How is obesity treated?
Scientific support: Prof. Dr. Matthias Blüher
Obesity is a chronic, progressive disease that requires lifelong treatment and can also be a risk factor or trigger for many other chronic diseases. Obesity therapy is based on a combination of dietary changes, more exercise and behavioral therapy. The main goals of obesity treatment are long-term body weight reduction, the prevention of concomitant diseases and improvement in health.
A reduction in weight
- has a positive effect on many organ systems,
- can reduce the risk of obesity-associated complications or prevent their progression, and
- can improve quality of life.
However, the relapse rate after obesity treatment is very high. It is therefore crucial to achieve long-term weight control beyond the actual weight loss phase.
Contents
1. When is weight reduction recommended?
As the severity of obesity increases, so does the risk of various concomitant diseases and complications. Doctors can assess whether a person’s body weight and body fat distribution represent a health risk by examining the individual’s overall clinical picture. From a medical point of view, weight loss is recommended for the following people:
- People with obesity (body mass index (BMI) of 30 kg/m² or higher)
- People who are overweight (BMI between 25 and 29.9 kg/m²) and additionally have
- diseases associated with obesity, such as high blood pressure or type 2 diabetes,
- diseases that are aggravated by obesity (for example of the musculoskeletal system),
- an abdominal fat distribution (abdominal obesity) with a waist circumference of over 88 centimeters (women) or 102 centimeters (men), or
- a high level of psychosocial distress.
2. What are the goals of obesity treatment?
The most important goals of obesity treatment are a long-term reduction in body weight, the prevention of concomitant diseases and an improvement in health. Weight reduction prevents the development of complications that are associated with severe obesity. Weight loss supports the treatment of existing obesity-related complications. Moreover, the quality of life and well-being can be improved.
Obesity treatment can take place both in GP practices and in specialized obesity centers. To achieve the best possible success, the treatment goals should be realistic and tailored to the patient’s individual requirements. In addition to medical aspects such as existing concomitant diseases and complications, personal expectations, previous experience with weight loss and existing resources should also be taken into account when setting treatment goals.
According to the current guideline for the prevention and treatment of obesity (2024), the following weight goals should be reached within a period of 6 to 12 months:
- With a BMI between 25 and 34.9 kg/m²: weight loss of 5 percent or more of the initial weight
- With a BMI of 35 kg/m² or higher: weight loss of 10 percent or more of the initial weight
Good to know:
Losing just 5 to 10 percent of your body weight can have a positive effect on your health.
3. How to achieve long-term weight reduction goals
Body weight often increases again after successful weight loss. Many people find it difficult to permanently change their lifestyle and make a balanced diet and plenty of exercise part of their everyday life in the long term. The constant availability of food, our living and working environments and the physiological processes that take place in the body during weight loss make it even more difficult to keep the weight at a constant level.
Long-term and close supervision by the treating physician – even beyond the weight loss phase – can help to maintain newly learned behavioral patterns on a long-term basis. In addition, regular self-observation, for example by weighing yourself once a week, can help you to maintain the weight loss you have achieved.
The basic program for the treatment of obesity consists of 3 pillars: Nutrition, exercise and your own behavior. The greatest success can be achieved through a combination of building blocks from these 3 pillars. In general, all measures can only be effective if they are carried out for a sufficiently long time and with appropriate intensity.
If the basic program does not lead to any weight loss or at least sufficient weight loss, medical or surgical measures can be taken to support the treatment of severe obesity.
Which measures make sense and can be implemented in individual cases can vary greatly from person to person. It is therefore important that the attending physician discusses the possible treatment options with the patient and that they jointly determine a suitable strategy and individual treatment goals.
Read here how you can reduce and stabilize your weight in the long term.
