The Cost of Overweight and Obesity on the Island of Ireland

t The Cost of Overweight and Obesity on the Island of Ireland Ivan J Perry, Dept. of Epidemiology and Public Health, University College Cork. JANPA Launch- WP 4 Meeting September 2015

Acknowledgements UCC/ HSE Department of Public Health, Limerick Dr Anne Dee, Karen Kearns, Victoria O Dwyer NUIG - Professor Ciaran O Neill, Dr. Edel Doherty, Dr. Aoife Callan DCU - Professor Anthony Staines, Dr. Treasa McVeigh, Dr. MaryRose Sweeney QUB - Professor Frank Kee, John Hughes National Cancer Registry - Dr. Linda Sharp Institute of Public Health - Professor Kevin Balanda Safefood- Dr Cliodhna Foley-Nolan

Main findings in BMJ open

Overview Brief overview of the obesity epidemic in adults and children in Ireland Burden of disease linked to obesity Background to the Irish Cost of Obesity Study including earlier international work on this issue Methods used in Irish Cost of Obesity Study Main findings and Recommendations Pitfalls and limitations

Economist magazine Dec 11th 2003

Past and projected prevalence of overweight in selected countries

Overweight and obesity in children in selected countries

Overweight and obesity in Irish adults (18-64 years) in 1990, 2001 and 2011

SLÁN(measured BMI) vs TILDA(measured BMI) in middle-aged and older adults 90% 80% 70% 31% 37% 60% 34% 32% 31% 50% 25% 40% 30% 20% 49% 39% 39% 47% 40% 44% 10% 0% Slán 2007 Males 45+ Slán 2007 Females 45+ Slán 2007 Male & Female TILDA 2011 Males 50+ TILDA 2011 Females 50+ TILDA 2011 Male & Female Obesity Overweight

Childhood overweight & obesity prevalence in Ireland 2002 to 2014 Keane et al BMC Public Health 2014

Likelihood of developing Type II diabetes attributable to overweight & obesity in males & females 1200% 1141% 1000% 800% 600% 574% 400% 292% 200% 140% 0% Male overweight Male obese Female overweight Female obese

Liklihood of developing cancers attributable to overweight & obesity in males 140% 129% 120% 100% 80% 95% 82% 60% 40% 20% 0% 15% 13% 21% 40% 28% 5% 25% Male Overweight Male Obese

Liklihood of developing cancers attributable to overweight & obesity in females 250% 222% 200% 164% 150% 100% 50% 0% 8% 13% Breast Post menopausal 82% 85% 66% 60% 53% 45% 35% 20% 24% 15% Large Bowel Uterus Oesophagus Kidney Pancreas Gall bladder Female Overweight Female obese

Liklihood of developing chronic illness attributable to overweight & obesity in males 300% 250% 251% 200% 210% 181% 150% 142% 100% 50% 65% 80% 27% 78% 15% 49% 91% 59% 96% 80% 0% High Blood Pressure Coronary Heart Disease Heart Failure Stroke Clot on Lung (PE) Back Pain Osteoarthritis

Liklihood of developing chronic illness attributable to overweight & obesity- females 300% 250% 200% 210% 251% 181% 150% 142% 100% 50% 0% 65% 80% 27% 78% 15% 49% 91% 59% 96% 80% Female overweight Female obese

Global Burden of Disease 2010

Background Safefood initiative-obesity Taskforce Report 2005 highlighted the lack of information on the economic burden of overweight and obesity Comprehensive assessment of the cost of overweight and obesity in Ireland Began April 2011

Project aims and objectives The overall aim of the project was to provide a comprehensive assessment of the cost of overweight and obesity on the island of Ireland Objectives To review and summarise the international literature on cost of obesity studies with a particular focus on those published since 2001, with a view to guiding and informing the approach adopted in the current project. To determine the direct health service related costs of overweight and obesity in the Republic of Ireland and Northern Ireland from a public health care payer perspective. To estimate the indirect cost, due to sickness, absence and premature mortality, related to overweight and obesity in both the Republic of Ireland and in Northern Ireland. To examine the combined health service and lost production costs associated with overweight and obesity, and examine variations in these estimates across illnesses and jurisdictions. To make recommendations based on the findings

