pretreatment values. In this respect, obesity behaves like hypertension: the medicine works while it is taken.

Effectiveness varies. Some patients lose more than 20 percent of body weight, while others plateau at a few percent despite the full dose and regular appointments. For the latter, we change the medicine or return to work with a dietitian and a specialist in the psychology of eating, instead of exceeding the approved dose.

Five prescription substances are available in Poland, and patients know them by their brand names. We list them below so that nobody buys the same medicine twice under different names. Semaglutide at doses up to 2.4 mg weekly is Wegovy, approved for obesity treatment. The same semaglutide at doses up to 2 mg is Ozempic, approved for type 2 diabetes and subject to export restrictions. Tirzepatide is Mounjaro, approved for both diabetes and obesity. Liraglutide 3.0 mg is Saxenda, given daily. Tablets combining naltrexone and bupropion are Mysimba, while orlistat is sold as Xenical and in lower-dose non-prescription products.

Effectiveness differs considerably. Semaglutide and tirzepatide produce weight loss in the teens and around twenty percent, liraglutide less, and oral medicines less still. In COR-I, average weight loss after 56 weeks was 6.1 percent with naltrexone/bupropion versus 1.3 percent with placebo, while orlistat produces an average of 2 to 3 kg more loss than placebo after a year. Oral medicines still have a place: where injections are contraindicated, where there is a strong aversion to needles, or where the budget cannot cover a GLP-1 analogue for a year. In patients with diabetes treated with insulin or a sulfonylurea, we monitor glucose separately because combining these with an incretin medicine increases hypoglycaemia risk and usually requires reducing diabetes medicine doses.

Coexisting diseases narrow the choice. Mysimba is contraindicated in uncontrolled hypertension, epilepsy, a history of eating disorders, opioid use and end-stage kidney failure. Before starting it, we measure blood pressure and pulse because bupropion raises both. We do not use liraglutide with creatinine clearance below 30 ml/min or above the age of 75. For tirzepatide, the product information does not require dose adjustment in kidney disease, although evidence in end-stage disease is limited. Orlistat is contraindicated in malabsorption syndrome and cholestasis.

Cost also determines the choice, because none of these medicines is reimbursed for obesity treatment. Semaglutide costs PLN 550 to 890 monthly, tirzepatide PLN 800 to 1900, liraglutide at full dose PLN 500 to 1250, naltrexone/bupropion tablets PLN 370 to 600, and orlistat PLN 160 to 350. We checked prices in September 2026; they increase with dose, so patients pay the upper end of the range at the target dose. A year of semaglutide costs PLN 6.6 to 10.7 thousand, and tirzepatide PLN 9.6 to 22.8 thousand; the lower figure covers a year of gradual dose escalation, and the higher a full year at the target dose. We discuss this amount before the first prescription, not halfway through treatment.

The most common symptoms affect the digestive tract and occur in the first weeks and after each dose increase. They include nausea, vomiting, diarrhoea, constipation and fullness after a small meal. In semaglutide studies, between a quarter and almost half of participants reported them, and 4.5 percent stopped treatment because of them, versus 0.8 percent in the placebo group. Symptoms ease after a few weeks in most people. Slower dose escalation, smaller portions and limiting fatty foods and alcohol throughout dose escalation, not just on injection day, can help.

Less common complications need attention because their symptoms are easily dismissed. Gallstones occurred in 1.6 percent of semaglutide-treated patients versus 1.1 percent taking placebo, causing severe pain under the right rib margin radiating to the shoulder blade. Acute pancreatitis is rare and presents with upper abdominal pain spreading to the back along with vomiting; the medicine must then be stopped and the patient must go to hospital the same day. In people with diabetes and advanced retinopathy, rapid improvement in blood glucose control may temporarily worsen retinal changes, so we request an eye check before treatment. Persistent vomiting, no bowel movements and a swollen abdomen are signs of bowel obstruction and an urgent situation. We also ask patients to seek urgent help for sudden, painless loss of vision in one eye, because European safety monitoring has recorded rare cases of ischaemic damage to the optic nerve with semaglutide.

We discuss pregnancy with women of reproductive age before prescribing. GLP-1 analogues are contraindicated in pregnancy; semaglutide is stopped two months before planned conception and tirzepatide one month before. For contraceptive pills, European tirzepatide product information does not require additional protection because changes in absorption proved small. For patients who prefer extra reassurance, we suggest a barrier method during dose escalation. If pregnancy nevertheless occurs during treatment, we stop the medicine that day and refer to a gynaecologist; this is not an indication to terminate the pregnancy.

There are also everyday practical issues that nobody asks about but that can undermine treatment. An unopened injection pen is kept in a refrigerator at 2 to 8 degrees. After first use, semaglutide can be kept below 30 degrees for up to six weeks, and liraglutide for a month, away from sunlight and out of the car; the exact period is in the specific product leaflet. Needles go into a rigid container, not a rubbish bag. Medicines must not be bought outside a pharmacy. Poland's Chief Pharmaceutical Inspectorate has repeatedly warned about counterfeit pens sold through adverts and sales platforms, some containing insulin instead of semaglutide. Hypoglycaemia after such an injection starts with trembling hands, cold sweats and confusion; something sweet must then be given and help called.

