Obesity – Health, Prevention, and Treatment

In Germany, approximately 13 million adults (about 19%) are obese; in Switzerland, obesity affects about 1 million adults (about 12%). This makes severe obesity a widespread health problem in both countries. The editorial team at Leading Medicine Guide spoke with Dr. Jörg Celesnik to learn about the treatment options available and what to consider.

Obesity is one of the greatest health challenges of our time. More and more people in Germany and Switzerland are suffering from severe obesity, a condition that goes far beyond a purely aesthetic problem. Obesity is a chronic and multifactorial condition associated with a variety of comorbidities such as diabetes, high blood pressure, cardiovascular diseases, and orthopedic problems. In addition to its health consequences, obesity often leads to a significant reduction in quality of life, which frequently results in psychosocial stress. The steadily rising number of people affected—especially children and adolescents—highlights the importance of prevention, education, and modern treatment options in effectively helping those affected.

The rise in obesity in Germany and Switzerland can be attributed to a complex interplay of social, economic, and individual factors. 

“Over the past nearly two decades, the number of patients with obesity has risen significantly, but there is no single explanation for this. This trend is multifactorial and reflects a global pandemic. In the Ruhr region, for example, where the Knappschaft Kliniken Bottrop are located, living conditions have changed fundamentally over the past 50 years, primarily due to structural change. In the past, many people worked in mining and heavy industry, where physical labor meant a high calorie expenditure. Today, these jobs are virtually nonexistent, so people burn less energy in their daily lives while their calorie intake remains the same. In addition, more and more young people are spending their time on their cell phones instead of being active outdoors on the soccer field, which further reduces their basal metabolic rate. Socioeconomic inequality also plays a decisive role. People from socially disadvantaged backgrounds often turn to high-calorie, nutrient-poor foods that are readily available, because they frequently cannot afford healthier options. Over the past 20 to 30 years, the availability of food has increased significantly. Fast-food chains and supermarkets constantly offer a wide variety of ready-made meals, snacks, and XXL portions, which encourages the consumption of large quantities. In the past, meals were firmly anchored in family life—such as Sunday dinner or shared breakfasts and dinners—which is hardly common today. Eating is increasingly becoming a secondary activity, so that meals are consumed on the side while watching TV, at work, at the computer, or on the go. “All these factors combined—changing work conditions, technological progress, socioeconomic disparities, and changing eating habits—partially explain the complex rise in obesity over the past decade,” says Dr. Celesnik, describing the dilemma, and continues:

“The rising number of people with obesity is attributable not only to socioeconomic factors but also to a variety of individual influences. Among other things, family predisposition can play an important role here. At our center, we often treat several family members at the same time, which underscores the genetic component. Psychological stressors such as stress and depression also play a significant role. In today’s modern world, they have increased significantly. In such situations, many people turn to food for comfort, which exacerbates the problem. However, it is difficult to determine whether psychological problems are the cause of obesity or vice versa, which is why a thorough evaluation is necessary to develop targeted treatment options. Sleep also plays an often-underestimated role. Too little sleep significantly disrupts hormonal balance, which in turn makes weight control more difficult. Overall, some things have gotten out of hand, and certain factors are difficult to influence. Medications are another significant factor: Many conditions are successfully treated today with highly effective medications, but some of these medications—such as antidepressants, beta-blockers, corticosteroids, and certain antidiabetic drugs—can have side effects that promote weight gain. It is particularly important for people who rely on such medications long-term to keep these connections in mind in order to tailor their treatment individually.”

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Obesity has far-reaching consequences that go well beyond purely physical health and can severely impair both the mental and social quality of life of those affected. 

