Professor Plamen Staikov, MD, is an internationally recognized authority in the field of bariatric surgery and abdominal surgery. As Medical Director and Chief Physician at Sachsenhausen Hospital in Frankfurt am Main, he is regarded as an expert in minimally invasive and innovative bariatric procedures, as well as in the surgical treatment of cancer. His area of expertise covers the entire spectrum of bariatric surgery, with specialisms including gastric bypass, sleeve gastrectomy, mini-gastric bypass and other techniques. As one of Europe’s leading obesity centers, Sachsenhausen Hospital, under the leadership of Prof. Dr Staikov, performs more than 1,000 operations per year and also offers specialized revision surgery for patients from across Germany and worldwide.
With experience of more than 10,000 operations performed as Head of the Surgical Department, his main focus is on laparoscopic surgery. In addition to treating gastrointestinal disorders and performing gallbladder operations, he specializes in obesity and oncological surgery. His Obesity Center in Frankfurt Sachsenhausen is one of the leading facilities for the treatment of morbid obesity and is a renowned center for surgical diabetes treatment in Europe. Together with his team of colleagues, he is proficient in all bariatric procedures and offers particular expertise in the field of revision surgery following previous bariatric procedures.
In addition to bariatric surgery, the Department of Surgery under his leadership covers the full spectrum of tumor surgery, reflux surgery, trauma surgery, proctology and endocrine surgery. The focus is on the use of minimally invasive surgical techniques to ensure patients receive gentle treatment in a state-of-the-art operating theater. The exceptional expertise of Prof. Dr Staikov and his team enables not only the effective treatment of severely obese patients, but also the successful management of complex cases from all over the world.
His commitment to innovative surgical techniques, combined with his professional expertise, makes him a leading authority in the field of bariatric and abdominal surgery. According to the Robert Koch Institute, nearly 13 million adults in Germany suffer from obesity; and around 6% of children. For this reason, the editorial team at Leading Medicine Guide took the opportunity to speak with Prof. Dr Staikov about this condition and the treatment options available.
Obesity, as a chronic condition, has become one of the greatest global health challenges of the 21st century. It is characterized by an excessive accumulation of body fat and has a significant impact on the health and well-being of those affected. With increasing prevalence, obesity affects not only body weight but also other aspects of an individual’s life and can lead to a variety of health risks.
Obesity is associated with a wide range of health risks that can significantly impair general well-being.
“The risks of obesity have been known for many decades, and over 50 associated conditions stem from morbid obesity. One of the most significant risks concerns the cardiovascular system. People with obesity have an increased risk of high blood pressure, coronary heart disease, heart failure or strokes. Excess body fat can cause the heart to work harder to supply the body with blood, which increases the strain on the cardiovascular system. Furthermore, the risk of type 2 diabetes increases significantly in people with obesity. This results from insulin resistance caused by excess fat tissue. “The condition can lead to long-term complications such as nerve damage, eye problems and kidney disorders,” explains Prof. Dr Staikov at the start of our conversation.
Respiratory diseases are also more common in people with obesity, particularly sleep apnoea, which involves pauses in breathing during sleep, as well as asthma, which is exacerbated by the extra weight and the resulting breathing difficulties. “Anyone suffering from chronic sleep disturbances consequently suffers from fatigue as well, and simply lacks proper rest at night. This leads to stress and increased feelings of hunger – in such cases, the patient eats even more and finds themselves in a devastating spiral,” explains Prof. Dr Staikov, adding: “One thing is quite clear: once obesity is present, it is quite clear that the obesity will also progress. A distinction is made between three different degrees, determined by the Body Mass Index (BMI). Treatment is already necessary from a BMI of 30 onwards. Unfortunately, however, in Germany health insurance funds often only agree to surgical treatment for obesity, for example, once a BMI of 50 has been reached. This already corresponds to super-obesity and, in that sense, is almost too late for the patient, as complications arising from obesity are usually already present. “There are no good structures in place.”
Obesity is generally classified using the Body Mass Index (BMI). BMI is calculated by dividing weight in kilograms by the square of height in meters. The World Health Organization (WHO) has established guidelines for classifying BMI into different degrees of obesity.
Underweight: BMI below 18.5
Normal weight: BMI between 18.5 and 24.9
Overweight: BMI between 25 and 29.9
Obesity Class I (mild): BMI between 30 and 34.9
Obesity Class II (moderate): BMI between 35 and 39.9
Obesity Class III (severe): BMI of 40 or higher.