The medicine reduces appetite but does not change eating habits. With rapid weight loss, part of the loss is muscle rather than fat, and this affects every patient, not only those who have eaten once a day for years. The dietitian designs a meal plan around work hours and food preferences, with a daily deficit of 500 to 750 kcal relative to needs calculated from body weight and activity, and ensures protein intake of 1.2 to 1.5 g per kilogram of ideal body weight. The first dietitian appointment takes place in the first month of treatment, with subsequent visits every few weeks, at Młynarska 24 or online.

The specialist in the psychology of eating addresses what the medicine does not change. Eating in response to anger, boredom or fatigue is not about appetite, so it is the first behaviour to return after stopping the medicine. The same applies to night eating and snacking in front of a screen. For severe binge-eating episodes, we also suggest a psychiatric consultation because this is a separate diagnosis, not simply a habit. We teach patients to recognise situations in which they reach for food without hunger and look for alternatives, because this determines whether results last after medication ends.

We choose the type of exercise according to joint and heart health. After a heart attack or with heart failure, we suggest starting with level-ground walking and adding uphill walks later. Two resistance training sessions a week matter more than step count because they protect muscle during rapid weight loss. After cardiac procedures, we recommend cardiac rehabilitation first and plan gym exercise only once it is completed.

Alcohol adds calories that nobody enters in their diary. Half a litre of beer contains about 250 kcal, a 150 ml glass of wine about 120 kcal, and several drinks in an evening cancel out the entire daily deficit. The body metabolises alcohol first before returning to fat, so fat burning pauses in the meantime. Alcohol also weakens control over how much you eat, making the meal afterwards larger than usual.

The medicine slows stomach emptying, so alcohol stays there longer and more often causes nausea, while vomiting makes dehydration easier. Alcohol is also a major risk factor for acute pancreatitis, discussed in the safety section: severe upper abdominal pain radiating to the back requires urgent contact. In people with diabetes taking insulin or sulfonylureas, alcohol increases the risk of night-time hypoglycaemia. We therefore ask patients to limit alcohol throughout treatment, especially during dose-escalation weeks, when nausea is strongest.

Alcohol also affects the heart. It can trigger an episode of atrial fibrillation and raises blood pressure in people with hypertension independently of calories. In someone with arrhythmia and obesity, limiting alcohol therefore brings two benefits at once and is one of the first things we ask for.

If discussion reveals that alcohol is a separate problem, we suggest addiction treatment as well as obesity treatment. In the same building, we provide alcohol addiction treatment in Wałbrzych and addiction therapy, so the patient does not have to start searching from scratch. For daily drinkers, we do not ask for abrupt alcohol withdrawal because this is dangerous for some people; we plan the timing and approach together. We usually treat obesity in parallel, but with active drinking and liver damage, we address the addiction first.

We hold the first consultation in the clinic or by video, with both formats lasting the same time. The choice depends on what needs examining. If the patient has no heart disease, has a full set of tests and reports no concerning symptoms, a video consultation is sufficient for diagnosis, eligibility assessment and prescribing, saving half a day of travel.

We ask patients to attend the clinic when a hands-on examination and a stethoscope are needed. Listening to the heart and lungs, assessing lower leg swelling, examining the abdomen, inspecting the skin in the armpits and groin, and measuring blood pressure with an appropriately sized cuff cannot be done on camera. We also ask patients to come in if they have experienced breathlessness, palpitations or near-fainting, or cannot measure their waist themselves. If such a symptom occurred recently or is worsening, we ask them to contact us before the scheduled appointment.

Follow-ups before dose changes take place remotely, as described in the treatment section: the patient reports home measurements and symptoms, and the doctor sets the dose and sends a prescription code. After roughly six months, we ask for an in-person visit to weigh the patient on the same scale and repeat the measurements. Home scales can differ by as much as two kilograms, so we compare readings from one scale rather than home readings with clinic readings.

We issue electronic prescriptions that can be filled at any pharmacy. We do not provide treatment without contact with the patient or issue prescriptions based solely on a form or message, because the dose depends on how the patient tolerates the medicine, which a form cannot show.

The medicine is the largest expense because none of these products is reimbursed for obesity treatment; some are reimbursed for type 2 diabetes, but that is a different indication with different criteria. Appointments are an additional cost: the first costs PLN 250, follow-ups are shorter and cheaper, and sessions with the dietitian and specialist in the psychology of eating are charged separately. Annual cost depends mainly on the medicine chosen and ranges from PLN 7 to 23 thousand, so we discuss it before starting to avoid patients stopping halfway through for financial reasons.

