Between lockdowns, school closures and work-from-home orders imposed by governments throughout the 2-year-old coronavirus pandemic, Europe's obesity problem has only grown in size. Politico reports that more people are stuck at home, staying away from the doctor, or missing out on visits to treatment clinics that can offer them a lifeline — adding extra pandemic pounds on top of a condition that already afflicted nearly 1 in 5 adults in the EU.
What makes the condition so intractable is that some of the defining characteristics of modern life — cheap and widely available food and a break from the hard physical labor of the past — contribute to its prevalence. Policymakers too often treat obesity as the result of individual bad choices, like eating too much junk food, and not as the result of the complex interplay between genetics and our changing way of life. Not all countries are equal in this regard. Finland, a pioneer in the field of obesity treatment, found itself better prepared when the pandemic struck thanks to early investments it made in digitalization. Already in 2016, the Nordic country had launched an online platform where patients could keep in touch with physicians, receive psychological therapy, and get nutrition and lifestyle advice remotely. When COVID-19 hit, patients were able to keep receiving that care uninterrupted.
“We are quite proud that we did not cut obesity treatment: Instead we digitalized it,” said Kirsi Pietiläinen, the University of Helsinki's top obesity researcher, who is also involved in treatment of the disease. Pietiläinen said that the platform's daily users have doubled during the pandemic. There was also some improvisation: Group treatment sessions, previously done face-to-face, switched to Microsoft Teams.
The COVID effect
The pandemic has lent new urgency to the problem of treating obesity. According to research from the EU’s disease control agency, it is the No. 1 comorbidity linked to coronavirus mortality. Early data shows that the pandemic has contributed to weight gain linked to stress, reduced activity and comfort eating. One poll from Public Health England found that over 40 percent of adults put on weight during lockdowns, with an average gain of 3 kilos. Even more concerning, pandemic weight gain seems to be worse in children. NHS Digital has reported that obesity rates among 4- and 5-year-olds rose from 9.9 percent in 2019-20 to 14.4 percent in 2020-21. Among pupils aged 10 and 11, obesity prevalence increased from 21 percent to 25.5 percent over the same period.
Obesity is defined as an excessive or abnormal accumulation of fat tissue. It is usually measured using the body-mass index (BMI), with a BMI over 30 considered obese, although health experts describe that as an imperfect metric.
The exact causes of obesity still aren’t fully understood, though the science has made strides in recent years. And researchers are starting to rethink the causes and leave behind a simplistic model of the disease that just focuses on calories.
Under the traditional view, obesity is an energy-balance problem. People consume more calories than they burn off during the day, and these are converted into fat. The human body is like an engine that burns gasoline at a set rate: It might burn more or less fuel depending on how much it gets used, but the basic equation is fixed. Put too much fuel into the body, and the excess gets stored as fat.
Over time, if enough extra fuel is added, you gain weight. The solution appears simple: Add less fuel and burn more energy, and the pounds come off. Or, in other words, diet and exercise.
Researchers in the field are trying to change that narrative, based on findings that have emerged over the past five years. "We know nowadays that there's a very strong biological drive to obesity, and it varies from person to person," said Pietiläinen. "When the obese state develops for one reason or another, that state becomes self-perpetuating."
It’s not that food and calories don’t play a role. But untangling cause and effect is difficult. People’s genetics and bodies vary. And food is more than just calories — different types of food appear to affect the body differently, for example, impacting hormone levels or gut bacteria. Fat tissue itself isn't just a neutral store of energy; it actively resists coming off. Add in socioeconomic factors and preexisting medical conditions, and things get complicated. Meanwhile, plenty of unknowns remain, said Pietiläinen.
New paradigms
In terms of treatment, all this means that the old advice — that burning excess fat is just a matter of diet and exercise — is out of date, even if both are available tools for treatment experts. Other options include individual and group therapy, or bariatric surgery, a stomach operation that is used to tackle severe obesity.
According to Johanna Brix, who runs an obesity clinic in Vienna and is the president of the Austrian Obesity Association, the lockdowns have had a polarizing effect: People who were physically active before the pandemic now have more time to exercise. But those who were sedentary have remained so.
Missed appointments with specialists are also setting patients back. “Many people didn't come to the clinics because of the pandemic,” said Brix. “What we get now is this load of patients who are sometimes very ill.” Despite the difficulties of the pandemic, progress made by science in the form of new drugs is giving obesity researchers hope.
These medicines are called Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and were first used for diabetes. Their use has now been expanded to treat its close cousin, obesity. They help to regulate insulin levels and provoke a feeling of fullness in the people taking them. There had been obesity drugs before, like amphetamine-based treatments, but downsides outweighed the benefits. By comparison, GLP-1 drugs have fewer side effects, giving obesity experts a real pharmaceutical option for treatment for the first time.
According to Novo Nordisk, the Danish pharmaceutical company that developed GLP-1 medicine semaglutide, drugs in the class lead to sustained weight loss of around 17-18 percent in clinical trials. This compares with 25-30 percent achieved through bariatric surgery. “We really have a new possibility to start treatment earlier, before comorbidities start,” said Brix, who expressed hopes for the impending arrival of semaglutide, which the European Medicines Agency recommended in November for the obesity indication. There are other, even more promising treatments in the pipeline, added Brix.
Policy pitfalls
Experts in the field are thrilled at the new options, and say they are a major advance. But the medicines also illustrate the obstacles that patients have to deal with to get treated. Obesity treatment services have taken a hit during the pandemic. As with other noncommunicable diseases, resources were diverted away from obesity to maintain health systems flooded with COVID-19 patients. "This is true for all kinds of chronic illnesses, but it's even more true for obesity, which doesn't get the same kind of attention as other chronic diseases," said Luca Busetto, a doctor and academic in Padova, Italy, who blamed the neglect on obesity's reputation as the result of bad lifestyle choices.
Diabetes drugs were all reimbursed by the national health system, said Busetto. By contrast, obesity medicines were not, and patients have to pay out of pocket for them. In general, European governments are only now starting to take obesity seriously, with a handful, including Ireland, Italy and Germany, drafting national obesity “plans.” Such initiatives are a common tool of public health policy — almost all EU countries, for example, have a cancer plan. These lay out national strategies, standards and measures for prevention and treatment of a given illness, creating a joined-up and standardized approach.
Jacqueline Bowman-Busato, EU policy lead at the European Association for the Study of Obesity, said that too often obesity treatment turned into a “postcode lottery.” One region or city may have great experts and treatment centers, while another offers next to nothing.
Brussels could help, added Bowman-Busato: With other noncommunicable diseases, the Commission has led the way, creating an EU-level plan that created a template for national governments to follow.
That hasn't been the case with obesity so far. Under the Commission's current strategy for noncommunicable diseases, the condition was included with tobacco and alcohol under the category of health determinants. "That basically means no obesity plan," she explained.
