Obesity in Adults: Position Statement of Polish Association for the Study on Obesity, Polish Association of Endocrinology, Polish Association of Cardiodiabetology, Polish Psychiatric Association, Section of Metabolic and Bariatric Surgery of the Association of Polish Surgeons, and the College of Family Physicians in Poland
3. Obesity—Definition, Causes, and Consequences
3.1.1. Diagnostic Tools and Data Interpretation
3.1.2. Determination of the Severity of the Disease According to the Judgment of the Clinician
3.2. Causes of the Development of Obesity
3.2.1. Environmental Factors
3.2.2. Genetic Factors
3.2.3. Emotional Eating and Eating Disturbances (Binge Eating Syndrome and Night Eating Syndrome)
Emotional Eating (EE)
Binge Eating Disorder (BED)
Night Eating Syndrome (NES)
3.2.4. Obesity Associated with Hormonal Disturbances
- Cushing’s syndrome, ACTH dependent (Cushing’s disease), and ACHT independent;
- Hypothyroidism in the course of primary or secondary thyroid dysfunction;
- Pituitary dysfunction in the form of multihormonal hypofunction of this gland, including growth hormone deficiency;
- Damage to the hypothalamus with the impaired secretion of hypothalamic neurohormones.
- Serum TSH levels as part of tests performed in all people with obesity, regardless of the presence of symptoms suggesting thyroid dysfunction;
- Free thyroxine (FT4) and anti-thyroid peroxidase (anti-TPO) antibodies are recommended to be measured if elevated TSH is found.
Pituitary Dysfunction in the Form of Multihormonal Hypofunction of the Pituitary Gland, Including Growth Hormone (GH) Deficiency, and Rare Damage to the Hypothalamus with Impaired Secretion of Hypothalamic Neurohormones
3.2.5. Medication-Related Obesity
- Antiepileptic drugs
3.3. Consequences and Complications of Obesity
3.3.1. The Metabolic Complications of Obesity
- Nonalcoholic fatty liver disease (NAFLD), currently called metabolic-associated fatty liver disease (MAFLD);
- Pre-diabetes (impaired glycemia fasting [impaired fasting glucose (IFG)] and impaired glucose tolerance [impaired glucose tolerance (IGT)] and type 2 diabetes;
- Atherogenic dyslipidemia (decreased HDL-C, elevated TG, at frequent slight changes in TC and LDL-C concentrations);
- Cardiovascular diseases (hypertension, coronary artery disease, carotid atherosclerosis, and stroke);
- Obesity-induced glomerulopathy;
- Cancers (e.g., colon, breast, and endometrium);
- Hormonal disturbances that lead to infertility in women (functional hyperandrogenism and polycystic ovary syndrome [PCOS]) and men (hypogonadism).
Non-Alcoholic Fatty Liver Disease (NAFLD)/Metabolic-Associated Fatty Liver Disease (MAFLD)
Prediabetes and Type 2 Diabetes
Obesity-Related Glomerulopathy (ORG)
The Main Hormonal Disturbances
- Growth hormone (GH) deficiency
- Hypogonadism in Men
- Serum concentrations of total and free testosterone, sex hormone-binding globulin (SHBG), FSH, LH, and PRL.
- Functional hyperandrogenism in women and polycystic ovary syndrome (PCOS)
- Serum concentrations of FSH, LH, PRL, estradiol, total testosterone, and SHBG (between 3–5 days of the menstrual cycle);
- Concentrations of androstenedione, 17-hydroxyprogesterone, and progesterone (depending on individual indications).
3.3.2. Diseases Caused by Mechanical Consequences of Excessive Accumulation Visceral Fat
Gastroesophageal Reflux (GERD)
Obesity Hypoventilation Syndrome (OHS)
Sleep Apnea Syndrome (OSA)
3.3.3. Mechanical Damage Caused by Excessive Load
Chronic Venous Disease
Stress Urinary Incontinence
Depression and Anxiety
4. Obesity in Patients with Schizophrenia in a GP’s Practice
- The presence of risk factors of or clinically overt cardiovascular disease (CVD) and/or diabetes mellitus, family history of CVD, smoking status, eating habits, and level of physical activity;
- Body weight and height with calculated BMI, waist circumference, and blood pressure (mean value of at least two measurements during a single visit);
5. Treatment of Obesity
5.1. Therapeutic Goals
- Approximately 10–40% in body weight reduction in patients diagnosed with non-alcoholic steatohepatitis in the course of MAFLD.