4. Change of diet
In order to lose weight, you have to consume more energy than you take in. The attending physician should determine an individual energy deficit together with the patient. In most cases, the desired energy intake is around 500 to 600 kilocalories (kcal for short, often colloquially just referred to as calories) below the individual daily requirement. This helps to achieve a continuous weight reduction of around 0.5 kilograms per week. However, the weight loss can usually be maintained no longer than over a period of 3 to 6 months and then lessens. But not all people respond to calorie reduction in the same way.
There are various options to achieve an energy deficit with weight loss through nutrition. The macronutrient composition (contents of fats, proteins and carbohydrates) of the ingested food plays a subordinate role. Less energy intake can be achieved by reducing the intake of fat, carbohydrates or a combination of both. Various diets are also suitable, such as the Mediterranean diet, a wholefood diet according to the recommendations of the German Nutrition Society (DGE), or a vegetarian/vegan diet. A meal replacement strategy (replacing 1 to 2 main meals per day with what are called substitute or formula products) or the various forms of intermittent fasting also represent a therapeutic option for weight loss.
What is important is that the diet suits the person with obesity, is balanced and can be implemented in the long term. It is also possible to switch between the different forms of nutrition.
In the long term, the following measures in particular have a weight stabilizing effect:
- A reduction in the overall amount of food, but especially of ultra-processed, very energy-rich and energy-dense foods such as
- snacks high in sugar or fat
- sugar-sweetened beverages and fruit juices
- An increased consumption of
- fruit and vegetables
- protein-rich foods, for example pulses (beans, lentils, chickpeas), milk and dairy products, nuts or oatmeal
- high-fiber foods, for example vegetables, pulses, whole-grain bread and whole-grain pasta or fruit
We recommend nutritional counseling, especially at the beginning of therapy. In this context, individual nutritional recommendations and achievable goals can be defined that are based on personal circumstances and preferences as well as the state of health of the person affected.
If, for example, people with a BMI of 30 kg/m² or more need to lose a lot of weight in the short term for medical reasons, special diets – called formula products or formula diets – with a very low amount of energy (total energy 800 to 1200 kcal per day) can also be used. However, these should only be used for a maximum of 12 weeks and only under medical supervision.
Regardless of which nutritional strategy is followed, care should always be taken to ensure that the body continues to be supplied with all the important nutrients. Highly unbalanced diets can be associated with high health risks and do not result in a long-term weight loss success. They are therefore not recommended.
5. More exercise
In addition to nutrition, exercise plays an important role in obesity therapy. This is because physical activity leads to increased energy consumption and promotes muscle building, which again increases energy consumption. It also reduces the loss of muscle mass associated with weight reduction. Exercise also contributes to weight reduction and stabilization. In addition, exercise has a positive effect on health and quality of life and can contribute to the improvement of cardiovascular, metabolic and psychosocial diseases.
However, exercise therapy alone only has a moderate effect on weight loss. For example, a weight reduction of 2 to 3 kilograms in total is realistic. In combination with a change in diet, the weight reduction effects to be expected are even greater.
The current guideline for the prevention and treatment of obesity (2024) recommends exercising for at least 30 to 60 minutes a day to support weight loss. The type of exercise plays a subordinate role. Endurance sports such as hiking, walking, jogging, cycling or swimming are well suited. Strength training or a combination of endurance and strength training also supports weight loss. In older people in particular, strength training counteracts a reduction in bone density, which can go hand in hand with weight loss. Forms of exercise with low or moderate intensity, such as walking or tai chi, also have a positive effect on health and weight loss.
The type and intensity of exercise should be selected individually according to your state of health and preferences. With a BMI of over 35 kg/m², sports that are easy on the joints, such as walking, cycling or water aerobics, should be preferred.
Before starting exercise therapy, you should discuss it with your attending physician in order to clarify possible risks in advance.
Furthermore, people with obesity should try to make their everyday life more active and incorporate more exercise into their leisure time. This can be achieved in numerous ways. Here are a few examples:
- Take the stairs instead of the elevator.
- Avoid using the car, streetcar or bus for shorter distances.
- Take a relaxing walk in the evening.
