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Vol. 72. Issue 11.
Pages 916-924 (November 2019)
Original article
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Excess Weight in Spain: Current Situation, Projections for 2030, and Estimated Direct Extra Cost for the Spanish Health System
Exceso de peso en España: situación actual, proyecciones para 2030 y sobrecoste directo estimado para el Sistema Nacional de Salud
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Álvaro Hernáeza,b,c, M. Dolores Zomeñob,d,e, Irene R. Déganof,g, Silvia Pérez-Fernándezf,g, Alberto Godayc,d,h,i, Joan Vilaf,j, Fernando Civeirag,k, Ricardo Mourec,l, Jaume Marrugatf,g,
Corresponding author
jmarrugat@imim.es

Corresponding author: Institut Hospital del Mar d’Investigacions Mèdiques-IMIM. Dr. Aiguader 88, 08003 Barcelona, Spain.
a Grupo de Investigación en Riesgo Cardiovascular, Nutrición y Envejecimiento, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
b Facultad de Ciencias de la Salud Blanquerna, Universitat Ramón Llull, Barcelona, Spain
c CIBER de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
d Grupo de Investigación en Riesgo Cardiovascular y Nutrición-REGICOR, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain
e Programa de Doctorado en Alimentación y Nutrición, Facultat de Farmàcia, Universitat de Barcelona, Barcelona, Spain
f Grupo de investigación REGICOR, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain
g CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
h Servicio de Endocrinología, Hospital del Mar, Barcelona, Spain
i Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
j CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
k Unidad de Lípidos y Arteriosclerosis, Servicio de Medicina Interna, Hospital Universitario Miguel Servet, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
l Departamento de Bioquímica y Biomedicina Molecular, Institut de Biomedicina IBUB, Universitat de Barcelona, Barcelona, Spain
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Tables (3)
Table 1. Characteristics of Studies Included in the Systematic Review Search
Table 2. Estimate of Cases of Overweight and Nonmorbid and Morbid Obesity in Spanish Adults and Their Additional Direct Cost (2006, 2016)
Table 3. Estimate of Cases of Overweight and Nonmorbid and Morbid Obesity in Spanish Adults in 2030 and Their Additional Direct Cost if Excess Weight Progresses at Current Rates or Holds Steady at 2016 Levels
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Abstract
Introduction and objectives

Excess weight promotes the development of several chronic diseases and decreases quality of life. Its prevalence is increasing globally. Our aim was to estimate the trend in excess weight between 1987 and 2014 in Spanish adults, calculate cases of excess weight and its direct extra costs in 2006 and 2016, and project its trend to 2030.

Methods

We selected 47 articles in a systematic literature search to determine the progression of the prevalence of overweight, nonmorbid obesity, and morbid obesity and average body mass index between 1987 and 2014. We projected the expected number of cases in 2006, 2016, and 2030 and the associated direct extra medical costs.

Results

Between 1987 and 2014, the prevalence of overweight, obesity, and morbid obesity increased by 0.28%/y (P=.004), 0.50%/y (P <.001) and 0.030%/y (P=.006) in men, and by 0.10%/y (P=.123), 0.25%/y (P=.078), and 0.042%/y (P=.251) in women. The mean body mass index increased by 0.10 kg/m2/y in men (P <.001) and 0.26 kg/m2/y in women (significantly only between 1987 and 2002, P <.001). We estimated 23 500 000 patients with excess weight in 2016, generating 1.95 billion €/y in direct extra medical costs. If the current trend continues, between 2016 and 2030, there will be 3 100 000 new cases of excess weight, leading to 3.0 billion €/y of direct extra medical costs in 2030.

Conclusions

Excess weight in Spanish adults has risen since the creation of population registries, generating direct extra medical costs that represent 2% of the 2016 health budget. If this trend continues, we expect 16% more cases in 2030 and 58% more direct extra medical costs.

Keywords:
Overweight
Obesity
Morbid obesity
Systematic literature search
Medical extra costs
Projection
Abbreviations:
BMI
Resumen
Introducción y objetivos

El exceso de peso potencia algunas enfermedades crónicas y reduce la calidad de vida, y su prevalencia crece en todo el mundo. El objetivo es estimar la evolución del exceso de peso entre 1987 y 2014 en población española adulta, calcular los casos de exceso de peso y sus sobrecostes médicos directos en 2006 y 2016, y proyectar su tendencia a 2030.