- At least 5% to 15% in body weight reduction in patients diagnosed with the following:
- Type 2 diabetes (lower HbA1c, reduce the number and/or doses of hypoglycemics drugs used, and remission of the disease, especially if it lasts a short time).
- Dyslipidemia (decrease in blood triglycerides and non-HDL cholesterol, and increase in HDL cholesterol).
- Arterial hypertension (reduction of systolic and diastolic pressure and reduction of the number and/or doses of antihypertensive drugs).
- Polycystic ovary syndrome (return of ovulatory cycles and regular menstruation, reduction of hirsutism, improvement of insulin resistance, and reduction of androgen levels in the blood).
- At least 5% to 10% in body weight reduction is recommended in patients diagnosed with the following:
- Male hypogonadism (increased testosterone levels in the blood).
- Stress urinary incontinence (reduced frequency of episodes of incontinence).
- At least 7–8% in body weight reduction is recommended in patients diagnosed with bronchial asthma (improvement in terms of forced expiratory volume in 1 s and reduction in the severity of symptoms).
- At least 7–10% in body weight reduction is recommended in patients diagnosed with obstructive sleep apnea.
- At least 10% in body weight reduction is recommended in patients with the following:
- Prediabetes (preventing the development of type 2 diabetes and improving glucose levels).
- Improving female infertility (return of menstrual ovulation cycle, pregnancy, and the birth of a live newborn).
- Osteoarthritis (reduction of pain and improvement of motor function);
- Gastroesophageal reflux (reduced symptoms).
- At least 5% in body weight reduction is recommended in patients with the following:
- Steatosis stage in the course of MAFLD (reducing lipid accumulation in the liver and improving metabolic function) .
5.2. Rule of the Five A’s in the Treatment of Obesity in a GP’s Practice
- ASK—asking questions should be a motivational interview. During the interview, the patient should be made aware of the impact of their body weight on general health and quality of life. Avoid embarrassment, guilt, and stigmatization during the conversation. Always use adequate medical vocabulary and emphasize that obesity is a disease that can and should be treated. One should also avoid judging the patient during the interview. However, the assessment of the patient’s readiness for change cannot be avoided.
- Does the patient want to be treated for obesity to improve their health?
- Does the patient want to change his or her eating habits permanently and does not see it as a struggle?
- Does the patient feel that their current way of eating is harmful to them?
- Is the patient aware that the treatment will be long and is ready to cooperate with their doctor?
- Will the patient try to accept the proposed treatments?
- ASSESS—assessment of the causes of weight gain, health status, and occurrence of complications caused by excess fat in the body. It is very important to correctly and fully determine the cause of weight gain, especially emotional eating and eating disorders (BED and NES). The patient’s physical health can be assessed on the basis of a 100-point visual analog scale (VAS). Screening for depression (the Beck scale) and the Hospital Anxiety and Depression Scale (HADS) should also be performed. Anamnesis should also be taken with the patient regarding chronic diseases, and in the absence of a prior diagnosis of obesity complications, their diagnosis should be undertaken.
- ADVICE—presenting treatment options that can be used in a particular patient. In the selection of therapeutic methods, the primary cause of obesity should be considered, followed by the stage of the disease and the occurring complications. It is very important that, during the conversation with the patient about the recommendations, they have a sense of understanding. In addition, the patient should be made aware that the treatment process will be long and requires commitment from them and that the doctor and other members of the therapeutic team are there to help them overcome difficulties. The patient should be presented with all therapeutic options that should be used in their case and discuss the benefits and possible risks associated with them.
