In Germany, around 13 million adults (about 19%) are obese; in Switzerland, obesity affects about 1 million adults (around 12%). Severe overweight is therefore a widespread health problem in both countries. The editorial team of the Leading Medicine Guide spoke with Dr. med. Jörg Celesnik to learn about available treatment options and what to consider.
Obesity is among the greatest health challenges of our time. An increasing number of people in Germany and Switzerland suffer from severe overweight, which goes far beyond a purely aesthetic issue. Obesity is a chronic, multifactorial disease associated with a wide range of comorbidities such as diabetes, hypertension, cardiovascular disease, and orthopedic problems. In addition to health consequences, obesity often leads to a considerable reduction in quality of life and frequently results in psychosocial strain. The steadily rising number of those affected, especially among children and adolescents, underscores the importance of prevention, education, and modern therapeutic offerings to provide effective help.
The rise in obesity in Germany and Switzerland can be traced to a complex interplay of societal, economic, and individual factors.
„Over the past nearly two decades, the number of patients with obesity has increased significantly, but there is no simple explanation. This development is multifactorial and reflects a global pandemic. In the Ruhr region, for example, where Knappschaft Kliniken Bottrop is located, living conditions have fundamentally changed over the last 50 years, primarily due to structural transformation. In the past, many people worked in mining and heavy industry, where physical labor meant high calorie expenditure. Today, these jobs scarcely exist, so with the same caloric intake, less energy is burned in everyday life. In addition, more and more young people spend their time on their phones instead of being active outdoors on the soccer field, further lowering basal energy expenditure. Socioeconomic inequality also plays a decisive role. People from socially disadvantaged backgrounds often rely on energy-dense, nutrient-poor foods that are readily available because healthier options are often unaffordable. Over the last 20 to 30 years, the availability of food has increased dramatically. Fast-food chains and supermarkets constantly offer a variety of ready-made meals, snacks, and XXL portions, promoting the consumption of large quantities. In the past, family routines included firmly anchored mealtimes, such as Sunday dinner or shared breakfasts and dinners, which is now far less common. Eating has increasingly become a sideshow, with food consumed while watching TV, working, at the computer, or on the go. All these factors together—changing work conditions, technological progress, socioeconomic disparities, and altered eating habits—partially explain the complex development of obesity in the last decade“, explains Dr. Celesnik, further elaborating:
„The increasing number of people with obesity is not only due to socioeconomic factors but also to a variety of individual influences. Family predisposition can play an important role, among other things. In our center, we often treat several family members at the same time, underscoring the genetic component. Psychological burdens such as stress and depression also play a significant role and have increased considerably in today’s industrialized world. Many people turn to food for comfort in such situations, which exacerbates the problem. It is difficult, however, to determine whether psychological problems cause obesity or the other way around, which is why careful evaluation is necessary to develop targeted treatment options. Sleep also plays an often underestimated role. Too little sleep significantly disrupts hormonal balance, making weight control more difficult. Overall, some things have gotten out of hand, and certain factors are hard to influence. Medications are another significant point: Many diseases are successfully treated today with very effective drugs, but some of these—such as antidepressants, beta blockers, cortisone, and some antidiabetics—can have side effects that promote weight gain. Especially for people who depend on such medications long-term, it is important to keep these connections in mind in order to tailor treatment individually“.
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Obesity has far-reaching effects that extend well beyond physical health and can severely impact both the psychological and social quality of life of those affected.
„With massive overweight—more correctly termed excess weight today—the body is subjected to significant strain, increasing the risks for numerous diseases. One must be aware that markedly elevated body weight burdens the cardiovascular system, raising the risk of hypertension, type 2 diabetes, sleep apnea, and arteriosclerosis. Excess weight also places major stress on the joints, leading to increased wear and pain. Hardly any joint remains unaffected, regardless of limitations in mobility. Overall, the risk of chronic diseases that can significantly impair life increases. The psychological aspect is just as relevant. Overweight remains stigmatized, even though the World Health Organization recognized obesity back in 2000 as an independent chronic, incurable disease—a very groundbreaking step that was implemented in Germany only about five years ago. While this recognition facilitates treatment, it does not change the fact that those affected often face prejudice and may develop mental health issues such as depression, anxiety, eating disorders, or even psychotic illnesses. This situation creates a vicious cycle: Psychological burdens foster unhealthy eating behaviors and thus intensify obesity. Lack of exercise and physical limitations reduce everyday mobility and flexibility as well as participation in social life, leading to social exclusion, which can further exacerbate psychological problems. In addition, obesity is associated with an increased risk of numerous malignant diseases, especially tumors. Colorectal cancer in particular is directly linked to obesity. Only a multimodal perspective and approach can break this cycle and offer effective support“, explains Dr. Celesnik.
