Obesitas hos vuxna

Omfattning av kunskapsstödet

Andra relaterade kunskapsstöd

Följande kunskapsstöd på 1177 för vårdpersonal kan vara relevanta:

Nationellt vårdprogram för behandling av obesitas hos barn och ungdomar

Nationellt vårdprogram vid ohälsosamma levnadsvanor – prevention och behandling

Rehabilitering och delar av försäkringsmedicinskt arbete – generisk modell för kliniskt arbete (pdf)

Om hälsotillståndet

Definition

Obesitas definieras som ökad eller dysfunktionell ansamling av fettväv med risk för ohälsa [2]. På populationsnivå definieras obesitas med body mass index (BMI) där BMI ≥30 kg/m² visat ökad risk för obesitasrelaterad ohälsa. På individnivå behövs en bredare bedömning än bara BMI för att fastställa diagnos [3].

Förekomst

Enligt Folkhälsomyndigheten lever cirka 18 % av Sveriges vuxna befolkning med ett BMI ≥ 30. Cirka 4,5 % har ett BMI ≥ 35.

Orsaker

Obesitas är en kronisk sjukdom med komplexa bakgrundsorsaker. En genetiskt orsakad obalans av aptitregleringen leder ofta till att energiintaget överstiger energiförbrukningen. Att bibehålla viktnedgång är svårt då kroppen vill återta vikten genom ökad hunger och minskad mättnadskänsla.

Följdsjukdomar och samsjuklighet

Obesitas innebär ökad risk för död i förtid, framför allt relaterat till en ökad risk för cancer och hjärt-kärlrelaterad sjukdom. 

Följdsjukdomar till obesitas, sjukdomar som orsakas eller förvärras av obesitas, till exempel:

• typ 2-diabetes
• hjärt-kärlsjukdomar [14], såsom hypertoni, förmaksflimmer, hjärtsvikt, hjärtinfarkt och stroke
• olika cancerformer
• dyslipidemi
• sömnapnésyndrom
• artros i viktbärande leder (främst höfter, knän och fötter)
• njursvikt samt tromboembolism
• metabolisk dysfunktionsassocierad steatotisk leversjukdom (MASLD, tidigare NAFLD)
• idiopatisk intrakraniell hypertension. 

Samsjuklighet relaterat obesitas, det vill säga tillstånd med samband till obesitas, till exempel:

• psykiatriska diagnoser, till exempel depression, ångest och ätstörningar
• neuropsykiatriska funktionsnedsättningar
• gallsten och psoriasis
• polycystiskt ovarialsyndrom (PCOS) och nedsatt infertilitet[15]
• inkontinens
• sänkt hälsorelaterad livskvalitet, både fysisk och mental [16].

Personer med BMI 30–35 utan aktuella obesitasrelaterade riskfaktorer kan över tid både öka i vikt och drabbas av följdtillstånd.

Sjukdomsförlopp

Avgörande för att minska följdsjukdomar och samsjuklighet för personen med obesitas är att initiera tidig utredning och diagnostik samt att tillhandahålla personcentrerad och individualiserad multi­professionell behandling med beaktande av orsakssamband, risker och utlösande faktorer.

Obesitas är en kronisk sjukdom som för många individer blir progressiv genom livet, och därför kräver återkommande stöd och sjukvårdsinsatser, både för obesitassjukdomen och för följdsjukdom och samsjuklighet.

Utredning

Handläggning vid utredning

Utredning vid misstänkt obesitas omfattar en strukturerad genomgång av anamnes, status, provtagning och bedömning av eventuella följdtillstånd och samsjuklighet. Syftet är att bedöma svårighetsgrad och behov av riktad obesitasbehandling eller egenvård. Vid misstänkt bakomliggande sjukdom fortsätt utredningen utifrån specifik frågeställning.

Aspekter kring respektfullt bemötande

Personer med obesitas har i hög utsträckning tidigare negativa erfarenheter av vården, vilket bör beaktas i samtalet. Lyssna förutsättningslöst och fördomsfritt [23]:

• be alltid om lov innan samtal om patientens vikt och fråga om vikten ur ett hälsoperspektiv
• anta inte att patienten har vissa levnadsvanor
• mottagningsutrustning som är anpassad för patienter med obesitas är viktigt.

Anamnes

Grundläggande frågor om obesitas: 

• har vikten varit ett problem genom hela livet, eller finns livshändelser då vikten ökat
• erfarenheter av tidigare viktnedgångsförsök 
• vad är patientens upplevelse av orsak till viktuppgång
• levnadsvanor.