- AGREE—obtaining the patient’s consent to the proposed therapeutic goal and treatment plan. It is necessary to be aware that it is the patient who implements the doctor’s recommendations; therefore, they cannot be arbitrary and must consider the patient’s capabilities and the degree to which they are willing to comply with the recommendations. In other words, this stage is a compromise between what the patient should do, according to the doctor, and what the patient can and wants to achieve. At this stage, negotiations should be conducted with the patient based on respect for their autonomy and their right to choose. However, the choice should be conscious, i.e., the consequences should be explained to the patient. Obtaining the patient’s acceptance of the proposed therapeutic goal and treatment plan may require many discussions. This should not discourage the doctor from taking them. In addition, the physician must be willing to modify his recommendations based on the needs and capabilities of the patient.It is very important at this stage to work on realizing the patient’s expectations regarding weight loss. The patient should also be made aware that meeting the behavioral change goals is more important than weight loss itself because this will ultimately help them achieve the intended weight reduction. Success for each patient will have a different dimension, but it is important that the patient focuses on improving mental and physical health, not on the number of kilograms lost.
- ASSIST—supporting the patient in the therapeutic process. After agreeing on their therapeutic goal, the doctor should help the patient identify barriers that may hinder treatment (social, medical, emotional, and economic) and factors that facilitate treatment (motivation and social support). The role of the doctor is to identify the causes of the disease, educate, recommend adequate therapeutic methods, and support the patient in their implementation. An important element of support is setting the schedule of follow-up visits, determining their frequency, and informing the patient what will be checked during the visit, which will make it easier for the patient to implement the recommendations. The schedule should specify the number of visits necessary to achieve the therapeutic goal, minimum and maximum time intervals between visits (the exact date of the next visit should be determined at the previous visit), parameters that will be checked during the visit, and what should be brought to the next visit (e.g., physical activity and results of additional tests).
5.3. Nutritional Interventions
5.4. Behavioral Therapy
- Losing weight too quickly is not beneficial for health (risk of developing liver steatosis and gallstones) and is associated with risks such as the ‘yo-yo’ effect (loss of lean mass and lowering the level of basic expenditure energy);
- The use of a very restrictive diet may cause deficiencies in vitamins and microelements;
- Treatment is not a short period of dieting, but a permanent change in lifestyle, including habits, nutrition, and increasing physical activity, and any unfavorable change in this aspect will lead to disease relapse;
- The real success is long-term maintenance weight loss of at least 10% from the initial body weight, not the number of kilograms that the patient will be rid of.
- Eating while watching TV;
- Calming oneself with food;
- Eating foods with the wrong composition;
- Eating in a hurry;
- Eating under the influence of the greatest hunger;
- Eating between meals;
- Irregular eating habits.
5.5. Physical Activity
- Emotional eating;
- Low self-esteem;
- Suspected NES;
- Suspected BED;
- Suspected food addiction.
- Self-monitoring (e.g., keeping a food diary);
- Techniques to control the eating process (e.g., slow chewing);
- Control of stimuli and their reinforcement or reduction (e.g., shopping according to a list);
- Additional cognitive techniques;
- Obesity (BMI ≥ 30 kg/m2);
- Overweight (BMI ≥ 27 kg/m2), with obesity complications, such as hypertension, lipid disturbances, ischemic disease, myocardial infarction, type 2 diabetes, sleep apnea, or PCOS.
- Chronic malabsorption syndrome;
- Hypersensitivity to orlistat.
- BMI ≥ 30 kg/m2 (obesity);
- BMI 27 kg/m2 to <30 kg/m2 (overweight) if the patient has one or more complications of obesity (e.g., type 2 diabetes, dyslipidemia, compensated hypertension).
- Hypersensitivity to any substance active or auxiliary;
- Uncontrolled high blood pressure;
- Current epilepsy or seizures in the interview;
- A tumor of the central nervous system;
- The period immediately following an abrupt withdrawal from alcohol or benzodiazepines in an addicted person;
- History of bipolar disorder;
- Taking bupropion or naltrexone for another indication other than weight loss;
- Bulimia nervosa or anorexia nervosa now or in the past;
- Addiction to long-term use of opioids or opiates (e.g., methadone) and shortly after their discontinuation in the addicted person;
- Taking monoamine oxidase inhibitors (MAOI);
- Severe liver problems;
- End-stage renal failure or severe disorders of kidney function;
- Pregnancy and breastfeeding.
- With a BMI ≥ 30 kg/m2 (obesity);
- With a BMI of 27–30 kg/m2 (overweight) if accompanied by ≥1 of complications related to excessive body weight (including prediabetes or type 2 diabetes, hypertension, lipid disorders, or obstructive sleep apnea).
