Recalibrating the scale
Contributing to a holistic and fair response against obesity.
5 priorities in the fight against obesity
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Recalibrating the Scales—Why?
Obesity, regarded as “the epidemic of the 21st century”, remains largely unacknowledged. It is associated with stigma and prejudice that prevent the issue from being dealt with effectively. It is the second biggest cause of death in the world and the biggest health challenge worldwide where chronic illness is concerned, according to the World Health Organization (WHO).
The proportion of the population that is either overweight or obese has increased around the world, encompassing different age groups (including children and teenagers) and different regions of the globe. Initially, obesity was associated with countries with higher GDPs but now affects countries with lower incomes; indeed, the latter record the greatest increase in incidence and prevalence of the disease. Worldwide, four million people die each year as a result of being overweight or obese, says WHO. In Portugal, the data reveal a worrying trend in this disease, that currently affects 1.5 million people (National Health Survey 2019).
Without proper treatment, obesity gradually damages the body’s normal processes. It does not affect only the individual concerned; it affects families, health systems, economies, and social progress, compromising the health of future generations. To ignore the risk—especially within the context of the COVID-19 pandemic, where obesity is a risk factor for complications caused by infection with the novel coronavirus—is to contribute to a country that is more unhealthy, vulnerable, and asymmetric, and that is unable to stop the progression of this chronic disease and its consequences.
Now more than ever, we need effective strategies and responses that can contain and reverse the prevalence of obesity. It is urgent to move on from putting the onus on the individual towards a shared vision of public health in which everyone has a part to play. This document, born of that pressing need, was drawn up jointly by the Portuguese Association of Obese and Formerly Obese Patients (Associação de Doentes Obesos e Ex-Obesos, ADEXO) and the Portuguese Society for the Study of Obesity (Sociedade Portuguesa para o Estudo da Obesidade, SPEO).
Recalibrating the scale together
An effective response in the fight against obesity depends on all of us. Left untreated, the increase of obesity in Portugal is a barrier to the country socio-economic equity and progress.
Portugal blazed a trail when it recognized obesity as a chronic disease and a priority public health issue
in 2004. May we now be able to find new roads to action with a shared responsibility among all stakeholders.
It is time to learn from the past, decide to act differently, and find solutions for the future. It is time to recalibrate the scales in the fight against obesity.
Together we will make the treatment of obesity fairer.
Together we will create the right conditions to put an end to stigma and discrimination against those living with obesity.
Together, using a prevention-focused approach that removes existing barriers, we will build a healthier, more prosperous society today and for future generations.
Together against obesity.
Obesity:
a complex chronic disease with multiple causes
WHO defines obesity as an abnormal or excessive fat accumulation that presents a risk to health. The definition is usually linked to Body Mass Index (BMI), which measures the ratio between an individual’s weight and height (weight in kg / height in metres2).
Obesity in adults as a function of BMI (kg/m2)
Obesity is a complex serious chronic disease that has many causes and aggravating factors. Its prevalence is increasing worldwide, and, from a clinical point of view, it is an organic disease that carries a high risk of mortality and shorter average life expectancy.
The causes of obesity include genetic factors (heredity accounts for 70-80% of an individual’s BMI), psychological factors, behavioural factors (linked to more sedentary lifestyles and nutritionally unbalanced diets) and external factors, such as education, income level, access to health care, and commercial interests (including a greater availability of processed foods), among others.
Left untreated, obesity becomes a risk factor for other serious illnesses: so far, it has been linked to over 200 diseases and health problems.
Its multiple causes, linked to the risks of comorbidities and mortality, require ongoing medical follow-up and a long-term response, both individually and collectively, from a public health perspective. Obesity is a complex disease that requires a holistic approach (OPEN – Obesity Policy Engagement Network).
Source (adapted): EASO – European Association for the Study of Obesity
Obesity in adults, linked to BMI (Kg/m2)
It is a chronic, serious and complex disease, originated and worsened by multiple causes. With increasing prevalence worldwide, obesity is, from a clinical point of view, a biological disease with a high risk of mortality and a lower average life expectancy.
