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E c o no mic E va lua tio ns o f Die t a nd Supple me nta tio n DR MI CHE L E SADL E R, CONSUL T ANT NUT RI T I ONI ST DI RE CT OR, RANK NUT RI T I ON L T D Spe nding o n he a lth Gr owing population Age ing

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SLIDE 1

E c o no mic E va lua tio ns o f Die t a nd Supple me nta tio n

DR MI CHE L E SADL E R, CONSUL T ANT NUT RI T I ONI ST DI RE CT OR, RANK NUT RI T I ON L T D

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SLIDE 2

Spe nding o n he a lth

Gr

  • wing population

Age ing population – ne xt 15 ye a rs +4.4 millio n 65+ ye a rs; +1.3 millio n 85+ ye a rs

Inc r e asing tr e atme nt c osts – spe nding o n c hro nic dise a se s e xpe c te d to do ub le

in ne xt 15 ye a rs

Inc r e asing e xpe nditur e on dr ugs – rise s b y 5% e a c h ye a r

T e c hnologic al de ve lopme nts

Me dic al advanc e me nts

All add to pr e ssur e for inc r e ase d spe nding on the NHS:

Re c e nt a nno unc e me nt: E xtra £20b n a ye a r b y 2023 Ave ra g e a nnua l funding inc re a se o f 3.4%

£££

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SLIDE 3

Po lic y o ptio ns

“Brexit dividend”

Inc re a se ta xe s

Inc re a se b o rro wing

Re duc e se rvic e s

Priva tisa tio n

Cut o the r pub lic se rvic e s

Impro ve NHS pro duc tivity

Institute for F isc al Studie s R e por t May 2018

  • Pr
  • pose d tax r

ise s of up to 2.6% of national inc ome (£34-£56 billion in today’s terms) r e quir e d by the mid 2030s

  • Additional r

ise of 0.4% of national inc ome to me e t the pr e ssur e s on soc ial c ar e

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SLIDE 4

Re duc e de ma nd fo r he a lth se rvic e s?

L ife style :

  • I

mpro ve d die t

  • Sto pping / re duc ing smo king
  • I

nc re a sing physic a l a c tivity

  • Re duc ing o ve r-c o nsumptio n o f a lc o ho l
  • Re duc ing re c re a tio na l drug use

Pe r sonal r e sponsibility

Se lf-he lp

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SLIDE 5

Die t a nd c hro nic dise a se

Ro le o f die t in pre ve ntio n o f die t-re la te d dise a se s is we ll-e sta b lishe d

Die ta ry g uide line s a ime d a t pro mo ting g o o d he a lth

He a lthy die ts - ma ke a n impo rta nt c o ntrib utio n to he a lth ma inte na nc e

UK E a twe ll Guide – F

  • o d-b a se d die ta ry g uide line s

fo r g e ne ra l po pula tio n fro m a g e 2+ ye a rs

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SLIDE 6

E c o no mic b urde n o f ill he a lth due to life style c ho ic e s

E stima te d e c o no mic c o sts to the UK NHS fo r 2006-2007

Of risk fa c to rs fo r c hro nic dise a se : CHD, dia b e te s, c a nc e rs, a rthritis, c irrho sis, de nta l c a rie s e tc

  • £5.8 billion: Ill he alth r

e late d to poor die t

  • [£5.1 billion: Ove r

we ight and obe sity]

  • £3.3 billion: Smoking
  • £3.3 billion: Alc ohol c o nsumptio n
  • £0.9 billion: Physic al inac tivity

Of b e ha vio ura l risk fa c to rs po o r die t ha d hig he st impa c t o n NHS b udg e t, fo llo we d b y a lc o ho l c o nsumptio n, smo king a nd physic a l ina c tivity

Good die t and nutr ition has pote ntial for vast c ost savings for the NHS

Sc a rb o ro ug h e t a l, 2011. T he e c o no mic burde n o f ill he alth due to die t, physic al inac tivity, smo king , alc o ho l and

  • bse ity in the UK: an

update to 2006-07 NHS c o sts. J Pub l He a lth 33 (4) 5278-535.

