Obesity treatment Wałbrzych

Obesity has the ICD-10 code E66, and the 2024 recommendations of the Polish Society for the Treatment of Obesity describe it as a chronic disease that requires long-term care. One example is a patient who once lost twenty kilograms and returned to their previous weight within two or three years. After losing fat tissue, the body may use less energy than the new body weight would suggest. Levels of ghrelin, which stimulates appetite, rise, while levels of leptin, which signals energy stores to the brain, fall. This regulation persists for at least a year after weight loss ends, and longer in some people. These changes can make it harder to maintain a lower body weight. That is why we run treatment with regular check-ups and change the plan when it stops working. We also explain that there will be weeks during treatment when body weight does not change.

How does obesity develop and why does it keep progressing?

Obesity develops gradually. Over years, the body receives more energy from food than it burns and deposits the excess in fat tissue, until the amount of fat tissue starts to harm health. At first the existing fat cells grow larger, and if the surplus persists, the body produces new ones. Fat tissue stored in the abdomen, around the organs, acts as an active organ. It releases substances that sustain chronic low-grade inflammation and can reduce tissue sensitivity to insulin.

The tendency to obesity is largely inherited. In twin studies, genes accounted for 40 to 70 percent of the differences in body weight, which is why obesity often affects both parents and their children. This tendency shows itself especially when high-calorie products are always available and the day is spent sitting at work and in the car. Short sleep, chronic stress, pregnancy, menopause and stopping smoking also promote lasting weight gain.

At the initial consultation we look for the factors that maintain excess weight in the individual patient, so the medical history covers more than diet. We review all current medicines, because oral glucocorticoids, some antidepressants and antipsychotics, certain antiepileptic drugs and insulin can promote weight gain. In studies of beta-blockers, body weight was on average about a kilogram higher than in control groups, although the difference may vary between individuals. We ask about working hours, because night shifts disrupt the body clock, and about alcohol, which adds to energy intake. We check the thyroid: an underactive thyroid can affect body weight, but it usually does not explain obesity as a whole.

Which diseases develop with obesity?

Over time, some people with obesity develop high blood pressure, raised blood glucose, high triglycerides and fatty liver, not always in the same order. A higher body weight means more circulating blood, so the heart works under greater strain.

The link between obesity and heart failure was described in the observational Framingham study, which followed 5,881 people for an average of 14 years. Each additional BMI point was associated with a 5 percent higher risk of heart failure in men and a 7 percent higher risk in women, and obesity with roughly twice the risk seen at a healthy weight. Heart failure usually develops over years and for a long time causes no symptoms that patients would link to their weight. Breathlessness when walking uphill, easy to notice on the slopes of Wałbrzych, should be discussed with a doctor, because it can have several causes, including heart-related ones.

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, which is class II obesity under the World Health Organization thresholds shared by both sexes: 25 marks overweight, and 30, 35 and 40 mark the successive classes of obesity. BMI does not describe where fat is stored, however, and at the same BMI the risk of complications differs between someone who carries fat on the hips and someone who carries it around the abdomen.

Waist circumference complements BMI and needs only a tape measure. It is placed midway between the lowest rib and the palpable edge of the hip bone, and the result is read during a relaxed exhale. The lower threshold, 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 limit for substantially increased metabolic risk. We assess waist circumference together with BMI, blood pressure and test results, and the scope of further assessment depends on the overall picture of health. We ask patients who measure themselves at home before the consultation to check that the tape lies level and does not slip to the narrower part above the abdomen, because the result then comes out too small.

Before blood pressure is measured, upper-arm circumference needs to be measured. It determines the cuff size, and the cuff determines how reliable the reading is for diagnosing and treating high blood pressure. We also discuss weight history: what the patient weighed at around twenty, in which year weight started to rise, what was happening then, which diets and medicines they tried, how many kilograms returned and after how long. This conversation helps us understand what made earlier attempts to lose weight difficult.

When can an obesity medicine be considered, and what limits the choice?

The doctor decides on a medicine after assessing the patient's health and the indications in the summary of product characteristics, the official description of the medicine. BMI is one of the criteria, and meeting a threshold does not guarantee a prescription. For many products the threshold is a BMI of 30 or more, or 27 to 29.9 with at least one weight-related condition. For semaglutide, the summary gives examples of such conditions: prediabetes or type 2 diabetes, high blood pressure, lipid disorders, obstructive sleep apnoea and cardiovascular disease. Indications differ somewhat for other products, and orlistat has its own thresholds: a BMI of 30 or more, or above 28 with risk factors. Below a BMI of 27 the medicines discussed here have no standard indication, but the doctor still assesses waist circumference and test results, treats coexisting conditions and may plan work with a dietitian.