In addition to physical problems, obesity significantly affects mental health. Feelings of shame, guilt, or inadequacy are widespread. Anxiety disorders and depressive symptoms also occur more frequently. Psychological stress can in turn influence eating behavior, with emotional eating or binge eating used as coping mechanisms, which further encourages weight gain and creates a vicious cycle.
Long-term prevention of obesity requires a holistic approach that considers lifestyle, nutrition, physical activity, and psychological and social factors. Strategies that start early and aim for sustainability rather than short-term success have proven particularly effective.
Dr. Celesnik explains the approach and recommendations of Knappschaft Kliniken Bottrop: „In our practice, preventive strategies have proven effective, especially for patients who have not yet reached an extreme obesity category 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 treatment BMI is around 50, which falls within the range of severe obesity, the grade 3 form. Here in Germany, we are still far behind, whereas our neighboring countries, such as the Netherlands, Belgium, France, and England, offer surgery much more frequently and earlier. As part of counseling, we rely on general, easy-to-implement strategies that can help everyone. This includes, above all, a balanced diet with plenty of variety and tailored to individual needs. Less sugar and fewer processed foods are key points because they unnecessarily drive up calorie intake. We consciously advise against highly sweetened beverages like energy drinks, which are full of calories and unnecessary additives. We avoid the term ‘diet’ in the context of treatment; most of our patients have already suffered for a long time by the time they come to us. The term ‘diet’ is often linked to negative experiences that mean significant deprivation and fuel 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, a corresponding optimization of behavior, and, additionally, integrating regular physical activity into everyday life. This also includes consciously building physical activity into daily routines—for instance, 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 sustainably improve endurance, mobility, and body weight. A very important point is to examine one’s own behavior patterns and the ‘why.’ People often resort to unhealthy habits like evening snacking in front of the TV, and one should ask whether the 1,500 calories consumed in a bag of chips are truly necessary and what healthier alternative might achieve the same effect“, and he emphasizes:
„The decisive point is that people need guidance. They need a ‘pilot’ who supports them in implementing these changes, motivates them, and shows them the way to a healthier lifestyle. The primary care physician is just as crucial and should actively accompany and guide the patient. In our center, we work with numerous partners in the field of professional nutritional counseling. These experts speak with patients as equals about their daily diet and eating behavior and help analyze individual habits that may have been present since childhood. Documenting nutrition—e.g., with a food diary—can help patients gain an overview of their energy intake. Many are surprised by how many calories they consume incidentally once they document it precisely. This concept is complemented by professional nutritional counseling“.
Modern therapeutic concepts for obesity increasingly focus on individualized care that takes into account patients’ physical health, psychological stability, and social circumstances. The goal is not only weight reduction but also sustainable improvement in quality of life and prevention of secondary diseases such as diabetes, hypertension, or joint problems.
„I would like to illustrate the process at our center with an example. Let’s consider a patient with a BMI of 55 who falls within the guideline-supported range for surgery. In Germany, while surgery is guideline-compliant starting at a BMI of 40—or at 35 with additional comorbidities—at a value of 55 all non-surgical treatment options for obesity fail. The question of when to actually intervene is complex, as earlier practice often involved waiting longer and attempting to reduce weight through conservative measures. Today, we recognize that delaying increases the risk of secondary diseases, which is why an intervention is primarily justified for this BMI category. The path to surgery usually begins with contacting our center by email or phone, where the patient reports that, due to massive overweight, they can hardly move and their quality of life is limited. After this initial contact, the patient receives a questionnaire from us that covers many important aspects: medical history, past ‘diets,’ physician-supervised weight-loss programs, any previous surgeries, as well as the general nutritional situation and current quality of life. Based on the information provided, a personal conversation with our certified care coordinators follows. They evaluate the questionnaire and, together with the patient, create an individualized preparatory treatment plan. This is followed by a consultation with a certified bariatric surgeon from our center so that the patient, well-informed and counseled, can undergo a guideline-compliant surgical procedure in a timely manner. For this patient group, there is usually no other way to achieve relevant weight loss without surgery. Until a few years ago in Germany, health insurance approval was still required, which greatly delayed the process, and many applications were initially rejected. Today, we almost always operate after guideline-compliant preparation without prior cost approval“, says Dr. Celesnik, then explaining what must take place before surgery:
„Before surgery, we conduct a thorough medical consultation to clarify patients’ expectations and review their comorbidities. It is important to determine whether expectations align with realistic prospects of success. Required preparation for patients also includes completing a short checklist that covers all relevant points, including a psychological assessment. This clarifies whether there are psychological contraindications that argue against surgery or should be addressed beforehand. If, for example, there is a mental illness that influences eating behavior, psychotherapy may be necessary to avoid jeopardizing the success of the procedure. All these aspects and more are part of a comprehensive preparatory process designed to create the best possible conditions for sustainable weight reduction“.
