Upload
phamcong
View
215
Download
0
Embed Size (px)
Citation preview
25 AUG 2017: LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN GREECE, REPUBLIC OF IRELAND, ROMANIS AND SOLOVENIA 1
THE LIFETIME IMPACTS AND COSTS OF CHILDHOOD OBESITY/OVERWEIGHT IN EUROPE. PART 1:
MODELLING METHODOLOGY
DATA REQUIREMENTS
RESULTS FOR THE REPUBLIC OF IRELAND AND NORTHERN IRELAND
Deliverable D4.6
Work Package WP 4: Evidence (the economic rationale for action on childhood obesity)
Responsible Partner: IPH-IRL
Participating Member States: HZZO & HZJZ (Croatia), ATEITH & AHEPA (Greece), UCC-CHDR (IRL & NIR), ISS (Italy), MS (Portugal), NIMCP (Romania), NIJZ (Slovenia)
JANPA – Joint Action on Nutrition and Physical Activity (Grant agreement n° 677063) has received funding from the European Union’s Health Programme (2014 – 2020)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 2
The content of this Deliverable represents the views of the author only and is his/her sole
responsibility; it cannot be considered to reflect the views of the European Commission
and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of
the European Union.
The European Commission and the Agency do not accept any responsibility for use that may
be made of the information it contains.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 3
GENERAL INFORMATION
Joint Action full title Joint Action on Nutrition and Physical Activity
Joint Action acronym JANPA
Funding This Joint Action has received funding from the European
Union’s Health Programme (2014-2020)
Grant Agreement Grant agreement n°677063
Starting Date 01 September 2015
Duration 27 Months
DOCUMENT MANAGEMENT
Deliverable D4.6
WP and Task WP4 and Task 4.4
Author IPH-IRL
Due month of the deliverable M27
Actual submission month End of JANPA
Type
R: Document, report
DEC: Websites, patent fillings,
videos, etc.
OTHER
R
Dissemination level
PU: Public
PU
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 4
ROLES
COUNTRY ORGANISATION ROLE
Croatia HZZO
Zlatko Boni
HZIZ
Sanja Music
Country liaison, Data collation
Croatian Team Co-Leader
Country liaison, Data collation
Croatian Team Co-Leader
Greece
ATEITH
Maria Hassapidou
AHEPA
Konstantinos Bouas
Country liaison , Data collation
Greek Team Co-Leader
Greek Team Co-Leader
Ireland
(Republic of Ireland)
IPH-IRL
Kevin Balanda
WP4 Lead Team
WP4 Leader, D4.6 Author
UK HEALTH FORUM
Laura Webber
Sub-contractor (to IPH-IRL)
Pre-modelling data processing
Simulation modelling and cost
estimation
Ireland
(Republic of Ireland &
Northern Ireland)
UCC CHDR
Ivan J Perry
IPH-IRL
Kevin Balanda
Country liaison
Irish Team Co-Leader
Country liaison, Data collation
WP4 Team Leader
Irish Team Co-Leader
Italy ISS
Angela Spinelli
Laura Lauria
Country liaison, Data collation
Italian Team Co-Leader
Italian team Co-Leader
Portugal MS
Pedro Graça
Andrea Costa
Gisele Camara
Country liaison
Portuguese Team Co-Leader
Portuguese Team Co-Leader
Data collation
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 5
Romania
NIMCH
Michaela Iuliana Nanu, National
Institute for Mother and Child
Health, Bucharest
Ioana Nanu, National Institute for
Mother and Child Health,
Bucharest
Country liaison, Data collation
Romanian Team Co-Leader
Romanian Team Co-Leader
Slovenia
National Institute of Public Health
- NIJZ
Mojca Gabrijelcic Blenkus,
National Institute of Public Health
(NIJZ), Ljubljana
Aleš Korošec, National Institute of
Public Health (NIJZ), Ljubljana NIJZ
Country liaison, Data collation
Slovenian Team Co-Leader
Slovenian Team Co-Leader
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 6
ACKNOWLEDGEMENTS
International Scientific
Advisory Group
Associate Prof Jennifer Baker, Institute of Preventive Medicine in
Denmark and the University of Copenhagen. Denmark
Dr Margherita Caroli, Nutrition Unit, Department of Prevention,
Azienda Sanitaria Locale Brindisi. Italy
Dr Anne Dee, Health Service Executive. Republic of Ireland
Dr Tony Fitzgerald, Department of Statistics and & Department of
Epidemiology & Public Health. University College Cork. Republic of
Ireland
Prof David Madden, School Of Economics, University College Dublin.