Age does not rule out treatment, but it affects the choice of medicine. We treat adults only. Liraglutide is not recommended from the age of 75. Naltrexone/bupropion tablets are not recommended over 75 and require caution over 65. Data on semaglutide and tirzepatide from the age of 85 are limited. Restrictions related to the heart, kidneys and liver differ between products. Semaglutide and liraglutide used for obesity are not recommended in NYHA class IV heart failure, that is, with breathlessness at rest, while the tirzepatide summary contains a different statement. Semaglutide and liraglutide are also not recommended in severe kidney or liver impairment. With tirzepatide, kidney or liver disease alone does not require a dose change, but data in severe disease are limited and the doctor proceeds with caution. A past episode of acute pancreatitis calls for a careful, individual assessment before starting a GLP-1 medicine. Naltrexone/bupropion tablets are contraindicated, among other situations, in epilepsy or a history of seizures, current or past anorexia or bulimia, long-term opioid use, end-stage kidney failure and severe liver impairment.

The obesity treatment programme lasts six months, takes place online and costs PLN 1,799. The patient buys medicines separately at a pharmacy with an e-prescription. At the 30-minute initial consultation the doctor reviews all current medicines, including those for the heart and blood pressure, discusses test results and orders any missing tests. The patient measures weight, waist and blood pressure at home beforehand. At the end, the doctor decides whether the patient can be treated in the programme. After assessment, the doctor may issue an e-prescription for the starting dose and plan a dietary consultation. Results within the thresholds do not guarantee a prescription.

For this price the patient has two 30-minute doctor consultations, two 40-50-minute online consultations with a psychologist and five medical reviews of app data without a call. The patient books the video consultations in the Nasz Gabinet app, on dates counted from the initial consultation.

The price also includes an AI assistant and monitoring of body weight and treatment progress.

The doctor issues an e-prescription after each medical review. In the app the patient records weight once a week and body measurements once a month. After each injection, the patient takes a photo of the pen, and the medical team looks at it. The doctor looks through this information before the check-up. According to the Polish Society for the Treatment of Obesity (PTLO), obesity treatment should last a year or longer, so after the programme it can be extended with a continuation package. The package lasts 3 months and costs PLN 350, and the patient receives an e-prescription every month after a medical review, without video consultations.

The dose is increased gradually to give the digestive system time to adapt. Injectable semaglutide starts at 0.25 mg weekly and is increased every 4 weeks until the patient reaches 2.4 mg after 16 weeks. Tirzepatide starts at 2.5 mg weekly, and after 4 weeks the dose is 5 mg. Further increases of 2.5 mg are made only if needed, at intervals of at least four weeks. The maintenance dose of tirzepatide can be 5, 10 or 15 mg, so not every patient reaches the highest dose. Liraglutide is given daily, and its dose is increased weekly from 0.6 mg to 3.0 mg. If the medicine is poorly tolerated, the doctor may postpone a dose increase. We practise the first injection with the patient by video and agree a rotation of injection sites from the start, because injecting into the same spot increases the risk of local reactions, including hardened skin.

At a check-up the patient reports weight, blood pressure and pulse from home measurements, describes how the medicine is tolerated and how much they drink each day, and the doctor decides on the next dose. Dehydration from vomiting or diarrhoea is more dangerous in people taking diuretics, so we usually recommend about two litres of fluid a day, unless a cardiologist or nephrologist has advised fluid restriction; their advice then applies. With persistent vomiting or diarrhoea, especially in heart failure or during diuretic treatment, drinking more is not enough and the patient needs to contact a doctor. We match physical activity, including resistance exercise, to the patient's health, because rapid weight loss can mean losing muscle along with fat. As a guide, we plan 1.2 to 1.5 g of protein per kilogram of ideal body weight, which for a woman 165 cm tall may mean about 70 to 90 g a day; with reduced eGFR we set protein intake lower, in consultation with a nephrologist. The doctor sets the timing of follow-up blood tests, such as glucose, lipids, liver tests and creatinine, individually.

Rules for assessing effectiveness differ between medicines. In adults, liraglutide is stopped if at least 5 percent of initial body weight has not been lost after 12 weeks on 3.0 mg. Naltrexone/bupropion tablets are stopped if weight loss has not reached 5 percent of initial body weight after 16 weeks, and the benefits and safety of treatment are reassessed at least once a year. Orlistat is stopped if at least 5 percent of the body weight measured before treatment has not been lost after 12 weeks. For semaglutide and tirzepatide, the doctor sets the timing and method of assessing the effect individually. A result below expectations calls for assessment of the causes and a decision on further treatment, which does not have to mean switching medicine. We discuss maintaining results, signs of weight regain and the plan after medication ends before the first prescription.