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SLIDE 7

Po te ntia l impa c t o f a simple die ta ry c ha ng e

L lo yd-Willia ms e t a l, 2007 c a lc ula te d the po te ntia l pub lic he a lth impa c t o f

replacing one ‘unhealthy’ snack with one ‘healthy’ snack per person per

da y a c ro ss the UK

Ca lc ula te d the e xpe c te d c ha ng e s to die ta ry inta ke impa c t o n b lo o d c ho le ste ro l a nd sa lt le ve ls CHD a nd stro ke mo rta lity

T his mig ht pre ve nt ~6000 c a rdio va sc ula r de a ths e ve ry ye a r in the UK

Re pre se nt a la rg e c o st sa ving to the NHS

L lo yd-Willia ms e t a l, 2007. Sma ll c ha ng e s in sna c king b e ha vio ur: the po te ntia l impa c t o n CVD mo rta lity. Pub lic He a lth Nutritio n 2007, 12(6): 871-876.

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SLIDE 8

Po te ntia l impa c t o f the Sug a r Re duc tio n Stra te g y

Government call for 20% sugar reduction in foods Less sugar in peoples’ diets Less calories consumed Reduction in weight gain Reduction in chronic diseases e.g. diabetes, obesity +23,000 years of healthy life

  • £135m to the NHS over 10 years
  • £62m to social services over 10 years

90,000 fewer cases of diabetes

Da ta c o urte sy o f Dr Be n Amie s, Ma nc he ste r

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SLIDE 9

Mic ro nutrie nts a nd e c o no mic e va lua tio ns

 Sc ie ntific lite rature inc lude s e c o no mic e va lua tio ns fo r b e ne fits o f

supple me nta tio n with mic ro nutrie nts, a nd lo ng c ha in o me g a -3 fa tty a c ids

 I

nve stig a te impa c t o f supple me nta tio n o n he a lth c a re e xpe nditure in a ta rg e t po pula tio n

 I

nsig ht into re la tive c o sts a nd a sso c ia te d he a lth g a ins

 Summa rise d a s e stimate s o f c o st-e ffe c tive ne ss o r c o st sa ving s

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SLIDE 10

E xa mple : Vita min D a nd fa lls

Vita min D supple me nta tio n sho wn to re duc e fa lls in o lde r pe o ple – ha s a utho rise d E U he a lth c la im - e ffe c tive , we ll-to le ra te d a nd a ffo rda b le

A third 65+ ye a r-o lds a nd ha lf 80+ ye a r-o lds fa ll a t le a st 1/ ye a r injurie s & fra c ture s

Co sts to the NHS e stima te d a t o ve r £2b illio n a nd o ve r 4 millio n b e d da ys (F

e nto n, PHE Blo g , 2014) 

Due to a g e ing po pula tio n, a nnua l dire c t c o sts a rising fro m fa lls in 65+ ye a r o lds pre dic te d to rise sub sta ntia lly

E c o no mic s o f the ra pe utic inte rve ntio n ha ve b e e n inve stig a te d

(Bisc ho ff-F

e rra ri HA & Sa dle r M, 2018. Autho rise d E U he a lth c la im fo r vita min D a nd re duc e d risk o f fa lls. In F

  • o ds, Nutrie nts and

F

  • o d I

ng re die nts with Autho rise d E U He alth Claims, Vo lume 3. E

  • d. M. J. Sa dle r. Wo o dhe a d Pub lishing , 2018, Cha pte r 4, 49-63)
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SLIDE 11

E va lua tio n: 3-Ste p pro c e ss

1.

E ffic ac y asse ssme nt (b e ne fit) fo r he a lth re la tio nship b e twe e n mic ro nutrie nt a nd

  • utc o me o f inte re st – e ffic a c y a sse sse d fro m huma n tria l da ta , c o ho rt studie s, me ta -

a na lysis, mo de lling

2.

