Cost-of-illness analysis reveals potential healthcare savings with reductions in type 2 diabetes and cardiovascular disease following recommended intakes of dietary fiber in Canada

Modelling the health and economic impact of sugary sweetened beverage tax in Canada

Background

With the increasing concerns about the health and economic burden attributed to sugar-sweetened beverages (SSBs) consumption, SSB taxation has been proposed and implemented in many countries. Many previous economic evaluations of SSB taxation have shown that this kind of policy is cost-effective. However, the magnitude of impact varies. This study aims to design a comprehensive model to estimate the impact and cost-effectiveness of the SSB tax in Canada.

Methods

A proportional multi-state life table-based Markov model was chosen to estimate the impacts of SSB tax in Canada. The health-related quality of life (including disability-adjusted life years (DALYs) and quality-adjusted life years (QALYs)), the costs (including health care costs and intervention costs), and the tax revenue were the main health and economic outcomes. We compared the simulated SSB tax with the current practice from the public health care payer perspective, and the tax was applied to the 2015 adult Canadian population up to 100 years. The economic model was built following guidelines from the Canadian Agency for Drugs and Technologies in Health.

Results

After implementing a CAD$0.015/oz SSB tax, 282,104 cases of overweight and obesity, 210,542 cases of diseases, and 2,189 deaths could be prevented. The simulated SSB tax has the potential to avert 2.3 million DALYs, gain 1.5 million QALYs, and save CAD$32,583 million in health care costs in a lifetime period. The incremental cost-effectiveness ratio for the SSB tax was CAD$ -24,933/QALY. The SSB tax with different tax levels (CAD$0.01/oz and CAD$0.02/oz) remained cost-effective.

Conclusion

Implementing the SSB tax in Canada is a potential cost-effective policy option for reducing obesity and related chronic diseases. The model built in this study provides a more accurate estimate of health and economic impact of SSB tax and could be used to estimate other sugar tax options.

The economic burden of excessive sugar consumption in Canada: should the scope of preventive action be broadened?

Objective

Excessive sugar consumption is an established risk factor for various chronic diseases (CDs). No earlier study has quantified its economic burden in terms of health care costs for treatment and management of CDs, and costs associated with lost productivity and premature mortality. This information, however, is essential to public health decision-makers when planning and prioritizing interventions. The present study aimed to estimate the economic burden of excessive free sugar consumption in Canada.

Methods

Free sugars refer to all monosaccharides and disaccharides added to foods plus sugars naturally present in honey, syrups, and fruit juice. Based on free sugar consumption reported in the 2015 Canadian Community Health Survey–Nutrition and established risk estimates for 16 main CDs, we calculated the avoidable direct health care costs and indirect costs.

Results

If Canadians were to comply with the free sugar recommendation (consumption below 10% of total energy intake (TEI)), an estimated $2.5 billion (95% CI: 1.5, 3.6) in direct health care and indirect costs could have been avoided in 2019. For the stricter recommendation (consumption below 5% of TEI), this was $5.0 billion (95% CI: 3.1, 6.9).

Conclusion

Excessive free sugar in our diet has an enormous economic burden that is larger than that of any food group and 3 to 6 times that of sugar-sweetened beverages (SSBs). Public health interventions to reduce sugar consumption should therefore consider going beyond taxation of SSBs to target a broader set of products, in order to more effectively reduce the public health and economic burden of CDs.

Type 2 Diabetes-Related Health Economic Impact Associated with Increased Whole Grains Consumption among Adults in Finland

The prevalence of type 2 diabetes (T2D) is increasing rapidly worldwide. A healthy diet supporting the control of energy intake and body weight has major importance in the prevention of T2D. For example, a high intake of whole grain foods (WGF) has been shown to be inversely associated with risk for T2D. The objective of the study was to estimate the expected health economic impacts of increased WGF consumption to decrease the incidence of T2D in the Finnish adult population. A health economic model utilizing data from multiple national databases and published scientific literature was constructed to estimate these population-level health economic consequences. Among the adult Finnish population, increased WGF consumption could reduce T2D-related costs between 286€ and 989€ million during the next 10-year time horizon depending on the applied scenario (i.e., a 10%-unit increase in a proportion of daily WGF users, an increased number (i.e., two or more) of WGF servings a day, or alternatively a combination of these scenarios). Over the next 20–30 years, a population-wide increase in WGF consumption could lead to much higher benefits. Furthermore, depending on the applied scenario, between 1323 and 154,094 quality-adjusted life years (QALYs) could be gained at the population level due to decreased T2D-related morbidity and mortality during the next 10 to 30 years. The results indicate that even when the current level of daily WGF consumption is already at a relatively high-level in a global context, increased WGF consumption could lead to important health gains and savings in the Finnish adult population.

