Introduction

Brazil currently holds the second place in the worldwide ranking of the largest number of bariatric surgeries performed per year, accounting for more than 100,000 yearly procedures [1,2,3,4]. Despite the continuous growth of these numbers over recent years, there is a pent-up demand of individuals who could benefit from surgery, but cannot achieve it, since obesity affects almost 20% of the Brazilian adult population, which means almost 25 million people, of which about five million are eligible for bariatric surgery [5, 6].

Over the second decade of the twenty-first century, Brazil has struggled against serious economic issues, which led to a severe crisis that affected the entire health care system, either public or private. Following years of low inflation and steady economic growth, the country went through an economic depression characterized by decreases in the gross domestic product (GDP), increasing inflation levels, and growing unemployment rates. The Brazilian depression is considered to have begun in 2014, following successive decreases in the GDP associated with the bankruptcies of several companies, high unemployment rates, and a decrease of the international and domestic investment rates [7]. The 2014–2017 crisis was a result of a combination of economic policies that reduced Brazil’s potential economic growth and a fiscal crisis that led to an unsustainable growth of the public sector debt. Several factors contributed to create and deepen this crisis: an increased governmental interventionism on fiscal and monetary policies, which led to non-coordinated changes in the interest rates allied with a tight control of government-regulated prices (such as petrol-derived products), detached of the international scenery [8]. This led to decreases in the governmental health expenditures and also in the number of people who have access to private health care insurance plans [9].

Bariatric surgery is known to produce significant long-term decreases in direct and indirect health costs [10, 11]. Nonetheless, to perform such proceedings and guarantee the expansion in its numbers, certain expenses are demanded, such as the costs to maintain multidisciplinary teams and afford specific medical devices.

The effect of nationwide economic policies on the necessary expansion in the number of bariatric procedures is unclear and its knowledge may help in planning specific actions to allow it to reach a larger portion of the entire population that may benefit from them.

Objective

This study aims to determine whether there are correlations between the growth rate in the number of bariatric surgeries and the main macroeconomic variables over time in Brazil.

Methods

This is a nationwide analysis of the previous surveys regarding the estimated number of bariatric surgeries in Brazil from 2003 through 2016, the growth rate in these numbers from 2004 through 2016, and the main macroeconomic variables of Brazil during the evaluated period (GDP, inflation rate, and unemployment rate). The growth rates of bariatric surgeries during the study period were correlated with each macroeconomic variable to determine whether there is any significant association between them. The growth rates of bariatric surgeries were also correlated with the growth rate of the number of registered bariatric surgeons in Brazil and with the overall health care costs per capita.

The number of bariatric surgeries performed in Brazil was obtained by means of the periodic reports of the Brazilian Society of Bariatric and Metabolic Surgery (SBCBM) [12]. The main macroeconomic variables evaluated were obtained by means of the official reports of the Brazilian government organization Applied Research Institute (IPEA); the data considered were the yearly rates of nominal GDP, inflation determined by the broad consumer price index (IPCA), and unemployment determined by the proportion of unemployed individuals that belong to the economically active population [13]. The number of registered bariatric surgeons in Brazil was provided by the SBCBM. The overall health care costs per capita were obtained by means of the World Health Organization (WHO) health expenditures database [14].

Statistical Analysis

To determine the correlation between the analyzed variables, the Spearman correlation tests were used. The Spearman tests generate rank correlation coefficients (values of R) that vary from − 1 to 1; the values next to the edges signal negative or positive correlations, respectively. The level of significance adopted was 5% (p < 0.05). The software SSPS v. 16.0 (Chicago, IL, USA) was used for the analysis.

Results

The overall number of surgeries increased from 16000 in 2003 to 100,512 in 2016. The highest yearly growth (34%) rate was observed in 2006. Figure 1 presents the detailed data on the referred number of surgeries performed in Brazil from 2003 through 2016. There was a tendency towards positive or mildly negative macroeconomic parameters in the first half of the evaluated period, followed by a rapid worsening of such statistics, leading to higher inflation and unemployment rates, as well as decreases in the GDP and health care expenditure per capita. These data are presented in Fig. 2.

