Spain, like its European neighbours, is waking up to a looming obesity problem. Although obesity prevalence is roughly around the European average, levels of awareness and concern about the problem are lower than in many other European countries.

1. © The Economist Intelligence Unit Limited 2016
Commissioned by
CONFRONTING OBESITY IN SPAIN
The need for greater awareness and policy
integration
Spain, like its European neighbours, is waking up to a looming obesity problem. Although obesity
prevalence is roughly around the European average, levels of awareness and concern about the
problem are lower than in many other European countries. This has contributed to an emphasis of
Spanish obesity policy on prevention rather than treatment.
Moreover, the decentralisation of Spanish healthcare makes obesity policy primarily the responsibility
of the country’s 17 autonomous regions, making it more difficult to bring about a truly integrated
approach to the condition, those interviewed for this case study say.
According to OECD data, 16.6% of the Spanish population were obese in 2011, up from 8.8% in 1993
and 13.3% in 2003 and slightly above the latest OECD average of 15.5%.1
A national survey from 2011-
12 revealed that 17% of the population were obese, while 53.7% were overweight.2
And the latest
WHO estimates put the overall figure for the share of obese and overweight people at 57% in 2015.3
Yet
there are strong regional discrepancies, with the prevalence of obesity especially high in Murcia and
Andalusia.4
Obesity costs were estimated to make up some 7% of total healthcare spending in 2002.5
However,
given the rising prevalence, this share is likely to have increased since then. Moreover, when indirect
costs such as production losses, reduced labour productivity, higher rates of worker disability and
impact on salaries are included, the overall cost burden increases sharply.6
Associated diseases for
which obesity is a major risk factor also add to the overall costs. A 2013 article found that diabetes, a
documented associated disease, accounted for 8% of direct healthcare costs in Spain.7
Child obesity has been one of the key focal points of Spain’s obesity strategy. Child overweight
rates are high compared with other OECD countries, with 26% of boys and 24% of girls classified as
overweight in Spain, compared with an average of 23% and 21%, respectively, in OECD countries.8
But
although Spain had one of the highest rates of child obesity in Europe, according to at least one study
this rate has not risen significantly in recent years.9
Lack of familiarity with the problem could affect policy response
As is the case in some neighbouring European countries, Spain’s relaxed attitude towards obesity
appears to stem, at least in part, from varying degrees of knowledge among policymakers and
healthcare providers about the condition and its impact on the healthcare system.
A country case study by The Economist Intelligence Unit
1
OECD, OECD Health Statistics
2015. Available at: http://
www.oecd.org/els/health-
systems/health-data.htm
2
Ministry of Health, Social
Services and Equality, Encuesta
Nacional de Salud de España
2011/12. Tablas [Spanish
national health survey 2011/12.
Tables]. Available at: http://
www.msc.es/estadEstudios/
estadisticas/encuestaNacional/
encuestaNac2011/
DeterminantesSalud_
DistribucionPorcentual.pdf.
Quoted in: WHO, Nutrition,
Physical Activity and Obesity
Spain, 2013. Available at: http://
www.euro.who.int/__data/
assets/pdf_file/0020/243326/
Spain-WHO-Country-Profile.
pdf?ua=1
3
The UK Health Forum,
Forecasting/projecting
adulthood obesity in 53 WHO EU
region countries; a report for
the World Health Organisation,
August 2015.
4
Valdés, S, García-Torres,
F et al, “Prevalence of
obesity, diabetes and other
cardiovascular risk factors in
Andalusia (southern Spain).
Comparison with national
prevalence data. The Di@bet.
es study,” Revista Española
de Cardiologia, 2014; 67 (6);
442-448.

2. 2 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN SPAIN The need for greater awareness and policy integration
“Prevalence [of obesity] isn’t as high as in other countries, but one of the big problems we have
with obesity is that we are getting used to being overweight,” says Manuel García Goñi, vice dean for
international affairs and associate professor of economics at Universidad Complutense de Madrid.