The causes of obesity include genetic factors (heredity is responsible for 70-80% of the BMI), psychological, behavioural (associated with greater sedentary lifestyle and nutritionally unbalanced diets) and external factors, such as education, income level, access to health care and business interests (including increased availability of processed foods), among others.
Without treatment, obesity becomes a risk factor for other serious diseases: it is associated with more than 200 diseases and health problems.
Its multiple causes, associated with the risks of comorbidities and mortality, require continued medical control and a long-term response – both individual and collective – from a public health perspective. Obesity is a complex disease that must be addressed holistically (OPEN – Obesity Policy Engagement Network).
Source (adapted): EASO – European Association for the Study of Obesity
Obesity:
a health emergency
Portugal was one of the first countries in the world to recognize obesity as a disease. However — and despite a number of public initiatives over the years, such as the National Program for Combating Obesity, the National Program for Promoting Healthy Eating, and the National Program for Promoting Physical Activity—the prevalence of this disease is increasing.
PORTUGAL
1.5 million adults live with obesity
= 16.9% of the Portuguese population (National Health Survey 2019)
WORLD
650 million adults live with obesity
= 13% of the world population (WHO, 2016)
The predictions stated in the World Obesity Report (prepared by the World Obesity Federation) are clear: at this rate, there will be more people suffering from obesity in Portugal than there are inhabitants in the Greater Lisbon area by 2025. The report estimates that there will be more than 2.4 million people with obesity, if both adults and children are included. In Europe, over half the population is overweight or obese (51.6%, Eurostat data).
According to the World Obesity Federation, Portugal is “high risk” and will not meet the United Nations target for stopping the increase in obesity in adults by 2025: the chance is 0.0% for men and very poor for women (2.0%).
Failing to stop obesity results in a society that is less healthy and more vulnerable, but also has an impact on national health system expenditure.
Still according to the World Obesity Report, the price Portugal will pay for not treating obesity is hig
1.6M
bilion euros
(data for 2016)
Consequences
and costs of obesity
Obesity is a risk factor for several diseases, reduces patients’ average life expectancy, affects families, and increases the pressure on the health system and the economy. Ultimately, the increase in people who are overweight and suffering from obesity make society less fair and less healthy, allocating means for treating the consequences of a disease at the expense of more effective, pre-emptive action: prevention and control during the early stages of the disease. Within the context of the COVID-19 pandemic, the consequences of obesity are more severe. The disease is considered a risk factor for complications when a patient becomes infected with the novel coronavirus.
26,4%
(PNPAS 2020)
+48%
risk of premature death from COVID-19 in people with obesity
(Study led by the University of North Carolina Individuals with obesity and COVID‐19)
38,4%
of COVID-19 patients in intensive care are people who live with obesity.
(ICNARC report on COVID-19 in critical care – UK)
Consequences and costs of obesity
Individual
More
+200 diseases and complications linked to obesity, including
- diabetes
- cardiovascular disease
- some types of cancer
- arthritis
- infertility
- depression and anxiety
- incontinence
Risk factor for complications in COVID-19 infection.
Shorter life expectancy. Increased risk of mortality. Reduced quality of life.
Low self-esteem, which also arises as a result of stigma and discrimination linked to the disease.
Family
More
Reduced family well-being while managing the disease and its comorbidities.
Effort by the patient’s carers, especially when multiple pathologies are involved.
Financial impact of the disease and its treatment.
Possible hereditary burden of the disease.
Discrimination (poor access to home loans caused by barriers when taking out Mortgage Insurance).
Health systems and the economy
More
Portugal: 207 euros per capita per year for treating diseases linked to excess bodyweight (10% of total health care expenditure).
Worldwide: 13% of health care expenditure.
It is estimated that the OECD will spend 8% of its budget on treating obesity and related diseases between 2020 and 2050.
Indirect economic costs (unproductivity, absenteeism, unemployment, etc.): 3.3% of OECD overall GDP.
Society
More
Social asymmetry reinforced by unequal access to the treatment of obesity.
Social discrimination of people living with excess weight or obesity.
Greater risk to future generations.
How can we stop the obesity epidemic?