When evaluating a surgical candidate, it is important not only to consider the weight category but also to assess additional factors.
„This includes checking for hormonal abnormalities, which is why we perform a hormone panel to identify potential issues that might argue against surgery. The medical history, including any past tumors, must also be considered, as certain conditions can influence the decision. Another key criterion is whether the patient suffers from reflux. For example, if there is severe heartburn, this must be factored into the choice of surgical procedure. In the case of our example patient, however, we assume that everything in life has gone well so far—apart from chronic obesity. We would recommend a sleeve gastrectomy. In this procedure, the stomach is reduced to a volume of about 140 milliliters, which mechanically limits food intake and, through hormonal effects, reduces hunger. The gnawing hunger that plagues many patients and leads to uncontrolled snacking largely disappears. This means that patients must be prepared before surgery for how they will need to eat afterward. Another essential aspect is patient reliability after surgery. Our many years of experience show that, based on motivation and behavior, we can estimate well who will truly benefit from the procedure. Within a multimodal concept, it is important to ensure good preparation. Although the guidelines allow a prompt operation without further preparation, we ideally recommend a three- to six-month preparatory period, even for patients with a high BMI. During this time, there is nutrition therapy, behavior training, and education about what lies ahead after surgery. Physical activity is important, but for our sample patient—with, for example, 158 kilograms—the options to increase energy expenditure through exercise are significantly limited. Training at the gym or on a stepper is hardly realistic due to the strain, and stigmatization also plays a major role“, Dr. Celesnik clarifies, and further details pre-op preparation:
„As a rule, every patient receives a targeted nutritional adjustment prior to surgery, with special focus on a so-called protein phase. This phase, which usually lasts two weeks, asks patients to consistently change their diet to minimize calories and carbohydrates and instead significantly increase their protein intake. This has the positive side effect of markedly shrinking liver volume. Many patients also suffer from fatty liver disease, where fat deposits impair function. Liver shrinkage is extremely important from a surgical perspective because the operations are performed minimally invasively. Reducing liver volume makes the procedure technically easier.“
With a successful procedure in a patient with a BMI of 55, weight loss of approximately 80% to 85% of the original excess weight can be achieved within about 18 months. This means the patient could realistically reach the 100-kilogram mark, which—given an example weight of around 158 kilograms, based on a height of 1.80 meters—would be a significant milestone.
„Weight loss is, of course, only one part of the process. Excess skin after reducing such extensive overweight can become an issue. Interestingly, this affects women more often than men, particularly when the skin is older. There is the option to surgically remove excess skin, and we work with highly qualified partners specializing in reconstructive procedures. With massive excess skin after major weight loss, this is a different type of operation than simple fat removal. If there are medical indications—such as eczema or fungal infections beneath the so-called abdominal apron—health insurance usually covers the costs of these treatments as well. After surgery comes the most important phase: aftercare. As a certified center, we are obligated to provide lifelong follow-up. The first follow-up is six weeks after the operation, with further appointments at three, six, nine, and twelve months, as well as at one and a half and two years. These are initially conducted in person, but with increasing patient numbers, follow-up is increasingly handled digitally or by phone. Active care in the first two years is particularly intensive because the willingness to participate regularly is especially high during this period. After this time, adherence to follow-up generally declines; nevertheless, there is always the option of lifelong check-ups with us“, Dr. Celesnik makes clear.
Obesity has a decisive impact on the risk of metabolic and cardiovascular diseases. Visceral fat—the fat surrounding 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 act systemically and influence numerous metabolic and inflammatory processes.
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„Looking at men in particular, we often see real difficulties with visceral fat tissue—especially stubborn abdominal fat, commonly referred to as a ‘beer belly.’ This fat is not only a cosmetic concern for many but poses a significant health risk. We therefore hold intensive medical conversations to motivate men. We make it clear that remaining in this state carries serious health risks because abdominal fat is extremely dangerous. Our focus is not on cosmetic aspects but on health. While weight loss is sometimes framed publicly mainly in terms of beauty standards, that is only a side effect. At a BMI of 50, for example, life expectancy is shortened by seven to twelve years. The likelihood of developing metabolic syndrome—consisting of dyslipidemia, diabetes mellitus, and hypertension—is extremely high in obesity. I also see the connection to malignant diseases as confirmed. Many people hardly recognize themselves in the mirror after losing weight because they have not yet fully processed the change emotionally. It often takes longer to internalize that the person in the mirror truly is a very different individual, now with more quality of life and fewer disease-related complaints. Our goal is to make people genuinely healthier, not just change their outward appearance. We aim to sustainably reduce the risk of serious illnesses and markedly 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 achieve lasting change, mere lifestyle adjustments are not enough; professional help is often necessary. With a BMI of 40 and above, the chance of achieving a normal weight alone is extremely low. The body becomes programmed in such a way that a return to the normal range is hardly possible. Even drinking only water would hardly suffice because the body has, in effect, unlearned how to burn fat“.