“In cases of severe overweight—which is now more accurately referred to as excess weight—the body is subjected to considerable strain, which increases the risk of numerous diseases. It is important to realize that significantly increased body weight puts a strain on the cardiovascular system, which raises the risk of high blood pressure, type 2 diabetes, sleep apnea, and atherosclerosis. In addition, excess weight places heavy demands on the joints, leading to increased wear and tear and pain. Virtually no joint remains unaffected, regardless of the degree of mobility restriction. Overall, the risk of chronic diseases that can significantly impair quality of life increases. The psychological aspect is just as relevant. Being overweight continues to be stigmatized, even though the World Health Organization has recognized obesity as a distinct, chronic, incurable disease since the year 2000—a groundbreaking step that was only implemented in Germany a little over five years ago. While this recognition facilitates treatment, it does not change the fact that those affected are often confronted with prejudice and may develop mental health issues such as depression, anxiety, eating disorders, or even psychotic disorders. This situation creates a vicious cycle: Psychological stress promotes unhealthy eating behaviors, thereby exacerbating obesity. A lack of physical activity and physical limitations reduce mobility and flexibility in daily life and participation in social activities, leading to social exclusion, which in turn can exacerbate mental health problems. In addition, obesity is associated with an increased risk of numerous malignant diseases, especially cancers. Colorectal cancer, in particular, is directly linked to obesity. “Only through a multimodal perspective and approach can this cycle be broken and effective support offered to those affected,” explains Dr. Celesnik. 

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In addition to physical problems, obesity has a significant impact on mental health. Feelings of shame, guilt, or inadequacy are widespread. Anxiety disorders and depressive symptoms are also more common. Psychological stress, in turn, can influence eating behavior, with emotional eating or binge eating being used as coping mechanisms, which further promotes weight gain and creates a vicious cycle.

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Long-term prevention of obesity requires a holistic approach that takes into account lifestyle, nutrition, physical activity, as well as psychological and social factors. Strategies that begin early and aim for sustainability rather than short-term success have proven particularly effective. 

Dr. Celesnik explains the approach and recommendations of the Knappschaft Kliniken Bottrop: “In our practice, prevention strategies have proven effective, especially for patients who have not yet reached the category of extreme obesity but are already on their way there. We conduct regular counseling sessions because most people who come to us already have a very high body mass index (BMI). Our average BMI for patients undergoing treatment is around 50, which already falls within the range of severe obesity—that is, Grade 3 obesity. Here in Germany, we are still lagging far behind in this regard, while our neighboring countries, such as the Netherlands, Belgium, France, and England, offer surgery much more frequently and at an earlier stage. During the consultation, we focus on general, easy-to-implement strategies that could help anyone. Above all, this includes a balanced diet that is varied and tailored to individual needs. Reducing sugar and processed foods is key, as they unnecessarily drive up calorie intake. We specifically advise against highly sweetened beverages such as energy drinks, which are packed with calories and unnecessary additives. We avoid using the term “diet” in our treatment; most of our patients have already endured a long history of struggle by the time they come to us. The term “diet” is usually associated with negative experiences involving significant deprivation, which contribute to the vicious cycle of cravings and the yo-yo effect. Instead of short-term diets, our goal is a long-term and lasting change in eating and nutritional habits, along with corresponding behavioral adjustments, with the ultimate aim of permanently and regularly integrating physical activity into daily life. This also includes consciously incorporating physical activity into daily life—such as taking the stairs instead of the elevator or covering short distances by bike or on foot instead of by car. These small steps add up and help to sustainably improve endurance, flexibility, and body weight. A very important point is to examine your own behavioral patterns and the “why” behind them. People often resort to unhealthy habits like snacking in front of the TV in the evening, but one should ask oneself whether the 1,500 calories consumed from a bag of chips are really necessary and what healthier alternative might achieve the same effect,” he says, emphasizing:

“The key point is that people need guidance. They need a ‘guide’ who supports them in implementing these changes, motivates them, and shows them the path to a healthier lifestyle. Just as crucial is the primary care physician, who should actively guide and support the patient. At our center, we collaborate with numerous partners in the field of professional nutritional counseling. These experts speak with patients on an equal footing about their daily diet and eating habits and help them analyze individual eating patterns that may have been with them since childhood. Documenting their diet—for example, through a food diary—can help patients gain an overview of their energy intake. Many are surprised by how many calories they consume without even realizing it once they start keeping a detailed record. This approach is complemented by professional nutritional counseling.”

Modern treatment approaches for obesity are increasingly focused on individualized care that takes into account patients’ physical health, mental well-being, and social circumstances. The goal is not only weight loss but also a sustainable improvement in quality of life and the prevention of complications such as diabetes, high blood pressure, or joint problems.