What do we not do when treating obesity?

• We do not treat heart disease. Heart failure, arrhythmias and coronary artery disease are managed by a cardiologist or another treating doctor, and the obesity treatment plan takes their recommendations into account. New or worsening heart symptoms need medical assessment without waiting for a scheduled appointment.
• We do not change doses of heart medicines prescribed by another doctor. If blood pressure falls after weight loss and dizziness, weakness or fainting spells appear, the patient should contact a doctor without delay, and fainting requires urgent medical help.
• We do not perform specialist cardiac tests. Echocardiography, exercise testing and Holter monitoring are carried out by a cardiology laboratory, and the doctor discusses the results with the patient when planning treatment.

The doctor selects tests according to the patient's conditions, medicines and changes in treatment; this also determines whether an earlier result is recent enough. Most often these are a full blood count, fasting glucose or glycated haemoglobin, a lipid profile, liver tests, creatinine with calculated eGFR, and TSH. Glucose and glycated haemoglobin show whether diabetes or prediabetes is present, which affects the choice of medicine and the assessment of indications at a BMI of 27 to 29.9. The lipid profile and liver tests are part of assessing metabolic disorders and liver health, but on their own they do not establish how advanced a disease is. Creatinine with eGFR helps choose the medicine. TSH is a screening test of thyroid function, and further tests depend on the clinical picture.

There are also measurements that a laboratory cannot take. The patient measures blood pressure at home with a correctly sized cuff, and we record the resting pulse as a reference point, because GLP-1 medicines can slightly increase it. We ask whether the lower legs swell and whether there are dark, velvety patches on the skin of the neck and armpits. These may raise suspicion of insulin resistance, although they do not confirm it. We also ask about breathlessness on exertion and palpitations. Normal blood test results do not replace an examination of a person who reports breathlessness.

We order an electrocardiogram when indicated, for example with an irregular pulse, palpitations, fainting spells or breathlessness out of proportion to effort. With an abnormal ECG or symptoms suggesting heart failure, a cardiology assessment is needed before a prescription, with echocardiography if the cardiologist decides so. Chest pain, marked breathlessness at rest and fainting require urgent medical help rather than a planned test.

A GP can order some tests under the National Health Fund when they are indicated and does not need a referral from us. Patients can also have tests done privately at a collection point and send the results before the consultation. We order fasting insulin, the HOMA-IR index and hormone panels only when the result may affect diagnosis or treatment.

The condition of the heart shapes decisions that change the obesity treatment plan: whether breathlessness needs investigation before the first prescription, how to interpret a blood test in obesity, and how to plan weight loss before a cardiac procedure. A measurement or test result has to be reliable before it influences a treatment decision.

What causes breathlessness in obesity?

In obesity, circulating blood volume may be larger. A study that assessed cardiac haemodynamics and used echocardiography included 99 people with heart failure with preserved ejection fraction and a BMI of at least 35, 96 people with the same condition and a BMI below 30, and 71 people without heart failure. Plasma volume, estimated from haematocrit, body weight and other parameters, was reported as a median: 3,907 ml in the group with obesity and 2,772 ml in the group without obesity, about 40 percent larger. Fat stored around the heart, inside the pericardial sac, may also restrict filling of the heart chambers. In this form of the disease, increased load and restricted filling of the heart can worsen breathlessness on exertion. A group result does not describe every person with obesity.

Breathlessness has many possible causes, including lung disease, anaemia, heart disease and low physical activity. Weight loss may ease symptoms, but heart failure needs cardiology treatment that weight loss does not replace. That is why we ask after how many stairs the patient has to stop, whether they sleep with their head raised, whether their legs swell by the evening and whether they wake at night short of breath. The answers help decide whether a cardiology assessment and an echocardiogram are needed before a prescription, but they do not replace diagnostic tests.

How is obesity treated in heart failure with preserved ejection fraction?

In this form of heart failure the ejection fraction is preserved, but the heart chambers may relax and fill abnormally and pressures inside the heart may be raised. In obesity, this is the most common form of heart failure. For years the choice of medicines was very narrow. Today SGLT2 inhibitors, which reduce the risk of hospital admission, are an important part of guideline-based treatment. For a long time, however, obesity medicines had not been studied in this condition.

Two randomised trials provided such data. In the STEP-HFpEF trial, 529 people with obesity, this form of heart failure and no diabetes took semaglutide 2.4 mg or placebo for 52 weeks. The Kansas City questionnaire score, in which patients rate symptoms and physical function 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 walk distance increased by 21.5 metres versus 1.2 metres. In the SUMMIT trial, 731 people with obesity and this form of 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 participants versus 15.3 percent in the placebo group. The relative risk of this composite outcome was 38 percent lower, and the difference came mainly from fewer episodes of worsening heart failure.

