When it comes to the scale of the obesity problem and the strategy for addressing it, Italy is a study in contrasts. Levels of overweight and obesity among adults are lower than the European average. However, childhood obesity has already reached crisis levels, highlighting that the obesity burden is likely to rise significantly in the years ahead if policymakers do not take action.

1. © The Economist Intelligence Unit Limited 2016
Commissioned by
CONFRONTING OBESITY IN ITALY
The need to overcome structural challenges and
regional disparities
When it comes to the scale of the obesity problem and the strategy for addressing it, Italy
is a study in contrasts. Levels of overweight and obesity among adults are lower than the
European average. However, childhood obesity has already reached crisis levels, highlighting
that the obesity burden is likely to rise significantly in the years ahead if policymakers do not
take action. Meanwhile, efforts have been made to classify obesity as a disease in Italy, but the
country still lacks an overall, multidisciplinary obesity strategy that integrates comprehensive
approaches to both prevention and treatment of the problem. Hence, there remains a lot of room for
improvement in policymaking to combat obesity in Italy.
According to the latest OECD data, the prevalence of obesity in Italy was 10.3% in 2014, among the
lowest rates in Europe and well below the OECD average of 15.8%.1
However, this was up from 8.6%
in 2000. The latest World Health Organisation (WHO) estimates put the overall figure for the share of
obese and overweight people in Italy at 48% in 2015, with a projection of 52% for 2025.2
With more
than half of the population expected to be overweight or obese by 2025, Italy is not even among the
worst affected countries—it is placed 44th among the 53 European countries examined by the WHO.
This is yet another illustration of the pan-European obesity epidemic identified in a recent report from
The Economist Intelligence Unit (EIU) on Confronting obesity in Europe.3
Rising economic costs
Given the high levels of childhood obesity in Italy, the burden on the country’s health system is set to
rise. More than one-third of Italian children (36% of boys and 34% of girls) are overweight or obese,
compared with an OECD average of 23% of boys and 21% of girls.4
Hence, the costs of obesity could
rise substantially; currently, the annual cost of obesity is estimated at €9bn (US$9.9bn) against a
background of continued austerity in the country.5
Obesity also contributes to other chronic conditions, most notably type 2 diabetes, which is one of the
most significant burdens on Italy’s health system. A 2011 Ministry of Health (MoH) report noted that
diabetics cost the Italian health system two-and-a-half times more than non-diabetics of the same
age and sex, with over 70,000 hospital admissions for diabetes annually. In 2010, the MoH noted,
diabetes was responsible for 10-15% of all healthcare costs in Italy.6
The OECD has estimated that a
comprehensive strategy for preventing obesity from causing chronic diseases, such as diabetes and
hypertension, could prevent some 75,000 deaths a year in Italy, compared with 155,000 deaths in
Japan, 70,000 in England, 55,000 in Mexico and 40,000 in Canada. This would cost around US$22 per
capita in Italy (compared with US$12 per capita in Mexico, US$19 in Japan and England, and US$32 in
Canada), while the cost per life year gained through prevention is lower than US$20,000.7
A country case study by The Economist Intelligence Unit
1
OECD, OECD Health
Statistics 2016. Available
at: http://www.oecd.org/
els/health-systems/health-
data.htm
2
The UK Health Forum,
Forecasting/projecting
adulthood obesity in 53
WHO EU region countries; a
report for the World Health
Organisation, August 2015.
3
The Economist Intelligence
Unit, Confronting obesity
in Europe: Taking action
to change the default
setting, November 2015.
Available at: http://
www.eiuperspectives.
economist.com/healthcare/
confronting-obesity-
europe-taking-action-
change-default-setting
4
OECD, Obesity and the
Economics of Prevention:
Fit not Fat, Key Facts – Italy,
Update 2014. Available at:
http://www.oecd.org/italy/
Obesity-Update-2014-ITALY.
pdf

2. 2 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN ITALY
The need to overcome structural challenges and regional disparities
Structural challenges and cautious optimism
There are major structural challenges to addressing obesity in Italy. “We are facing a very complex
disease, even more complicated than diabetes and hypertension, and we need a very [strong]
network to confront the disease,” says Roberto Vettor, professor of internal medicine and head of the
department of medicine at the University of Padua as well as director of the Centre for the Study and
Integrated Therapy of Obesity. “There is a lack of organised structure facing the problem.”
Italy’s decentralised health system means that there are considerable variations in regional access to
obesity services. “The gradient between north and south is really clear,” says Paolo Sbraccia, president
of the Italian Society of Obesity (SIO) and professor of internal medicine at the University of Rome Tor
Vergata.