Métodos

Se seleccionaron 47 artículos en una búsqueda bibliográfica sistemática para determinar la progresión de las prevalencias de sobrepeso, obesidad y obesidad mórbida y del índice de masa corporal promedio entre 1987 y 2014. Con estos datos, se estimó el número de casos en adultos españoles en 2006, 2016 y 2030 y sus sobrecostes directos.

Resultados

Entre 1987 y 2014, las prevalencias de sobrepeso, obesidad y obesidad mórbida aumentaron el 0,28%/año (p=0,004), el 0,50%/año (p<0,001) y el 0,030%/año (p=0,006) en los varones y el 0,10%/año (p=0,123), el 0,25%/año (p=0,078) y el 0,042%/año (p=0,251) en las mujeres. El índice de masa corporal aumentó 0,10 puntos/año en varones (p<0,001) y 0,26 en mujeres (significativamente solo entre 1987-2002, p <0,001). Se estimaron 23.500.000 casos de exceso de peso en 2016, cuyo sobrecoste médico directo supuso 1.950.000.000 euros/año. De mantenerse la tendencia, entre 2016 y 2030 aparecerán 3.100.000 nuevos casos de exceso de peso, y se alcanzará en 2030 un sobrecoste médico directo de unos 3.000.000.000 euros/año.

Conclusiones

El exceso de peso en los adultos en España aumenta desde que existen registros, y en 2016 supuso un sobrecoste directo del 2% del presupuesto sanitario. Con esta tendencia, en 2030 se habrá incrementado un 16% el número de casos y un 58% su sobrecoste sanitario directo.

Palabras clave:
Sobrepeso
Obesidad
Obesidad mórbida
Revisión bibliográfica sistemática
Sobrecostes médicos
Previsión
Full Text
INTRODUCTION

Excess weight is a priority concern in public health because it raises mortality (increased 7% to 20%, 45% to 94%, and 176% by overweight, obesity, and morbid obesity, respectively)1 and is the fourth preventable factor that most impairs quality of life.2 The prevalence of excess weight has risen since data were first recorded: in 2014, obesity was present in 10.8% of men and 14.9% of women worldwide, and these figures are expected to jump to 18% and 21%, respectively, by 2025.3

In Spain, excess weight has been analyzed in methodologically heterogeneous population studies, and the trend has only been described in national health surveys, which observed an increase in overweight and obesity of 1.8% and 8.5%, respectively, between 1987 and 2012.4 Likewise, although the individual direct extra medical costs of excess weight are known,5 there is no estimate of the total extra costs for our health system.

This purpose of the study was: a) to determine the trend of excess weight and average body mass index (BMI) in the general Spanish adult population; b) to estimate the prevalence and number of cases of overweight, obesity, and morbid obesity in 2006, 2016, and 2030, and c) to estimate total direct extra costs thereof.

METHODSDesign

The study design consisted of a systematic review search and estimate of trends over time.

Search Criteria

We examined primary literature sources published since 1985 describing the prevalence of excess weight, obesity, or morbid obesity or average BMI (quotient between weight in kg and the square of height in meters) in representative samples of the general Spanish adult population. The study considered overweight to be BMI ≥ 25 and <30, nonmorbid obesity to be BMI ≥ 30 and <40, and morbid obesity to be BMI ≥ 40.

The selection of sources is described in Figure 1. PubMed and Embase were searched for articles that contained body mass index, BMI, overweight, words that started with obes in the title or abstract, or obesity or overweight as MeSH Terms, Spain in the title, abstract, or affiliations or Spanish in the title or abstract, and prevalence in the title, abstract, or as MeSH Term (search performed on 6 March 2017). Only studies including the following were considered: a) general Spanish adult population (≥ 16 years, excluding populations that were only working populations); b) results reported by sex; c) participants’ age range, and d) year of examination. Two of the authors (A. Hernáez and J. Marrugat) reviewed the search titles (n=873) and classified them as relevant or irrelevant. The abstracts of articles with titles classified as relevant by at least 1 author (n=201) were reviewed using the same criterion, and 131 articles were obtained for a full-text review. A review of the literature references cited in these series provided an additional 18 references (n=149). Any discrepancies were resolved by consensus. When aggregate studies of previous series were identified, the data were collected from the individual studies if possible. When several publications were found for the same study, the publication with more participants or more detailed information was retained.