Both studies were published in peer-reviewed medical journals, and their results are described in the summaries of product characteristics of both medicines. Describing these results does not mean the medicines are authorised to treat heart failure, so we do not prescribe them for that purpose. The trials do not show how much of the improvement comes from weight loss itself and how much from other effects of the medicine. Heart medicines are decided by the cardiologist, and obesity treatment does not replace them.

Does weight loss help with atrial fibrillation and before ablation?

Obesity is one of the modifiable risk factors for atrial fibrillation, along with alcohol, sleep apnoea and high blood pressure. In a meta-analysis of 51 studies covering 626,603 people, every 5 BMI points was associated in cohort studies with 29 percent higher odds of developing atrial fibrillation. The same rise in BMI was associated with 10 percent higher odds of atrial fibrillation after heart surgery and 13 percent higher odds of recurrence after ablation. A cardiologist may therefore recommend weight loss before the procedure or alongside preparation for it.

The Australian observational LEGACY study included 355 people with atrial fibrillation and a BMI of at least 27, followed for up to five years. Participants were not randomised, so the result describes an association and does not prove cause and effect. People who lost at least 10 percent of their weight had roughly six times higher odds of arrhythmia-free survival than those with the smallest weight loss. Weight fluctuations above 5 percent were associated with roughly twice the risk of arrhythmia recurrence. Losing weight and keeping it off may improve the results of atrial fibrillation treatment, but it does not guarantee that the procedure will not need to be repeated. The date of ablation is set by the cardiologist.

How should blood pressure be measured in obesity, and when should blood pressure medicine doses be reviewed?

Before treating high blood pressure, a doctor needs a reliable measurement. In a study with randomised order of measurements in 195 people, the same device gave different results depending on the cuff. In people who needed an XL cuff, a standard cuff overestimated systolic pressure by an average of 19.5 mmHg, and in people who needed a size L cuff by 4.8 mmHg. In people with a very slim arm who needed a size S cuff, a standard cuff underestimated the result by an average of 3.6 mmHg. These are average measurement errors in the study and should not be subtracted from your own reading. What matters is the arm circumference range printed on the cuff. Such an error can affect the diagnosis of high blood pressure and the choice of treatment.

With reliable measurement, the effect of weight loss on blood pressure becomes visible. In a meta-analysis of 25 randomised trials with 4,874 participants, the average change per kilogram of weight lost was 1.05 mmHg for systolic and 0.92 mmHg for diastolic pressure. In some patients, previous doses of blood pressure medicines become too high after weight loss, although needing fewer medicines is not guaranteed. We ask for a home blood pressure diary and for contact when dizziness, weakness or fainting spells occur on standing, whatever the measured value. Fainting requires urgent medical assessment. Doses are changed by the doctor treating the high blood pressure.

What should you do about palpitations and a faster pulse during treatment?

GLP-1 medicines can increase heart rate. The summary of product characteristics for semaglutide used in obesity reports an average increase of 3 beats per minute from a baseline of 72. An increase of at least 10 beats per minute at any time during treatment was recorded in 67 percent of treated participants versus 50.1 percent of those on placebo. In tirzepatide trials in people with obesity and in people with heart failure, the pulse rose by about 3 beats per minute on average. Study averages do not establish the cause of palpitations in an individual. In patients with atrial fibrillation or coronary artery disease, we pay particular attention to the pulse and record it before the first dose.

New or persistent palpitations should be reported to a doctor. Several resting pulse measurements and a check of the rhythm help distinguish a single increase from a lasting change. An irregular pulse can have various causes, and an electrocardiogram helps identify them. The doctor also assesses hydration, other medicines and whether a break in treatment is needed, and the summaries of some products advise stopping treatment if a significant rise in heart rate persists. Palpitations with chest pain, marked breathlessness or fainting require urgent medical help.

Do heart medicines make weight loss harder?

Some heart medicines can promote weight gain. A systematic review of eight randomised trials lasting at least six months found that body weight at the end of the studies was higher in groups taking beta-blockers than in control groups. The median difference was 1.2 kg, ranging from −0.4 to 3.5 kg, and the gain appeared in the first months and did not increase afterwards. A study average neither explains nor rules out a larger gain in an individual. When weight rises after a heart attack, the doctor considers various causes, including fluid retention.

