According to the definition of the World Health Organisation (WHO) obesity is a chronic disease which does not subside automatically and has a tendency to recur. Untreated obesity causes numerous complications, such as: cardiovascular diseases, type 2 diabetes, cancers, stroke, as well as mental disorders, such as depression or anxiety. Considering the BMI ratio, WHO has distinguished three obesity classes: 30 ≤ BMI
Obesity and its complications are life-threatening, require permanent treatment and result in tens of thousands deaths per year. According to OECD, due to obesity-related diseases Polish people live about four years shorter on average as compared with persons with regular weight.
According to NIK’s estimates based on public data, approx. 9 million adults in Poland suffer from obesity. In line with the data provided by the National Health Fund in 2020-2022, nearly 800 thousand patients were treated for obesity in primary care and outpatient clinics and the total of 2.2 million healthcare services were provided to them. The number of patients doubled in three years covered by the audit and the number of healthcare services related to obesity went up by over 40%. More than 0.5 million services were provided in the cases where obesity was the primary diagnosis and over three times more where obesity was a comorbidity.
Data obtained in the audit showed that in 2022 overweight and obesity concerned, depending on the province, approx. 60-70% of the population.
Negative consequences of obesity also affect the economic and social areas. The OECD data reveals that every year approx. 1.5 million hospital admissions are related to obesity and the treatment of this disease and its complications absorbs 20% of the healthcare budget. The data of ZUS (Social Insurance Office) shows that in 2012-2022 expenditures from the Social Insurance Fund for healthcare services related to obesity-attributable inability to work increased from about PLN 22 million to nearly PLN 31 million. Absenteeism and lower productivity at work are also linked to obesity.
Within 10 years the number of days of obesity-related absence from work increased over seven times, i.e. from approx. 28 thousand to nearly 206 thousand, whereas relevant expenditures have gone up 12 times: from about PLN 1.7 million to nearly PLN 21 million. According to the OECD estimates due to obesity-induced diseases in 30 years Poland is going to lose about PLN 108 billion (4.1% GDP), which makes the average of approx. PLN 3.6 billion per year (about 0.14% of GDP).
The audit covered the Ministry of Health, 15 primary care facilities and 5 medical facilities providing outpatient specialist care, including: cardiology, endocrinology, diabetes, surgery and metabolism clinics.
In 2021, NIK alarmed in its audit report on obesity in children and youth that the Polish healthcare system lacks comprehensive, standardised solutions to prevent and treat overweight, obesity and their complications. NIK points out that in terms of the organisation of obesity prevention and treatment in adults the findings remain up-to-date. Besides, NIK underlines that by the end of this audit the Ministry of Health failed to develop guidelines on treating persons with obesity.
Key audit findings
As much as ¾ of patients with diagnosed obesity were also treated for other diseases. That was the case for 206 of 277 patients from the audited primary care facilities, as part of the sample analysed in the NIK audit. In the audited period the following diseases were the most frequent to occur with obesity: arterial hypertension, type 2 diabetes and thyroid insufficiency. The audit findings largely reflect the nationwide data.
Neither at the local nor at the nationwide level were sufficient measures taken to identify needs related to overweight and obesity prevention. No data were gathered on the number of persons threatened with obesity and suffering from this disease. Reports in this area have been published for years but systematic research showing the trend and the scale of the problem is missing. This situation translates into poor prevention and treatment of patients with overweight and obesity. NIK emphasises that obesity diagnosis and treatment in adult patients both in primary and outpatient specialist care proves ineffective. Too late obesity diagnosis results in developing a range of concomitant diseases. It also makes it harder to treat obesity and prevent complications.
Primary medical care
Responsibility for the prevention, diagnosis and selection of proper obesity treatment method lies in the first place with primary care doctors. The NIK audit revealed, though, that primary care doctors did not feel competent to treat persons with obesity. They complained about the lack of time and had problems with identifying obesity in their patients. As a result such persons were often sent to outpatient specialist clinics handling obesity complications. At the same time, the doctors agreed there was a deficit of dieticians and interdisciplinary teams, including physicians, dieticians, psychologists and physiotherapists where persons with obesity could be referred to. Patients with obesity did not have common access to those specialists because the guaranteed benefits package did not cover this type of support. At the same time, NIK points out that the dietician profession has not been regulated by the law.
Out of patients of the audited primary care facilities, who were consulted at least once by a doctor during a medical visit in a given year in the audited period, the results of measuring patients’ body weight and height were recorded only in 30% of analysed medical documentations. The number of patents whose data were submitted to the National Health Fund remained unknown, though. NIK points out that the lack of annual measurements of patients’ weight and height makes it difficult to monitor the progress of obesity treatment. At the same time, NIK underlines that since 2020 primary care facilities have had legal obligation to report the said data to NFZ.