Status

Följande statusmoment är relevanta:

• blodtryck 
• buk (till exempel förstorad lever, bukväggsbråck, överskottshud)
• vikt, längd, BMI
• midjemått. 

Provtagningar

Överväg följande prover:

• glukos, HbA1c 
• lipidstatus
• TSH
• Hb
• kreatinin.

Diagnoskriterier

Diagnosen baseras på en samlad klinisk bedömning på individnivå. Diagnos med enbart BMI är inte tillräckligt.

Bedömningen utgår från:

• BMI ≥ 30 kg/m², med hänsyn till ålder, kön, etnicitet och förekomst av dysfunktionell ansamling av fettväv, till exempel ökat midjemått
• kliniska faktorer såsom symtom, funktionsnedsättning, organpåverkan, risk för obesitasrelaterade följdsjukdomar eller situationer där viktnedgång bedöms ha medicinsk betydelse
• andra relevanta fynd, exempelvis fördelning av fettmassa, samsjuklighet eller påverkan på dagliga funktioner.

Ett ökat midjemått över 88 cm hos kvinnor och över 102 cm hos män används som stöd i bedömningen, eftersom dessa värden är förenade med ökad metabol risk [27]. 

Fastställ och kommunicera diagnosen tillsammans med patienten. Säkerställ att den dokumenteras korrekt.

Behandling

Handläggning vid behandling

Behandling av obesitas är långsiktig och multiprofessionell. Målet är att förbättra hälsa och livskvalitet där behandlingsfokus ligger på viktnedgång. En viktnedgång på ungefär 5–10 % är ofta tillräcklig, men vid etablerade följdsjukdomar kan minst 15 % viktreduktion vara motiverad.

Behandlingen utgår från stöd till hållbara förändringar av levnadsvanor. Planera insatser individuellt: egenvård, kombinerad levnadsvanebehandling, vid behov ytterligare åtgärder som läkemedelsbehandling eller kirurgi.

Egenvård

Egenvård innebär råd och åtgärder som patienten genomför själv i vardagen för att främja hälsa och förebygga viktökning. Fokus ligger på matvanor, fysisk aktivitet, sömn och stress. Egenvård är aktuellt framför allt vid lägre risknivåer eller obesitas utan följdsjukdomar eller samsjuklighet.

Transkulturella aspekter på obesitasvård

En förståelse för olika kulturer bör finnas när du pratar matvanor och kroppsvikt med dina patienter. Kulturer är dynamiska och föränderliga, inte något som patienten kommer med och som vårdpersonal kan bli expert på. Personer från samma land har inte nödvändigtvis samma kultur, många gånger inte ens samma språk. Att undvika stereotyper är också att arbeta patientcentrerat.

Olika villkor för hälsan kan handla om språkbarriärer och annorlunda föreställningar, men även om strukturella faktorer. Man kan till exempel ha svårt att ta ledigt från jobbet för att gå till vårdbesök, leva i ekonomisk utsatthet eller inte ha möjlighet att välja sin mat.

Behandlingsval

Behandlingsinsatser väljs utifrån svårighetsgrad, samsjuklighet och individuella förutsättningar. Vid högre BMI eller uttalade följdsjukdomar blir mer aktiva och kombinerade insatser aktuella.

Rehabilitering

Rehabilitering med stöd av fysioterapeut

I fysioterapeutens uppdrag ingår att:

• ge stöd för att öka den fysiska funktionsförmågan
• som en integrerad del i den ordinarie verksamheten uppmärksamma ohälsosamma levnadsvanor, ge enkla råd, samt vid fysisk inaktivitet och ohälsosamma matvanor genomföra rådgivande samtal och kvalificerat rådgivande samtal – vid behov av vidare insatser ska vårdgivaren hänvisa till relevant aktör
• använda Fysisk aktivitet på recept (FaR) som behandlingsalternativ för att förebygga och behandla sjukdom enligt gällande riktlinjer, samt hjälpa till att hitta lämpliga former av fysisk aktivitet.

Rehabilitering med stöd av arbetsterapeut

I arbetsterapeutens uppdrag ingår att stödja till att praktiskt omsätta livsstilsförändringar, att förebygga ohälsa och främja hälsa och välbefinnande, samt att arbeta med hinder och möjligheter i vardagen:

• uppmärksamma ohälsosamma levnadsvanor och ge enkla råd, samt att vid fysisk inaktivitet och ohälsosamma matvanor genomföra rådgivande samtal och kvalificerat rådgivande samtal – vid behov av vidare insatser ska vårdgivaren hänvisa till relevant aktör
• göra en analys för att identifiera vilket stödbehov personen har samt se till att insatserna genomförs och sedan utvärderas tillsammans med personen
• anpassning av aktivitetsutförande för att klara aktiviteter i det dagliga livet (ADL) och ge kompensatoriska åtgärder för att klara ADL.