Unlike elsewhere in Europe, experts in Italy are cautiously optimistic that their country’s policymakers
are ready to accept the premise of obesity as a multifaceted disease, rather than merely the result of
poor lifestyle choices.
In May 2016 the SIO successfully petitioned representatives of the Italian Senate (part of the
bicameral Italian parliament) to circulate a petition stating that obesity is a disease. If successful,
Professor Sbraccia says, this could be the first step towards enshrining the concept in law, allowing
the health system to create a more comprehensive approach to treating obesity. (The American
Medical Association classified obesity as a disease in June 2013.) In The EIU’s pan-European report on
Confronting obesity in Europe, Professor Francesco Rubino, chair of metabolic and bariatric surgery at
King’s College London, argues that policymakers have a hard time accepting that obesity is a medical
condition because the belief that it is easily reversible is so pervasive.8
Both prevention and treatment have been part of Italy’s approach to addressing obesity. Although
Italy has no strategy dedicated to combatting obesity, it was specifically mentioned as part of the
National Prevention Plan for 2010-12, which focused on the prevention of non-communicable diseases
and the promotion of healthy lifestyles. Measures included improving food at schools and workplaces,
encouraging physical activity in schools, and increasing the consumption of fruit and vegetables more
widely.
Some regions have also launched their own initiatives. In Campania in southern Italy, for example,
local officials have set out goals to foster awareness of the problem and increase the number of people
screened for obesity.9
However, the Campania region still faces an “obesity epidemic”, with the highest
prevalence rates compared with other regions of Italy and Europe, especially in the 8-9-year age range.10
“Most people believe it is a problem that has to be faced or counteracted, rather than just a problem
having to do with willpower or lazy people,” Professor Sbraccia observes. “I think that in the last 15
years, as in many countries, the sensible campaigning did not really reduce the numbers [of obese
people], but at least it made most of the population aware of the problem.”
Italy’s national health service (Servizio Sanitario Nazionale—SSN) has guidelines for treating obesity.
Weight-loss drugs are covered by the country’s health insurance and are available to those with a
body mass index (BMI) of 30+ (or 28+ with associated diseases) in cases where lifestyle changes and
counselling have been ineffective. Bariatric surgery is available for adults with a BMI of 40+ (or 35+
with associated diseases) in cases where previous weight-loss efforts have failed.11
In 2012 Italy was
5
European Association for
the Study of Obesity (EASO),
Obesity in Italy. Available
at: http://easo.org/media-
portal/country-spotlight/
obesity-in-italy/
6
Ministry of Health,
“Appropriatezza clinica,
strutturale, tecnologica
e operative per la
prevenzione, diagnosi
e terapia dell’obesita
e del diabete mellito,”
Quaderni del Ministero
della Salute, No. 10, July-
August 2011, page xlvi.
Available at: http://www.
salute.gov.it/imgs/C_17_
pubblicazioni_1707_
allegato.pdf
7
OECD, Obesity Update
2012. Available at:
http://www.oecd.org/
health/49716427.pdf
8
The Economist Intelligence
Unit, Confronting obesity
in Europe: Taking action to
change the default setting
9
European Association for
the Study of Obesity (EASO),
Obesity Perception and
Policy: Multi-country review
and survey of policymakers,
2014, pp. 23-24. Available
at: http://easo.org/wp-
content/uploads/2014/05/
C3_EASO_Survey_A4_Web-
FINAL.pdf

3. 3© The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN ITALY
The need to overcome structural challenges and regional disparities
mid-table in terms of access to bariatric surgery in a study comparing seven European countries, with
128 surgeries per 1m population—below Belgium (928), Sweden, (761), France (571) and Denmark
(just under 200), but above England (117) and Germany (72).12
The Italian Society of Obesity Surgery (SICOB) is due to present revised surgical guidelines to a joint
congress of Italian surgical societies at the end of September 2016, according to Professor Diego
Foschi, chairman and co-author of the guidelines and head of the School of Surgery at the University
of Milan. The new guidelines, which would replace the existing recommendations introduced in 2008,
provide information on the newest bariatric procedures and guidance on how to determine the most
suitable operations for individual patients.
“I think it is important to have knowledge of the new procedures and a good indication of the patients
for whom they are appropriate,” says Professor Foschi. The guidelines also reiterate the importance
of ensuring that access to treatment is uniform across the country, he adds, noting that only 10,000
obese patients have surgery annually in Italy, compared with around 1m who could potentially be
eligible.