Figure 1.

Literature search strategy.

(0.25MB).

A total of 47 articles were included in the review. These articles were then used to extract the prevalences of overweight, obesity, and morbid obesity as well as average BMI, year of data collection, and whether weight and height data were reported by patients or collected by health professionals. The mean age of participants was also calculated or estimated. The quality of the articles was analyzed, according to whether or not the article expressly defined the following: a) volunteers’ age and location; b) sampling method; c) recruitment response rate reported as ≥ 70%; d) anthropometric information for excluded participants; e) definition of overweight, obesity, and morbid obesity; f) exact methodology used to measure weight and height; g) instrumentation used to determine weight and height, and h) measures taken to reduce any observation bias.6 A broader explanation of these aspects is given in the “Determination of Study Quality” section of the supplementary data.

Statistical Analysis

The trends of excess weight over time were calculated using multivariate linear regression models: the prevalences of excess weight or average BMI (separated by sex) were the dependent variables, the year of data collection and the mean age of the individuals were the independent variables, and the contribution of each study was weighted according to sample size.7 For each dependent variable, we studied whether or not the use of patient-reported weight and height data in each study (as a categorical variable) significantly affected model behavior. Likewise, we assessed whether or not the inclusion of nonlinear trends reached statistical significance; when this occurred, possible inflection points were estimated by the break point method.8 Previous trends were depicted by weighting each study equally according to sample size (greater size, larger plot point).9 These analyses were performed using R Software (version 3.4.1).10

Prevalences and Cases of Excess Weight in 2006, 2016, and 2030

The prevalences of overweight, obesity, and morbid obesity in 2006 and 2016 were calculated as described above, and the mean age of the Spanish adult population was estimated for each year from the National Statistics Institute data11 (see “Methods” in the supplementary data). For projections up to 2030, 2 scenarios were considered: a) the current trend persists and b) the prevalences of excess weight holds steady at 2016 values.

The cases of excess weight were calculated by applying the previous prevalences to populations of men and women aged ≥ 16 years in 2006 and 2016 and the projections for 2030.12

Approximate Estimate of Total Direct Extra Medical Costs

Mora et al.5 estimated that direct extra costs due to excess weight in Spain (considering excess costs in these patients due to primary care, specialist, and emergency visits; hospitalizations; laboratory, radiologic, and other types of diagnostic tests; and pharmaceutical prescriptions) were €43.49, €115.13, and €145.64 per year for men and €60.73, €142.95, and €170.07 per year for women with overweight, nonmorbid obesity, and morbid obesity, respectively (compared with persons of normal weight, with the euro value in 2010 taken as a reference).5 The above parameters were adjusted for inflation from 2006 to 2010 (7.91%) and from 2010 to 2016 (5.92%) based on the Consumer Price Index,13 assuming a stable macroeconomic situation with a theoretical annual inflation of 2% from 2016 to 203014 and multiplying by the number of cases previously calculated to estimate the approximate total direct extra costs. A broader explanation of these aspects and the exact values of direct extra costs per person in 2006, 2016, and 2030 is given in the “Methods” section of the supplementary data and Table 1 of the supplementary data, respectively.

RESULTS

The articles considered provide data from 51 studies conducted between 1987 and 2014 (Table 1),4,15–60 which included 149 955 men and 167 159 women. The prevalences of overweight, obesity, and morbid obesity and average BMI appeared in 36, 46, 11, and 29 studies, respectively. The studies were of variable quality (35% were low; 57%, medium; and 8%, high) (Table 2 of the supplementary data).

Table 1.

Characteristics of Studies Included in the Systematic Review Search

BMI, body mass index.

From 1987 to 2014, the prevalences of overweight, total obesity, and morbid obesity increased by+0.28% per year (P=.004),+0.50% per year (P <.001), and+0.030% per year (P=.006) in men and by+0.10% per year (P=.123),+0.25% per year (P=.078), and+0.042% per year (P=.251) in women (Figure 2). None of the above trends exhibited significant nonlinear behavior or break points (P> .05). The equations of these progressions are shown in Table 3 of the supplementary data.

