Obesity: a pandemic that hits Italy and Spain, but the weapons to fight it are still blunt
Some call it a new “pandemic”, but obesity is certainly already a “global epidemic” as the WHO has renamed it: 1.9 billion people are overweight, 650 million are obese with 4 million deaths per year as a consequence of this condition that triggers chronic diseases such as diabetes, cardiovascular diseases and even tumors. And Italy, the first country in the world that is preparing to approve a law that recognizes obesity as a disease, is among the most affected with one in three Italians overweight and one in ten obese and a near future that makes one think of the worst given that the country that was once the standard-bearer of the Mediterranean diet - a model in the world and the first “vaccine” against extra pounds - is second in Europe for the number of obese or overweight children.
In Spain, one in two people is overweight and almost 20% is obese. But how can we stop this obesity pandemic? The strategies and problems vary from country to country, even in Europe, and range from the lack of qualified personnel in hospitals, which is recorded in Spain for example, to the number one problem of resources to pay for treatments and, above all, the new promising anti-obesity drugs that are invading the market and that Italy would like to offer.
Italy is about to become the first country in the world to approve a law that recognizes obesity as a true "progressive and relapsing" disease and those who suffer from it will have the right to receive free care that will be provided for by the essential levels of care, that is, by those services that the National Health Service must guarantee to all citizens. The law, approved at the beginning of last May, could be definitively passed by the summer. But the road to care for millions of patients is still very long and bumpy: the measure is made up of a few articles, allocating modest resources needed just to start an Observatory for the study of obesity and launch information and communication campaigns on the importance of prevention: this chronic disease is in fact the result of multiple factors closely linked to each other, including for example sedentary lifestyles and reduced physical activity, poor diet, socioeconomic determinants, psychological aspects and stress in addition to genetic factors. And being able to intervene in time also means saving money, given that it is estimated that between direct and indirect costs (related pathologies to be treated) the cost impact on the National Health Service exceeds 13 billion every year. In short, betting and investing in anti-obesity treatments could ultimately be convenient for everyone.
The problem, however, is to actually follow up on article 2 of the law which states that "subjects affected by obesity" will be able to benefit from "the services included in the essential levels of assistance (the so-called Lea) provided by the National Health Service". Which means that with the updating of the Lea, all those anti-obesity services such as visits and analyses, the new drugs that are becoming established in recent years up to bariatric surgery and medical indications on lifestyles such as medical prescription of sports activity will have to be included among the free treatments (or upon payment of the ticket).
"After the approval of this law, there will be no going back. It's like when diabetes care became one of the services provided by the essential levels of care. Now we need to find the resources, identify the centers and define the therapies. And it must be done because the cost of obesity is such that any intelligent state would be better off treating it before it becomes a problem," Andrea Lenzi, an endocrinologist and one of the leading experts on the subject in Italy, explained to Il Sole 24 Ore, so much so that he collaborated on drafting the law. "The treatments," Lenzi explains, "will not concern those who are overweight or all six million obese people in Italy. There will be specific guidelines and indicators to identify those who are entitled to them with precise pathways: an obese person will first go to the family doctor who, in the event of complications, will refer them to a specialized clinic in the area which in turn can send them to the regional specialist center which will produce a complete diagnosis and a treatment plan that could last several months."
The other epochal step could be the free prescription of new anti-obesity drugs. A delegation from the Italian Medicines Agency (AIFA) flew to England in recent days to study the path already taken by London in the war on obesity: in particular, AIFA is trying to understand how and if to replicate the English model here, also because the National Health Service is very similar in its functioning to our NHS.
In fact, the English National Health Service has currently recommended, through the NICE (National Institute for Health and Care Excellence), the reimbursement of a drug for obesity in adult patients who meet some specific requirements: very advanced obesity (second degree obesity with a body mass index - BMI - greater than or equal to 35 kg/m²) and at least one other major pathology related to weight (type 2 diabetes, hypertension, cardiovascular disorders).
These requirements limit the potential group of beneficiaries. Its prescription is then expected in association with a low-calorie diet and increased physical activity, while its reimbursement is conditional on achieving, within 6 months, a weight loss equal to or greater than at least 5 percent. Otherwise, the continuation of the therapy is evaluated on the basis of the benefit-risk balance for the patient.