Knowledge about obesity, its causes, and its consequences has grown a great deal in recent years. Nevertheless, treatment of the disease remains focused on its consequences and not on its causes. In addition, when it occurs upstream, the prevailing attitude remains simplistic, ad hoc, and focused exclusively on the patient and his or her lifestyle, ignoring the huge array of factors that increase the risk of obesity.
We advocate that effective treatment of obesity requires a cross-sectional, holistic, and multidisciplinary approach that can deal with the different causes and prevent the development of associated complications. Given the chronic nature of obesity, we support personalized, lifelong strategies backed by the best scientific evidence available and technological innovation.
There are treatment options, but these are rendered ineffective in practice due to a lack of integrated and fair approaches. Although obesity is considered a chronic disease, several barriers prevent the growing prevalence of the disease from being checked and a successful intervention in this public health issue.
For each of the five key barriers we identify in this document, we present priority lines of action. These are not complete solutions but, rather, proposals for a new paradigm in the treatment of this chronic disease. We believe that by means of a dialogue between health professionals, patients, decision-makers, and society in general, we can break down existing barriers to an effective treatment of obesity in Portugal and move towards cooperative responses that can stop the epidemic of the 21st century.
We must “recalibrate the scales” in the fight against obesity; we must do more and better, grounded on a new viewpoint and focus of action. We must do all this so that, as a country, we can fight obesity effectively, holistically, and fairly.
Line #1 Recalibrate the approach
Health system focused on the consequences, not the causes
More
Obesity is an important risk factor for diabetes, cardiovascular disease, and cancer, among others. Despite obesity being classified as a complex chronic disease, health systems remain more focused on treating these comorbidities and other complications than on tackling the causes of obesity.
Refocusing the response from health systems would allow a more effective and more efficient approach both to the treatment of obesity and to the prevention of related health problems (thus reducing the incidence and prevalence of chronic disease in Portugal).
Recommended strategy
Promote a holistic, dignified approach to the treatment of obesity
More
Obesity cannot be seen as an individual problem (one that comes down to “bad” lifestyle) but, rather, as a serious and complex public health issue with consequences to the progress and well-being of our society and of future generations. Only this perspective makes it possible to redefine health system priorities, building effective public programs and action plans that focus on:
- preventing and treating the causes of obesity;
- fair and dignified access to prevention and treatment initiatives by thepopulation;
- full operation of the 19 obesity treatment centres following accreditation and contract through the Ministry of Health;
- more extensive monitoring and follow-up of people living with overweight and obesity.
Line #2 Recalibrate medical training
Lack of training for health professionals
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One third of general practitioners in Europe do not feel confident enough to tackle the complexities of obesity, according to the European Association for the Study of Obesity. This lack of preparation is mainly due to the lack of specialist training in obesity (43% of doctors has received fewer than four hours of training on the subject).
The scenario is much the same in Portugal. Lack of training for health professionals (especially in primary and secondary care settings) represents a barrier to diagnosis, treatment, monitoring, and referral to specialist appointments.
Recommended strategy
Mobilize resources for specialist training
More
We advocate that strategies and initiatives for training health professionals should be outlined so that such professionals can indeed be a first line of response in the diagnosis, monitoring, awareness, and treatment of people with obesity.
Specialist training for health care professionals is also a priority in order to:
The specialised training of professionals is also a priority for:
- eliminate doctor–patient discrimination and individual stigma on the person living with overweight or obesity;
- encourage a cross-sectional, multidisciplinary approach to obesity;
- facilitate early diagnosis and intervention;
- increase the success rate of behavioural interventions.
Line #3 Recalibrate the role of primary health care
Lack of access to appointments for obesit
More
There is an imbalance between the prevalence of the disease in Portugal and the capacity of primary health care units (Health Centres and Family Health Services) to offer specialized obesity services. Gaps in the availability of appointments for obesity within primary care are a barrier to early diagnosis and treatment of the disease.
Without specialized obesity care in public health units, economic inequalities in access to appointments and treatment stand out, waiting times increase, and the opportunity to create outreach strategies to tackle the disease is lost.