Rehabilitering och behandling med stöd av sjuksköterska

I sjuksköterskans uppdrag ingår att:

• erbjuda patienten ökade möjligheter att förbättra, bibehålla eller återfå sin hälsa, hantera hälsoproblem, sjukdom eller funktionsnedsättning och uppnå bästa möjliga välbefinnande och livskvalitet
• stödja patienten med pedagogisk kompetens och kunna leda patienten i utbildnings- och handledningsaktiviteter på grupp- och individnivå riktade mot såväl patienter som närstående
• bedöma patientens hälsotillstånd genom såväl patientens subjektiva upplevelser som objektiva data, samt fastställa omvårdnadsdiagnoser där patientens behov av omvårdnad identifieras och prioriteras utifrån en analys av patientens behov, resurser, risker och problem
• planera omvårdnaden tillsammans med patienten utifrån fastställda mål samt tillsammans med patienten utvärdera patientens hälsotillstånd mot uppsatta mål
• genomföra såväl omvårdnadsåtgärder som åtgärder ordinerade av annan profession tillsammans med patienten
• stödja patenten som står på obesitasläkemedel genom att dosjustera läkemedel utifrån delegeringsbeslut av verksamheten och enligt riktlinjer från Socialstyrelsens bestämmelser om behörighet att ordinera läkemedel
• planera, konsultera och samverka med teamet och andra aktörer för att säkerställa kontinuitet och säkerhet för patienten.

Arbetslivsinriktad rehabilitering

Den arbetslivsinriktade rehabiliteringen handlar om åtgärder på och i nära anslutning till arbetsplatsen och syftar till att den arbetstagare som är drabbad av en skada eller sjukdom ska återfå eller behålla sin arbetsförmåga och återgå i arbete.

Habilitering

Försäkringsmedicin och intyg

Sjukskrivning

Sjukskrivning kan vara aktuellt utifrån patientens aktuella tillstånd.

Intyg

Patienten kan få förebyggande sjukpenning om hen avstår från att arbeta på grund av medicinsk behandling eller rehabilitering såsom sjukgymnastik eller dietistbesök. Behandlingen eller rehabiliteringen ska syfta till att förebygga eller förkorta sjukdom. Resetiden kan medräknas om denna sker under arbetstiden.

Förebyggande sjukpenning – Försäkringskassan

Obesitas kan räknas som en funktionsnedsättning om sjukdomen leder till hinder i patientens vardag, och då kan kostnad för till exempel läkemedel räknas som en merkostnad. För att en patient ska kunna få merkostnadsersättning krävs ett läkarutlåtande.

Merkostnadsersättning, Försäkringskassan

Tandvårdsbidrag: Underlag för särskilt tandvårdsbidrag, Försäkringskassan

Kvalitetsuppföljning

Indikatorer för uppföljning

Indikatorlista Nationella riktlinjer för vård vid obesitas: Indikatorer för vård vid obesitas (pdf)

Patientmedverkan och kommunikation

Personcentrering och dokumenterad överenskommelse

Personcentrering innebär att ta hänsyn till patientens egna mål, resurser och förmågor. Utgångspunkten är att fråga efter vad som är viktigt för patienten och att medverka i utredning, behandling och uppföljning. Uppmuntra närståendes medverkan om patienten själv inte kan föra sin talan.

Aspekter kring respektfullt bemötande

Dokumenterad överenskommelse

Stöd och information för patient och närstående

Patientinformation på 1177: Obesitas – fetma och övervikt hos vuxna

Patientinformation från Dietisternas riksförbund:

• Inför bariatrisk kirurgi
• Kostbehandling efter bariatrisk kirurgi

Patientorganisation: Riksförbundet Obesitas Sverige är patientorganisation för personer med obesitas.

Relaterad information

Utbildning och information

Socialstyrelsen, Kunskapsguiden:

• Obesitas – bemötande och behandling, Kunskapsguiden 
• Om obesitas, Kunskapsguiden

Kompletterande underlag

Nationella riktlinjer för vård vid obesitas, Socialstyrelsen

Nationella riktlinjer 2024, Vård vid ohälsosamma levnadsvanor, Socialstyrelsen

Nordiska riktlinjer för monitorering och supplementering med vitaminer/mineraler samt uppföljning efter metabol och bariatrisk kirurgi

Nationella riktlinjer ätstörningar, Socialstyrelsen

Grund för rekommendation (pdf)

Konsekvensbeskrivning (pdf)

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