Clinic al be ne fit – pre dic t c ha ng e in numb e r o f c linic a l e ve nts, pre va le nc e o f

de fic ie nc y e tc

3.

E stimate c osts – mo de lling o f c o st sa ving s/ c o st e ffe c tive ne ss a rising fro m inte rve ntio n

with the mic ro nutrie nt

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SLIDE 12

Re lia b ility o f e c o no mic e va lua tio ns

De pe nds o n a c c ura c y o f da ta / e stima te s a t e a c h ste p

E .g . E ffe c tive ne ss - stre ng th o f e vide nc e fo r he a lth b e ne fits – E U a utho rise d he a lth c la im? T ria l da ta vs o b se rva tio na l (c o ho rt da ta )?

Se nsitivity a na lysis – use d to q ua ntify unc e rta inty a ro und the re sults

  • Use a lte rna tive , mo re / le ss c ha lle ng ing , e vide nc e -b a se d va lue s to sho w

the ra ng e o f po ssib le re sults

Qua lity o f re po rting o f the e va lua tio n - tra nspa re nc y

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SLIDE 13

Wha t da ta is the re fo r mic ro nutrie nts?

Syste matic r e vie w of pe e r

  • r

e vie we d lite r atur e

  • E

xplo re d e c o no mic e va lua tio ns o f po te ntia l b e ne fits o f mic ro nutrie nt o r lo ng - c ha in o me g a -3 fa tty a c id supple me nta tio n

  • L

ite ra ture se a rc h

  • Re le va nt studie s – pe e r-re vie we d pa pe rs, fro m 2000 o nwa rds, in de ve lo pe d

c o untrie s, inve stig a te d he a lth b e ne fit o f die ta ry supple me nta tio n a nd e va lua te d dire c t o r indire c t c o sts o f die ta ry-re la te d dise a se / diso rde r

  • Outc o me o f inte re st: pote ntial for

c ost savings or c ost e ffe c tive ne ss

  • Na rra tive re vie w - me ta -a na lysis (po o le d sta tistic a l a na lysis) no t po ssib le due to

diffe re nt inte rve ntio ns & o utc o me s, diffe re nt a ppro a c he s to c o sts a sse ssme nt, diffe re nt wa ys re sults e xpre sse d

Sa dle r MJ, 2017 A re vie w o f e c o no mic e va lua tio ns fo r b e ne fic ia l he a lth o utc o me s o f mic ro nutrie nt a nd lo ng -c ha in o me g a -3 fa tty a c id supple me nta tio n. Int J F d Sc i & Nutr

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SLIDE 14

Re sults: Ove rvie w o f inc lude d pa pe rs

Clinic al outc ome Inte r ve ntion / Supple me nt Pape r s

Re duc tio n o f ne ura l tub e de fe c ts F

  • lic a c id

2 (6) I Q g a ins in c hildre n I

  • dine

1 (2) Re duc tio n o f fa lls in o lde r pe o ple Vita min D 3 (3) Re duc e d hip fra c ture risk - o lde r pe o ple Vita min D 1 (1) Re duc tio n o f o ste o po ro tic fra c ture s - prima ry a nd se c o nda ry pre ve ntio n Vita min K 2; Vita min D a nd c a lc ium; Vita min D, c a lc ium a nd vita min K

2; Vita min D, c a lc ium

a nd vita min K

2

3 (6) Surviva l fo llo wing he a rt a tta c k; re duc tio n o f se c o nda ry CV e ve nts DHA/ E PA 2 (3) Re duc tio n o f mo rb idity fro m infe c tio ns Co mme rc ia l multivita min/ mine ra l supple me nt 1 (1)

T OT AL 13 (22)

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SLIDE 15

CHE E RS !!

Qua lity o f re po rting o f e c o no mic e va lua tio ns va rie s wide ly

Co nso lidate d He a lth E

c o no mic E va lua tio n Re po rting Sta nda rds (CHE E RS): 24- ite m c he c klist fo r re po rting he a lth e c o no mic a sse ssme nts, e .g .