Fig. 1
figure 1

The number of bariatric surgeries performed over time in Brazil. Source: Brazilian Society of Bariatric and Metabolic Surgery (SBCBM)

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Fig. 2
figure 2

The annual percent variation of the number of surgeries, macroeconomic variables, number of surgeons, and overall health care expenditure. GDP gross domestic product. 2016 data for the overall health care expenditure not yet available

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In regard to the correlations between the growth rate of the number of surgeries and the macroeconomic and health care variables, there were significant positive correlations of the growth rate of surgeries with the yearly variation of the GDP (R = 0.5558; p = 0.04863) and also with the yearly variation of the overall health expenditure per capita (R = 0.78322; p = 0.00259). The growth rate of the number of bariatric surgeries did not present significant correlations with the unemployment and inflation rates, respectively, as well as with the growth rate of the number of registered bariatric surgeons. The variation of the GDP was also not significantly correlated with the health care expenditures per capita (Table 1). Figure 3 presents the complete ranks and respective correlation coefficients (R) and values of p by means of dispersion graphs.

Table 1 Correlations between the growth rate of bariatric surgeries and macroeconomic variables over time
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Fig. 3
figure 3

Correlations between the yearly growth rate of bariatric surgeries, macroeconomic variables, growth rate of the number of surgeons, and variation of the overall health care expenditure. a Growth rate of bariatric surgery versus gross domestic product; b growth rate of bariatric surgery versus unemployment rate; c growth rate of bariatric surgery versus inflation rate; d growth rate of bariatric surgery versus growth rate of bariatric surgeons; e growth rate of bariatric surgeries versus overall health care expenditure per capita; f gross domestic product versus overall health care expenditure per capita. R correlation coefficient

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Discussion

Obesity has reached epidemic proportions over the last decades, and this phenomenon has not spared underdeveloped countries. In fact, obesity is actually responsible for more deaths than malnutrition worldwide [15]. Brazil, despite significant social advances over since the late twentieth century, still presents concerning rates of poverty and economic inequality among its population, as well as a deficient access to health-providing services [16]. Recently, a significant deterioration of the economic parameters associated with a convoluted political situation even led to riots and the destitution of the then Brazilian Head of State. The influence of such turmoil on the already insufficient health system is hard to determine; however, its effects can be indirectly measured through methods such as the model proposed by this study [7].

There were significant associations of both the evolutions of the GDP and health care expenditure per capita with the growth rate in the number of bariatric surgeries; interestingly, the evolutions of the GDP and health expenditure per capita did not present a significant association between themselves. These findings indicate that the major macroeconomic variable and its direct consequences on health expenditure are somewhat correlated with the offer of a specific procedure to a population which is likely to directly benefit from it. To our knowledge, such finding is unprecedented, since there are no studies specifically analyzing the net impact of the overall economic situation on the bariatric surgery field. Since the number of procedures performed is far from reaching the actual necessities, this decrease in its expansion points out that the potential benefits of a better control of obesity and comorbidities are impaired, either individually or systemically. For example, the reimbursement provided by the Health Department for public hospitals to provide bariatric surgeries was approximately US$ 2000 per procedure, considering the then current exchange rate of US dollars when those values were determined [17]; the overall public health costs of an individual with type 2 diabetes in Brazil was estimated by Borges et al. [18] at about US$ 1844 per year. This means that a single individual with diabetes almost requires the cost of an entire bariatric procedure each year. In Brazil, more than 90% of the bariatric procedures are performed by private health-providing services; the vast majority of these services are reimbursed by third-party payers (health insurance plans); during the crisis, the number of individuals whose main health care was provided by such insurance companies also decreased by about three million people which could not afford their costs [9]. The overall costs of a bariatric surgery provided by private supplemental health-providing services were estimated by Kelles et al. around US$ 4000 [19].

