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Die Adipositas ist eine chronische Erkrankung, die aus einer Wechselwirkung von Veranlagung und Umgebungseinflüssen (falsche Ernährung, Mangel an Bewegung, psychologische Faktoren) entsteht. Aufgrund der hohen Prävalenz von Folgekrankheiten stellt die Prävention und die Therapie der Adipositas eine der grossen Herausforderungen für unser Gesundheitssystem dar. Ziel jeder Therapie ist es, eine weitere Gewichtszunahme zu stoppen und dann das Gewicht zu reduzieren, um Folgekrankheiten wie z.B. Typ 2 Diabetes zu verhindern. Wegen der hohen Rückfallquote muss jede sinnvolle Intervention dem Anspruch genügen, langdauernd wirksam zu sein. Bei kurzzeitigen, befristeten Therapien (z.B. Diäten, Kuren) kommt es in über 90% der Fälle nach einem initialen Erfolg anschliessend zu einem erneuten Gewichtsanstieg («Jo-Jo-Effekt»). Die hier beschriebenen Daten beziehen sich auf die Wirksamkeit der Behandlung bezüglich Übergewicht und dessen somatischen Folgen. Aufgrund der wissenschaftlichen Datenlage ist die wirksamste Therapie ein integratives Konzept, das auf drei Säulen beruht: erstens soll eine langfristige Umstellung der Ernährung durch Fett- und Kalorienreduktion (tägliches Kaloriendefizit 500–1000 kcal) erfolgen, zweitens gehört ein verhaltenstherapeutisches Element dazu, das die langfristige Änderung der Ess- , Bewegungs- und Lebensgewohnheiten unterstützt, verbunden mit Massnahmen zur Vermeidung von Zwängen und Schuldgefühl im Zusammenhang mit dem Essen, mit einem verbesserten Körperbild und einer Strategie zur Rückfallprophylaxe; drittens soll die körperliche Aktivität gefördert werden. Medikamente (Xenical®, Reductil®) können in ausgewählten Fällen als Bestandteil einer zeitlich befristeten Behandlung eingesetzt werden, sie ersetzen jedoch die oben genannten Massnahmen zur Lebensstiländerung nicht. In bestimmten Fällen ist es auch wichtig, die das Essverhalten überlagernden psychischen Komorbiditäten zu behandeln. Bei therapieresistenter morbider Adipositas (BMI > 40 kg/m2) und beim Vorhandensein von Folgeerkrankungen muss die Indikation für eine chirurgische Intervention in Betracht gezogen werden (Gastric Banding oder Gastric Bypass). Obwohl mit Risiken behaftet, sind diese Methoden bezüglich Gewichtsverlust die effektivsten Massnahmen.

Obesity is a chronic disease resulting from various genetic factors and environmental conditions (nutrition, sedentary life-style, psychological factors). The importance of prevention and therapy of obesity is emerging because of the high prevalence of metabolic complications. The first goal of any therapy must be a stabilisation of weight, followed by a reduction of body weight. Any intervention must be long-acting. Short-acting therapies (diets) result in a regain of body weight in over 90%. The most effective therapy is an integrative concept basing on: change of nutrition by reduction of fat and carbohydrate intake (daily deficit of 500-1000 kcal). psychotherapeutic approach, targeting a long-term change of eating-behaviour and life-style, avoiding guilt feelings. encouraging physical activity. Drugs (Orlistat, Sibutramin) may be helpful in selected cases as a part of a limited treatment, they do not replace changes in lifestyle. Surgical interventions (gastric banding, gastric bypass) can be considered in morbid obesity with the presence of metabolic complications, as they are the most effective way of weight reduction.

The prevalence of obesity is increasing world wide, resulting in morbidity, mortality, and reduced quality of life. The aim of this study was to assess comorbidities and complaints of subjects with morbid obesity in comparison to milder forms of overweight. Therefore, 299 patients visiting our obesity consultation were examined and surveyed prospectively. 41% of the subjects were morbidly obese showing a significantly higher prevalence of arterial hypertension, edema, dyspnea, eczema and depression. Additionally, sleepiness, reduced work capacity, physical inactivity, disadvantages in social life and disturbed eating habits were observed more frequent. Evaluation of subjects with morbid obesity should include a large spectrum of complications, in order to be able to offer a comprehensive support and treatment.

The diabetic foot is still a medical problem of first order, not only for the quality of life of the affected patients but also for the society due to its high costs. Preventive measures are known to lower the risk for amputations by 40-85%. The introduction of interdisciplinary teams caring for diabetic patients with foot problems has been shown to reduce the incidence of amputations, and practicing physician should examine regularly the feet of diabetic patients. It is postulated that centres with interdisciplinary foot care teams should be established in the whole country to which patients with diabetic foot problems can be referred in order to diminish the rate of amputations.

The classification of newly diagnosed diabetic patients as type I (insulin-dependent) or type II (non-insulin-dependent) diabetes and the implied therapeutical consequences there of are based on clinical observations and laboratory tests. In case differential diagnosis is difficult, the measurement of the c-peptide secretion to assess beta-cell capacity can be helpful. For adequate control especially after long-standing diabetes in obese patients it is important to identify patients with potential secondary drug failure. Poor compliance with diet is thought to be a major reason for poor response to treatment. On the other hand, diabetics with poor control because of deterioration of beta-cell function must be distinguished. In these situations the measurement of c-peptide concentrations may contribute to identify the need for insulin treatment. As a result the development of diabetic complications can be retarded and beta-cell function can be preserved by adequate insulin therapy, whereas the consequences of hyperinsulinaemia in insulin treated patients not needing insulin can be avoided. In our opinion the c-peptide/glucose-quotient serves as simple, cost-effective and non-invasive method in the assessment of beta-cell capacity. Insulin therapy is indispensable in the case of inadequate insulin secretion.

Nutritional recommendations for diabetics are nowadays more flexible and better adapted to the individual patient. They resemble those offered to the public at large. Caloric intake is determined by body size and weight as well as physical activity. Approximately 60% of the energy should be consumed in the form of carbohydrates and monounsaturated fatty acids. The proportion of fatty acids and carbohydrates is fixed according to the individual nutritional habits. The intake of saturated and polyunsaturated fatty acids should be restricted. Meals and carbohydrates should be distributed over the day as three main meals with two to three snacks in between. Recommendations should always be adapted to the practical possibilities of the individual and to his particular metabolic situation.