- Place frequently used tools out of easy reach.
- Interrupt sedentary activities every 20 to 30 minutes with short standing and walking breaks.
In order to change your own exercise behavior in the long term, you should increase exercise slowly at the beginning and then gradually intensify it – depending on your individual fitness and existing concomitant diseases and complications.
Get active! Find more information about sports and physical activity here.
6. Behavioral therapy
In order to reduce your body weight and keep it stable in the long term, it is often necessary not only to change your diet and increase exercise, but also to change previous lifestyle habits. Behavioral therapy should be an integral part of obesity treatment. It can be carried out both individually and in groups.
As part of behavioral therapy, previous eating behavior is analyzed and possible strategies are identified that can help to change lifestyle in the long term and develop alternative behavioral patterns and problem-solving approaches. Dealing with setbacks and possible weight gain should also be part of the therapy. The therapeutic approach should be tailored to the patient’s individual situation.
The following aspects can help you to change your behavior:
- Observe your behavior and be happy about your successes!
- Practice strategies that help you to control your food intake, for example:
- Only buy food when you have eaten enough.
- Stick to fixed meal times and avoid eating in front of the TV or monitor.
- Limit your stock of food.
- Set yourself realistic goals.
- Discover activities that you enjoy.
- Seek support from like-minded people. Cooking or doing sport together is often more fun than doing it alone.
- Make sure you get enough sleep and have a regular sleep pattern.
- Practice relaxation techniques.
Read here how healthy sleep reduces the risk of overweight and obesity.
Constant stress can damage your health. Find out here how you can take countermeasures.
7. Medication
If you fail to achieve any weight reduction or if you achieve only slight weight loss and stabilization with the basic obesity treatment program, drug therapy can help you as a supportive measure. It is important to always combine this with nutritional, exercise and behavioral therapy.
The following persons may obtain a doctor’s prescription for drug therapy in order to lose weight or to subsequently maintain their weight:
- people with a BMI of 27 kg/m² or higher (with orlistat with a BMI of 28 kg/m² or higher) who have additional risk factors (e.g. prediabetes or elevated blood lipid levels) and/or pre-existing complications such as type 2 diabetes and cardiovascular disease, and
- people with obesity (BMI of 30 kg/m² or higher).
The suitable medication should be chosen in close consultation between the doctor and the patient. Furthermore, the patient’s individual situation (whether complications are already present, which dosage form and which mode of action are suitable) and the respective therapeutic goals as well as tolerance and safety should also be taken into account.
What medications are available?
In Germany, 3 groups of active ingredients are currently approved and available on the market for the drug-based treatment of obesity:
- Lipase inhibitors: orlistat
- GLP-1 receptor agonists: liraglutide and semaglutide
- Dual GLP-1/GIP receptor agonist: tirzepatide
For a long time, orlistat was the only drug available for the drug therapy of overweight (BMI of 28 kg/m² and higher) and obesity. Orlistat inhibits the absorption of fats from the intestine and thus also the absorption of calories. Studies show an average weight reduction of 2.9 kilograms under orlistat therapy. According to its approval, treatment with orlistat should be discontinued if a weight loss of at least 5 percent of the initial weight has not been achieved after 12 weeks at a dosage of 3 times 120 milligrams per day. Common side effects are soft stools, increased bowel urgency and flatulence.
GLP-1 receptor agonists were originally developed as a treatment option for people with type 2 diabetes. For several years, the GLP-1 receptor agonist liraglutide has also been approved at a higher dosage (3 milligrams per day) for the treatment of overweight and obesity (without type 2 diabetes) (trade name Saxenda®, solution for injection in a pre-filled pen). It is administered once a day as an injection into the subcutaneous fat. However, the medication should be discontinued if a weight loss of at least 5 percent of the initial weight is not achieved within 12 weeks at a dosage of 3 milligrams per day. Studies have shown that liraglutide leads to an average weight loss of around 8 percent of the initial weight within one year. Subsequently, the body weight remains at a constant level and there is no further significant weight reduction.