Patients should not stop or change heart medicines on their own, and a beta-blocker must not be stopped suddenly. If a medicine may make weight loss harder, its indications and any possible change are assessed by the doctor managing the heart treatment. With diuretics, we pay attention to hydration on days with vomiting or diarrhoea. With anticoagulants, the treating doctor reviews the dose, because some are dosed according to body weight and kidney function; not every change in weight requires a dose change. Before a planned procedure, including a cardiac one, the patient tells the procedure team about all these medicines and about the GLP-1 medicine, because delayed stomach emptying can change preparation for anaesthesia.

The table below helps interpret your own results and does not replace a doctor's assessment. It shows the test, the factor that distorts the result in obesity, what we do and, briefly, the effect on the result.

Semaglutide and tirzepatide mimic gut hormones released after a meal. Semaglutide acts on the GLP-1 receptor, and tirzepatide on the GLP-1 and GIP receptors. These medicines slow stomach emptying, act on appetite-regulating centres in the brain and enhance glucose-dependent insulin release. In many patients appetite decreases and a portion that used to seem normal turns out to be too large, although the strength of this effect varies. The action of tirzepatide on the additional GIP receptor may contribute to the greater weight loss seen in trials, but it does not fully explain the difference in effectiveness.

In the STEP 1 trial, semaglutide 2.4 mg weekly led to an average weight loss of 14.9 percent after 68 weeks versus 2.4 percent with placebo, and in the SURMOUNT-1 trial tirzepatide led to 15 to 20.9 percent after 72 weeks, depending on the dose. For a person starting at one hundred kilograms, these averages would correspond to roughly 15 to 21 kilograms, but individual results vary and are not a forecast for a patient. Both trials included dietary counselling and advice on physical activity, so we treat the medicine as one part of broader treatment.

Body weight often rises after the medicine is stopped, so we discuss the risk of regain before the first prescription. Participants in a STEP 1 subgroup who stopped both the medicine and the lifestyle programme at the same time regained on average about two thirds of the weight they had lost within a year. Much of the improvement in blood pressure, glucose and lipids was reversed, although not everyone returned to baseline values. These results do not show that tapering the medicine prevents regain, so we plan care after medication ends individually.

Patients respond differently to treatment. Some lose more than 20 percent of their body weight, while others lose a few percent despite a full dose and regular appointments. With a weaker response, the doctor assesses the causes and tolerance and then decides on further treatment: a different medicine, more intensive work with the dietitian and the psychodietitian (a dietitian trained in the psychology of eating), or continuing the current treatment. We do not increase the dose above the authorised one.

Patients know obesity medicines by their brand names, so we give them next to the active substances to prevent anyone from buying the same medicine twice under different names. Below we describe the products discussed on this page; this is not a complete list of medicines on the market. Semaglutide authorised for obesity is Wegovy. Its summary of product characteristics describes once-weekly injections with a maintenance dose of 2.4 mg and, in selected adults with a BMI of at least 30, also 7.2 mg after at least 4 weeks on 2.4 mg. Wegovy tablets have also been authorised in the European Union. Authorisation does not mean that every form and dose is available in Polish pharmacies. Semaglutide in doses of up to 2 mg is Ozempic, authorised for type 2 diabetes. Tirzepatide is Mounjaro, authorised for type 2 diabetes and weight management. Liraglutide 3.0 mg is Saxenda, given daily. Tablets combining two substances, naltrexone and bupropion, are Mysimba. Orlistat in 120 mg hard capsules is Xenical, and a lower dose of orlistat is also available without a prescription.

In trials of semaglutide and tirzepatide, average weight loss ranged from about 15 to about 21 percent depending on the medicine and dose; it was smaller with liraglutide and smaller still with Mysimba and orlistat. These figures come from different trials without a direct comparison of the medicines, and they do not describe the result of every patient. In the COR-I trial, average weight loss after 56 weeks was 6.1 percent with naltrexone/bupropion versus 1.3 percent with placebo, and orlistat leads on average to 2 to 3 kg more weight loss than placebo after a year. Oral treatment may be considered, among other situations, when injectable medicines are contraindicated, when a patient strongly dislikes injections, or when the cost of long-term GLP-1 treatment exceeds what the patient can afford; an oral product must also match the indications and contraindications. In a person with diabetes treated with insulin or a sulfonylurea, we monitor blood glucose, because combining these with a GLP-1 medicine increases the risk of hypoglycaemia. The doctor changes diabetes medicine doses when the results require it.