  • De ta ils o f spe c ific q ue stio n the a na lysis se t o ut to a ddre ss
  • E

xpla in why c ho se n time ho rizo n wa s a ppro pria te

  • De ta ils o f c o sts e stima te s – study vs mo de l-b a se – re a so ns fo r c ho o sing mo de l
  • Curre nc y, da te / ye a rs, c o sts a djustme nts me tho d
  • De ta ils o f a ssumptio ns
  • F

ull disc lo sure o f va lue s a nd ra ng e s fo r a ll study pa ra me te rs

  • Disc ussio n o f g e ne ra lisa bility o f the re sults
  • Disc lo sure o f the funding so urc e

Huse re a u e t a l. 2013. Co nso lida te d He a lth E c o no mic E valua tio n Re po rting Sta nda rds (CHE E RS)--e xpla na tio n a nd e la b o ra tio n: a re po rt o f the ISPOR He a lth E c o no mic E va lua tio n Pub lic a tio n Guide line s Go o d Re po rting Pra c tic e s T a sk F

  • rc e . Va lue He a lth. 16(2):231-250.
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SLIDE 16

Da ta synthe sis

E a c h o f the 13 pa pe rs we re sc o re d a g a inst CHE E RS c he c klist to a sse ss q ua lity

5 pa pe rs g o o d q ua lity; 7 pa pe rs lo we r q ua lity; 1 pa pe r po o r q ua lity

Also e xa mine d q ua lity b a se d o n the stre ng th o f the e vide nc e use d fo r e ffic a c y a nd va lidity o f c o sts a sse ssme nts

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SLIDE 17

F inding s: Ro b ustne ss o f e ffic a c y da ta

3 he a lth o utc o me s we re suppo rte d b y ro b ust da ta fo r e ffic a c y:

  • Re duc e d risk o f NT

D

  • Re duc e d risk o f fa lls
  • Re duc e d risk o f o ste o po ro tic fra c ture s

Suppo rte d b y c o mpa riso n with E U list o f he a lth c la ims

Othe r he a lth o utc o me s we re suppo rte d b y le ss ro b ust da ta , a nd fo r so me e vide nc e o f e ffic a c y wa s te nta tive e .g . vita min K a nd b o ne fra c ture

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SLIDE 18

F inding s: Pre dic te d c o sts

Mo st e valua tio ns b a se d c o sts o n multiple so urc e s a nd da ta synthe sis

So me e va lua tio ns b a se d c o sts o n a sing le study

I n so me e va lua tio ns c o sts we re ta ke n fro m a diffe re nt c o untry to tha t fo r whic h the c o st sa ving s we re inte nde d

Mo st a na lyse s we re b a se d o n dire c t c o sts o nly

E xc e ptio ns we re :

  • Mo na ha n e t a l (2015) - c o nside re d spe c ia l e duc a tio nal c o sts & mo ne ta ry value
  • f a n I

Q po int re a na lysis o f io dine supple me nta tio n in pre g na nt wo me n

  • Sc hmie re t a l (2006) c o nside re d c o sts fo r lo st pro duc tivity due to mo rb idity &

mo rta lity re a na lysis o f lo ng c ha in o me g a -3 fa tty a c id supple me nta tio n in me n with a histo ry o f he a rt a tta c k

Mo na ha n e t a l, 2015. Co sts a nd b e ne fits o f io dine supple me nta tio n fo r pre g na nt wo me n in a mildly to mo de ra te ly io dine -de fic ie nt po pula tio n: a mo de lling a na lysis. T he L a nc e t Dia b e te s & e ndo c rino lo g y. 3(9):715-722. Sc hmie re t a l, 2006. T he c o st-e ffe c tive ne ss o f o me g a -3 supple me nts fo r pre ve ntio n o f se c o nda ry c o ro na ry e ve nts. Ma na g e d Ca re 15(4):43-50.