Cost of obesity studies in the international literature since 2001

Range of Study Designs Top down:-based on estimation of population attributable fractions (PAF method) Bottom up: - based on analyses of cross-sectional and/or longitudinal datasets Mixed approaches

Literature review - what have other countries found? Overweight and obesity account for somewhere between 1% and 9% of total healthcare costs Indirect costs may be as much again or even more Costs increase with increasing BMI

Conclusions from Literature Review On an individual level the highest BMI groups are most costly On a population level the overweight group are more costly as they are a larger group

What costs were included? Most comprehensive studies measure direct and indirect costs overweight and obesity Direct Costs include: In-Patient Out-patient General Practice Drugs and prescribing costs Indirect Costs include lost productivity due to: Time off work due to overweight and obesity related illness Premature mortality

Chronic conditions associated with overweight & obesity Cancers Colon Oesophageal Post-Menopausal Breast Endometrial Kidney Gallbladder Pancreas Other Type 2 Diabetes Cardiovascular Disease Hypertension Cardiac Failure Venous thromboembolism Asthma Gallbladder Disease Low Back Pain Osteoarthritis Gout

Top down:- PAF method inputs Estimated prevalence of overweight and obesity List of co-morbid conditions associated with overweight & obesity The magnitude of the causal association between overweight & obesity and each condition, expressed as a relative risk (RR) with 95% confidence intervals PAF estimated from the PF (fraction of the population exposed to overweight plus the fraction exposed to obesity) and the magnitude of the estimated RR (relative risk) of disease associated with both overweight and obesity National cost data from hospital discharge data (HIPE) or other sources as appropriate.

Meta-analysis of studies of overweight & obesity and Type 2 diabetes** **Prospective cohort studies of sufficient size reporting risk estimate based on the incidence of disease)

Bottom up cross-sectional approach Based on the analyses of cross-sectional survey data for healthcare usage and productivity loss (e.g. absenteeism) by BMI category. Highly dependent on the quality of the available data on health outcomes and productivity loss and the representativeness of the sample. Also dependent on the availability of cost data, either directly as a core element of the dataset or via resource use information that can be linked to average cost data

Methods used in the all Ireland cost of obesity study

Data sources and methods for direct costs Top down:paf method Hospital Inpatient Enquiry (HIPE) & the Primary Care Reimbursement Scheme (PCRS) databases in the Republic of Ireland Hospital Inpatient System (HIS) and the Business Services Organisation (BSO) databases in Northern Ireland. Bottom up cross-sectional method Regression analyses of associations between overweight and obesity and self-reported health care utilisation in: the SLÁN 2007 dataset (Republic of Ireland) the Irish National Longitudinal Study of Ageing (TILDA) datasets (Republic of Ireland) the 2010/11 Health Survey Northern Ireland.

Data sources for indirect costs Sickness related absenteeism Republic of Ireland: the SLÁN 2007 dataset were analysed for evidence of associations between overweight and obesity and self-reported absenteeism during the previous year, using regression analyses similar to those used in the estimation of direct costs. the Department of Social Protection illness benefit data for 2009, with the calculation of population attributable fractions of days absent from work for overweight and obesity-related co-morbid conditions. For Northern Ireland, the 2005/6 Health and Wellbeing Survey dataset was analysed. These analyses were augmented by an analysis of sickness benefits data obtained from the Analytical Services Unit of the Department of Social Development (Northern Ireland). Premature mortality Mortality data were obtained from the Irish Central Statistics Office (CSO) and the Northern Ireland Statistics and Research Agency (NISRA) to estimate the impact of obesity and overweight on premature mortality.

