Sweden has a relatively low obesity rate of 11.7% but it has been rising in recent years. Responsibility for combating obesity is dispersed across several agencies in Sweden in a decentralized system. While prevention through diet and exercise is emphasized, access to bariatric surgery is generous by European standards. However, experts say Sweden could benefit from a more coordinated national strategy and greater focus on outcomes through increased research and monitoring of treatment programs.

1. © The Economist Intelligence Unit Limited 2016
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CONFRONTING OBESITY IN SWEDEN
A reasonable base, with room for
improvement
For a country with a relatively low prevalence of obesity, Sweden is arguably one of the most
forward-looking countries in terms of research into the problem and the funding of intervention
options. It is also one of the most decentralised countries as far as the provision of services is
concerned.
The prevalence of obesity in Sweden was 11.7% in 2013, according to the latest OECD data—well below
the OECD average of 15.5% and among the lowest rates in Europe.1
However, this was still up from
9.8% in 2003. Moreover, experts have become increasingly concerned about the rise in the number of
overweight and obese children and adults in recent years. The latest World Health Organisation (WHO)
estimates put the overall figure for the share of obese and overweight people in Sweden at 51% in
2015, with a projection of 66% for 2025.2
This concern has driven efforts to promote stronger public-health campaigns, increase the amount
of research into obesity and boost the impact of different approaches to combatting and treating
it. At the same time, there remains at least a partial disconnect between research and initiatives at
the municipal and regional levels on the one hand, and efforts to create a more integrated national
approach to obesity on the other.
A decentralised approach to obese patients
Responsibility for combatting obesity is dispersed across several agencies in Sweden. Fredrik Nystrom,
a professor of internal medicine and endocrinology and a consultant at Linkoping University, notes
that while the country’s National Food Agency is responsible for giving advice on diet to the non-
obese, those who already have the condition and associated co-morbidities are governed by the
National Board of Health and Welfare, which has responsibility for treating those who are sick.
Meanwhile, the Swedish Agency for Health Technology Assessment and Assessment of Social Services
(SBU) is responsible for conducting research into which treatments actually work.
“In the end, the National Board can give some guidelines, but [services] are organised differently
in different counties,” according to Professor Nystrom. At the same time, he and other experts say
that the lack of an overarching strategy complicates efforts to address the problem. “There are minor
initiatives locally, but no national initiatives at all,” notes Claude Marcus, a professor of paediatrics
at the Karolinska Institutet in Stockholm. “I think we really need that, and it is something that is
discussed quite a lot.”
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
The UK Health Forum,
Forecasting/projecting
adulthood obesity in 53 WHO
European region countries; a
report for the World Health
Organisation, August 2015.

2. 2 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN SWEDEN A reasonable base, with room for improvement
Prevention remains a strong driver of policy
Despite some of the innovative research being carried out in the country, the approach to obesity in
Sweden is still largely shaped by an understanding of obesity as a lifestyle issue that is for the most
part down to a poor diet and lack of exercise.
Professor Nystrom points out that the SBU undertook an investigation into the effects of behavioural
change in combatting obesity in 2012 and “it was very clear that exercise does not inhibit obesity, and
has never been shown to work”.
In the case of diet, he says, the SBU completed a two-year review of 16,000 dietary studies published
through May 2013, and as a result altered its national dietary guidelines to reject popular low-fat diets
in favour of advice to eat a low-carbohydrate, high-fat diet.3
Although Professor Marcus acknowledges that there is often too much emphasis placed on the
contribution of lifestyle to the problem, he thinks that the changes in society over the past few
decades have created an environment in which obesity rates can easily climb. “People are neither worse
nor better than they were 30 years ago, but now there is more obesity. The primary reason is that we
have the possibility to eat things that we like 24/7. It’s the total availability of everything.” At the same
time, he disagrees that education has much of a role to play in combatting the problem. “People know
what is healthy and unhealthy.”
Liberal policy on treatment
Despite the strategic emphasis on preventing obesity, access to some forms of treatment is
significantly wider in Sweden than in neighbouring countries. Although Sweden’s health system does
not currently cover anti-obesity medicines, a new weight-management drug, which was approved by
the European Medicines Agency (EMA) in 2015, is likely to be approved for reimbursement in Sweden,
Professor Marcus says.
Access to bariatric surgery in Sweden is one of the most generous in Europe. In a study comparing
seven European countries, only Belgium (with 928 procedures per 1m population in 2012) had a higher
utilisation rate for bariatric surgery than Sweden (761), which was well above the rates in France (571),
Denmark (just under 200), Italy (128), England (117) and Germany (72).4
“If someone benefits from surgery with no contraindications, they will get it in a couple of months,”
says Professor Nystrom, noting that Sweden’s generous reimbursement policy has helped to make the
procedure a key part of treatment for patients who are already obese. “It is among the most common
surgical procedures we have.”
Indeed, one of the most commonly referenced research projects on the long-term impact of bariatric
surgery is Swedish. The Swedish Obese Subjects (SOS) study, which examined more than 4,000 patients
3
“Sweden Becomes First
Western Nation to Reject
Low-fat Diet Dogma in
Favor of Low-Carb High-fat
Nutrition”, Health Impact
News, 2013. Available at:
http://healthimpactnews.
com/2013/sweden-
becomes-first-western-
nation-to-reject-low-
fat-diet-dogma-in-favor-
of-low-carb-high-fat-
nutrition/
4
Borisenko, O, Colpan, Z
et al, “Clinical Indications,
Utilization, and Funding
of Bariatric Surgery in
Europe”, Obesity Surgery,
August 2015, Vol. 25, No. 8,
pp 1408-16.

