Health priorities have shifted in modern times. While average life expectancy has surged over the last century, we grapple with new health challenges. Diseases like malaria, typhoid, diphtheria, polio, mumps and measles, once epidemics of history, are now treatable.
However, we now face ailments our ancestors never encountered, such as obesity, diabetes, hypertension, cardiovascular diseases, cancer, allergies, anorexia and depression. These are referred to as civilization-related lifestyle diseases, the byproducts of the modern era. Alongside viruses, which remain a primary scourge, these conditions constitute today's foremost public health concerns, according to the World Health Organization (WHO).
Although controversial, the most prominent and widespread of these is obesity. Obesity is one of the most dangerous disease sources of our age, which is increasing both globally and in Türkiye. Lifestyle, profession, geographical conditions and eating habits play an important role in the prevalence of obesity. While the obesity rate is low (only 4%) in Japan, where many follow a seafood-based diet, obesity rates in the United States, a fast-food paradise, have reached as high as 31%. In rural areas where physical labor is intense, the obesity rate is lower than in urban areas. Even phenomena that seem irrelevant at first glance, such as the economic crises, can trigger obesity: Impoverished societies tend to become obese by consuming more carbohydrates. Likewise, age, gender, genetics, hormonal effects and cultural habits also influence the tendency.
For today's humanity, obesity is a factor that critically increases the risk of several chronic diseases, which are the leading causes of death worldwide, according to the WHO. Obesity causes metabolic syndromes, cardiovascular diseases, diabetes, high blood pressure, high cholesterol, stroke, liver diseases, some types of cancer, respiratory diseases, sleep apnea, muscular system diseases and sexual dysfunction, all resulting in significant decreases in the quality of life and longevity.
Even though Türkiye is not yet a developed country, it is in an obesity crisis. According to the data announced by the WHO, Türkiye ranks first in obesity rates in Europe. Obesity continues to spread in Turkish society like a pandemic. Obesity has become almost widespread among Generation Z. Children, especially those who consume a lot of processed and packaged foods, are in the greatest risk group. So much so that the obesity rate in children under the age of 5 in Türkiye is 8.1% as of 2018; with this data, Türkiye ranks second in Europe in terms of child obesity.
Obesity is not merely an individual or aesthetic concern; it also represents a significant societal scourge and public health issue. Examining the rising prevalence of diabetes, the primary chronic disease associated with obesity in Türkiye underscores the severity of the situation. According to 2020 data from the International Diabetes Federation (IDF), Türkiye has 7 million diabetic patients aged 20-79, comprising approximately 15% of the adult population. Independent estimates project this number to reach 10 million by 2023.
Türkiye is not alone in facing the challenges of the diabetes pandemic; it is a global health issue rivaling even COVID-19. A study published in the esteemed medical journal Lancet, based on research from the University of Washington Health Measurement and Evaluation Institute, reveals that in 2021, there were 529 million diabetic patients worldwide, with projections indicating this number will exceed 1.3 billion by 2050. Notably, no country is expected to experience a decrease in diabetes rates over the next 30 years. This data underscores that diabetes has become one of the most pervasive global health concerns, posing significant financial and administrative challenges for healthcare systems worldwide.
The Turkish Statistical Institute (TurkStat) provides significant insights into the matter. According to TurkStat's 2022 Türkiye Health Survey, the obesity rate among individuals aged 15 and above was 20.2% in 2022. When broken down by gender, 23.6% of women were found to be obese, with 30.9% classified as pre-obese, while 16.8% of men were obese, with 40.4% classified as pre-obese.
Furthermore, back problems, primarily caused by obesity, emerged as the most prevalent health issue in 2022, affecting 24.6% of individuals. This was followed by neck problems at 17.2%, hypertension at 16.1%, diabetes at 11.4% and allergies at 9.6%. Obesity stands out as the foremost public health concern, with tobacco and alcohol usage trailing far behind. According to TurkStat, the daily tobacco usage rate among individuals aged 15 and above was 28.3% in 2022, while the rate of alcohol usage within the past year stood at 12.1%.
Additionally, TurkStat data reveals that the health-protective service most utilized in Turkish society in 2022 was blood pressure measurement, with 44.7% of individuals availing themselves of this service. Meanwhile, 39.6% of people had their cholesterol levels checked within the past year and 41.6% had their blood sugar levels monitored.