“I’d like to use an example to illustrate the process at our center. Let’s imagine a patient with a BMI of 55 who falls within the guideline-recommended range for surgery. In Germany, the guidelines state that surgery is indicated for a BMI of 40 or higher, or for a BMI of 35 with additional comorbidities, and that at a BMI of 55, all non-surgical treatment options for obesity have failed. The question of when to actually intervene is complex, as the previous practice often involved waiting for an extended period and attempting to reduce weight through conservative measures. Today, we recognize that delaying treatment increases the risk of complications, which is why surgery is primarily justified in this BMI category. The path to surgery usually begins with the patient contacting our center by email or phone to explain that, due to severe obesity, they can barely move and their quality of life is severely limited. Following this initial contact, we send the patient a questionnaire that covers many important aspects: medical history, previous “diets,” medically supervised weight-loss programs, any prior surgeries, as well as general dietary habits and current quality of life. Based on this information, a personal consultation follows with our certified specialist coordinators, who evaluate the questionnaire and work with the patient to develop a personalized preliminary treatment plan. This is followed by a consultation with a certified bariatric surgeon from our center, so that the patient can undergo surgery promptly, in accordance with guidelines, while being well-informed and fully educated about the procedure. For this group of patients, there is usually no other way to achieve significant weight loss without surgical intervention. Until a few years ago, prior authorization from the health insurance provider was still required in Germany, which significantly delayed the process and resulted in many applications being denied at the initial stage. “Today, we almost always perform surgery following guideline-compliant preparation without prior cost approval,” says Dr. Celesnik, who then explains everything that must be done before surgery:

“Before the surgery, we conduct a detailed preliminary medical consultation to clarify the patients’ expectations and assess their comorbidities. It is important to determine whether their expectations align with realistic prospects for success. For patients, the necessary preparation also includes, among other things, working through a short checklist that covers all relevant points, including a psychological evaluation. The purpose of this is to determine whether there are any psychological contraindications that would preclude surgery or that should be addressed beforehand. For example, if a patient has a mental health condition that affects their eating behavior, psychotherapy may be necessary in some cases to ensure the surgery’s success is not compromised. All these aspects—and more—are part of a comprehensive preparation process designed to create the best possible conditions for sustainable weight loss.”

When evaluating a candidate for surgery, it is important not only to consider the patient’s weight category but also to examine other factors. 

“This includes determining whether there are any hormonal imbalances, which is why we assess hormone levels to identify any potential issues that could preclude surgery. A history of conditions such as cancer must also be taken into account, as certain medical conditions can influence the decision. Another key criterion is whether the patient suffers from reflux. If, for example, the patient experiences severe heartburn, this must be taken into account when selecting the surgical procedure. In the case of our example patient, however, we assume that everything in life has gone well so far, except for chronic obesity. In this case, we would recommend a sleeve gastrectomy. This procedure reduces the stomach’s volume to approximately 140 milliliters, which both mechanically limits food intake and reduces hunger through hormonal effects. The feeling of hunger that torments many patients and leads to uncontrolled snacking largely disappears as a result. This means that patients must be prepared before surgery for how they will need to eat after the procedure. Another essential aspect is the patients’ commitment after surgery. Our many years of experience show that, based on patients’ motivation and behavior, we can accurately assess who will truly benefit from the surgery. It is important to ensure thorough preparation as part of a multimodal approach. Although the guidelines permit surgery in the short term without further preparation, we ideally recommend a three- to six-month preparation period, even for patients with a high BMI. During this time, patients receive nutritional therapy, behavioral training, and education about what to expect after surgery. Physical activity is important, but for our typical patient—weighing, for example, 158 kilograms—the possibilities for increasing energy expenditure through exercise are significantly limited. “Working out at the gym or on a stepper is hardly realistic due to the physical strain involved, and stigmatization also plays a major role here,” explains Dr. Celesnik, elaborating further on preoperative preparation:

“As a rule, every patient undergoes a targeted dietary change before surgical treatment, with particular emphasis placed on a so-called ‘protein phase.’ This phase, which usually lasts two weeks, requires patients to consistently adjust their diet to minimize calories and carbohydrates as much as possible and instead significantly increase their protein intake. This has the positive side effect of significantly reducing liver volume. Many patients also suffer from fatty liver, whose function is impaired by fat deposits. From a surgical perspective, shrinking the liver is extremely important because the procedures are performed using minimally invasive techniques. Reducing the liver’s volume makes the surgery technically easier.”

