Since 1997, the World Health Organization (WHO) considers obesity a chronic disease. The condition causes several damages to the functioning of the body, is responsible for triggering serious illnesses, can lead to death and causes deep stigmas in people.
Despite the seriousness of the problem and its epidemic proportions, treatments for obesity and overweight tend to be available only to the portion of the population that can afford it.
Society still attributes excess weight to laziness, lack of willpower and unbridled eating. The obese person is usually lonely when facing the condition, suffering prejudice even from health professionals who should guide them towards the solution. For those who are overweight, the issue is often ignored until it gets worse.
“Obesity is not simply an inevitable consequence of a wealthy and increasingly sedentary society, but an ‘evil’ condition of modern life that can be prevented or reversed with substantial benefits for the health of an individual and society as a whole” , states the International Obesity Federation, on its official website.
In the Unified Health System (SUS), there is treatment available for conditions that are a consequence of obesity and primary guidelines for individuals who are overweight. While we mourn many deaths and spend billions on health conditions that are related to being overweight, we fail to address the cause of the problems, the underlying comorbidity.
Disease that causes other diseases
Obesity is defined as the situation in which there is enough excess body fat to cause harm to health. Accumulation leads to metabolic changes, which disrupt the regulation of glucose and insulin. Dysregulation causes permanent inflammation in body organs, increasing the risk of chronic diseases such as high blood pressure, diabetes, heart and respiratory conditions and even some types of cancer.
A study published in May 2022 in the scientific journal JAMA, one of the most important in the world, states that obesity is even the main risk factor for the development of Alzheimer’s, the most common dementia. The disease is related to genetic factors, but recent research shows that environmental conditions – such as fat accumulation – also trigger degenerative disease.
Another survey, from 2019, by French and British scientists, suggested that obesity is the second most important risk factor for the development of cancer, second only to smoking. A Scottish survey has shown that overweight individuals may even have a lower immune response to Covid-19 vaccines.
According to a study published in 2019 by scientists from the Federal University of São Paulo (Unifesp) in the scientific journal Preventing Chronic Disease, from the United States Center for Disease Control and Prevention (CDC), about 168,000 deaths per year in Brazil are attributable to overweight and obesity.
Data from the Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey (VIGITEL) survey, carried out by the Ministry of Health, show that, in 2021, 26.3% of the Brazilian population had a medical diagnosis of hypertension and 9.14%, of diabetes. According to information from the Food and Nutrition Surveillance System (SISVAN), also from the government, in 2022, about 66% of Brazilians were overweight (which includes overweight and obesity).
A group of researchers from Fiocruz calculated how much obesity, hypertension and diabetes cost the SUS: they are BRL 3.45 billion annually, considering expenses with hospitalizations, outpatient procedures and medicines distributed to patients. To give you an idea, this amount would be enough to build 3,450 UBSs (basic health units – the end of the public network where preventive health actions for the population take place).
“The three conditions – obesity, hypertension and diabetes – form a triad. It is common for them to occur together in the same person. In general, they are preventable and controllable, they shouldn’t generate so many costs”, says researcher Eduardo Nilson, from the Brazilian Observatory of Food Habits (OBHA), Fiocruz, one of the authors of the work.
In new research, which is being prepared for publication in scientific journals, the scientists project expenditures of BRL 4.2 billion on direct costs and BRL 45 billion on indirect costs for 2030 caused by premature deaths related to obesity.
Delayed treatment in the SUS
“People with obesity suffer prejudice, they are seen as lazy, they hear that obesity is a choice. Is not true. It’s a chronic disease. Many think the treatment is simple: eat less and exercise. But that’s not all,” explains endocrinologist Bruno Halpern, president of the Brazilian Association for the Study of Obesity and Metabolic Syndrome (Abeso).
In the Unified Health System, what is offered to the obese patient is the minimum: change in diet and encouragement to exercise. For cases of individuals with a very high body mass index (BMI), above 35, with comorbidities, the recommendation is bariatric surgery.
Halpern cautions that many patients simply need deeper care. Some have a compulsion, others have suffered prejudice throughout their lives and internalized emotions, making the condition worse, and have a poorly functional eating pattern or are unable to exercise and diet. “There is a lack of knowledge even among doctors. Obesity has biological and physiological basis, many cases need medicine. You can’t think it’s something that can be solved just by eating less and exercising”, says the doctor.