- With a BMI ≥ 30 kg/m2 (obesity);
- With a BMI of 27–30 kg/m2 (overweight) if accompanied by ≥1 of complications related to excessive body weight (including prediabetes or type 2 diabetes, hypertension, lipid disorders, obstructive sleep apnea, or cardiovascular disease).
5.8. Bariatric Surgery
5.8.1. Requirements for Reference Centers
- BMI > 40.0 kg/m2;
- BMI 35.0–39.9 kg/m2 in a patient with obesity complications (e.g., type 2 diabetes, hypertension, severe joint diseases, dyslipidemia, a severe form of OSA). The latest guidelines recommend surgery in patients with BMI in this range, regardless of obesity complications;
- Mental disorders—personality disorders, severe depression;
- Drug abuse;
- Eating disorders;
- No possibility of proper, long-term postoperative care;
- Poor long-term prognosis due to life-threatening diseases .
5.8.3. Types of Operation
5.8.4. Post-Treatment Monitoring and Intervention
- Patient tolerates oral diet and drinks at least 1000 mL of fluids per day;
- Does not require intravenous fluids;
- Postoperative pain is manageable with oral medication;
- The level of physical activity is similar to that before the operation;
- After discharge, the patient will remain under the care of third parties and, if necessary, contact with the treatment center is ensured;
- There were no complications that required hospitalization .
Perioperative Monitoring for up to 30 Days
Monitoring during the First Year after Surgery
5.9. Effectiveness of Obesity Treatment
6. Barriers and Overcoming Them in the Treatment of Obesity at the Primary Care Level
7.1. Recommendations for General Practitioners (GPs)
- Screening for overweight and obesity, including weight measurement and BMI calculation, should be performed on all adult patients reporting to their GP once a year;
- The measurements of body weight, height, and waist circumference should be an integral part of physical examination and should be recorded in the medical history.
- The first visit of patients in GP (at the latest during two consecutive visits);
- Patient visit due to overweight and obesity;
- If possible, at each visit the reason for which are complications of obesity, including hypertension, type 2 diabetes, dyslipidemia, coronary artery disease, osteoarthritis, and other comorbidities related to obesity;
- At each routine visit, if a doctor suspects a patient is overweight or obese;
- In all patients with normal BMI values (18.5–24.9 kg/m2), waist circumference should be measured to assess metabolic risk;
- In all patients with BMI < 35 kg/m2, waist circumference should be measured to assess visceral obesity occurrence;
- In all patients with overweight and obesity, anamnesis should be taken in the direction of complications, and diagnostics should be performed in their direction. Such activities should be carried out systematically;
- Diagnostics for overweight and obesity should be performed in all patients treated for their complications;
- All patients with overweight and obesity should be screened for emotional eating, eating disorders (binge eating syndrome and night eating syndrome), as well as depression and anxiety (HADS);
- A patient with obesity should be treated with respect, and his/her illness should not be a source of shame and self-blame;
- After making a diagnosis of overweight or obesity, the doctor should explain to the patient the essence of the disease and its consequences and assess his/her readiness to change and the primary cause of the development of obesity;
- A physician should use appropriate medical vocabulary in relation to an obese patient, show empathy towards him/her and give advice appropriate to his/her situation, as well as implement all possible therapeutic procedures, including pharmacotherapy and psychotherapy and, if indicated, also surgical treatment. The patient must agree to the proposed treatment methods and accept them;
- The principle of person-centered care should be the norm in the approach to patients with obesity;
- During treatment, a schedule of follow-up visits should be set, and the patient should be informed about what will be checked during them. If necessary, expand the methods of implemented treatment and support the patient in the event of difficulties;
- Remember that a patient with obesity may be aware of their disease, but they do not talk about it because they are ashamed, and the doctor must be able to talk about it;
- It is unethical not to recognize and not treat obesity instead or refer the patient to another doctor who will treat it.