In a 2014 survey by the European Association for the Study of Obesity (EASO), Spanish policymakers
demonstrated a good knowledge of the national rate of obesity: 70% were aware of the condition,
compared with an average of 34% in other countries included in the survey (mostly from Europe, plus
Brazil, Canada, Mexico and the US). However, all of those surveyed in Spain underestimated the total
rate of overweight in the country.10
In addition, although most of the policymakers surveyed accepted
that a lack of understanding of the risks associated with obesity had some impact on policy, just 40% of
those in Spain saw it as a strong driver.11
It is also unclear where Spanish policymakers place the key responsibility for combatting their
country’s obesity problem. Although Spain’s strategy concentrates on child obesity, fewer than half of
the policymakers surveyed by the EASO said they regarded families as being “very responsible” for the
problem, and at least one-fifth regarded healthcare professionals as having no responsibility at all.12
Well-established prevention policy
Prevention has been a key focus of Spanish approaches to combatting obesity, as exemplified by the
country’s Strategy for Nutrition, Physical Activity and the Prevention of Obesity (NAOS), which was
established in 2005 with the goal of promoting a healthy diet and increased physical activity. Of
the Spanish policymakers in the EASO survey, 60% believed that awareness-raising campaigns were
effective.13
Spain passed a law on food safety and nutrition in 2011, which established the legal framework for
implementing NAOS and set up a process for reviewing the strategy every five years. The Ministry of
Health has also established a set of obesity-related indicators to help to support data collection. In
addition, the government set up an Observatory of Nutrition and the Study of Obesity in 2013, which
is designed to both measure and analyse obesity trends and report on policy evolution.14
Nevertheless,
over three-quarters of Spanish policymakers in the EASO survey said there was a need for more
evidence to inform policy.15
Although the government has not gone down the taxation route favoured by some other European
countries, Spain’s Agency for Food Safety and Nutrition (AESAN) has reached an agreement with a
number of food and beverage companies to carry messages promoting healthy lifestyles on television.
It has also extended restrictions on advertising to young people to the age of 15 (from 12 previously)
and applied them to the Internet as well as television.16
Lack of joined-up policy towards treatment
These initiatives highlight a policy emphasis on the prevention of obesity. But even in the area of
prevention, public spending remains extremely low, according to the experts interviewed for this case
6
Sicras-Mainar, A, Gil,
J et al, “Healthcare use
and costs associated with
obesity in Badalona, Spain:
a study protocol”, BMJ
Open, 2012;2:1.
7
Lopez-Bastida, J, Boronat,
M et al, “Costs, outcomes
and challenges for diabetes
care in Spain”, Globalization
and Health, 2013.
8
OECD, Obesity and the
economics of prevention: Fit
not fat, Key facts – Spain
update 2014. Available at:
https://www.oecd.org/
spain/Obesity-Update-
2014-SPAIN.pdf
9
EASO, Obesity Perception
and Policy, p. 27.
10
Ibid, p. 35.
11
Ibid, p. 38.
5
Vásquez, R and López,
JM, “Análisis: Obesidad:
la epídemia del siglo
XXI”, Revista española
de Economía de la Salud,
2002:1(3):34–45. Quoted
in: European Association for
the Study of Obesity (EASO),
Obesity Perception and
Policy: Multi-country review
and survey of policymakers,
2014, p. 6. Available at:
http://easo.org/wp-
content/uploads/2014/05/
C3_EASO_Survey_A4_Web-
FINAL.pdf
12
Ibid, pp. 36-37.
13
Ibid, p. 41.

3. 3© The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN SPAIN The need for greater awareness and policy integration
study. Meanwhile, in the approach to treatment there is an absence of joined-up thinking, says Dr
Antonio Torres, chief of the General and Digestive Surgery Service at the Clinico San Carlos Hospital in
Madrid and former president of the International Federation for the Surgery of Obesity and Metabolic
Disorders (IFSO).
“The policymakers are facing obesity as a huge problem, but I think that the politicians are almost
always thinking in a very short period of time, not planning things for maintaining a long-term
scenario,” Dr Torres notes. “Strategies such as surgery and psychological treatment are very expensive,
and there is a restriction of money for spending in this situation.”