Healthcare Cost Savings Associated with Increased Whole Grain Consumption among Australian Adults

Many dietary guidelines emphasise "mostly" whole grain food choices as part of an overall healthy eating pattern based on evidence for enhancing nutritional status and reducing chronic disease. Still, countries including Australia fall short of their consumption targets. Furthermore, healthcare cost savings associated with increasing the consumption of whole grains in alignment with the Daily Target Intake (DTI) recommendation of 48 g are unknown. The aim of this study was to assess the potential savings in costs of healthcare and lost productivity associated with a reduction in the incidence of Type 2 Diabetes Mellitus (T2DM) and cardiovascular disease (CVD) through meeting the 48 g DTI recommendation for whole grains among the Australian adult population (>20 years). A three-step cost-of-illness analysis was conducted using input parameters from: 1) estimates of proportions of consumers (5%, 15%, 50%, and 100%) who would increase their current intake of whole grains to meet the recommended DTI in Australia; 2) relative reductions in risk of T2DM and CVD associated with specific whole grain consumption, as reported in meta-analysis studies; and 3) data on costs of healthcare and productivity loss based on monetary figures by national healthcare authorities. A very pessimistic (5% of the population) through to universal (100% of the population) adoption of the recommended DTI was shown to potentially yield AUD 37.5 (95% CI 22.3-49.3) to AUD 750.7 (95% CI 445.7-985.2) million, and AUD 35.9 (95% CI 8.3-60.7) to AUD 717.4 (95% CI 165.5-1214.1) million in savings on annual healthcare and lost productivity costs for T2DM and CVD, respectively. Given such economic benefits of the recommended consumption of whole grains, in exchange for refined grains, there is a real opportunity to facilitate relevant socioeconomic cost-savings for Australia and reductions in disease. These results are suggestive of a much greater opportunity to communicate the need for dietary change at all levels, but particularly through food-based dietary guidelines and front-of-pack labelling initiatives.

The Effect of Processing on Bioactive Compounds and Nutritional Qualities of Pulses in Meeting the Sustainable Development Goal 2

Diversification of plant-based food sources is necessary to improve global food and nutritional security. Pulses have enormous nutritional and health benefits in preventing malnutrition and chronic diseases while contributing positively to reducing environmental footprint. Pulses are rich in diverse nutritional and non-nutritional constituents which can be classified as bioactive compounds due to their biological effect. These bioactive compounds include but are not limited to proteins, dietary fibres, resistant starch, polyphenols, saponins, lectins, phytic acids, and enzyme inhibitors. While these compounds are of importance in ensuring food and nutritional security, some of the bioactive constituents have ambivalent properties. These properties include having antioxidant, anti-hypertensive and prebiotic effects. Others have a deleterious effect of decreasing the digestibility and/or bioavailability of essential nutrients and are therefore termed antinutritional factors/compounds. Various processing techniques exist to reduce the content of antinutritional factors found in pulses. Traditional processing of pulses comprises soaking, dehulling, milling, germination, fermentation, and boiling, while examples of emerging processing techniques include microwaving, extrusion, and micronization. These processing techniques can be tailored to purpose and pulse type to achieve desired results. Herein, the nutritional qualities and properties of bioactive compounds found in pulses in meeting the sustainable development goals are presented. It also discusses the effect of processing techniques on the nutritional and non-nutritional constituents in pulses as well as the health and environmental benefits of pulse-diet consumption. Major challenges linked to pulses that could limit their potential of being ideal crops in meeting the sustainable development goal 2 agenda are highlighted.