Mode of action of GLP-1 receptor agonists
GLP-1 receptor agonists mimic the effect of the intestinal hormone glucagon-like peptide-1, or GLP-1 for short. GLP-1 receptor agonists influence appetite and satiety and can support reduced food intake. They promote the release of insulin from the pancreas and at the same time inhibit the hormone glucagon, an “antagonist” of insulin. In addition, GLP-1 leads to delayed gastric emptying and an earlier onset of satiety – mediated by the central nervous system – which supports weight loss.
Gastrointestinal complaints such as nausea, vomiting and a feeling of fullness often occur as a side effect of GLP-1 receptor agonists. However, these often decrease in the course of treatment and can be reduced by increasing the dose at a slow rate.
The GLP-1 receptor agonist semaglutide has been available in higher doses (2.4 milligrams per week) for people who are overweight or obese in Germany since summer 2023 (trade name Wegovy®, solution for injection in a pre-filled pen). It is injected once a week into the subcutaneous fat. In the pivotal trial, participants with obesity undergoing treatment with semaglutide in combination with a change in lifestyle achieved a weight loss of around 15 percent of their initial weight within one year.
A tablet form of semaglutide is already approved for the treatment of type 2 diabetes (trade name Rybelsus®). The manufacturer is also seeking approval for this dosage form for the treatment of obesity.
Dual receptor agonists as a further development of GLP-1 receptor agonists
The active substance tirzepatide is a further development of the GLP-1 receptor agonists. As a dual receptor agonist, it has an additional activating effect on the receptors of a second intestinal hormone besides the GLP-1 receptors. This intestinal hormone is the glucose-dependent insulinotropic peptide (GIP). Studies have shown that people with type 2 diabetes who were treated with tirzepatide achieved a greater weight reduction than when they were treated with semaglutide. In study participants with obesity without type 2 diabetes, more than 60 percent of the patients that were treated with tirzepatide achieved a weight reduction of more than 20 percent of their initial weight.
Tirzepatide (trade name Mounjaro®, solution for injection in a pre-filled pen) has been approved for the treatment of type 2 diabetes since December 2023 and for weight management since spring 2024. Like semaglutide, tirzepatide is injected once a week into the subcutaneous fat and has a side-effect profile that is similar to that of GLP-1 receptor agonists.
The duration of treatment is currently not limited; however, data from long-term studies with more than 3 years of treatment are not yet available.
Other comparable active ingredients are currently still in development. Retatrutide, for example, is a triple receptor agonist that mimics the function of 3 hormones (GLP-1, GIP and glucagon).
In Germany, drugs that are approved purely for weight reduction and weight maintenance are currently excluded from reimbursement by health insurance companies. As slimming products, they belong to the group of what are called “lifestyle drugs,” which focus on improving the quality of life.
8. Surgical treatment
If diet, exercise and behavioral therapies for weight loss have been exhausted or if the BMI is over 50 kg/m2 (primary indication), surgical treatment of obesity may be another treatment option. In this case, experts refer to bariatric surgery (from the Greek word baros = weight, heaviness).
According to the German guideline on surgery for obesity and metabolic diseases (2018), surgery is recommended in the following cases:
- In case of extreme overweight (BMI of 40 kg/m2 or higher (grade III obesity))
- In case of a BMI of 35 kg/m2 or higher (grade II obesity) and existing complications that are associated with obesity, such as:
- Type 2 diabetes
- High blood pressure or other cardiovascular diseases
- Sleep apnea syndrome (breathing disorders during sleep)
- Fatty liver disease
- Kidney disease
- Bronchial asthma
- Joint diseases
In special cases, surgical treatment can also be considered for people with a BMI between 30 and 34.9 kg/m² (grade I obesity) and existing obesity-associated complications.