Some tests and services are free. A GP can request a full blood count, glucose, lipid profile, liver function tests, creatinine and TSH without needing a referral from us. The cardiovascular disease prevention programme covers people aged 35 to 65 with no previous diagnosis of heart disease, diabetes or chronic kidney disease, and provides measurements, a lipid profile and risk assessment. Adults are entitled to a health check under the Moje Zdrowie programme from age 20, every five years up to age 49 and every three years from age 50; after a Moje Zdrowie check, they must wait a year before accessing cardiovascular disease prevention. In clinics providing coordinated care, dietary consultations and educational advice are available in the cardiology and diabetes pathways, but eligibility requires a diagnosis from a list that does not include obesity, code E66; patients access this care with diabetes, hypertension, heart failure, thyroid disease or chronic kidney disease.

A GP referral is needed to see a cardiologist, diabetologist or endocrinologist. Bariatric surgery and cardiac rehabilitation after a heart attack or cardiac procedures remain publicly funded.

We provide recommendations and referrals, but do not book appointments on patients' behalf. We write recommendations in a form that the GP and cardiologist can use immediately, listing tests, doses and the date of the next assessment.

We consider surgery at a BMI of 40 or above, or from 35 if the patient has a weight-related disease such as type 2 diabetes, obstructive sleep apnoea or poorly controlled hypertension. These are the eligibility criteria in Polish centres. The 2022 joint statement of the American and international societies for metabolic and bariatric surgery recommends lower thresholds: BMI 35 without coexisting diseases and 30 with metabolic disease. However, surgical centres work to criteria agreed with the National Health Fund. The operating centre determines the final criteria and sequence of tests, and we refer the patient with complete results and a description of previous treatment.

We regard medication neither as a compulsory step before surgery nor as a way to postpone it. In some patients, it produces results that make surgery unnecessary. In others, it enables weight loss before surgery, reducing complication risk, or helps afterwards if weight plateaus above the expected level. After surgery, we manage the patient together with the centre and monitor protein, iron, vitamin B12 and vitamin D, because postoperative deficiencies do not cause immediate symptoms.

Before any general anaesthetic, including for cardiac or orthopaedic procedures, the anaesthetist must know about the GLP-1 analogue. The 2024 joint statement of five societies does not recommend routinely skipping a dose before elective procedures. Instead, it proposes a day of clear fluids before anaesthesia; if in doubt, the anaesthetist uses ultrasound to check whether the stomach is empty. We therefore ask patients not to skip doses on their own but to tell the anaesthetist about the medicine, so that they can decide based on the procedure. At the appointment, we provide written information about the medicine to take to the procedure.

Patients travel to the clinic on Młynarska from Świdnica, Świebodzice, Boguszów-Gorce, Szczawno-Zdrój, Jedlina-Zdrój, Głuszyca, Mieroszów, Nowa Ruda, Kamienna Góra, Strzegom, Dzierżoniów and Ząbkowice Śląskie. For some, this is the nearest clinic where a doctor provides obesity treatment.

The first appointment is in person so that we can examine, measure and make a plan. Follow-ups before dose changes take place by video, so a patient from Nowa Ruda or Kamienna Góra does not travel every four weeks simply to increase a dose. We ask them to return in person after six months to repeat measurements and the examination.

Patients have blood tests locally, at a collection point or through their GP, and send results before follow-up; at the effectiveness assessment, results should be no more than a month old. If a cardiology consultation or echocardiogram becomes necessary during treatment, we recommend a facility nearer home to avoid extra travel, and waiting times may be shorter there than in Wałbrzych.

Two health resorts operate just beyond the city boundary: Szczawno-Zdrój, whose treatment indications in the Ministry of Health's resort register include obesity and diabetes, and Jedlina-Zdrój, which covers cardiac disease and hypertension.

How patients access a sanatorium and what the National Health Fund requires

Any doctor contracted with the National Health Fund, including a GP, can issue an electronic referral, which is assessed by a doctor at the regional branch. A stay in a health resort sanatorium lasts 21 days and is partly paid for by the patient, who contributes to accommodation and meals; a health resort hospital stay lasts the same length and is free. Another referral may be issued no earlier than a year after the previous treatment ends. The Fund refers only people able to travel independently, care for themselves and use the treatments, so a referral for someone with severe obesity and limited mobility may be rejected; we explain this beforehand rather than letting the patient wait months for a response.

What three weeks at a health resort cannot replace

A sanatorium provides what is often most lacking at home: three weeks of regular meals, exercise and supervised treatments, without work or duties. After a heart attack or cardiac procedure, we advise starting with cardiac rehabilitation and adding obesity treatment afterwards. Three weeks are not enough for a chronic disease, however. Nobody there will issue a GLP-1 analogue prescription as part of the treatment indication, and weight lost at the resort returns at the same rate as after any other short course if the patient has no treatment plan on returning home.

We therefore suggest that patients returning from Szczawno or Jedlina view the trip as the beginning of treatment rather than its end. We review the sanatorium discharge summary and test results, plan treatment for the coming months and set an assessment date. Continuing treatment after returning home is the hardest part, and the one we monitor most closely.