Review of whole grain and dietary fiber recommendations and intake levels in different countries

This review of whole grain and dietary fiber recommendations and intake levels was presented at the symposium on whole grains, dietary fiber, and public health, convened in Beijing, China, on May 11, 2018. The review reflects on inconsistencies among the definitions of whole grains and fiber as well as recommended intake levels in different countries. The lack of consistent dietary recommendations from authoritative sources may delay the regional implementation and consumer adoption of diets that include whole grains and fiber. Currently, few countries include specific intake recommendations for whole grain, and even among those countries with guidance the recommendations can be vague and qualitative. As a result of the well-documented associations between increasing whole grain intake and reduced disease risk, there is compelling evidence to create clear, actionable dietary recommendations for both whole grains and fiber. Furthermore, work is ongoing to develop uniform standards for whole grain and whole-grain food to ensure recommendations are being met. Health and regulatory authorities are encouraged to acknowledge the public health benefits that could be derived from strong, clear whole-grain and dietary fiber recommendations; examine existing definitions (whole grain as an ingredient, whole-grain food, and dietary fiber); and adopt the most appropriate approach to best serve public health needs for their respective populations.

Impact of interventions to reduce overnutrition on healthcare costs related to obesity and type 2 diabetes: a systematic review

CONTEXT

In recent decades, obesity and type 2 diabetes mellitus (T2DM) have both become global epidemics associated with substantial healthcare needs and costs.

OBJECTIVE

The aim of this review was to critically assess nutritional interventions for their impact on healthcare costs to community-dwelling individuals regarding T2DM or obesity or both, specifically using CHEERS (Consolidated Health Economic Evaluation Reporting Standards) criteria to assess the economic components of the evidence.

DATA SOURCES

Searches were executed in Embase, EconLit, AgEcon, PubMed, and Web of Science databases.

STUDY SELECTION

Studies were included if they had a nutritional perspective, reported an economic evaluation that included healthcare costs, and focused on obesity or T2DM or both. Studies were excluded if they examined clinical nutritional preparations, dietary supplements, industrially modified dietary components, micronutrient deficiencies, or undernutrition; if they did not report the isolated impact of nutrition in complex or lifestyle interventions; or if they were conducted in animals or attempted to transfer findings from animals to humans.

DATA EXTRACTION

A systematic review was performed according to PRISMA guidelines. Using predefined search terms, 21 studies evaluating food habit interventions or taxation of unhealthy foods and beverages were extracted and evaluated using CHEERS criteria.

RESULTS

Overall, these studies showed that nutrition interventions and taxation approaches could lead to cost savings and improved health outcomes when compared with current practice. All of the included studies used external sources and economic modeling or risk estimations with population-attributable risks to calculate economic outcomes.

CONCLUSIONS

Most evidence supported taxation approaches. The effect of nutritional interventions has not been adequately assessed. Controlled studies to directly measure economic impacts are warranted.

Economic Burden of Not Complying with Canadian Food Recommendations in 2018

Poor diet has been identified as a major cause of chronic disease. In this study we estimated the 2018 economic burden of chronic disease attributable to not complying with Canadian food recommendations. We retrieved the chronic disease risk estimates for intakes of both protective (fruit, vegetables, milk, whole grains, nuts and seeds) and harmful foods (sugar-sweetened beverages, processed meat, red meat) from the Global Burden of Disease Study, and food intakes from the 2015 Canadian Community Health Survey 24-hour dietary recalls (n = 19,797). Population attributable fractions (PAFs) were calculated for all food-chronic disease combinations, and mathematically adjusted to estimate the 2018 annual direct (hospital, physician, drug) and indirect (human capital approach) economic burden for each disease. Not meeting the eight food recommendations was estimated to be responsible for CAD$15.8 billion/year in direct (CAD$5.9 billion) and indirect (CAD$9.9 billion) costs. The economic burden of Canadians under-consuming healthful foods exceeded the burden of overconsumption of harmful foods (CAD$12.5 billion vs. CAD$3.3 billion). Our findings suggest poor diet represents a substantial economic burden in Canada. Interventions may be more effective if they are wide in focus and promote decreased consumption of harmful foods alongside increased consumption of healthful foods, with emphasis on whole grains and nuts and seeds.

Economic modeling for improved prediction of saving estimates in healthcare costs from consumption of healthy foods: the Mediterranean-style diet case study

Background

By design, existing scenario-based nutrition economics studies on the financial benefits of healthy dietary behaviors generally report uncertainty in inputs and wide ranges of outcome estimates.