Regional disparities
Despite the recognition of the problem, the lack of a defined overall strategy and the disparities in the
delivery of obesity treatment across the country contribute to uneven access to obesity care, those
interviewed for this case study say.
On the one hand, socioeconomic differences, primarily between the poorer south and the wealthier
north of the country, lead to different manifestations of the problem in different areas. Italy’s
southern regions suffer from a relative deficit of sporting centres, for example. Physical-activity levels
for children are well below those in neighbouring European countries.
Moreover, the traditional emphasis on food has become more harmful as diets have become more
calorific, underpinning the problem of child obesity. “A mother might worry if a child is thin, but be
happy when it is chunky,” says Professor Sbraccia.
But even more important, those interviewed say, is the relative scarcity of joined-up integrated
networks for dealing with obesity and associated problems. A 2011 MoH document acknowledged that
a healthcare model suited to the characteristics of obese patients required highly specialised centres
that co-operate closely with other community medicine facilities, general practitioners (GPs), primary-
care paediatricians and local hospital facilities that request consultations.13
Yet the number of multidisciplinary obesity centres in Italy remains low, with around 20 such centres
unevenly spread across the country. In areas where such specialised help is not available, obese
patients are generally forced to rely on GPs and local nutrition and dietary centres that are of variable
quality. “If the network were working really well, 20 centres might be just enough if well spread-
out and well connected with smaller centres, and if the model of hub and spokes worked properly,”
Professor Sbraccia says. “But the network is not close, and the hub and spokes don’t work properly.”
In 2012 Professor Sbraccia prepared evidence for the MoH advocating the establishment of a range of
services for obesity treatment in the country’s largest hospitals. “Unfortunately, this document goes
to regions, and regions can follow or not,” he says.
10
Contaldo, F, Mazzarella,
G et al, “Influence
of urbanization on
childhood obesity”,
Nutrition, Metabolism and
Cardiovascular Diseases,
June 2015, Vol. 25, No. 6,
pp. 615-616.
11
EASO, Obesity Perception
and Policy
12
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.
13
Ministry of Health,
“Appropriatezza clinica,
strutturale, tecnologica
e operative per la
prevenzione, diagnosi e
terapia dell’obesita e del
diabete mellito”.

4. 4 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN ITALY
The need to overcome structural challenges and regional disparities
Professor Vettor observes that the Veneto region, which includes Verona and Padua, has been one
of the leaders, with a “very controlled clinical pathway” connecting GPs, paediatricians and other
specialists between the two main city hubs. The network links all facilities dealing with obesity, from
prevention through endocrinology, nutrition, surgery and post-surgical treatment, and rehabilitation
and recovery after surgery. There are efforts to set up comprehensive networks in at least three other
northern regions. But he acknowledges that “we are not representative of what is happening in Italy”.
In the south, Professor Vettor explains, despite the existence of recognised centres of excellence
in regions such as Sicily, there is no network approach to the problem. In addition, regions with no
co-ordinated treatment pathways are unlikely to get the best outcomes from a disease that shows
different “phenotypes”, from overweight patients requiring intensive diet and exercise interventions
to morbidly obese patients who are likely to be candidates for surgery. “The integrated approach
represents the gold standard of efficacy. It is impossible to have different strategies going alone
without an integrated view,” Professor Vettor says.
The way forward
Professor Sbraccia and Professor Vettor agree that combatting obesity in Italy will require policymakers
to employ the full range of tools in their arsenal, including both prevention and treatment. First, they
say, it is vital for Italy’s policymakers to recognise obesity as a disease in order to provide a foundation
for national programmes and adequately reimburse medical treatment. According to Professor
Sbraccia, lawmakers could consider new taxes and regulations on sugar levels in food, requirements for
schools to include more physical activity, and a better reimbursement regime for new obesity drugs.
Meanwhile, interviewees argue that those treating the most seriously obese patients should reconsider
their approaches. In our pan-European report Professor Rubino argues for moving beyond the focus
on BMI. “I think the restrictions imposed by relying on BMI are not serving the patients and are not
serving the healthcare systems.” Professor Vettor echoes this sentiment, saying that there should be
an effort to move from a “quantitative” consideration of the disease that focuses on metrics such as
BMI to a more “qualitative” one that looks more widely at metabolic and cardiovascular aspects or
disability, among other factors. “We need to have a recognition that the disease has different stages,
and these different stages have to be treated in different ways. But all of these interventions—diet,
exercise, drugs, surgery—are equivalent from the point of view of therapeutic dignity.”