In October 2022, the International and American Societies for Obesity and Metabolic Disease Surgery published new recommendations for bariatric surgery. They each specify threshold values for surgery that are 5 BMI points lower. It is to be expected that the values will also be reviewed as part of the upcoming revision of the German guideline and revised downwards if necessary.
Goals of bariatric surgery
The sustainable weight reduction targeted by surgical measures for obesity is intended to
- improve the quality of life,
- improve concomitant diseases,
- extend the patients’ life, and
- maintain the patients’ participation in working life and social life in general.
When people with type 2 diabetes undergo bariatric surgery with the aim of improving blood glucose metabolism, experts refer to metabolic surgery.
Good to know:
The main goals of bariatric surgery are to improve existing obesity-associated complications and to improve quality of life.
Surgical obesity treatment: Requirements
Before planning bariatric surgery, it is important to rule out rare causes of severe obesity – for example hormonal disorders – and to examine patients comprehensively with regard to possible concomitant diseases and their suitability for surgery. Detailed information about the course of surgery as well as possible risks and the necessary aftercare are also important aspects that should be discussed with the attending physician in advance.
In general, older patients (over 65) also benefit from bariatric surgery. The same applies to patients with chronic inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis.
Severely overweight people with type 1 diabetes may also undergo bariatric surgery. Weight reduction can also have a positive effect on existing insulin resistance.
Bariatric surgery should not be performed in the case of untreated mental illness, eating disorders or existing substance addiction.
Pregnancy should be avoided during the period of severe weight loss following a surgical procedure. In general, however, women who wish to have children may be treated. Once the patient’s weight and state of health have stabilized, there is no reason why pregnancy under gynecological supervision should not be planned. Food supplements should be taken during pregnancy to avoid a deficiency in the supply of nutrients to mother and child.
Bariatric surgery: Effects, risks and aftercare
Weight loss after bariatric surgery can be very effective. However, this is a surgical procedure that should be very carefully considered. As with other operations, there is a general surgical and anesthetic risk. In addition, most of the procedures performed cannot be reversed and the altered condition of the gastrointestinal system remains for life. Follow-up operations, such as skin tightening, may also be necessary.
Moreover, there may be other side effects that only occur in the long term, for example deficiency symptoms. This requires good aftercare and, if necessary, the intake of vitamin and mineral supplements.
The positive health effects associated with bariatric surgery are all the greater, the better and more closely monitored the medical care is after the procedure. As part of aftercare, not only should weight development be observed and the administration of medication and nutritional supplements monitored, but psychological concerns should also be a focus.
With regard to lifestyle, patients should be advised on how to maintain an appropriate diet and increase physical activity.
Participation in a self-help group can also be a useful way of exchanging views with other people who have undergone similar measures.
Good to know:
Bariatric surgery should only be performed in specialized clinics that have been certified by the German Society for General and Visceral Surgery (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, DGAV), for example, or that meet the required quality standards of the professional society. These centers also provide the necessary aftercare. Bariatric surgery abroad is not recommended because there is no aftercare and subsequent support.
What surgical methods are available to treat obesity?
Surgical intervention for obesity (bariatric surgery) aims at reducing the volume of the stomach and/or shortening the gastrointestinal passage. It is intended to reduce food intake – through an earlier feeling of satiety – and/or reduce the absorption of nutrients. The extent to which surgical interventions influence food intake and utilization and change metabolic processes depends on the method used.
There are a number of different methods in bariatric surgery. The most common procedures in Germany are currently sleeve gastrectomy and gastric bypass. The adjustable gastric band has become less important in recent years and should only be used after special consideration. There is no generally recommended surgical procedure. The choice of procedure should always be made on an individual basis, taking into account the medical, psychological, social and general circumstances of the patient in question.
Today, bariatric surgery usually is a laparoscopic procedure (“keyhole surgery”). This reduces the surgical risks and shortens the healing process.
Gastric sleeve
A gastric sleeve reduces the total volume of the stomach. The surgeons remove large parts of the stomach and transform it into a sleeve-shaped organ. This severely restricts the amount of food that can be consumed in one go.