Republic of Ireland
Dr Martin O’Flaherty, University of Liverpool. England
Dr Pepijn Vemer, Department of Pharmacoepidemiology &
Pharmacoeconomy, University of Groningen. Netherlands
Italy Dr. Roberto Da Cas, Dr. Giuseppe Traversa National Centre for Drug Research and Evaluation, Istituto Superiore di Sanità Dr. Luigi Palmieri, Dr. Chiara Donfrancesco, Dr. Simona Giampaoli Department of Cardiovascular, Dismetabolic and Ageing-associated diseases, Istituto Superiore di Sanità; Dr. Daniela Pierannunzio, Dr. Valentina Minardi, Dr. Gianluigi Ferrante, Dr. Benedetta Contoli, Dr. Maria Masocco, Mr. Massimiliano Caldora National Center for Disease Prevention and Health Promotion, Istituto Superiore di Sanita Dr. Claudio Cricelli, Dr. Francesco Lapi, Dr. Serena Pecchioli Italian College of General Practitioners and Primary Care
Greece e-GOVERNMENT CENTER FOR SOCIAL SECURITY SERVICES (IDIKA S.A.)
Mathioudakis Kostas, Department of Electronic Prescriptions
HELLENIC STATISTICAL AUTHORITY
Eleni Katsorhi, Department for Statistical Information Provision
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 7
CANCER REGISTRY OF CRETE (CRC)
Dimitra Sifaki-Pistolla, School of Medicine, University of Crete
MINISTRY OF HEALTH
Ioanna Kontele, Dpt. of Public Health
Irene Grimani, Dpt. of Health Data Processing and Analysis
Portugal We would like to thank:
Carla Lopes, The National Food, Nutrition and Physical Activity Survey (IAN AF), Faculdade de Medicina da Universidade do Porto
Carla Rêgo e Margarida Nazareth, EPACI study
Carlos Dias, The National Health Examination Survey 2013-2016 (INSEF), Instituto Nacional de Saúde Doutor Ricardo Jorge, I.P.
Joana Sousa, Escola Superior de Tecnologia da Saúde de Lisboa (ESTeSL)
Julian Perelman, Universidade Nova de Lisboa / Escola Nacional de Saúde Pública
Margarida Gaspar de Matos, HBSC Portugal study
Rita Horgan, trainee nutritionist at Directorate-General of Health
Vanessa Silva, Administração Central do Sistema de Saúde, I.P.
Pedro Barras, Administração Central do Sistema de Saúde, I.P.
Slovenia We would like to thank : National Institute of Public Health – NIJZ, Health Data Unit Blaženka Jeren, Miloš Kravanja, Mojca Simončič, PoldkaButinar, Metka Zaletel, Ana Zgaga, Irena Zupanc
National Institute of Public Health – NIJZ, Health Survey and Health Promotion Unit Sonja Paulin, Tatjana Kofol Bric National Institute of Public Health – NIJZ, Prevention and Promotion Programes Unit Rade Pribakovič Brinovec National Institute of Public Health – NIJZ, Health Care System Unit Sabina Sedlak, Nevenka Kelšin Faculty of Sport, University of Ljubljana, Gregor Starc, for providing SLOfit data
Collaborating Partners
Ursula O’Dwyer, Department of Health, Republic of Ireland
Cliodha Foly-Nolan, safefood, Republic of Ireland
EU Joint Research Centre (EU JRC)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 8
WHO Europe
CONVENTIONS AND DEFINITIONS
Adult 18 or more years
Adult Healthy Weight (HW) 18.5 ≤ BMI < 25.0
Adult obesity (OB)1 Defined by WHO cut-off point (30.0 ≤ BMI)
Adult Overweight (OW) 25.0 ≤ BMI < 30.0
Advanced study A more involved participation in WP4
Adult Underweight (UW) BMI < 18.52
Basic study A less involved participation in WP4
Body Mass Index (BMI)
Two BMI categories will be used throughout the life course:
Healthy weight (HW)
Obese/Overweight (OB/OW)
Bottom-up methods Methods used to estimate impact-related and cost-related model
inputs and outputs that are based on analysis of disease and
healthcare data in cross-sectional studies or longitudinal studies
that also include BMI data
Child 0-17 years
Childhood age categories for
reporting
Age categories for children that are used in the tables of model
outputs:
Younger children: 0 – 6 years
Older children: 7 -11 years
Adolescents: 12 – 17 years
Childhood obesity Based on an individual’s BMI at age 18 years as they exit childhood
(using IOTF cut-off points).
1 WHO defines three sub-categories of obesity: these are not considered in this study because of lack of data.
Obesity category I (OB-I): 30.0 ≤BMI < 35.0)
Obesity category II (OB-II): 35.0 ≤ BMI < 40.0)
Obesity category III (OB-III): 40.) ≤ BMI
2 Underweight individuals are included in the Healthy Weight (HW) category
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 9
Closed Cohort Simulation
Model (CCSM)
A simulation model that takes an initial cohort (representative of
the population at the time), ages them and simulates their
experiences throughout their lives. No additional entries into or
exits from the cohort (except by death of existing cohort members)
are allowed. A broad approach to burden of disease and cost of
illness studies; their primary interest is in the current and future
experiences of the initial cohort and not the whole population
living in any future year.