Figure 2.

Trend for prevalences of overweight (A), obesity (B), and morbid obesity (C) and linear trend analysis in epidemiologic studies in Spanish adults between 1987 and 2014.

(0.45MB).

Average BMI values rose linearly between 1987 and 2014 in men (+0.10 per year; P <.001), with no significant break point, and increased between 1987 and 2002 in women (+0.26 per year; P <.001) and did not drop significantly between 2002 and 2014 (–0.14 per year; P=.265) (Figure 3).

Figure 3.

Trend for body mass index between 1987 and 2014, linear trend analysis, and break point determination in epidemiologic studies in Spanish adults.

(0.18MB).

There was no difference in the behavior of either trend according to whether weight and height data were reported by patients or were collected by health professionals (P> .05 in all cases).

From 2006 and 2016, more than 3.1 million new cases of excess weight appeared (Table 2), which increased direct extra costs of this disease by €524 million per year up to €1.95 billion in 2016, 2% of the health budget (€95.722 billion according to the latest estimate).61

Table 2.

Estimate of Cases of Overweight and Nonmorbid and Morbid Obesity in Spanish Adults and Their Additional Direct Cost (2006, 2016)

BMI, body mass index; EC, extra cost.

If the current trend persists, in 2030 there will be about 27.2 million adults with excess weight, with direct extra costs of about €3.08 billion per year (Table 3). This would be approximately an additional 3.1 million cases (and additional €440 million per year of extra costs) compared with the scenario in which the disease stabilizes at 2016 values. Assuming a linear increase, cumulative extra costs between 2016 and 2030 in the worst case scenario would rise to €3.081 billion.

Table 3.

Estimate of Cases of Overweight and Nonmorbid and Morbid Obesity in Spanish Adults in 2030 and Their Additional Direct Cost if Excess Weight Progresses at Current Rates or Holds Steady at 2016 Levels

BMI, body mass index; EC, extra costs.

DISCUSSION

Excess weight is increasingly prevalent among Spanish adults: the data collected indicate that overweight, obesity, and morbid obesity rose significantly in men between 1987 and 2014, whereas obesity increased only slightly in women. The average BMI increased linearly and significantly in men over this period and in women only until 2002. These data are consistent with the rise in overweight and obesity of 1.8% and 8.5% described in national health surveys between 1987 and 2012,4 although they differ from the pattern of BMI increase reported by other studies.3 Possible explanations for this weight gain are that, during the study period, the Spanish population: a) acquired less healthy dietary patterns (higher intake of cookies, industrial pastries, dairy desserts, juice, and soft drinks); reduced their fruit intake at home; and dramatically increased eating out62; b) continued to follow a moderately sedentary lifestyle,63 or c) experienced an increase in employment levels, working hours, and purchasing power (particularly before the financial recession that began in 2009), which would have encouraged less traditional dietary standards or more sedentary lifestyles.64

Excess weight leads to considerably higher direct extra medical costs because these patients use health care more often (mainly due to more primary care, specialist, and emergency medical visits; more hospitalizations; more laboratory, radiologic, and diagnostic tests, and more drug prescriptions), both due to the excess weight itself and due to its multiple associated comorbidities.5,65 According to our estimates, these direct extra medical costs were approximately €1.95 billion in 2016 (2% of the annual health budget), consistent with those described for other health systems (0.7%-2.8%).66 Because direct medical expenses account for about half the total extra cost of obesity in other European systems (which also consider higher costs due to possible sick leave, loss of productivity and performance, the cost of time invested by other health system workers, etc),67 the total extra cost due to excess weight could be around €3.9 billion for 2016. It was estimated that these were approximately €2.5 billion by the late 1990s65 and, therefore, a cost increase of €1.4 billion per year within the next 15 to 20 years is plausible.