Poor treatment effects
The NIK audit revealed that the obesity treatment effects were either unsatisfactory or could not be evaluated due to the lack of data. In the audited primary care facilities the BMI ratio was not monitored and body weight measurements were recorded only in 10.5% of medical history charts. The majority of primary care doctors did not monitor health condition or treatment effects in their patients with identified obesity. Only one in three patients, in whom obesity was diagnosed in the audited period, were weighed before making that diagnosis. NIK emphasises that the failure to monitor patients threatened with obesity delays the diagnosis and contributes to more frequent complications. In 2021, as compared with 2020, nearly half of patients reduced their body weight and obesity progressed in one third of them. The situation deteriorated over time. In 2022, nearly 28% of patients reduced their weight against 2021, and weight gain was observed in the great majority of patients, i.e. in over 62% of persons with obesity.
Lack of reliable data
The system of gathering data on the number of persons treated for obesity did not reflect the scale of the problem. The Minister of Health’s instruction on filling in reports was imprecise, which generated differences in estimating the number of patients taken care of because of obesity with primary care providers.
In line with the nationwide data, in the audited period – despite the statutory obligation – only approx. 70% of primary care facilities filed statistical reports to the Ministry of Health. Incorrect data were found in all the audited entities which submitted those reports. According to NIK the absence of complete and reliable data made it difficult for the Minister to take effective actions. In line with the reported data, in 2020-2021 patients over 19 years of age remaining in active care because of obesity accounted for an average of 1.3% of patients declared for primary care doctors with a given healthcare provider. In view of the data of WHO and NFZ (National Health Fund), the estimated scale of obesity in adults in Poland is nearly 20 times higher than indicated by the reports. This situation shows that not all patients were covered by primary healthcare: according to estimates, only one in six primary care patients remained in active care.
In line with NFZ data, in each audited year approx. 21 million of patients used at least one primary care service. According to the BMI ratio calculated for 7% of those patients, obesity in the following years was identified in about 30% of persons. NIK underscores at the same time that a bigger problem is the lack of data for most patients: the data concerning as much as 93% of persons who at least once visited a primary care doctor were not provided to NFZ.
Outpatient specialist care
In the audited period, the number of persons waiting for healthcare services in specialist clinics went up. For example, the queue of patients waiting for an appointment at a diabetes clinic almost quadrupled: from 1.4 to 5.3 thousand patients. In 2020-2022, the waiting time for appointments in specialist clinics also increased. For example, patients of diabetes clinics in urgent cases waited 10 days in 2020 to be seen by a doctor, and in 2022 it was already 30 days. In stable cases, the average waiting time was reduced only in endocrinology clinics: from 246 to 221 days, i.e. by 10%.
Medical equipment for patients with obesity
All the audited primary care facilities had the required equipment, i.e. scales with a growth meter and manometers with different cuff sizes. However, in some cases, there was no equipment in place to properly measure patients with class III obesity.
The NIK audit indicated that the Minister of Health had no knowledge of the availability and demand of medical entities for diagnostic equipment for patients with the so-called morbid obesity, e.g. magnetic resonance imaging, computed tomography. In December 2020, the Minister of Health only obtained data from governors on the number of bariatric ambulances (with increased load capacity) adapted to assist patients with class III obesity.
According to these data, there were only 33 bariatric ambulances available Poland-wide, and their distribution was uneven: in four provinces there were no such vehicles at all, and in one there were six.
Costs of obesity prevention and treatment
NIK alerts that primary care facilities earmarked negligible amounts of money for health promotion. According to data of GUS (Central Statistical Office), in 2020 the expenditure for prevention and public health made up less than 2% of nearly PLN 152 billion spent on healthcare from public and private expenditures.
Meanwhile, the costs of treating obesity and its complications are horrendous. It is estimated that direct costs related to obesity could exceed PLN 9 billion, and indirect costs could reach almost PLN 27 billion, where the total spending of the National Health Fund on healthcare in 2022 was PLN 133.6 billion.
The only publicly funded obesity treatment procedure in Poland is bariatric surgery. In the audited period, this kind of treatment was applied in almost 17.5 thousand patients, and NFZ spent PLN 233 million for this purpose. The unit cost of bariatric treatment of a patient (outside the KOS-BAR program) exceeded PLN 13 thousand in 2021 and totalled PLN 16.5 thousand in 2022.