The possibility of downturns is inherent to modern economic systems worldwide, and their effects may be devastating in countries with relevant socioeconomic issues. However, since health-providing systems should be planned and organized on a long-term basis and aim at systemic net gains over the population health, the impairment in the growth of the bariatric field is likely to produce even worse results in a further analysis. Given the importance of obesity to the overall burden of health costs, countercyclical policies are mandatory to ensure a continued growth in the face of an expanding pent-up demand, even during crises. Although a decrease or deceleration in the number of bariatric operations can provide some early saving of resources, it will ultimately lead to higher long-term health costs [20]. There are some measures that health systems, insurance plans, and hospitals could implement which are likely to soften the effects of such crises, such as switching to minimally invasive procedures and developing enhanced recovery postoperative protocols, which may be a way to decrease overall costs of the postoperative care, disseminating information for professionals and health care planners on the overall net effects of bariatric surgery on decreasing long-term costs directed for obesity-related diseases, stimulating the expansion of coverage for surgery offer in the public health system, which is universal and could attenuate the crisis’ effect for people who lost their access to private health insurance plans, and managing the procedures to be preferably performed at high-volume excellence centers, a factor which is recognized to lead to a lower expenditure and better outcomes [21,22,23,24].

During the evaluated period, there were three major events that should positively influence the access to bariatric surgery in Brazil: the inclusion of laparoscopic bariatric surgery in the list of procedures which should be mandatorily offered by the health insurance companies; the regulation of the public offer of surgery, by means of an official ordinance published by the Department of Health in March 2013, which aimed to further the access and regulate the reimbursements for public hospitals; and a new policy for indication of bariatric surgeries published by the Federal Council of Medicine (CFM) in January 2016, which considered 21 comorbidities (Table 2) besides the classic five of the older policy (hypertension, diabetes, arthropathies, sleep apnea, and dyslipidemias) for individuals with BMI ≥ 35 kg/m2 [17, 25]. However, these three significant policy changes did not lead to the expected rise in the growth rate in the following years [17, 25]. More recently, a new determination of the CFM included a possible surgical indication of bariatric surgery for individuals with poorly controlled diabetes and BMI ≥ 30 kg/m2, but this new policy was published after the period of this study [26]. Interestingly, the absolute number of surgeries increased during the entire evaluated period; nonetheless, the growth rate was significantly lower during the majority of the recession years. It is reasonable to hypothesize that the pent-up demand for bariatric surgery is so large that it is able to maintain a certain growth in the number of surgeries, despite the economic downturn. Moreover, the increase in the number of registered bariatric surgeons and accredited services over time might have helped to alleviate these effects. However, the expansion would be expectedly higher over time whether there was not such economic retraction.

Table 2 Indication criteria for bariatric surgery according to the Brazilian Federal Council of Medicine (CFM)
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The current study presents some limitations that should be considered. It is an analysis of nationwide data from a large country which presents significant regional disparities; hence, some of the overall findings may be misleading. Moreover, since economic crises tend to be cyclical, analyses of longer periods are necessary to fully address these tendencies. Despite our attempt to limit the economic and health care variables for establishing their correlations, there are also several other variables that are difficult to evaluate, but also could interfere on the present results, such as specific changes in coverage or policies in regard to the availability and even indications of bariatric surgery, variations in the educational level of the population studied, the real number of active bariatric surgeons (the number of members of the SBCBM is an estimate of the total amount of surgeons, since it does not include each surgeon because it is not mandatory to be registered to perform these procedures in Brazil), and changes in economic variables may be influenced more by political decisions than by free trade principles. The Spearman analysis does not provide linear correlations, since it is a non-parametric method. Although it was appropriate for this study, since it included data that are usually not normally distributed, it also may present a difficult interpretation; for instance, there were years when GDP decreased and the number of procedures still rose. This occurs because the Spearman method is apt to detect overall tendencies within a given time interval and showed that the decrease of the GDP was correlated with the deceleration of the growth in the number of bariatric surgeries in the majority of the time points evaluated. Nonetheless, the significance of the observed results is clear and underlines the necessity of similar studies on other regions and to take into account these findings for an appropriate long-term planning for obesity management.

Conclusion

There were direct relationships between the growth rate of bariatric surgeries and the evolutions of the GDP and health care expenditure per capita. These variables appear to influence the nationwide offer of bariatric surgery.