The growing prevalence of excess weight could rapidly become unsustainable. If the current trend continues, in 2030 there will be 27.2 million cases of excess weight (3.1 million more cases than if the trend remains steady at 2016 values). This progression could be tackled by multilevel interventions (applying taxes to unhealthy foods, promoting settings that discourage weight gain, implementing educational policies that enhance healthy lifestyles, and organizing better prevention systems),68 such as has been undertaken in North Karelia, Finland.69 New pharmacological strategies (eg, bupropion-naltrexone, liraglutide) could also be useful.70 Apart from the health benefit, maintaining the prevalence of excess weight at current levels (already sufficiently high) would save about €3.0 billion by 2030. Considering that obesity prevention plans in Spain (such as the NAOS Strategy71) did not involve investments of such magnitude, these programs could be financially cost-effective in the short- to mid-term.

Limitations and Strengths

Our review search has several limitations. First, it included studies of uneven methodological quality conducted in 3 different decades. This heterogeneity was partially corrected by using multivariate linear regression models and by weighting the studies according to sample size. Second, the review maximized the number of time points by including studies that enrolled participants aged 15 to 17 years4,18,20,28,31,32,34,38,39,42,51,52,55,59; because these studies did not describe the use of other cutoff points or standards to quantify excess weight in this population, it was deduced that the studies used the same ones as for the adult population, which is not an ideal method. Third, excess weight did not increase significantly in women, probably due to greater dispersion in female prevalences. Fourth, an estimate of the mean age of Spanish adults was used to calculate the prevalences of excess weight because the National Institute of Statistics does not provide this information. Last, total extra cost due to this disease (considering all direct and indirect costs) could not be calculated, and only approximate direct extra medical costs could be estimated because there are no estimates of this parameter in the Spanish health system.

This study has several strengths. This is the first systematic literature search on excess weight trends conducted with all epidemiologic studies among the general Spanish adult population. In addition, it estimates the number of individuals who currently carry excess weight and then provides projections for 2030. Last, it contextualizes the social relevance of the problem by providing estimated figures of current and future direct extra costs.

CONCLUSIONS

The prevalences of overweight, obesity, and morbid obesity have risen since records were first kept in Spain, although the incremental rise among women is not statistically significant. The result is a prevalence of more than 23 million persons with excess weight, with direct extra medical costs of almost 2% of the 2016 health budget. According to this trend, by 2030 there will be about 3.1 million new cases and extra costs of about €3.0 billion per year (more than 3% of the current health budget). Stabilizing excess weight at 2016 levels, which are already alarming, would save almost €3.0 billion by 2030.

FUNDING

This study was funded by AGAUR (University and Research Aid Management Agency) (2014-SGR-240), the Health Department of the Generalitat de Catalunya (SLT006/17/00029), the Carlos III Health Institute (CES12/025, CD17/00122), CIBEROBN (Biomedical Research Center for the Obesity and Nutrition Pathophysiology Network), CIBERCV (Biomedical Research Center for the Cardiovascular Disease Network), and the European Regional Development Fund, as well as Novo Nordisk, which provided an unconditional grant.

CONFLICTS OF INTEREST

None declared.

WHAT IS KNOWN ABOUT THE TOPIC?

  • Excess weight is one of the factors most likely to increase the morbidity and mortality of chronic diseases, most likely to impair quality of life, and most likely to raise health costs.

  • The prevalence of excess weight has risen worldwide since the start of record-keeping.

WHAT DOES THIS STUDY ADD?

  • The prevalences of overweight, obesity, and morbid obesity in Spain increased 0.28% per year (P=.004), 0.50% per year (P <.001), and 0.030% per year (P=.006) in men and 0.10% per year (P=.123), 0.25% per year (P=.078), and 0.042% per year (P=.251) in women, respectively.

  • In 2016, there were 23.5 million cases of excess weight, leading to direct extra costs of €1.95 billion per year (2% of the health budget for 2016).

  • Stabilizing the prevalence of excess weight at 2016 levels would prevent 3.1 million new cases and save €3.0 billion in cumulative direct extra costs by 2030.

Acknowledgments

We appreciate the collaboration of Dr. Francisco Poyato (Novo Nordisk Pharma Spain, Madrid) in the discussion of the results of this work.

APPENDIX. SUPPLEMENTARY DATA

Supplementary data associated with this article can be found in the online version, at https://doi.org/10.1016/j.rec.2018.10.010.

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