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SLIDE 19

F inding s: L imita tio ns

~ 1/ 3rd o f a na lyse s re fle c te d sc e na rio s o f me dic a l inte rve ntio n with die ta ry supple me nts

Othe rs did no t c o st, o r e ve n a ddre ss, c o mmunic a tio n o f the supple me nta tio n stra te g y

  • E

.g . re a c hing the ta rg e t g ro up c o uld b e diffic ult a nd c o stly fo r pe o ple no t c urre ntly invo lve d with he a lth se rvic e s

I n so me a na lyse s the inte rve ntio n stra te g y invo lve d the he a lth c a re se tting a s the supple me nts we re c o ste d a s pre sc riptio ns (e .g . Po o le e t a l, 2015)

Po o le e t a l, 2015. Co st-e ffe c tive ne ss a nd b udg e t impa c t o f e mpiric a l vita min D the ra py o n uninte ntio na l fa lls in o lde r a dults in the UK . BMJ o pe n 5(9):e 007910.

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SLIDE 20

F inding s: Co st sa ving s/ e ffe c tive ne ss

Re sults we re sub je c t to unc e rta inty, e .g . a ro und

  • Ra te s o f c linic a l e ve nts
  • Pre va le nc e o f de fic ie nc y sta te s
  • Co sts o f the inte rve ntio n

Of the 13 inc lude d pa pe rs, 8 sta te d tha t the a sse ssme nts we re c o nse rva tive

 12/ 13 pape r

s pr e dic te d an e c onomic be ne fit

 21/ 22 e valuations we r

e r e por te d as be ne fic ial or c ost e ffe c tive

I n se nsitivity analysis whe n mo re c halle ng ing assumptio ns we re use d:

 E

stima te s r

e maine d c ost e ffe c tive in 6/ 13 pape r s

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SLIDE 21

E xa mple : Vita min D a nd fa lls

Clinic a l impa c t o f tre a ting a ll 60+ ye a rs with 800 iu c ho le c a lc ife ro l o ve r a 5- ye a r pe rio d wo uld:

  • Pre ve nt in e xc e ss o f 430,000 mino r fa lls
  • Avo id 190,000 ma jo r fa lls
  • Pre ve nt 1579 a c ute de a ths
  • Avo id 84,000 pe rso n-ye a rs o f lo ng -te rm c a re
  • Pre ve nt 8300 de a ths a sso c ia te d with inc re a se d mo rta lity in lo ng -te rm c a re

Po o le e t a l, 2015. Co st-e ffe c tive ne ss a nd b udg e t impa c t o f e mpiric a l vita min D the ra py o n uninte ntio na l fa lls in o lde r a dults in the UK . BMJ o pe n 5(9):e 007910.

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SLIDE 22

E xa mple : Vita min D a nd fa lls

F

  • r

r e duc tion in falls alone the inte rve ntio n is c o st-sa ving

T re a ting a ll a dults 60+ ye a rs:

  • Inc urs a n inte rve ntio n c o st o f £2.70b n o ve r 5 ye a rs
  • Produces a −£3.12bn reduction in fall-re la te d c o sts
  • Ne t sa ving o f £420M

I nc re a sing the lo we r b o und a g e limit b y 5-ye a r inc re me nts inc re a se s b udg e t impa c t to :

  • −£1.17b n fo r a dults 65+
  • −£1.75b n fo r a dults 70+
  • −£2.06b n fo r a dults 75+

Po o le e t a l, 2015. Co st-e ffe c tive ne ss a nd b udg e t impa c t o f e mpiric a l vita min D the ra py o n uninte ntio na l fa lls in o lde r a dults in the UK . BMJ o pe n 5(9):e 007910.