3. 3© The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN SWEDEN A reasonable base, with room for improvement
between September 1987 and January 2001, found that surgery led to remission of type 2 diabetes in
72.3% of patients two years after surgery, compared with just 16.4% in the control group; remission
rates dropped to 30.4% after 15 years, compared with 6.5% for the control group.5
Despite the relative ease of access to the procedure in Sweden, however, the number of patients has
dropped in recent year from 8,100 in 2011 to 6,900 in 2014 and an estimated 6,500 in 2015, according
to Johan Ottosson, a bariatric surgeon at Orebro University Hospital, who is in charge of collecting
official data through the country’s Quality Registry.
Part of the reason for the drop, Dr Ottosson speculates, is the fact that as 90% of patients get surgery
paid for by national health insurance, waiting lists were previously as long as two years. However,
public pressure has since driven government efforts to shorten the waiting time to just two or three
months, with the result that much of the backlog has been cleared.
At the same time, Dr Ottosson acknowledges that with healthcare provision the responsibility of county
governments, some have tried to put limits on eligibility for surgery to reduce costs. “They can do it
to some extent, but if they did it to a large extent, there would be a public outcry,” he says. He notes,
however, that although Sweden follows internationally accepted guidelines that recommend surgical
options for those with a body mass index (BMI) of 40 or above, or a BMI of 35 plus associated illnesses,
the definition of an associated illness can be more restrictive (type 2 diabetes) or more liberal (knee
pain when walking).
Meanwhile, Sweden has not been immune to some of the media backlash against bariatric surgery
that has been seen in neighbouring Denmark. “Five or six years ago [surgery] was described in very
positive terms—possibly too positive—but now [press reports] are often about side effects and pain,”
Dr Ottosson comments.
Room for improvement
Although the Swedish health insurance system offers arguably the greatest access to weight-loss
surgery of any of the EU member states, it still lacks the comprehensive coverage that is important
for monitoring outcomes, experts say. Professor Nystrom notes that the process of referring patients
for surgery goes directly from general practitioners (GPs) to surgeons, with no interim visits to other
medical professionals or counsellors. According to Dr Ottosson, “follow-up care is usually provided by
specially trained nurses in close relationship with surgeons, in some counties up to one year, but in
most counties up to two years after surgery. After this timeframe follow-up is offered by GPs on annual
basis, with written instructions from the surgical unit.”
By contrast, in the Netherlands patients must follow a strict pre-operative and post-operative regime,
which is co-ordinated by different parts of the healthcare system. The Dutch government pays to
screen obese patients to assess their eligibility for more intensive treatment, including surgery,
and both before-care and long-term follow-up are reimbursed by the country’s health insurance
companies.
5
Sjostrom, L, Peltonen, M et
al, “Association of bariatric
surgery with long-term
remission of type 2 diabetes
and with microvascular
and macrovascular
complications”, Journal of
the American Medication
Association, 2014; 311
(22):2297-2304.

4. 4 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN SWEDEN A reasonable base, with room for improvement
More scientific studies are required. “There is very little scientific input, and studies [of surgical
outcomes] are not looking at metabolic effects,” Professor Nystrom says. He also argues that other
changes in the country’s approach to obesity could make it more effective, including stronger
regulation of high-sugar foods in an effort to cut obesity rates, especially in children.
Professor Marcus also argues in favour of a sugar tax, something that Swedish policymakers have
debated in recent years. In addition, he says, the health system needs to consider reimbursing weight-
loss programmes that have been shown to be effective.