7.2. Recommendations for National Authorities
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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|WHO (1998)||AACE and ACE (2016)|
|BMI (kg/m2)||BMI |
|Obesity Complications Listed below This Table|
|Overweight||25.0–29.9||Overweight grade 0||25.0–29.9||None|
|Obesity grade I||30.0–34.9||Obesity grade 0||≥30||None|
|Obesity grade II||35.0–39.9||Obesity grade 1||≥25||At least one mild or moderate|
|Obesity grade III||≥40||Obesity grade 2||≥25||At least one severe|
|The Type of Emotions Causing Food Craving||Ask the Patient|
|Reaching for food during or after a stressful situation caused by both positive and negative factors||Do you feel stomach suction in stressful or anxious situations?|
Does stress make you reach for food?
|Eating when feeling anxious||Do you feel like eating after a stressful situation?|
|Rewarding oneself with food||Is success food?|
|Eating when something has failed—comforting with food||When something has not turned out, do you reach for food?|
|Eating in situations of boredom||When you are bored, do you reach for food? |
Do you use food during other activities, e.g., reading, watching TV, or working?
Do you reach for food while using the computer?
|Eating in order to reduce the feeling of fatigue||When you feel tired, does eating help to reduce this feeling?|
|Main criterion||Repeated episodes of unrestrained eating at least once a week for three months||Eating a minimum of 25% of the daily food ration after an evening meal or at night with awareness at least twice a week for at least 3 months|
|Symptoms||At least three of the following symptoms:||At least three of the |
|SSRIs other than paroxetine during long-term treatment|
|Before Treatment||After 6 Weeks||After 3 Months||Every 12 Months|
|Smoking, physical activity, and eating habits||X||X||X||X|
|Fasting glucose level||X||X||X||X|
|Fasting lipid profile||X||X||X|
|Family doctor barriers:|
|Barriers on the system side:|
|During the first visit with a new patient, anthropometric measurements should be performed, and if obesity is diagnosed, then:|
|1. Refer the patient to tests to diagnose obesity complications;|
2. Assess the patient’s readiness for treatment;
3. Implement the treatment;
4. Treatment monitoring—follow-up visits with brief advice at each visit;
5. At least once a year, perform an assessment of obesity complications.
|In relation to patients with obesity already under care:|
|1. Once a year, according to the recommendation of the National Health Fund, body weight measuring in all patients (e.g., before vaccinations or visits for other reasons);|
2. Weight measuring before each visit for patients with obesity complications, especially cardiovascular diseases;
3. Encouraging body weight measurements at home, asking about body weight during teleconsultations;
4. At least once a year in patients with obesity complications, control examinations assessing complications;
5. Short advice at every visit, if possible.
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Olszanecka-Glinianowicz, M.; Mazur, A.; Chudek, J.; Kos-Kudła, B.; Markuszewski, L.; Dudek, D.; Major, P.; Małczak, P.; Tarnowski, W.; Jaworski, P.; Tomiak, E. Obesity in Adults: Position Statement of Polish Association for the Study on Obesity, Polish Association of Endocrinology, Polish Association of Cardiodiabetology, Polish Psychiatric Association, Section of Metabolic and Bariatric Surgery of the Association of Polish Surgeons, and the College of Family Physicians in Poland. Nutrients 2023, 15, 1641. https://doi.org/10.3390/nu15071641
Olszanecka-Glinianowicz M, Mazur A, Chudek J, Kos-Kudła B, Markuszewski L, Dudek D, Major P, Małczak P, Tarnowski W, Jaworski P, Tomiak E. Obesity in Adults: Position Statement of Polish Association for the Study on Obesity, Polish Association of Endocrinology, Polish Association of Cardiodiabetology, Polish Psychiatric Association, Section of Metabolic and Bariatric Surgery of the Association of Polish Surgeons, and the College of Family Physicians in Poland. Nutrients. 2023; 15(7):1641. https://doi.org/10.3390/nu15071641Chicago/Turabian Style
Olszanecka-Glinianowicz, Magdalena, Artur Mazur, Jerzy Chudek, Beata Kos-Kudła, Leszek Markuszewski, Dominika Dudek, Piotr Major, Piotr Małczak, Wiesław Tarnowski, Paweł Jaworski, and Elżbieta Tomiak. 2023. "Obesity in Adults: Position Statement of Polish Association for the Study on Obesity, Polish Association of Endocrinology, Polish Association of Cardiodiabetology, Polish Psychiatric Association, Section of Metabolic and Bariatric Surgery of the Association of Polish Surgeons, and the College of Family Physicians in Poland" Nutrients 15, no. 7: 1641. https://doi.org/10.3390/nu15071641