Efforts of the Minister of Health
In the audited period, the Minister of Health took – on his own and in cooperation with other entities - a number of measures to prevent overweight and obesity by promoting healthy lifestyle and motivating people to change their attitudes and eating habits. These tasks were performed mainly as part of the National Health Programme for 2016-2020, and then the National Health Programme for 2021-2025. The Minister of Health carried out a pilot programme KOS-BAR for comprehensive specialist care for beneficiaries undergoing bariatric surgery. The programme implemented in 2021 was addressed to people suffering from obesity. In 2022, the programme costs are planned at over PLN 105 million. From 1 July 2021, the Ministry of Health introduced unlimited settlement of all outpatient care services, i.e. in accordance with actual performance. According to the Minister's assumptions, that solution was to reduce the waiting time for an appointment and shorten queues, and thus facilitate access to specialist doctors. However, the Minister's actions did not bring the expected results. The access to health services was significantly limited, primarily due to long waiting times for appointments in specialist clinics.
Pandemic
In 2020-2022, due to the COVID-19 pandemic, primary care activities related to overweight and obesity prevention were insufficient. In most cases, the scale of the problem and needs in this area were not identified. The COVID-19 pandemic was particularly difficult when it comes to obesity control. Adverse dietary changes and a decrease in physical activity resulting from isolation, working from home and limited access to infrastructure supporting physical activity (closed gyms) had a negative impact on the health of Polish people. On the other hand, primary care physicians focused on the treatment of COVID-19, and as a result, prevention and treatment of other diseases, including obesity, took a back seat.
One of the consequences of the COVID-19 pandemic was the worsening of obesity in adults. The Ipsos COVID 365+ survey showed that 42% of respondents gained an average of 5.7 kg. These data were also confirmed by a report of the Aflofarm Foundation, which indicated that approx. 41% of Poles reported a weight gain within a year of the pandemic outbreak.
Activities of local governments
In the audited period, the activities of selected 23 local government units related to the identification of needs and promotion of a healthy lifestyle were limited. More than ⅓ of 23 local governments to which the inquiry was sent did not take any action in this area. Other local governments, as part of obesity prevention in its broad sense, declared among other things that they created infrastructure supporting physical activity, such as outdoor gyms or bicycle paths. Educational institutions carried out preventive and educational activities addressed to children and young people, and social welfare facilities supported mainly adults. NIK emphasises that the law does not impose any obligations on local governments in terms of prevention and treatment of obesity in adults. However, the tasks of provincial, district and municipal governments include activities related to health protection. Also, the Act on Healthcare Benefits indicates the directions of health promotion activities of local governments for the benefit of residents.
Recommendations
NIK points out that the scale of health problems resulting from overweight and obesity requires a comprehensive action plan, including full prevention of overweight and obesity and access to obesity treatment in accordance with current medical knowledge and international standards. In view of the above, NIK has made the following recommendations to:
the Minister of Health to:
- prepare - in cooperation with other ministers - and implement a nationwide, comprehensive plan for the prevention of overweight and obesity (including, among other things, nutrition education);
- prepare and implement a nationwide, comprehensive plan for dealing with patients with obesity, preceded by an analysis of the functioning of the health care system in this area;
- provide resources, structures and organisational standards tailored to existing needs to enable the implementation of a comprehensive plan for the prevention and treatment of overweight and obesity, including a system of monitoring and supervision over the organisation and manner of providing healthcare, its effects, access to prevention, diagnosis and treatment, as well as the quality of health services provided;
- provide reliable sources of information on the scale of obesity in adults;
- conduct ongoing research on resources and needs for specialist equipment to support the treatment of people with severe obesity;
- effectively reduce waiting time for services in diabetes, endocrinology and cardiology clinics.
the National Health Fund to:
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enforce the obligation of primary care providers to provide data on the services rendered, including information on the patient's body weight and height at least once in a given calendar year, in line with the Ordinance on the scope of essential information processed by healthcare providers.
outpatient care providers to:
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systematically monitor if outpatient specialist doctors meet their obligation to submit information to the referring primary care doctor concerning the patient’s treatment, as specified in the Ordinance on the general terms and conditions of contracts for the provision of healthcare services, and to document this fact.
primary care providers to:
- submit to the National Health Fund, at least once a year, the results of measurements of patients' height and weight, in line with the Ordinance on the scope of essential information processed by healthcare providers;
- provide reliable, factually correct data in statistical reports on healthcare services;
- ensure effective supervision over the implementation of tasks related to people suffering from obesity, the quality of services provided and the maintenance of medical documentation, in line with the principles set out in the Ordinance on medical documentation.
At the same time, NIK points out that the Minister of Health has not implemented the recommendations included in the NIK audit report of 2021 on the availability of prevention and treatment for children and adolescents with metabolic disorders resulting from obesity and civilisation diseases. NIK emphasises that in the light of the audit findings, these recommendations remain valid.