Musculoskeletal conditions such as osteoarthritis are common in people with obesity. The extra weight puts strain on the joints, which can lead to inflammation and premature wear and tear. Apart from the physical risks, obesity also affects mental well-being. People with obesity are at increased risk of depression, anxiety and low self-esteem. The stigma associated with being overweight can lead to social exclusion and psychological stress, which in turn affects mental health. In summary, obesity has a significant impact on overall well-being, both physically and mentally, and increases the risk of a variety of serious conditions, which can severely impair the quality of life of those affected.
Genetic predisposition plays a significant but complex role in the development of obesity.
Studies have shown that genetic predisposition can influence the risk of developing overweight and obesity. “Although much remains unclear, it can be said that genetics is a key factor in the risk of developing obesity. Various genes can play a role in metabolic processes, the appetite regulation mechanism and the distribution of fat in the body. These genetic factors can increase an individual’s risk of weight gain when they interact with environmental factors. Added to this are lifestyle factors. We have an immense surplus of calories that is impossible to escape. There is always food nearby. On top of that, we generally do not get enough exercise. Many people believe that if they have walked 10,000–12,000 steps a day, they have been physically active. But that is nowhere near enough. Compared to previous generations, the number of calories we burn is much lower. “A diet rich in high-calorie and processed foods, as well as a lack of physical activity, contribute significantly to weight gain,” explains Prof. Dr Staikov.
Weight gain in people can vary greatly despite an apparently similar calorie intake, and this can be explained by a variety of factors. The gut flora, also known as the gut microbiome, plays a crucial role in various aspects of health, including metabolism and weight. The microbiome consists of a multitude of microorganisms, such as bacteria, viruses, fungi and other microbes, that live in the digestive tract. “The gut flora is like a fingerprint and is completely unique in its composition for each individual. Certain patterns have been identified that are associated with obesity. Metabolism is also individual. However, it is not possible to identify a single cause for the predisposition to obesity,” says Prof. Dr Staikov on the varying rates of weight gain among people.
Non-surgical treatment options for people with obesity include various measures for weight loss and improving health.
“As already mentioned – in Germany, obese patients are usually referred too late. In any case, a good range of nutritional, behavioral and exercise therapy with competent practitioners would be necessary. This would at least offer a good chance of weight loss in the early stages, with a BMI of around 30. In fact, for decades there has been a recommendation to treat obesity from a BMI of 30 onwards. Because the person affected cannot manage it alone; that is an illusion. Despite the existing recommendation, there is no structure whatsoever to help the millions of obese people. “The crucial moment is for the person affected to take action in good time,” explains Prof. Dr Staikov, describing the unsatisfactory situation for people suffering from obesity.
- A balanced, calorie-conscious diet can help with weight loss. A diet rich in fruit, vegetables, whole grains and lean protein can support weight loss.
- Regular exercise is crucial for weight loss and improving general health. A structured exercise program that includes aerobic exercise, strength training and flexibility exercises can help burn calories and improve metabolism.
- Psychological support and behavioral therapy can help to change unhealthy eating habits, manage emotional eating and establish new, healthy behaviors.
- In some cases, weight-loss medication may be prescribed to suppress appetite or reduce fat absorption. These medications are usually used in combination with dietary changes and exercise therapy.
- Regular medical care and monitoring are important to track weight loss progress, treat co-morbidities and identify potential complications.
The most common bariatric procedures – gastric bypass, sleeve gastrectomy and adjustable gastric banding – differ both in how they are performed and in their effects on weight loss and potential risks.
“There are three standard operations for obese patients. The gastric sleeve procedure, the Y-shaped bypass and the somewhat newer omega bypass. The key factors in choosing the procedure are the patient’s initial weight, any underlying conditions, existing eating disorders, whether the patient smokes or takes medication, and their general living circumstances. All of this must be discussed in detail with the patient, as these are key criteria for the surgical method. It must also be clarified whether the patient will be able to continue attending follow-up appointments five, ten or twenty years after the operation,” explains Prof. Dr Staikov.
Roux-en-Y gastric bypass (Y-bypass): This is a common form of bariatric surgery used for weight loss. In this procedure, the stomach is divided into a small upper pouch and a larger lower pouch. The upper pouch is connected directly to the small intestine to bypass most of the stomach and the upper small intestine. This reduces the amount of food consumed and leads to a reduced calorie intake.
The Omega-Loop gastric bypass (mini-gastric bypass) was introduced in 1997 by Robert Rutledge as a specific variant of gastric bypass surgery. Compared to the traditional Roux-en-Y gastric bypass, this method is characterized by the creation of a single new connection (anastomosis) between the gastric pouch and the small intestine.
