The scale of the problem is striking. According to the World Obesity Atlas 2025, 22 percent of Bulgarian adults are living with obesity and 54 percent are classified as overweight, meaning around two-thirds of the adult population carries excess weight. Out of roughly 4.58 million adults above the age of 19, more than 2.47 million have a high body mass index and just over one million already meet the threshold for obesity. The researchers project that the number of adults with high BMI will climb to approximately 2.83 million by 2030, a trajectory that threatens to overwhelm a healthcare system already under strain.

To capture the full economic picture, the team conducted a quantitative cost-of-illness analysis from a societal perspective, using a top-down, population-based approach. They calculated direct medical costs, including anti-obesity medicines, hospitalisations, bariatric surgery, and the treatment of major complications such as type 2 diabetes, cardiovascular disease, and joint replacements requiring hip or knee surgery. Indirect costs were measured through productivity losses from absenteeism, and the social burden was quantified using disability-adjusted life years, or DALYs, a metric that combines years of life lost to premature death with years lived in less-than-full health.

The direct healthcare bill came to €55,935,208 for just the first six months of 2025. Two categories dominated: hospitalisations due to complications accounted for 47 percent of the total, while anti-obesity medicines made up 48 percent. The medicine figure rests on a deliberately optimistic assumption, since only 1.3 percent of patients eligible for obesity treatment actually fill at least one weight-loss prescription, based on published international data. Applying that rate to Bulgaria’s obese population yields roughly 13,096 people on pharmacotherapy, with the market split between liraglutide at 20 percent, semaglutide at 40 percent, and tirzepatide at 40 percent. Even at those modest uptake levels, six months of therapy across all eligible patients would cost about €26.6 million, with tirzepatide alone accounting for nearly €2.5 million per month.

Hospital care tells its own story. The researchers tallied costs across clinical pathways coded by the National Health Insurance Fund, finding that knee and hip replacements represented the single largest obesity-linked expenditure, at over €11.8 million for the half-year, reflecting evidence that more than half of joint replacement patients live with obesity. Decompensated type 2 diabetes hospitalisations added nearly €3.9 million, ischaemic stroke admissions without thrombolysis cost close to €6 million, and acute myocardial infarction contributed over €1.5 million. Reimbursed ambulatory medicines for complications, spanning dyslipidaemia, hypertension, and diabetes drugs, added another €2.4 million. Bariatric surgery, by contrast, remains rare: only 85 procedures were claimed in the half-year at an average price of about €4,750, totalling just over €400,000.

Perhaps the most consequential finding is that indirect costs exceed direct medical spending. Productivity losses from absenteeism, calculated from sick leave certificates issued between January and June 2025 and valued at the 2025 minimum daily wage of €26.22, reached €57,922,356 in six months. Workers aged 41 to 60 drove the largest share of these losses, and the researchers note a clear upward trend in sick leave days that may reflect the progressive nature of obesity and its comorbidities. Because the analysis captured only absenteeism and not presenteeism, the true productivity gap is almost certainly wider, meaning the imbalance between indirect and direct costs is even more pronounced than the headline figures suggest.

The social burden, expressed in DALYs, totalled 42,468 years for one year across five major obesity-related complications: diabetes mellitus, ischaemic heart disease, hypertensive heart disease, chronic kidney disease, and stroke. The methodology combined national mortality data from the Bulgarian National Statistical Institute and the World Health Organization with population attributable fractions, which estimate what share of each disease would not occur if obesity were absent, based on obesity prevalence and disease-specific relative risks drawn from the published literature. Years of life lost to premature death emerged as the larger contributor to the DALY total, with diabetes, ischaemic heart disease, and stroke standing out as the leading drivers of obesity-attributable disease burden in the country.

The authors are careful about the limits of their estimates. Direct healthcare costs are likely underestimated because anti-obesity medicines and most bariatric procedures are not reimbursed by public funds in Bulgaria, meaning patients pay out of pocket and the true economic flow is difficult to track; there is no national register of bariatric operations. The study also excluded more than 200 known obesity-related comorbidities, including cancer, metabolic dysfunction-associated steatotic liver disease, and sleep apnoea, so the actual cost of treating complications is higher still. Hospitalisation calculations assumed conservatively that each patient experienced only one complication per year. Private payments, adolescent obesity, and broader social consequences such as unemployment and reduced socioeconomic productivity were likewise outside the scope of the analysis.

What emerges is a picture consistent with global trends. Worldwide, 2.5 billion adults were overweight in 2021 and 890 million were living with obesity, and adult obesity has more than doubled since 1990. Excess body weight was linked to an estimated 3.7 million deaths from non-communicable diseases in 2021, and DALYs attributable to high BMI rose by 15.7 percent between 2000 and 2021, while metabolic risks overall increased by nearly 50 percent. In Bulgaria specifically, high body mass index contributed to an estimated 5,594 premature deaths and 90,695 adult person-years of ill health in 2021, and it now ranks as the fourth-leading risk factor for DALYs per 100,000 people, behind high blood pressure, dietary risks, and tobacco.

The study’s authors argue that the policy response has not kept pace with the science. Although new and effective anti-obesity pharmacotherapies have reached the market, their high prices and lack of public reimbursement, in Bulgaria and across most of Europe, keep them out of reach for most patients. Bulgarian clinical guidelines, last updated in 2017 and 2019, still recommend only older options such as orlistat, liraglutide, and naltrexone, and the researchers point to the United Kingdom’s National Institute for Health and Care Excellence as a model for evidence-based reimbursement criteria. They propose an action plan targeting high-risk groups, defined as individuals with a BMI above 35 kg/m² and at least one obesity-related condition, with anti-obesity treatment of fixed two-year duration. Given that obesity is a complex, progressive, relapsing chronic disorder requiring long-term management, the researchers conclude that acting now, before the projected 2030 surge in prevalence, could spare both the healthcare system and society a substantially larger bill.

Subject of Research: The economic and social burden of obesity in Bulgaria, quantified through a cost-of-illness analysis of direct healthcare costs, productivity losses, and disability-adjusted life years

Article Title: The economic and social burden of obesity in Bulgaria

Article References: Mihaylova, S., & Petrova, G. (2026). The economic and social burden of obesity in Bulgaria. Pharmacia, 73, Article e204540. https://doi.org/10.3897/pharmacia.73.e204540

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e204540

Keywords: obesity, Bulgaria, cost of illness, DALYs, health economics, anti-obesity medicines, absenteeism, type 2 diabetes, cardiovascular disease, bariatric surgery, public health, productivity losses