Objectives

This modeling exercise aimed to establish precision in prediction of the potential healthcare cost savings that would follow a reduction in the incidence of cardiovascular disease (CVD) consistent with an increase in adherence to a Mediterranean-style diet (MedDiet).

Design

Using a Monte Carlo simulation model on a cost-of-illness analysis assessing MedDiet adherence, CVD incidence reduction, and healthcare cost savings in the United States and Canada, short- and long-term cost savings that are likely to accrue to the American and Canadian healthcare systems were estimated using 20 and 80% increases in MedDiet adherence scenarios.

Results

Increasing percentage of population adhering to a MedDiet by 20% beyond the current adherence level produced annual savings in CVD-related costs of US$8.2 billion (95% confidence interval [CI], $7.5-$8.8 billion) in the United States and Can$0.32 billion (95% CI, $0.29-$0.34 billion) in Canada. An 80% increase in adherence resulted in savings equal to US$31 billion (95% CI, $28.6-$33.3 billion) and Can$1.2 billion (95% CI, $1.11-$1.30 billion) in each respective country.

Conclusion

Computational techniques with stochastic parameter inputs, such as the Monte Carlo simulation, could be an effective way of incorporating variability of modeling parameters in nutrition economics studies for improved precision in estimating the monetary value of healthy eating habits.

TeDia - A Telemedicine-Based Treatment Model for Inpatient and Interprofessional Diabetes Care

INTRODUCTION

The proportion of hospitalized patients with diabetes as a secondary diagnosis increases continuously. Therefore, we have developed a team-based interprofessional and telemedicine-based diabetes management system named TeDia ("Telemedical Diabetology") and implemented it in an inpatient setting. The aim of the retrospective real-world study was to show the clinical impact of TeDia following its implementation.

MATERIAL AND METHODS

TeDia is characterized by an interpersonal and telemedicine-based exchange of hospital routine data between specially trained nurses ("diabetes managers") and external diabetologists. It was implemented in three acute hospitals of the Düsseldorf Catholic Hospital Group in Düsseldorf, Germany. Clinical awareness of diabetes, diabetes-related complications and diagnosis-related group (DRG)-based revenues were analyzed using ICD routine coding. Furthermore, the frequency of HbA1c determinations as well as hospitalization days were investigated.

RESULTS

Before (2010), during (2012) and after the implementation of TeDia (2014), the number of patients with ICD coding for diabetes, decompensated diabetes, diabetic neuropathy, diabetic nephropathy as well as complicated diabetes increased by +18%, +93%, +101%, +113% and +89%, respectively. Using the same DRG grouper, revenues increased by +53% (from 27 (2013) to 42 (2014) DRG points). Frequency of HbA1c determinations rose by +85%, whereas the time for an average length of stay decreased by -12% (-0, 91 days) in comparison to patients without diabetes.

CONCLUSION

TeDia improved clinical awareness for diabetes and its complications. This new treatment model increased revenues and reduced hospital days indicating enhanced treatment quality. Our findings emphasize the necessity of novel technologies in inpatient settings for the improvement of efficacy, safety and efficiency of diabetes care.

Whole Fruits and Fruit Fiber Emerging Health Effects

Less than 10% of most Western populations consume adequate levels of whole fruits and dietary fiber with typical intake being about half of the recommended levels. Evidence of the beneficial health effects of consuming adequate levels of whole fruits has been steadily growing, especially regarding their bioactive fiber prebiotic effects and role in improved weight control, wellness and healthy aging. The primary aim of this narrative review article is to examine the increasing number of health benefits which are associated with the adequate intake of whole fruits, especially fruit fiber, throughout the human lifecycle. These potential health benefits include: protecting colonic gastrointestinal health (e.g., constipation, irritable bowel syndrome, inflammatory bowel diseases, and diverticular disease); promoting long-term weight management; reducing risk of cardiovascular disease, type 2 diabetes and metabolic syndrome; defending against colorectal and lung cancers; improving odds of successful aging; reducing the severity of asthma and chronic obstructive pulmonary disease; enhancing psychological well-being and lowering the risk of depression; contributing to higher bone mineral density in children and adults; reducing risk of seborrheic dermatitis; and helping to attenuate autism spectrum disorder severity. Low whole fruit intake represents a potentially more serious global population health threat than previously recognized, especially in light of the emerging research on whole fruit and fruit fiber health benefits.

