When Brazil hosted the World Cup in 2014 the stadiums were outfitted to accommodate a condition that is considered a disability according to Brazilian law. Nearly 5,000 extra-wide seats were available in the football stadiums to accommodate obese attendees, who are classified as disabled by Brazilian law.
Obesity is a new problem in Brazil. Starting in 1982, a Brazilian non-governmental organisation (NGO) used weight to determine whether a child was unhealthy; malnutrition was cited as a cause of high infant mortality rates (8.3% in 1980). Programmes were put in place to encourage breastfeeding and prenatal care, and the government instituted a zero-hunger programme. While these programmes were successful in lowering Brazil’s hunger problems, they also put the country in a somewhat unique situation. The combination of rapid changes in population and an increasingly sedentary lifestyle places a double-burden on Brazil in which large underweight and overweight groups exist within the population. The World Health Organization (WHO) estimates the two problems coexist in 8 to 9% of households in Brazil.
According to Kantar Health’s National Health and Wellness Survey (NHWS), 34% of Brazilian adults (18+ years) are overweight, and another 18% are obese. Who are these people, and how much of a burden does obesity place on Brazil’s healthcare resources and society in general?
Comorbidities and quality of life
The NHWS calculated respondents’ body mass index (BMI) from self-reported height and weight information. BMI is categorised as follows:
- Normal Weight: BMI ≥ 18.5 kg/m2 and < 25 kg/m2
- Overweight: BMI ≥ 25 kg/m2 and BMI < 30 kg/m2
- Obese Class I: BMI ≥ 30 kg/m2 and BMI < 35 kg/m2
- Obese Class II: BMI ≥ 35 kg/m2 and BMI < 40 kg/m2
- Obese Class III: BMI ≥ 40 kg/m2
The study, presented recently at the European International Society for Pharmacoeconomics and Outcomes Research (ISPOR) meeting, found that overweight and obese adults in Brazil are older, more likely to be married or living with a partner, and college-educated than adults whose BMIs fall into the normal weight category. They are also more likely to drink alcohol and smoke, but less likely to exercise (see table).
| Normal Weight | Overweight | Obese | |
| Female | 53% | 43% | 50% |
| Married/living with partner | 47% | 60% | 62% |
| College educated | 35% | 38% | 37% |
| Drink alcohol | 58% | 60% | 59% |
| Smoke | 39% | 44% | 48% |
| Exercise | 61% | 59% | 50% |
The prevalence of metabolic comorbidities in overweight and obese adults in Brazil also tends to increase as BMIs increase. About 9% of Brazilian adults within the normal weight category have been diagnosed with hypertension; the prevalence rises to 17% among overweight adults and skyrockets to 42% in adults with class III obesity. Hypertension is a risk factor for stroke, and stroke is the leading cause of death and disability in Brazil.
Brazil is expected to have the fourth highest increase in diabetes between 2012 and 2030
Type 2 diabetes is quickly becoming a global health crisis, and rising obesity rates are cited as a leading reason for this change. Among adults in Brazil, the prevalence of type 2 diabetes jumps from 2% among those of normal weight to 5% of the overweight population and 12% in those with class III obesity. The International Diabetes Federation ranks Brazil as being expected to have the fourth highest increase in diabetes prevalence between 2012 (9.7%) and 2030 (12.3%).
Beyond comorbidities that affect the population physically, diagnosed anxiety or depression increases as BMI increases. About 21% of adults with normal weight have been diagnosed with anxiety or depression; the prevalence increases slightly to 22% in overweight adults. The increases among obese adults, however, is much more significant, with 28% of obese class I, 35% of obese class II and 40% of obese class II adults in Brazil having been diagnosed with anxiety or depression.
Likewise, respondents’ mental and physical quality of life falls as their BMI increases. Quality of life was assessed using the Short Form (36) Health Survey, version 2 (SF36-v2). After adjusting for gender, age and comorbidities using multivariable models there was no statistically significant difference in mental quality of life between adults with normal weight and those who are overweight, but the differences between those two populations and the obese population were statistically significant. Perhaps unsurprisingly, physical quality of life dropped significantly between each BMI category.
Direct and indirect costs of obesity in Brazil
Beyond the effects on individuals’ health, obesity has a high societal cost in Brazil – both directly and indirectly. The study by Eisai and Kantar Health looked at the effect of obesity on work productivity by assessing absenteeism (the percentage of missed work time due to health in the past seven days) and presenteeism (percentage of impairment due to health while at work in the past seven days). After adjustments, no differences on absenteeism were found between adults of normal weight and those who are overweight or obese. However, presenteeism was shown to be significantly affected among obese adults; impairment while at work was measured at 15.5% in the normal weight population and 15.6% in the overweight population, rising to 22.4% in the obese class III population. While overall work impairment was equal at 19% in the normal weight and overweight groups, it increased as BMI rose to 26.5% in the obese class III population.
The loss in work productivity results in higher indirect costs due to health in Brazil. Annual per capital indirect costs for employed adults who are normal weight are R$333; indirect costs among overweight adults slightly higher at R$338 per year, and these costs rise to R$458 in obese class III adults.
After adjustment, normal weight adults in Brazil visit their healthcare providers less often than those who are obese, on average four visits in the past six months compared with five among obese adults. Normal weight adults also report fewer emergency room visits than overweight and obese adults, although there is no difference in hospitalisations across the BMI categories. Like indirect costs, individuals’ direct healthcare costs generally increased along with BMI. Adults who are normal weight incur R$1,722 in costs for their private healthcare, compared with R$2,453 among obese class III adults.
A healthcare burden
Obesity is already becoming a public health concern in Brazil, and the prevalence of and costs associated with obesity are likely to continue to increase. Obesity is a risk factor for chronic conditions, such as hypertension and type 2 diabetes; prevalence of both conditions is expected to increase over the next 25 years, and with it indirect and direct healthcare costs, potentially creating an even greater burden on society and the healthcare system.
Disclosure: The study was sponsored by Eisai Inc