Methods of analyses for indirect costs Population attributable fractions (PAFs) for death and absenteeism (indirectly estimated from disability claims), associated with the defined list of overweight and obesity-related conditions, were derived for each jurisdiction using separate risk estimates for overweight and obesity and, wherever available, separate relative risk estimates for males and females. Deaths were weighted using years of potential life lost (YPLL) up to age 75. Discount rate of 4% applied Productivity loss was estimated using both human-capital and friction-cost methods. Main results based on estimated human capital costs

Main Results Republic of Ireland Northern Ireland (PPP Irish 2009 ) Direct costs 398,615,581 127,406,641 Indirect costs 728,968,662 382,917,113 Total costs 1,127,584,243 510,323,754

Results- Direct Costs Republic of Ireland Cost ROI General Practice 22,900,000 Hospital inpatient care 134,383,667 Hospital outpatient care 6,890,000 Drugs 234,441,904 Total 398,615,581

Results-Direct Costs Northern Ireland Direct costs NI General Practice 7,411,564 Hospital Inpatient Care 42,920,805 Drugs 77,074,272 Total 127,406,641

Main contributing conditions to Direct Healthcare Costs Cardiovascular disease Type II Diabetes Colon Cancer Stroke Gallbladder Disease

Results-Indirect due to Productivity Loss ROI Indirect cost ROI Absenteeism 135,977,068 Premature Mortality 592,991,594 Total 728,968,662

Results-Indirect due to Productivity Loss NI Indirect cost NI Absenteeism 235,500,000 Premature Mortality 147,417,113 Total 382,917,113

Main Drivers of Cost Premature Mortality Coronary Heart Disease Absenteeism Low Back Pain

Main Recommendations The findings highlight the extent of societal involvement in diet and health and the limitations of approaches which emphasise the importance of personal agencyin relation to diet and health The food sector is currently regulated to ensure food safety. Policy makers need to consider whether there is a need to extend this regulatory framework to address the effects of diet on health and wellbeing. Need for both population based and targeted (high risk group) strategies to tackle the obesity epidemic Key policies and actions will need to occur outside the health sector Workplace interventions needed to reduce the problem of Low Back Pain in the overweight and obese

Recommendations (Cont) Need for significant investment in research to examine the effect of fiscal and other government policies on consumer purchasing and their impact on overweight and obesity Need for modelling the overweight and obesity associated illness burden and costs into the future National surveys need to be designed to facilitate such cost of illness studies, and to evaluate the effects of public health interventions

Relative Price Changes for Fresh Fruits and Vegetables, Sugars and Sweets, and Carbonated Drinks, 1978 2009

Limitations of cost of illness studies Accepted that overweight and obesity increase the risk of illness, absenteeism from the workplace and early death, but the magnitude of these effects in the population is measured with poor precision Even greater imprecision in the estimation of associated direct healthcare cost and indirect societal costs. Variable and inconsistent data on absenteeism and limited primary research on presenteeism Potential problem of double counting in the application of the PAF method Effects on quality of life and mental wellbeing not addressed Uncertainty in relation to how best to value productivity loss: human capital versus friction costs methods and economic and social contribution of retired people? Need to consider the wide uncertainty bounds/confidence intervals around the summary cost estimates.

Limitations of cost of illness studies Given the extent of fixed staffing and infrastructure cost in health systems, how much of the estimated costs would be saved if the current burden of overweight and obesity were reduced.? Value of cost of illness studies derives primarily from their ability to inform discussion of the relative economic burden associated with major health problems as opposed to the precise quantification of absolute costs. It is arguable that estimation of the absolute burden or costs of illness provides a poor measure of relative need. The latter (need) is determined both by the burden of disease and the capacity to benefit from interventions. Under ideal circumstances, the priority assigned to overweight and obesity in public policy should be driven primarily by estimates of the incremental costs and the incremental benefits of interventions to prevent and/or manage overweight and obesity.

Thank you