Correspondence (letter to the editor): More Effective Therapeutic Approaches Should Be Deployed

Restricting the literature analysis to non-surgical treatment options (1) rules out the most effective therapy—that is, obesity surgery and metabolic surgery. This narrow perspective is not justified in scientific terms, since surgery for obesity and type 2 diabetes has long been accepted by the S3 guideline (2).

The authors included in their meta-analysis 15 randomized trials of modifications of behavior, nutrition, and physical activity/exercise as well as pharmaceutical approaches. The mean waist circumference—a measure of visceral obesity—was reduced by merely 2.65 cm, to 100.05 cm; even after combined lifestyle interventions, the loss was a mere 4.11 cm. To call such a treatment result moderate is simply a euphemism, in view of the defined thresholds. The achieved result is in most cases clinically irrelevant and, furthermore, is not maintained in the long term, and therefore it does not justify the enormous resource consumption.

Admittedly, prevention would constitute the only solution for this chronic disorder. Non-operative treatment modalities have been proved to fail in most patients in its current form. In routine clinical practice, the therapeutic goals—defined in the S3 guideline as long-term weight loss >15% (20%) kg/m2 in persons with a BMI >35 (40) kg/m2—are achieved only in exceptional situations.

Consequently, a new, different, more effective therapeutic approach needs to be deployed—and according to what is currently known this is the combination with surgical methods. In the meantime, the guideline has conceded the pointlessness of conservative methods alone in patients with a BMI >50 kg/m2. This is the threshold for the guideline to recommend the primary indication for surgery.

Optimizing obesity treatments requires a paradigm shift: early surgery and intensified conservative treatment afterwards. The responsibility for structured long-term follow-up must return to general practitioners and family physicians—this is relevant for reimbursement purposes.