Whereas obesity and also Type 2 diabetes are overwhelmingly preventable health care problems, initiatives such as routine cholesterol and blood sugar screenings, fostering healthy eating habits beginning in schools, restructuring the family medicine system to emphasize obesity prevention, identifying at-risk individuals and implementing targeted programs, incentivizing healthy lifestyles through tax breaks and incentives and labeling high-calorie beverages are crucial steps. Even small nudges have tremendous effects on diabetes. Likewise, preventive health services are one of the priority areas in combating obesity and preventing it from transforming into a chronic disease.
Experts emphasize that reducing energy intake through food, adopting proper eating habits and adopting an active lifestyle are the primary steps to overcoming obesity. However, obesity is not an individual problem, nor is its solution. This burden must be addressed with comprehensive social programs rather than leaving it solely to the individual's choice. It would be a great injustice to leave this burden on the shoulders of individuals who are encouraged to consume sugary and high-calorie diets through constant advertising bombardment every day in our capitalist society. Significantly reducing diabetes and obesity, or at least reducing the heavy burden on public health systems, requires strong public incentives.
In Türkiye, we often hear about the problem in public reports, but very few do anything meaningful, sustainable and useful. For instance, the Social Security Institution (SSI), which alone finances more than 76% of health services in Türkiye, does not currently allocate any resources to support an active lifestyle to prevent obesity, but if individuals contract chronic diseases as a result of obesity, it finances health services. SSI, which does not aim to detect individuals prone to diabetes or cover expenses of preventive health services for them, covers lifelong insulin for diabetics and pays for all diabetes-related treatments.
This negligence is not limited to obesity but also to other enemies of public health. Unfortunately, there are very few comprehensive and effective initiatives in the public sector, including the Ministry of Health, to combat any of the civilization-related lifestyle disease sources. SSI does not impose an additional premium burden on a heavy smoker, but when this person has lung cancer, it covers all his treatments without a penny of out-of-pocket payment. There is no difference in premium burden between an individual living a healthy life and an individual living an unhealthy life, or rather, living a healthy life is not subjected to encouragement. Employers' practices that nudge their employees to live a healthy life are not financially incentivized.
In summary, the public sector in Türkiye acts as if preventive health care is nonexistent and as if its health care and pharma expenses will not decrease if an individual's health is protected. While the Turkish welfare system covers an extensive range of health care services (even covering some genetic and rare diseases such as spinal muscular atrophy (SMA), Duchenne muscular dystrophy (DMD), and idiopathic pulmonary fibrosis (IPF), that are not covered even in Scandinavian countries), an approach that finances the disease, not the health, is maintained.
SSI, which provides unlimited health services to millions of diabetics in Türkiye, does not include the most basic and simple measures on its agenda, such as compulsory regular blood pressure measurements and nationwide cholesterol and blood sugar screening programs. Despite very few initiatives, the state in Türkiye does not include taking measures to prevent individuals from getting sick and does not pursue effective policies toward this end.
However, the principle of "prevention is always cheaper than repair," which is a fundamental principle in occupational health and safety, should be applied here. Türkiye should stop financing disease and move to a model that finances the protection of health and preventive treatments.
This is not only a question of policy priorities but also a question of macroeconomic stability. Milken Institute's "America's Obesity Crisis" report of 2018 estimates that the cost of obesity-related chronic diseases was $1.72 trillion in the U.S. in 2016. In its 2023 report, the IDF estimates that the global cost of obesity may reach a tremendous $4.32 trillion by 2035.
For Türkiye, the direct and indirect costs are roughly TL 1 trillion (approximately $32 billion) annually. In other words, if we switched to a preventive health model and financed individuals' health, the economic gain would be at a level that would cover almost all the gaps in Türkiye's social security system. This issue is critical because Türkiye's public health expenditures are very high: SSI's 2023 health expenditures are at TL 544 billion. Although this figure is projected to be TL 815 billion in 2024, it is expected to easily exceed TL 1 trillion. This is so despite the nation's protective pharmaceutical exchange rate policy and the fact that the SSI has the advantage of determining prices in the monopsony market. Yet, health financing is increasing at a level that will stake the macroeconomic balances.
In sum, the generous welfare system that Türkiye has established in the last 20 years under the leadership of President Recep Tayyip Erdoğan is facing an important challenge and it is now essential to switch to a welfare system that conducts efficiency-effectiveness analysis. If Türkiye wants to use its scarce resources efficiently in financing health care and maintain its generous welfare state, it must prioritize financing protection of health and preventive health care with a new perspective based on effectiveness-cost analysis.