The economic burden of not meeting food recommendations in Canada: The cost of doing nothing

Few studies have estimated the economic burden of chronic diseases (e.g., type 2 diabetes, cardiovascular diseases, cancers) attributable to unhealthy eating. In this study, we estimated the economic burden of chronic disease attributable to not meeting Canadian food recommendations. We first obtained chronic disease risk estimates for intakes of both protective (1. vegetables; 2. fruit; 3. whole grains; 4. milk; 5. nuts and seeds) and harmful (6. processed meat; 7. red meat; 8. sugar-sweetened beverages) foods from the Global Burden of Disease Study, and food intakes from the 2004 Canadian Community Health Survey 24-hour dietary recalls (n = 33,932 respondents). We then calculated population attributable fractions (PAFs) for all relevant food-chronic disease combinations by age and sex groups. These PAFs were then mathematically combined for each disease for each age and sex group. We then estimated attributable costs by multiplying these combined PAFs with estimated 2014 annual direct health care (hospital, drug, physician) and indirect (human capital approach) costs for each disease. We found that not meeting recommendations for the eight foods was responsible for CAD$13.8 billion/year (direct health care: CAD$5.1 billion, indirect: CAD$8.7 billion). Nuts and seeds and whole grains were the top cost contributors rather than vegetables and fruit. Our findings suggest that unhealthy eating constitutes a tremendous economic burden to Canada that is similar in magnitude to the burden of smoking and larger than that of physical inactivity which were estimated using similar approaches. A status quo in promotion of healthy eating will allow this burden to continue. Interventions to reduce the health and economic burden of unhealthy eating in Canada may be more effective if they are broad in focus and include promotion of nuts and seeds and whole grains along with vegetables and fruit rather than have a narrow focus such as primarily on vegetables and fruit.

Healthcare Expenditure and Productivity Cost Savings from Reductions in Cardiovascular Disease and Type 2 Diabetes Associated with Increased Intake of Cereal Fibre among Australian Adults: A Cost of Illness Analysis

An ageing population and growing prevalence of chronic diseases including cardiovascular disease (CVD) and type 2 diabetes (T2D) are putting increased pressure on healthcare expenditure in Australia. A cost of illness analysis was conducted to assess the potential savings in healthcare expenditure and productivity costs associated with lower prevalence of CVD and T2D resulting from increased intake of cereal fibre. Modelling was undertaken for three levels of increased dietary fibre intake using cereal fibre: a 10% increase in total dietary fibre; an increase to the Adequate Intake; and an increase to the Suggested Dietary Target. Total healthcare expenditure and productivity cost savings associated with reduced CVD and T2D were calculated by gender, socioeconomic status, baseline dietary fibre intake, and population uptake. Total combined annual healthcare expenditure and productivity cost savings of AUD$17.8 million-$1.6 billion for CVD and AUD$18.2 million-$1.7 billion for T2D were calculated. Total savings were generally larger among adults of lower socioeconomic status and those with lower dietary fibre intakes. Given the substantial healthcare expenditure and productivity cost savings that could be realised through increases in cereal fibre, there is cause for the development of interventions and policies that encourage an increase in cereal fibre intake in Australia.

Canadian Potential Healthcare and Societal Cost Savings from Consumption of Pulses: A Cost-Of-Illness Analysis