In England, a study has also begun on the possible reduction of direct and indirect public health spending in the medium to long term: not only the direct effects on health will be examined, but also the consequences both in social life (inactivity, limitations) and at work, measuring them for example based on absences from work or disabilities. This is a study that could be replicated in Italy, with Lombardy leading the way. "As soon as obesity treatment is included among the essential levels of care, with the approval of the law, the AIFA, through the Scientific and Economic Commission, will evaluate the possible reimbursement of the new drugs that are arriving, taking inspiration from existing models. This is why we went on a mission to England," confirmed Robert Nisticò, president of the Italian Medicines Agency, to Il Sole 24 Ore. He thus addresses the issue of the resources needed to reimburse the new drugs: "The problem is not so much the price, but the fact that it affects millions of people and therefore they must be provided based on stringent criteria and to those who really need them. It must be said, however, that not treating obesity leads to important consequences such as diabetes, cardiovascular risk, tumors. All pathologies with a significant social and economic impact. Prices, however - concludes the president of Aifa - will fall and then the drugs that are now injectable will become oral and therefore will be increasingly widely consumed".
In Spain, there are not enough nutritionists in public hospitals. Very few autonomous communities have a dietitian-nutritionist in their public hospitals. In addition, some nutrition units do not even include this professional figure. Why is it so difficult to find a dietitian-nutritionist in a public hospital in Spain?
"Due to the lack of political will, because there is overwhelming evidence of the benefits they bring." Luis J. Morán Fagúndez, president of the General Council of Official Orders of Dietitians-Nutritionists (CGCODN), explains the situation of his profession in Spain. With the exception of some regions, such as Galicia, which in 2022 incorporated 94 professionals into its primary care system, or Catalonia, where the figure exists, dietitians-nutritionists (DN) are practically absent in many public hospitals.
“In the regions where they exist, there are very few of them,” adds the president. “It is a cost-saving measure that would not entail additional expenditure for the public health system. It makes no sense and we do not understand it. In addition, the current demand for nutritional services is met by other professionals who do their best to cover this sector,” says Morán. For example, in the case of Andalusia, a region that Morán knows well as a member of the board of the Andalusian Society of Clinical Nutrition and Dietetics (SANCYD), there have been nutrition units in hospitals for more than 30 years: “They are made up of dieticians, endocrinologists, nursing assistants or food scientists, but not DNs. These professionals also ask for our presence.”
Another point raised by the expert is the inequality that this situation creates: "Since there are no DNs in public health, if a patient needs these services, they have to pay for them privately. For people with lower incomes, who have the highest rates of childhood and adult obesity, this is impossible. It's a vicious circle."
In Spain, 55.8% of the population is overweight and 18.7% is obese, according to data from a study by the Carlos III Health Institute (ISCIII) and the Spanish Agency for Food Safety and Nutrition (AESAN). The study, published in October 2023, also concluded that overweight and obesity in adults are more common among people and population groups with lower levels of education, or who live in smaller cities and areas with lower income levels. "We are seeing a continuous increase in rates, even in projections for 2050. If obesity continues to increase, it will lead to a serious public health problem, as associated pathologies, such as diabetes or various types of cancer, will become more common. This will result in a burden that the National Health System (SNS) will have difficulty managing," warns the nutritionist.
“There is a paradigm shift in the way we understand how to best address obesity and its comorbidities: by treating the root cause of all the negative outcomes caused by this disease,” Albert Lecube Torelló, vice president of the Spanish Society for the Study of Obesity (SEEDO), explains to this newspaper. The “Obesity First” movement is based on decades of research linking excess weight to more than 200 health problems, such as heart failure, premature death and even 13 types of cancer. And its impact is not limited to the most serious diseases, but also plays a major role in conditions such as type 2 diabetes, which affects 15% of Spaniards, nearly 9 out of 10 of whom have excess body fat.
“It is not about stopping treating diseases in which obesity plays an important role, such as diabetes, cardiovascular hypertension or dyslipidemia, but rather about increasingly recognising the need to treat the cause of the complications [obesity itself],” says Lecube, who is head of the Department of Endocrinology and Nutrition at the Arnau de Vilanova University Hospital in Lleida.
In 2024, the Spanish Council of Ministers approved the creation of the Inter-Ministerial Committee for the Reduction of Childhood Obesity. This new body, led by the Ministry of Health and composed of representatives from 18 ministries, will be responsible for guiding and coordinating the National Strategic Plan for the Reduction of Childhood Obesity 2022-2030. According to the government, the plan includes 200 measures aimed at improving the health and well-being of children and adolescents, addressing various social, legislative and communication aspects. The Committee's main functions include promoting the integration of the plan's strategies into public policies, ensuring coherence between sectoral initiatives, coordinating with regional and local governments, and overseeing communication strategies.
The Committee will also monitor and evaluate the impact of the plan using pre-established indicators. Childhood obesity is a major public health problem in Spain, especially affecting children from low-income families. According to a 2023 report based on 2020 data, 30% of children between the ages of 2 and 17 were overweight and 10% were obese.
*This article is part of the European collaborative journalism project “Pulse”
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