Recommended strategy
Create a program of appointments for obesity within primary health care services
More
We recommend that specialty consultations for obesity are implemented within primary health care, as is the case with consultations for diabetes and hypertension, for example. This is the only way to create a proximity network across the country that can act on the different causes and dimensions of the disease and on early treatment.
Increasing capacity within primary health care is essential for improved prevention, initial diagnosis, and follow-up of the disease. This increased capacity must include dietitians and psychologists, both crucial in supporting patients who are not eligible for surgery, within primary health care. This is especially important considering that the best results in promoting healthy lifestyles — a key strategy in preventing overweight and obesity — are achieved within primary care.
Having ensured proper training regarding obesity for health care professionals (Line #2), we also propose the development of specific indicators and objectives linked to preventing and treating obesity in primary health care.
Line #4 Recalibrate the treatment of obesity
Barrier identified
Inequalities in access to obesity treatment
More
Drugs for treating obesity are available on the Portuguese market but are not reimbursed by the State. This fosters economic inequality when deprived populations (who show greater disease prevalence) attempt to access treatment and a treatment gap between behavioural therapy and surgery, which is reimbursed but not suited to all patients. At present, patients must pay for these drugs in full and the cost is between €80 and €257.
There is also an economic barrier to access the vitamin supplements recommended after bariatric surgery; these, too, are not reimbursed.
Recommended strategy
Reimbursement of obesity medicines
More
Dignified treatment of obesity can only be achieved if all citizens have fair access to the various therapeutic approaches available, which can be tailored to suit each patient. To do so, evidence-backed medicines for the treatment of obesity must be reimbursed by the State, thus closing the economic gap between the various treatment alternatives.
We further recommend State reimbursement of the vitamin supplements recommended in bariatric surgery (the post-surgical phase).
Line #5 Recalibrate public perception
There is still stigma, discrimination, and prejudice against people living with obesity
More
There is widely held stereotyped belief that obesity is an individual choice (i.e., “you are obese because you want to “) based on bad eating habits and being “too lazy” to change. This perception is a barrier to effective treatment of the disease and lies at the heart of discrimination experienced by patients with obesity. The Portuguese Association Against Childhood Obesity estimated in 2020 that 65% of children with obesity are bullied at school. International statistics show that 88% of citizens suffer discrimination or criticism due to overweight (Obesity Society, 2012). In adults, overweight increases the chances of discrimination at work. In addition, obesity is linked to lower levels of happiness (“Women in Portugal today” study, Francisco Manuel dos Santos Foundation [FFMS], 2019).
Stigma can come from doctors themselves as a result of lack of specific training in obesity. According to data shared by OPEN, 74% of health care professionals believe that individual patients should manage their own weight (without ongoing follow-up by a specialist) and 55% of doctors state that stigma prevents patients with obesity from being given a diagnosis. Discrimination contributes to low self-esteem and can affect the success of treatments (Weight bias and obesity stigma: considerations for the WHO European Region report, WHO).
Recommended strategy
Create mechanisms to eliminate stigma and discrimination related to obesity
More
Discrimination against those who are overweight or living with obesity is one of the main barriers to tackling the disease effectively. We must reflect and implement different mechanisms for informing and raising awareness in various stakeholders: health care professionals, decision makers, politicians, companies, and the general public.
In the specific case of existing barriers to taking out insurance policies, we recommend a change to the Portuguese Insurance Contract Legal Framework to include people living with obesity. We also propose that publicly owned banks can guarantee loans without life insurance or the need to take out credit insurance as ways to unlock access to home loans.
We also urge that other effective strategies are found to fight discrimination and prejudice in their various forms. We recommend that the work to define priority actions is carried on in its own forum, with the input of political decision makers, health care professionals, and specialist associations.
Recalibrating the scale together
An effective response in the fight against obesity depends on all of us. Left untreated, the increase of obesity in Portugal is a barrier to the country socio-economic equity and progress.
Portugal blazed a trail when it recognized obesity as a chronic disease and a priority public health issue in 2004. May we now be able to find new roads to action with a shared responsibility among all stakeholders.
It is time to learn from the past, decide to act differently, and find solutions for the future. It is time to recalibrate the scales in the fight against obesity.