For the president of Abeso, the treatment of obesity without surgery in the SUS is practically non-existent. He recalls that there are islands of excellence in a few hospitals and universities, but care, most of the time, is generic, provided by health professionals who are not trained to deal with this type of patient. “It’s a question of health education and a criticism of the university, which teaches very little about obesity,” he explains.
In the public network, the obese individual suffers from the delay in scheduling exams and appointments, it is difficult to get a reassessment in a timely manner — in the weight loss process, the attention of the multidisciplinary team is important a few times a year -, they receive a diet that it often doesn’t suit their lifestyle and, with so many difficulties, dropouts are common.
And, in times of Ozempic and other drugs for obesity that are already traditional in the private network — options that have been transforming the treatment of overweight and obesity and increasing success rates —, there is no type of drug offered by the SUS with the purpose of losing weight. Weight.
“Obesity is the only disease that is not treated with medicine in the SUS. It’s an absurd. Of the two, one: either they don’t think it’s a disease and we need to convince them, or it’s because it’s a neglected condition, and there’s no sponsor. We have the best AIDS program in the world, we have a transgender program, we do transplants, but there is no medicine for obesity. We need to rethink the allocation of resources”, warns endocrinologist Fábio Moura, director of the Brazilian Society of Endocrinology and Metabolism (Sbem).
Still in April, WHO experts should meet to discuss the inclusion, for the first time, of drugs to combat obesity in the list of essential medicines. Among the active principles evaluated will be liraglutide, a component of Saxenda, a product from Novo Nordisk, which also manufactures Ozempic.
The updated list, which is used by low- and middle-income countries as a guide for public health decision-making, should be released in September.
In Brazil, the National Health Surveillance Agency (Anvisa) has already approved the marketing of five drugs against obesity: sibutramine, orlistat, lorcasserine hydrochloride, liraglutide (Saxenda, Xultophy and Victoza) and semaglutide (Wegovy, which is manufactured with the same Ozempic molecule).
Of these, only the first two were evaluated by Conitec, the body that analyzes the inclusion of medicines that will be offered by the SUS. In the reports, the committee considered that the evidence presented was not sufficient, and the products were not approved for government procurement.
Bariatric: chances below zero
According to a recent survey by the Brazilian Society of Bariatric and Metabolic Surgery (SBCBM), the medical intervention indicated to solve morbid obesity, the most advanced stage of the disease, reaches less than 1% of the people who need it.
When the patient depends on the Unified Health System (SUS), the chances of being able to perform the surgical procedure are below zero: between 0.3% and 0.4% of people with indication manage to go to the operating room.
“There is a lack of doctors and adequate care centers. Today, we simply cannot cope with the demand”, laments Valezi, SBCBM president.
According to data from the medical entity, today Brazil has 7,700 hospitals, present in 5,568 municipalities — however, of these, only 98 perform bariatric and metabolic surgery. Four Brazilian states (Amazonas, Rondônia, Roraima and Amapá) do not even offer the procedure.
Between 2017 and 2022, Brazil performed 315,720 bariatric surgeries, 252 thousand of which were paid for by health plans, 46,791 by the Unified Health System (SUS) and 16 thousand privately.
Bariatric surgery is mainly indicated for patients with obesity grade III – BMI above 40. “These are people with serious comorbidities who are often bedridden, with heart and respiratory problems. The surgery is their chance to get their lives back”, emphasizes Valezi.
In the Federal District, the declared waiting list for the procedure is 250 people. The number, however, represents about 1/4 of all people who seek the hospital with the intention of performing the surgery.
For the indication of a bariatrician, consultations with a cardiologist, endocrinologist, psychologist, nutritionist and physiotherapist are necessary. It is common for the patient to get lost on the via crucis without being able to book all the appointments and mandatory exams.
Halpern, president of Abeso, says that, in addition to everything, the patient who finally undergoes bariatric surgery in the SUS still suffers from the lack of postoperative follow-up. “He will need to take vitamins, multidisciplinary follow-up, and there are high chances of long-term complications. The patient is lost, ”he says.
Generalist treatment
questioned by metropolisesthe Ministry of Health showed a generalist approach to the problem, stating that it offers comprehensive and free treatment to overweight and obese people.
“In addition to weight reduction, priority is also given to improving health conditions, preventing and controlling comorbidities associated with the condition. Among the actions and strategies available in the SUS, there are nutritional and dietary monitoring, strategic actions to face chronic diseases and encouraging the adoption of healthy habits, in addition to dietary guides for the Brazilian population, among other actions”.
In the next article, understand what science knows about the causes of obesity, binge eating and the disease’s relationship with emotions.