„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 diabetes in many cases through metabolic surgery. No medication can achieve such lasting success. We are especially successful if surgery is performed within two years of the diabetes diagnosis“, says Dr. Celesnik.
Many years ago, the first GLP-1 medication was developed as a so-called „weight-loss injection,“ based on a hormone produced by the body. This hormone, which the body produces itself, plays a central role in regulating fat metabolism, fat absorption, and liver and metabolic processes.
„The actual effect in treating overweight lies less in permanently reducing stomach size and more in triggering, through hormonal action, a variety of mechanisms that lead to rapid weight loss. There are now combination preparations in which GIP, another hormone, is added to enhance the effect. However, official approval for these medications in Germany is only for overweight patients with a BMI of 30 to 35. This means that patients with a higher BMI formally fall outside the approval framework. Nevertheless, these medications are often used off-label—for example, in patients who have regained weight after previous obesity treatment to achieve a ‘reboot effect,’ or to reduce weight before a planned surgery. Possible side effects must always be considered when using them. One mechanism is that gastric emptying is significantly slowed, which increases the feeling of satiety because food remains in the stomach longer. There is also the risk that the stomach could be impaired in the long term, for instance through irreversible paralysis. Although the effect can be very effective, weight loss persists only as long as the medication is administered. After discontinuation, weight is quickly regained. In addition, there is a considerable black market on the internet where such medications are sold illegally. No one knows what problems might arise in the future from long-term use. Even so, these drugs should not be demonized, as they are an important building block in the spectrum of obesity treatments. What is crucial is that use is supervised by an expert who can assess the individual situation—this includes both specialists in obesity treatment and well-trained primary care physicians“, recommends Dr. Celesnik, adding:
„For patients with a BMI up to about 50 or 55, the ‘weight-loss injection’ without concomitant diabetes is not generally recommended, as it is a self-pay service. The cost is about 500 euros per month, which represents a significant financial burden for many patients. Medically, this treatment is also a gray area, because given the more than 12 million people with obesity in Germany, a nationwide coverage of the weight-loss injection by health insurers would hardly be economically feasible. Treating obesity therefore remains primarily a matter of targeted, medically supervised, and individually tailored therapy, with surgery—after a careful preparatory phase—being a very safe and sustainable option“.
Knappschaftskliniken Bottrop is home to a long-established and steadily growing obesity center that began performing surgeries in 2005. Dr. med. Jörg Celesnik has worked there since 2006 and has played a key role in building the obesity program.
„Today, we are a certified reference center for obesity and metabolic surgery—an honor held by only a small number of centers in Germany, namely in the low double digits. Specific criteria must be met for this certification, underscoring our high level of professionalism and quality. We place particular emphasis on very personal patient contact through our team. In addition to comprehensive counseling and conservative treatments, we offer highly professional, predominantly minimally invasive surgeries. Since 2019, we have also regularly used the da Vinci robot for procedures. It is important to understand that the robot only executes what the surgeon directs—it is not an independent, autonomous instrument. The robot operates next to the surgeon in the operating room and, through the precise transmission of the surgeon’s movements, ensures even greater accuracy. Our experience shows that the outcome of surgery primarily depends on the competence and experience of the surgeons. We have three highly specialized, very experienced certified surgeons performing the procedures. The entire surgical environment is optimally equipped: Our OR tables can support up to 350 kg, and our anesthesiologists are specially trained in caring for patients with severe obesity. The wards are also appropriately set up to adequately care for our bariatric patients. All these factors help ensure high patient safety and excellent results“, notes Dr. Celesnik, adding in conclusion:
„In 2025, we will perform about 150 bariatric surgeries. Moreover, it should not be overlooked that the proportion of patients with overweight within our overall patient base has also increased significantly. Our experience in bariatric surgery therefore also benefits patients with obesity who present with other conditions. There is a major difference between removing an appendix in someone who weighs 75 kg versus 185 kg—certain procedures are considerably more challenging in heavier patients. Finally, I would like to emphasize once again that obesity is a chronic disease. It can only be treated in a way that achieves long-term success through a multimodal—that is, multidisciplinary and multiprofessional—approach“.
Dr. Celesnik, thank you for this in-depth look at the chronic disease of obesity!
- Dr. med. Jörg Celesnik – Chief Physician and Head of the Department of General and Visceral Surgery at Knappschaft Kliniken Bottrop
- Head of the Bottrop Obesity Center
- Head of the Bottrop Hernia Center (Reference Center)
- Specialist in Visceral Surgery and Specialized Visceral Surgery
- Specialist in Minimally Invasive Surgery