“To emphasise this once again very clearly – we operate far too late in Germany. Compared to the rest of the world, we operate years and decades later in Germany than in other countries. With a BMI of 40 combined with type II diabetes, a patient in Germany can undergo surgery straight away. Without diabetes or other comorbidities, conservative treatment must first be undertaken for a period of six months. Only then can surgery be considered. However, people with a BMI of 40 usually already have serious comorbidities or complications of obesity, which unfortunately do not go away even after weight-loss surgery. These regulations are rooted in German health policy and the restrictions still imposed by health insurance funds, which have also ensured that people simply tend to see a doctor too late. There are also still health insurance funds that look for formal errors so that they can refuse to pay for the operation retrospectively. And all of this is at the expense of patients’ health,” criticizes Prof. Dr Staikov strongly.
The mini-gastric bypass (MGB) is a variant of the conventional gastric bypass procedure, which is less invasive and involves shorter operating times. It is similar to the traditional gastric bypass in that a smaller stomach pouch is created and part of the small intestine is bypassed.
“Studies suggest that the mini-gastric bypass is as effective as the traditional gastric bypass in terms of long-term weight loss and weight stability. In many patients, the MGB leads to significant weight loss and an improvement or even remission of comorbidities such as type 2 diabetes, high blood pressure and sleep apnoea. The choice of bariatric procedure, including the mini-gastric bypass, should be based on a thorough assessment of the individual’s health status, the patient’s preferences and a careful risk-benefit analysis. Ultimately, it is always about achieving the following goals: weight loss, weight control, management of comorbidities and a restored quality of life for the patient”, and presents the special features of the center in Frankfurt am Main: “Here at our center, we have a 50% surgery rate for the sleeve gastrectomy; the two types of bypass surgery are performed somewhat less frequently. One particularly positive feature here at the largest bariatric surgery center in the whole of Germany is the very low rate of revision surgery – approx. 10–15%. This rate is generally much higher elsewhere. The overall complication rate of 1–2% is also negligible. The operations usually take around 60 minutes, and the patient can leave hospital after approximately three days.”
Aftercare following bariatric surgery is crucial to the long-term success of the procedure.
“Obesity is a chronic condition that cannot be cured by surgery alone. It must be clearly explained to the patient that lifelong follow-up care is required. The rate of follow-up care in Germany is also very poor. Many patients simply go to their GP for a check-up. We strongly recommend that our patients come to us, as the treating center, for check-ups, as we can offer all the necessary support if any issues arise. Following treatment, we provide our patients with a diet and exercise plan (after they have been fully informed), as well as supplementary vitamins and calcium. “Following up on these recommendations is also part of the aftercare,” explains Prof. Dr Staikov. It is important that patients actively participate in aftercare and follow their treatment team’s recommendations in order to maintain healthy habits in the long term and minimize potential complications.
Semaglutide is a medication traditionally used to treat type 2 diabetes. Recently, however, it has also attracted attention as a potential treatment option for obesity.
Studies have shown that semaglutide, when used in higher doses than those for diabetes treatment, can lead to significant weight loss in people with obesity. The drug works by increasing feelings of fullness, reducing appetite and possibly influencing metabolism. Clinical trials have shown that the use of semaglutide in people with obesity led to greater weight loss compared to a placebo. Some study participants even achieved weight loss of more than 15% of their body weight.
“Medicines containing the active ingredient semaglutide are generally a valuable addition and have been on the market for several years now. We know what they can achieve, as a 15% weight loss is certainly remarkable. However, medicines only work for as long as you take them. It is also important to note that semaglutide is prescription-only and therefore not accessible to everyone, as the active ingredient must be paid for out of pocket and not everyone can afford this. As long as this financial aspect – around 200 euros a month – remains an issue, it is simply unfair. “We only prescribe the drug if a patient has a BMI of 30 or in cases where patients have previously undergone bariatric surgery and are showing signs of regaining weight. In principle, the active ingredient semaglutide can be helpful,” comments Prof. Dr Staikov.
As with any medication, side effects can occur with semaglutide, including nausea, vomiting, diarrhea or stomach discomfort. The use of this medication should be discussed with a doctor to weigh up the individual risks and benefits.
Hope for the future
“We urgently need a framework in Germany to ensure that every single person with a BMI over 30 has access to appropriate treatment. This depends on staffing levels and cost coverage. For example, patients still have to pay for their own necessary vitamin supplements even after surgery. Many patients actually shy away from surgery for fear of the financial consequences, which can be fatal. Obese people have no lobby in Germany,” states Prof. Dr Staikov, bringing our conversation to a close.
Many thanks to Prof. Dr Staikov for this highly informative and critical discussion on the topic of obesity!