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SLIDE 23

F inding s: Co st sa ving s/ e ffe c tive ne ss

Co st-sa ving s no t re po rte d fo r mulitvita min/ mine ra l & re duc e d mo rb idity fro m infe c tio ns K ilo nzo e t a l (2007)

  • Ba se d o n o ne tria l in 65+ ye a rs (me a n a g e 71.5 ye a rs) with a time ho rizo n
  • f 12 mo nths
  • Que stio na b le whe the r dura tio n o f supple me nta tio n wa s a de q ua te fo r a

sig nific a nt impa c t in this a g e g ro up

K ilo nzo MM, Va le L D, Co o k JA, Milne AC, Ste phe n AI, Ave ne ll A, e t a l. 2007. A c o st-utility a na lysis o f multivita min a nd multimine ra l supple me nts in me n a nd wo me n a g e d 65 ye a rs a nd o ve r. Clin Nutr. 26(3):364-370.

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SLIDE 24

He a lth b e ne fit – g o o d inve stme nt?

Gajic -Ve ljanoski e t al, 2012 pr

  • pose d that:

Whe re mic ro nutrie nt supple me nta tio n is kno wn to b e sa fe a nd a ffo rda b le , a small he alth be ne fit could tr anslate into a good inve stme nt ….. the re la tio nship b e twe e n pre dic te d c o sts a nd b e ne fits, a lo ng side se nsitivity a na lysis, ha s a po te ntia l ro le to indic a te the e xpe cte d value of fur the r r e se ar ch, or the e xpe cte d

  • ppor

tunity loss.

Ga jic -Ve lja no ski O, Ba yo umi AM, T

  • mlinso n G,

K ha n K , Che ung AM. 2012. Vita min K supple me nta tio n fo r the prima ry pre ve ntio n o f o ste o po ro tic fra c ture s: is it c o st-e ffe c tive a nd is future re se a rc h wa rra nte d? Oste o po ro sis Inte rna tio na l 23(11):2681-2692.

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SLIDE 25

Co nc lusio ns

Re lia b ility o f e stima te s fro m e c o no mic e va lua tio ns o f mic ro nutrie nt supple me nts a re de pe nde nt o n the q ua lity o f the da ta input to the mo de lling

De fic ie nc ie s in the e vide nc e b a se fo r b o th e ffic a c y a nd c o sts a re like ly

Whe re c o st e ffe c tive ne ss c a n b e de mo nstra te d in the c linic a l se tting , it is like ly tha t se lf-supple me nta tio n a lso c o ntrib ute s to the e ffe c t

Re se a rc h into this a spe c t is wa rrante d

T he e c o no mic b e ne fit o f ma inta ining nutritio na l sta tus in pe o ple with lo w inta ke s wo uld a lso b e o f inte re st, a g a inst o the r func tio na l o utc o me me a sure s

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SLIDE 26

Co nc lusio ns

T he o ve rall finding fro m the pub lishe d da ta tha t:

  • Ma ny o f the a na lyse s re po rte d a c o st sa ving , o r
  • We re c o st e ffe c tive a g a inst the c ho se n thre sho ld o f a c c e pta b ility

…sugge sts a pote ntial r

  • le for

supple me ntation with mic r

  • nutr

ie nts and with long c hain ome ga-3 fatty ac ids:

  • F
  • r spe c ific he a lth o utc o me s
  • T

a rg e te d a t spe c ific po pula tio n g ro ups

…in r

e duc ing the e c onomic bur de n on he alth c ar e budge ts

T he se re la tio nships sho uld b e e xplo re d furthe r

E c o no mic e va lua tio n ma y a lso b e a use ful to o l to prio ritise nutritio n re se a rc h funding

  • n he a lth b e ne fits tha t a re like ly to de live r po sitive impa c ts fo r b o th c linic al o utc o me s

a nd he a lth c a re b udg e ts

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SLIDE 27

Co nta c t:

Dr Mic he le Sa dle r Dire c to r, Ra nk Nutritio n L td Nutritio n Sc ie nc e Co nsulta nc y msa dle r@ b tc o nne c t.c o m www.ra nknutritio n.c o m

Re g iste re d Nutritio nist Me mb e r o f the Nutritio n So c ie ty (Gre a t Brita in) F e llo w o f the Ro ya l So c ie ty o f Me dic ine Co mmitte e Me mb e r o f SE NSE Nutritio n Co nsulta nts Me mb e r o f Nutritio nists in I ndustry