Coexisting conditions narrow the choice. Mysimba is contraindicated, among other situations, in uncontrolled high blood pressure, epilepsy or a history of seizures, a tumour of the central nervous system, a history of bipolar disorder, current or past anorexia or bulimia, long-term opioid use, abrupt withdrawal of alcohol or benzodiazepines, end-stage kidney failure and severe liver impairment. Before starting it we check blood pressure and pulse from home measurements, because bupropion can raise both. Liraglutide is not recommended in severe kidney impairment or from the age of 75. For tirzepatide, the summary does not require a dose change because of kidney disease alone, although data in severe disease are scarce. Orlistat is contraindicated in chronic malabsorption and cholestasis.

Cost also affects the choice. According to the list of reimbursed medicines in force from 1 July 2026, the products discussed here are not reimbursed for obesity; reimbursement of some medicines in type 2 diabetes applies to a different indication and separate criteria. The price depends on the product, dose, pack size and pharmacy, and for injectable medicines it changes while the dose is being increased. We discuss the monthly and yearly cost of the chosen medicine before the first prescription so that the patient can plan expenses.

The most common side effects affect the digestive system and usually appear in the first weeks of treatment and while the dose is being increased, although not after every dose change. They include nausea, vomiting, diarrhoea, constipation and feeling full after a small meal. In semaglutide trials, between a quarter and almost half of participants reported them. In the STEP 1 trial, 4.5 percent of people taking semaglutide stopped treatment because of gastrointestinal side effects, compared with 0.8 percent in the placebo group. In most people these symptoms ease after a few weeks. Slower dose increases, smaller portions and limiting fatty foods and alcohol while the dose is being increased all help.

Less common complications need attention because their symptoms are easy to dismiss. In trials of semaglutide for obesity, gallstones occurred in 1.6 percent of treated participants versus 1.1 percent of those on placebo; symptoms include severe pain under the right ribs spreading to the shoulder blade. Acute pancreatitis is rare. It causes severe, persistent upper abdominal pain, often spreading to the back, with or without vomiting. If it is suspected, the medicine must be stopped and urgent medical help sought without delay. In people with diabetes and diabetic retinopathy, a rapid improvement in blood glucose control can temporarily worsen changes in the retina, so an eye examination may be needed before treatment. Persistent vomiting, no bowel movements and a bloated abdomen may indicate bowel obstruction and require urgent medical assessment. A very rare side effect of semaglutide is ischaemic optic neuropathy. Sudden worsening or loss of vision in one eye requires urgent eye assessment.

With women of childbearing age, we discuss pregnancy plans before the doctor issues a prescription. Medicines in this group should not be used during pregnancy. Semaglutide is stopped at least two months before a planned conception and tirzepatide at least one month before. For contraceptive pills, the European summary of product characteristics for tirzepatide does not require additional protection, because the changes in absorption were small. A patient may discuss an additional barrier method with the doctor while the dose is being increased. Semaglutide and liraglutide should not be used while breastfeeding, and for tirzepatide the doctor decides individually. If pregnancy occurs during treatment, the medicine should be stopped and a gynaecologist consulted. Exposure to the medicine alone is not a reason to terminate a pregnancy.

Before treatment starts, we also agree how to store the medicine and dispose of needles. An unopened pen is kept in the fridge at 2 to 8 degrees and protected from freezing, heat and light. How long it can be stored after first use depends on the product and type of pen, so the leaflet for the specific medicine applies. Needles go into a rigid container, and how a full container is returned depends on local waste collection. The medicine should not be bought outside a pharmacy. The Chief Pharmaceutical Inspectorate in Poland has warned about falsified semaglutide pens. A counterfeit pen may contain a different substance, such as insulin, which causes hypoglycaemia. Hypoglycaemia causes symptoms such as shaking hands, cold sweat and confusion. A conscious person who can swallow safely should be given something sweet by mouth. Nothing should be given by mouth to a person with impaired consciousness, and this situation requires urgent medical help.

The medicine can reduce appetite, and the dietitian helps build an eating pattern the patient can keep up day to day. With rapid weight loss, part of the loss may be muscle, so the plan includes protein and physical activity. The dietitian designs a meal plan around working hours and the patient's preferences. The energy deficit, as a guide 500 to 750 kcal a day, and protein intake, as a guide 1.2 to 1.5 g per kilogram of ideal body weight, are matched to the patient's needs and health, and with kidney disease in consultation with a nephrologist. Dietitian and psychodietitian consultations are separate from the six-month programme, which includes two online consultations with a psychologist.

The psychodietitian works with the patient on eating driven by anger, boredom and tiredness, eating at night and snacking in front of a screen. Medication can reduce appetite, and alongside it the patient works on meal organisation and on situations that trigger eating without hunger. The patient learns to recognise these situations and looks for other ways of coping with emotions. Severe binge eating requires diagnostic assessment, so in that case we also suggest a psychiatric consultation. Skills developed with the psychodietitian can help maintain results after medication ends.