More interventionist approaches get little or no attention in either national or regional strategies. In
the EASO survey, over one-third of Spanish policymakers said that bariatric surgery was not used at all,
and just 7% said that surgery policy was working “well” or “very well”.17
In Spain, bariatric surgery is recommended for those with a body mass index (BMI) of 40 or with a
BMI of 35+ with co-morbidities. The comparatively low levels of bariatric surgery in Spain are related
to a number of factors, Dr Torres explains, including restricted insurance coverage and waiting lists
for surgery in the public sector of more than two years.18
“Approximately 25% of Spanish people have
private and state coverage, but there are some insurance companies that will pay [for surgery] and
some that won’t.”
According to Dr Torres, there are not enough units and multidisciplinary teams—both in terms of
numbers and quality—to treat all the obese and metabolic patients with surgical indications. He says
that of the 2m people with indications, only 7,000 (0.03%) have bariatric surgery in Spain every year.
Professor García Goñi notes that in Spain, despite national budgets and insurance, guidelines and
policy decisions relating to issues such as eligibility for surgery are delegated to the regions, some
of which carry out more specific health assessments or have their own regional obesity plans. In
Catalonia—one of the most advanced regions in terms of its use of data and evaluation of health
outcomes—researchers are looking into the cost-effectiveness of bariatric surgery, he says.
Researchers in the Canary Islands have also analysed the cost-utility of gastric bypass surgery versus
non-surgical care in treating morbidly obese patients.19
As a result of these regional variations,
Professor García Goñi says, “there may be some discrepancies in equity”.
According to the experts interviewed for this case study, access to counselling and other interventions
short of surgery is in particularly short supply. And just one-quarter of Spanish policymakers in the
EASO survey regarded counselling related to weight loss as being done “very well”.20
As far as pharmaceuticals are concerned, although anti-obesity medications are available in Spain,
payments are not covered by state health insurance. Consequently, around half of the policymakers in
the EASO survey said that drugs were used “a little” or “not at all”.21
14
Determinants of Diet and
Physical Activity Knowledge
Hub, Spanish strategy for
nutrition, physical activity
and prevention of obesity
(Estrategia NAOS). Available
at: https://www.dedipac.
eu/toolbox/Spanish%20
strategy%20for%20
nutrition,%20physical%20
activity%20and%20
prevention%20of%20
obesity%20(Estrategia%20
NAOS).html
15
EASO, Obesity Perception
and Policy, p. 45.
16
WHO, Nutrition, Physical
Activity and Obesity Spain,
2013.
17
EASO, Obesity Perception
and Policy, p. 44.
18
Burguera, B, Tur, JJ et
al, “An Intensive Lifestyle
Intervention is an Effective
Treatment of Morbid
Obesity: the TRAMOMTANA
Study – A Two-Year
Randomized Controlled
Clinical Trial”, International
Journal of Endocrinology,
2015, p. 2.
19
Castilla, I, Mar, J et al,
“Cost-utility analysis of
gastric bypass for severely
obese patients in Spain,”
Obesity Surgery, 2014 Dec;
24(12):2061-8.
20
EASO, Obesity Perception
and Policy, p. 43.
21
Ibid.

4. 4 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN SPAIN The need for greater awareness and policy integration
The need for greater awareness and policy integration
According to Dr Torres, greater recognition of obesity as a health problem should be among the
strategies for improving obesity policy, as this might raise health professionals’ awareness of the
problem. In addition, public and private heath provision should be better organised to allow for more
comprehensive and integrated treatment, including psychological treatment, he says.
Professor García Goñi agrees that more information about obesity is key. He adds, however, that
obesity policy has been undermined by insufficient spending and investment in public health, which
he thinks does not meet current needs. “We are going towards a health system in which everything
is patient-centred,” he adds. “An obese person is going to be a chronic patient for sure. We need to
change and reform our health system with a focus on chronic patients.”