Consumption of dietary pulses, including beans, peas and lentils, is recommended by health authorities across jurisdictions for their nutritional value and effectiveness in helping to prevent and manage major diet-related illnesses of significant socioeconomic burden. The aim of this study was to estimate the potential annual healthcare and societal cost savings relevant to rates of reduction in complications from type 2 diabetes (T2D) and incidence of cardiovascular disease (CVD) following a low glycemic index (GI) or high fiber diet that includes pulses, or 100 g/day pulse intake in Canada, respectively. A four-step cost-of-illness analysis was conducted to: (1) estimate the proportions of individuals who are likely to consume pulses; (2) evaluate the reductions in established risk factors for T2D and CVD; (3) assess the percent reduction in incidences or complications of the diseases of interest; and (4) calculate the potential annual savings in relevant healthcare and related costs. A low GI or high fiber diet that includes pulses and 100 g/day pulse intake were shown to potentially yield Can$6.2 (95% CI $2.6-$9.9) to Can$62.4 (95% CI $26-$98.8) and Can$31.6 (95% CI $11.1-$52) to Can$315.5 (95% CI $110.6-$520.4) million in savings on annual healthcare and related costs of T2D and CVD, respectively. Specific provincial/territorial analyses suggested annual T2D and CVD related cost savings that ranged from up to Can$0.2 million in some provinces to up to Can$135 million in others. In conclusion, with regular consumption of pulse crops, there is a potential opportunity to facilitate T2D and CVD related socioeconomic cost savings that could be applied to Canadian healthcare or re-assigned to other priority domains. Whether these potential cost savings will be offset by other healthcare costs associated with longevity and diseases of the elderly is to be investigated over the long term.

Health benefits and evaluation of healthcare cost savings if oils rich in monounsaturated fatty acids were substituted for conventional dietary oils in the United States

The impact of nutritional behaviors on health is beyond debate and has the potential to affect the economic outputs of societies in significant ways. Dietary fatty acids have become a central theme in nutrition research in recent years, and the popularity of dietary oils rich in healthy fatty acids, such as monounsaturated fatty acid (MUFA), for cooking applications and use in food products has increased. Here, the objective is to summarize the health effects of MUFA-rich diets and to systematically estimate the potential healthcare and societal cost savings that could be realized by increasing MUFA intakes compared with other dietary fat intakes in the United States. Using a scoping review approach, the literature of randomized controlled clinical trials was searched and a 4-step cost-of-illness analysis was developed, which included estimates of success rate, disease biomarker reduction, disease incidence reduction, and cost savings. Findings revealed improvements in established biomarkers and in incidence of coronary heart disease and type 2 diabetes, along with potentially substantial annual healthcare and societal cost savings when recommendations for daily MUFA intake were followed. In summary, beyond the beneficial health effects of MUFA-rich diets, potential economic benefits suggest practical implications for consumers, food processors, and healthcare authorities alike.

The Fiber Gap and the Disappearing Gut Microbiome: Implications for Human Nutrition

Increasing evidence indicates that modern lifestyle, and specifically a Western diet, has led to a substantial depletion of the human gut microbiome. This loss is implicated in the rampant increase of chronic diseases, providing an incentive to fundamentally transform human nutrition towards being more holistic and microbiome-focused.

Dietary fibre intakes and reduction in functional constipation rates among Canadian adults: a cost-of-illness analysis

BACKGROUND

Evidence-based research highlights beneficial impacts of dietary fibre on several aspects of the gut pathophysiology that are accompanied by a considerable financial burden in healthcare services. Recommended intakes of dietary fibre may thus associate with financial benefits at a population level.

OBJECTIVE

We sought to systematically assess the potential annual savings in healthcare costs that would follow the reduction in rates of functional constipation and irregularity with increased dietary fibre intakes among Canadian adults.

DESIGN

A cost-of-illness analysis was developed on the basis of current and recommended levels of fibre intake in Canada, constipation reduction per 1 g fibre intake, proportion of adults who are likely to consume fibre-rich diets, and population expected to respond to fibre intake. Sensitivity analyses covering a range of assumptions were further implemented within the economic simulation.

RESULTS

Our literature searches assumed a 1.8% reduction in constipation rates with each 1 g/day increase in fibre intake. With intakes corresponding to the Institute of Medicine's adequate levels of 38 g/day for men and 25 g/day for women, among 5 and 100% of the adult populations, anywhere between CAD$1.5 and CAD$31.9 million could be saved on constipation-related healthcare costs annually. Each 1 g/day increase in dietary fibre was estimated to result in total annual healthcare cost savings that ranged between CAD$0.1 and CAD$2.5 million.

CONCLUSIONS

The present research suggests an economic value of increasing dietary fibre intake beyond its well-known health benefits. Healthy-eating behaviours consistent with the recommended intakes of dietary fibre by the general public should hence be advocated as a practical approach for reducing costs associated with the management of constipation in Canada.