In the case of a successful procedure on a patient with a BMI of 55, a weight loss of approximately 80 to 85 percent of the original excess weight can be achieved within about 18 months. This means that, realistically, the patient could reach the 100-kilogram mark, which—based on an example weight of around 158 kilograms calculated from her height of 1.80 meters—would be a significant milestone.

“Weight loss is, of course, only part of the process. Excess skin following such extensive weight loss can become an issue. Interestingly, this affects women more often than men, especially when the skin is older. It is possible to surgically remove the excess skin; we work with highly qualified partners who specialize in reconstructive surgery. In cases of massive excess skin following significant weight loss, the procedure is different from simple fat removal. If there are medical indications, such as eczema or fungal infections under the so-called “fat apron,” health insurance generally covers the costs of these treatments as well. The most important phase—postoperative care—follows the surgery. As a certified center, we are obligated to provide lifelong support to our patients. The first follow-up appointment takes place six weeks after surgery, with additional appointments scheduled at three, six, nine, and twelve months, as well as after one and a half and two years. Initially, these appointments are conducted in person, but as the number of patients increases, follow-up care is increasingly provided digitally or by phone. Active care during the first two years is particularly intensive because patients’ willingness to participate regularly is especially high during this time. After this period, adherence to follow-up care usually declines; however, patients generally have the option of continuing to receive checkups from us for the rest of their lives,” Dr. Celesnik explains.

Obesity has a decisive influence on the risk of metabolic and cardiovascular diseases. Visceral fat, for example—the fat that surrounds the internal organs in the abdominal cavity—is metabolically active and produces a variety of hormones, cytokines, and inflammatory mediators known as adipokines. These substances have systemic effects and influence numerous metabolic and inflammatory processes.

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“When we look at men, we often see real difficulties with visceral fat tissue, especially stubborn belly fat, which is often colloquially referred to as a ‘beer belly.’ This fat is not only a cosmetic concern for many affected individuals, but also poses a significant health risk. That is why we also conduct in-depth medical consultations to motivate men. We clearly point out that remaining in this condition carries serious health risks, as abdominal fat is extremely dangerous. Our focus here is not on cosmetic aspects, but on health. Although weight loss is sometimes primarily associated with beauty ideals in the public eye, that is only a side effect. With a BMI of 50, for example, life expectancy is reduced by seven to twelve years. The likelihood of developing metabolic syndrome—which consists of lipid metabolism disorders, diabetes mellitus, and high blood pressure—is extremely high in cases of obesity. I also see the links to malignant diseases as well-established. Many people who have lost weight barely recognize themselves in the mirror because they haven’t yet fully processed the emotional aspects of the process. It often takes longer to realize that the person standing in front of the mirror is actually a completely different person—someone with a better quality of life and fewer health-related complaints. “Our goal is to truly make people healthier, not just to change their outward appearance. We aim to sustainably reduce the risk of serious diseases and significantly improve quality of life,” says Dr. Celesnik, making it unmistakably clear:

“Many men have now realized that the so-called ‘beer belly’ is stubborn. But to make lasting changes, mere adjustments to lifestyle habits alone are not enough; professional help is often necessary. With a BMI of 40 or higher, the chance of reaching a normal weight on one’s own is extremely low. Over time, the body is programmed in such a way that a return to the normal range is hardly possible. Even drinking only water would hardly be enough, because the person affected has already lost the ability to burn fat.”

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“The effect on diabetes is particularly impressive. In patients with a BMI over 40 and newly diagnosed type 2 diabetes mellitus, we can completely cure the diabetes in many cases through metabolic surgery. No medication can achieve such lasting success. We are particularly successful when surgery is performed within two years of the diabetes diagnosis,” said Dr. Celesnik.

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Many years ago, the first GLP-1 medication was developed as a so-called “weight-loss injection” based on a hormone produced naturally by the body. This hormone, which is produced naturally in the body, plays a central role in regulating fat metabolism, fat absorption, and liver and metabolic processes. 