We match the type of exercise to the condition of the joints and heart. A patient after a heart attack or with heart failure may start, for example, with walking on flat ground and add the hills of Wałbrzych later if their health allows. Resistance exercise helps protect muscle during weight loss and complements walking. The treating team sets the exercise and rehabilitation plan, and cardiac rehabilitation does not automatically require postponing all obesity treatment. In acute or decompensated heart disease, stabilising the patient's condition comes first.

We also ask about alcohol, which adds to energy intake. Half a litre of beer provides roughly 250 kcal and a 150 ml glass of wine about 120 kcal; the value depends on the drink. A few drinks in an evening can reduce or cancel out the daily energy deficit. While the body is metabolising alcohol, it uses less fat as a source of energy. Alcohol can also weaken control over how much a person eats.

Alcohol can worsen nausea and promote dehydration, especially with vomiting, and tolerance also depends on coexisting conditions. Alcohol is one of the important risk factors for acute pancreatitis, described in the section on side effects: severe upper abdominal pain spreading to the back requires stopping the medicine and urgent medical help. In people with diabetes taking insulin or sulfonylureas, alcohol increases the risk of hypoglycaemia, including at night. We therefore ask patients to limit alcohol during treatment, especially in the weeks when the dose is being increased.

Alcohol also affects the heart. It can trigger an episode of atrial fibrillation and, in people with high blood pressure, can raise blood pressure regardless of its calories. In a patient with an arrhythmia and obesity, limiting alcohol may therefore help in both areas, so we discuss it at the start of treatment.

If the conversation shows that alcohol is a separate problem, we also suggest addiction treatment. At the Nasz Gabinet clinic in Wałbrzych we provide alcohol addiction treatment in Wałbrzych and addiction therapy. In alcohol dependence, stopping drinking suddenly can be dangerous, so we agree with the patient how and when to cut down. Obesity treatment and addiction treatment can run in parallel, and with active drinking and liver disease the order and scope of treatment depend on the patient's health.

The initial and final doctor consultations and the two psychologist consultations take place by video. The five monthly medical reviews use the data in the app and do not involve a call. A video call allows the doctor to discuss medical history, medicines and test results. The doctor assesses the medical history and the results and then decides whether the patient can be treated in the programme, and decides on a prescription after assessing the patient's health.

Breathlessness, palpitations, fainting spells or swelling in the lower legs need to be reported to the doctor before the initial consultation. With such symptoms the doctor may order a cardiology assessment before a prescription. If such a symptom has appeared recently, we ask for contact before the scheduled appointment. Chest pain, marked breathlessness or fainting require urgent medical help.

At check-ups the patient reports home measurements and symptoms, and the doctor decides on the dose and prescription. Home scales can differ, so we compare weight changes on the same scales and in similar conditions, for example in the morning before breakfast.

Prescriptions are issued electronically, and the patient can have them dispensed at any pharmacy. Before issuing a prescription, the doctor assesses symptoms, tolerance of the medicine and changes in health, because the dose and safety of treatment depend on them. We do not issue prescriptions without such an assessment.

The medicine is usually the largest expense. According to the list of reimbursed medicines in force from 1 July 2026, the products discussed here are not reimbursed for obesity; reimbursement of some medicines in type 2 diabetes applies to a different indication and separate criteria. Our treatment programme costs PLN 1,799 for six months and includes consultations with a doctor and a psychologist. On top of that there may be dietary consultations, depending on the treatment plan. We discuss costs before treatment starts so that the patient does not have to stop it for financial reasons.

Some tests and services are free of charge. A GP can order tests such as a full blood count, glucose, a lipid profile, liver tests, creatinine and TSH when they are indicated, and does not need a referral from us. The cardiovascular disease prevention programme covers people aged 35 to 65 who have not been diagnosed with specified cardiovascular diseases, diabetes, chronic kidney disease or familial hypercholesterolaemia and who have not used the programme in the past five years. It includes measurements, a lipid profile and a risk assessment, and eligibility is checked by the provider. The adult health check in the Moje Zdrowie programme is available from the age of 20, every five years up to 49 and every three years from 50. After a Moje Zdrowie check, a person must wait 12 months before joining the cardiovascular prevention programme. The check may include educational advice, for example on nutrition, given by a dietitian or another authorised team member.

In primary care practices that provide coordinated care, dietary consultations and educational advice are available to patients with specified diagnoses, in separate areas of care, such as diabetes, high blood pressure, heart failure, thyroid disease or chronic kidney disease. The scope depends on the practice, and a diagnosis of obesity alone, code E66, does not qualify a patient for this pathway. A specialist clinic under the NFZ, such as cardiology, diabetology or endocrinology, usually requires a referral from a doctor working under public health insurance, not necessarily a GP; the regulations provide exceptions. Bariatric surgery and cardiac rehabilitation can be funded by the NFZ once eligibility criteria are met.