One advantage of this method is that it does not fundamentally alter the anatomy of the gastrointestinal tract, leaving all options open for any further surgical measures that may be required. In addition, nutrient absorption is not significantly impaired.
By installing a gastric sleeve, the excess weight can be reduced by around half within 5 years. This calculation is based on the ideal weight, which is a BMI of 25 kg/m². If a person’s weight is 100 kilograms higher than his or her ideal weight before the surgical procedure, the excess weight has statistically decreased to an average of 50 kilograms 5 years after sleeve gastrectomy.
According to study data, the blood glucose metabolism normalizes after 5 years in around 58 out of 100 patients with type 2 diabetes who have undergone sleeve gastrectomy. This is called diabetes remission. However, it is important to bear in mind that the diabetes may recur at a later point. Diabetes remission is highly dependent on the body’s insulin production prior to surgery.
The rate of complications after sleeve gastrectomy is relatively low. There is a risk that the long suture on the stomach wall leads to wound healing problems, loosens or bursts. In addition, the stomach may expand again in the course of time and body weight may increase again after 2 to 5 years.
Gastric bypass
A gastric bypass involves a surgical modification of the gastrointestinal tract such that large parts of the stomach and small intestine are omitted during the passage of food. Shortly after entering the stomach, the food passes directly into the lower parts of the small intestine.
As a result, the body absorbs fewer nutrients and therefore fewer calories. This leads to significant weight loss. However, patients must consume important nutrients such as vitamins and minerals on an ongoing basis to prevent deficiency symptoms.
There are different techniques for creating a gastric bypass. A frequently used method is what is called the proximal Roux-en-Y gastric bypass. Only a small piece of stomach remains after the cardia, which is connected directly to a lower section of the small intestine. The upper part of the small intestine remains connected to the rest of the stomach. It absorbs the digestive juices from the pancreas and bile and passes them directly into the lower part of the small intestine via a newly created connection.
A gastric bypass reduces excess weight, i.e., the percentage of weight that exceeds the ideal weight, by an average of 61 to 65 percent after 5 years.
This procedure is frequently used, particularly for people with type 2 diabetes, as blood glucose levels usually improve significantly after the operation. After 5 years, around 75 percent of all patients who have undergone surgery show a normalization of their blood glucose metabolism. Some patients can even do entirely without their antidiabetic drugs after the operation. As with the gastric sleeve, it is important to bear in mind that diabetes can recur at a later point.
This relatively extensive surgical procedure can involve general surgical risks. In addition, the sutures may tear or burst.
Adjustable gastric band
An adjustable gastric band involves placing a belt-like band made of silicone around the upper part of the stomach from the outside. This creates a constriction at the entrance to the stomach. As a result, the patient can only eat slowly and little, and the feeling of satiety sets in more quickly. However, liquid foods containing many calories, such as sugary drinks, continue to be problematic.
Due to late complications and less successful weight loss compared to other surgical procedures, the adjustable gastric band is becoming less and less important.
9. Digital health applications (Digitale Gesundheitsanwendungen, DiGAs)
Digital technologies can support basic therapy for obesity. Activity trackers such as pedometers or smart watches and electronic food diaries help you to identify your own behavioral patterns. Other systems are used to exchange information between medical professionals and patients.
Since 2020, doctors in Germany have been able to prescribe digital health applications, or DiGAs for short, on prescription. All DiGAs are tested and certified by the Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte, BfArM). The costs are covered by health insurance companies and the application is free of charge for users.
The BfArM lists all available DiGAs on its website.
DiGAs, which are used to support the treatment of obesity, can, for example:
- facilitate self-observation through simple documentation of eating and exercise behavior,
- motivate people to exercise more and eat a balanced diet,
- indicate a follow-up, as a basis for medical consultations,
- provide information on scientifically proven approaches to weight reduction,
- offer training programs on exercise and nutrition.
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As of: 17.02.2025