“The actual effect in treating obesity lies less in permanently reducing the size of the stomach and more in triggering, through the hormonal effect, a variety of mechanisms that lead to rapid weight loss. There are now combination drugs to which GIP, another hormone, is added to enhance the effect. However, these medications are officially approved in Germany only for overweight patients with a BMI of 30 to 35. This means that patients with a higher BMI are technically outside the approval criteria. Nevertheless, these medications are frequently used off-label—for example, in patients who have regained weight after previous obesity treatment to achieve a so-called “reboot” effect, or to reduce weight prior to a planned surgery. When using these medications, however, one must always be mindful of potential side effects. One mechanism of action involves significantly slowing gastric emptying, which increases the feeling of fullness because food remains in the stomach longer. However, there is also a risk of long-term damage to the stomach, such as irreversible paralysis. Although the effect can be very effective, weight loss is sustained only as long as the medication is administered. After discontinuing the medication, weight is regained quickly. In addition, there is a significant black market online where such medications are sold illegally. No one knows what problems may arise in the future as a result of long-term use. Nevertheless, these medications should not be demonized outright, as they are an important component of the treatment spectrum for obesity. “It is crucial that the medication be administered by an expert who can assess the individual’s situation; this includes both specialists in obesity treatment and well-trained primary care physicians,” recommends Dr. Celesnik, adding:

“For patients with a BMI of up to about 50 or 55 who do not have diabetes, the ‘weight-loss injection’ is not generally recommended, as it is a service that patients must pay for out of pocket. The cost is about 500 euros per month, which represents a significant financial burden for many patients. Furthermore, this treatment is a medical gray area, because with over 12 million obese people in Germany, widespread coverage of the weight-loss injection by health insurance companies would be virtually impossible to manage from an economic standpoint. The treatment of obesity therefore remains primarily a matter of targeted, medically supervised, and individually tailored therapy, in which surgical treatment—following a careful preparatory phase—is a very safe and sustainable option.”

The Knappschaftskliniken Bottrop is home to a long-established and steadily growing obesity center, which began performing its first surgeries in 2005. Dr. Jörg Celesnik has been working there since 2006 and played a key role in establishing the obesity program.

“Today, we are a certified reference center for obesity and metabolic surgery—a distinction held by only a handful of centers in Germany, specifically in the low double digits. To achieve this certification, certain criteria must be met, which underscores our high level of professionalism and quality. We place special emphasis on the very personal patient care provided by our team. In addition to comprehensive counseling and conservative treatments, we offer highly professional, predominantly minimally invasive surgeries. Since 2019, we have also been regularly using the da Vinci robot during procedures. It is important to understand that the robot only performs the actions directed by the surgeon—it is not an independent, autonomous instrument. The robot is positioned next to the surgeon in the operating room and ensures even greater precision by precisely replicating the surgeon’s movements. Our experience shows that the outcome of a surgery depends above all on the competence and experience of the surgeons. We have three highly specialized, very experienced, certified surgeons who perform the procedures. The entire surgical setting is optimally equipped: We have operating tables that can support up to 350 kg, and our anesthesiologists are specially trained to care for heavy patients. The wards are also appropriately equipped to provide adequate care for our bariatric patients. All these factors contribute to ensuring a high level of patient safety and excellent outcomes,” notes Dr. Celesnik, concluding:

“In 2025, we will perform approximately 150 bariatric surgeries. Furthermore, it should not be overlooked that the proportion of overweight patients within our overall patient population has also increased significantly. Our experience in bariatric surgery thus also benefits obese patients with other medical conditions. There is a big difference between removing an appendix from someone weighing 75 kg versus 185 kg—certain surgeries are significantly more challenging in heavier patients. In conclusion, I would like to emphasize once again that obesity is a chronic disease. It can only be treated through a multimodal—that is, multidisciplinary and multiprofessional—approach in a way that ensures long-term success.”

Dr. Celesnik, thank you very much for this in-depth look at obesity as a chronic disease!

 

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• Dr. Jörg Celesnik, M.D. – Chief Physician and Director of the Department of General and Visceral Surgery at the Knappschaft Clinics in Bottrop
• Director of the Bottrop Obesity Center
• Director of the Bottrop Hernia Center (Reference Center)
• Board-certified specialist in visceral surgery and specialized visceral surgery
• Specialist in Minimally Invasive Surgery