Patients book NFZ-funded services directly with the chosen provider. The patient can pass on information about the diagnosis, tests performed and recommended treatment to their GP and cardiologist.

According to Polish recommendations from 2025, bariatric surgery is considered at a BMI of 35 or more, regardless of obesity-related conditions, and at a BMI of 30 to 34.9 in a person with type 2 diabetes that remains poorly controlled despite treatment. Eligibility is assessed by the surgical centre, which considers BMI, coexisting conditions, nutritional status and physical function, among other factors. NFZ funding criteria and the requirements of a given centre are described separately and may differ from clinical recommendations. Older age alone does not rule out surgery. The patient attends the centre with test results and a description of previous treatment.

We treat medication neither as a mandatory step before surgery nor as a way of postponing it. In some patients, medication helps reduce weight before the operation or helps afterwards when weight stabilises higher than expected. Losing weight before surgery may bring benefits, but it does not always reduce complications, and a good result with medication does not guarantee that surgery will no longer be needed. After the operation we care for the patient together with the surgical centre. Monitoring of protein, iron, vitamin B12, vitamin D and other nutrients depends on the type of operation and the centre's recommendations, because deficiencies do not always cause symptoms straight away.

Before any general anaesthesia or deep sedation, including before a cardiac or orthopaedic procedure, the anaesthetist needs to know about the GLP-1 medicine. A joint statement by five societies from 2024 does not recommend routinely skipping a dose in all patients. In people without increased risk, treatment can continue. During dose escalation, at a high dose, with gastrointestinal symptoms or other risk factors, the plan may include a liquid diet for at least 24 hours before the procedure, an ultrasound check of the stomach contents, a change in the anaesthetic approach or postponing the procedure. The anaesthetist sets the details of fluids and fasting. The patient should not skip a dose on their own, but should tell the anaesthetist the name of the medicine, the dose and the date of the last dose.

We also provide online treatment for residents of Świdnica, Świebodzice, Boguszów-Gorce, Szczawno-Zdrój, Jedlina-Zdrój, Głuszyca, Mieroszów, Nowa Ruda, Kamienna Góra, Strzegom, Dzierżoniów and Ząbkowice Śląskie.

The doctor and psychologist consultations take place by video, so a patient from Nowa Ruda or Kamienna Góra does not have to travel to Wałbrzych, including when the dose changes. The five monthly medical reviews use app data without a call.

Patients can have blood tests closer to home, at a collection point or through their GP, and send the results before a check-up; the doctor decides which tests are needed and how recent they must be. If a cardiology consultation or an echocardiogram becomes necessary during treatment, the patient can choose a clinic closer to home to limit travel.

Just outside the city there are two health resorts: Szczawno-Zdrój, whose treatment profiles include obesity and diabetes, and Jedlina-Zdrój, where cardiac treatment is provided, including cardiac rehabilitation.

How do you get an NFZ referral to a sanatorium?

A referral for spa treatment is issued electronically by a doctor working under public health insurance, including a GP, and assessed by a doctor at the regional NFZ branch. A standard adult stay in a spa sanatorium lasts 21 days and is partly paid, because the patient contributes towards accommodation and meals. Treatment in a spa hospital also lasts 21 days with no charge for the stay, while spa rehabilitation is a separate form that lasts 28 days. A new referral can be issued no earlier than 12 months after the previous spa treatment ended, and sanatorium treatment is recommended no more often than once every 18 months. The NFZ refers people who can travel independently, look after themselves and take part in treatments. With obesity and limited mobility, a referral may be rejected because of this criterion, while BMI alone is not a reason for refusal. We tell patients considering a stay about this criterion.

Why is a further treatment plan needed after a spa stay?

A sanatorium stay includes regular meals, exercise and treatments supervised by medical staff. For a patient after a heart attack or heart procedure, we coordinate cardiac rehabilitation and obesity treatment according to their condition, without unnecessarily postponing obesity treatment. A spa stay does not replace an individual treatment plan and further follow-ups in a chronic disease. The doctor decides whether medication is needed and whether it should continue, and a spa treatment profile alone does not guarantee a prescription. Without a plan after returning home, the risk of regaining weight increases.

We suggest that patients returning from Szczawno or Jedlina treat the stay as one stage of treatment. Before the consultation the patient sends the discharge summary and test results from the sanatorium, and the doctor takes them into account in further treatment.