Current year 2015
Current value Cost expressed in 2016 euros
Direct healthcare costs Costs that result from outpatient and inpatient health services
(including surgery), laboratory and radiological tests, and drug
therapy.
Discounting
Discounting of future disease and disability and costs (because
people tend to devalue future disease and disability and costs
compared to present) is considered to be best practice.
Effect metric
Describes the effect of a reduction in mean childhood BMI
Excess metric
Describes an excess in some impact-cost indicator (e.g. direct
healthcare costs) that can be associated with current childhood
obesity/overweight.
Friction-cost approach An alternative approach for estimating value of productivity losses
(see Human-capital l approach)
Human-capital approach The approach used while estimating value of losses (see Friction-
Loss approach)
Impact-cost indicators Indicators that capture the impacts and costs that are incur as a
result of childhood obesity and overweight
Indirect healthcare costs Healthcare costs that are borne by the patient, their family and
community. They are not included in the JANPA costing model.
IOTF cut-off points
IOTF (now called World Obesity Federation) cut-off points used to
categorise childhood BMI. They apply to 2–17 year olds and map to
WHO’s adult BMI cut-off points
Lifetime BMI trajectory Lifetime trajectory of an individual’s annual BMI values throughout
their life
Life Expectancy at birth (LE) Measured in the year of birth
Obesity or overweight
(OW/OB)
A generic term used for a group of individuals who are either
overweight or obese (Jonoula et al)
Obesity-related impacts
Two types of consequences of childhood obesity and overweight
are considered:
Health impacts (diseases, disability and death)
Societal impacts (adult productivity losses and lifetime
income loss)
per case
Based on the number of cases of a disease and not the underlying
population size
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 10
Population Attributable
Fraction (PAF)
The proportion of an impact that would be avoided if a particular
risk factor was eliminated
Open Cohort Simulation
Model (OCSM)
A simulation model that takes an initial cohort (representative of
the population at the time), ages its members and simulates their
experiences throughout their lives. Additional entries (births and
immigration) and exits (emigration) are allowed to join as the
cohort ages so that the boosted cohort remains representative of
the whole population living in any future years. A broad approach
to burden of disease and cost of illness studies; the primary
interest here is in the current and future experiences of the whole
population in a particular year
Presenteeism Not covered in the JANPA costing model. It is reduced productivity
while attending work that is associated with obesity-related
disease or disability.
Private costs Costs incurred privately by patients, their families and
communities and not by the health and social care system
Relative Risk (RR) Also Odds Ratio (OR)
Sensitivity analysis
To represent the uncertainties inherent in data and modelling
assumptions
Societal costs These are the other resources that society and its citizens and
communities forego as a result of a health condition
Societal economic perspective
Includes impacts experienced and cost incurred by society and its
communities
Start-year First year of the simulation (2015)
Stochastic models Statistical models that operate probabilistically with random model
parameters having known distributions. For example:
The virtual children in the initial cohort are sampled from a
theoretical population that has a pre-specified population
distribution. At least asymptotically, the sample and the
population of interest have the same distribution
Transition probabilities and other model inputs are
random variables unknown and sampled from pre-
assigned distributions
Top-down methods Methods used to estimate impact-related and cost-related model
inputs and outputs that are based on the application of Population
Attributable Fractions (PAFs) to national disease and healthcare
data
Years of Life Lost (YLL) Years of life lost up to an individual’s national life expectancy in
their birth year
zBMI scores Because cut-off points for overweight and obesity vary with age,
gender-specific standardised z-score cut-off points will be used to
define BMI status at different ages.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 11
TABLE OF CONTENTS
ROLES .............................................................................................................................. 4
ACKNOWLEDGEMENTS .................................................................................................... 6
CONVENTIONS AND DEFINITIONS .................................................................................... 8
TABLE OF CONTENTS ....................................................................................................... 11
SUMMARY ...................................................................................................................... 14
MODELLING METHODOLOGY ................................................................................................. 14
DATA REQUIREMENTS ............................................................................................................ 15
IMPACTS AND COSTS IN THE REPUBLIC OF IRELAND AND NORTHERN IRELAND ........................ 15
RECOMMENDATIONS ...................................................................................................... 21
1. INTRODUCTION ........................................................................................................... 23
1.1 INTERNATIONAL CONTEXT ................................................................................................ 23
1.2 INTERNATIONAL EVIDENCE ............................................................................................ 24
1.3 JANPA WP4 ................................................................................................................... 26
1.3.1 Aims ........................................................................................................................................ 26
1.3.2 Modelling Principles ............................................................................................................... 26
1.3.3 “Basic” and “advanced” studies ............................................................................................. 27
1.3.4 Deliverables ............................................................................................................................ 27
1.4 OUTLINE OF THE DOCUMENT ............................................................................................ 28
2. MODELLING METHODOLOGY ....................................................................................... 29
2.1 CONCEPTUAL FRAMEWORK .............................................................................................. 29
2.2 CLOSED COHORT SIMULATION MODELS ............................................................................ 30
2.2.1 Simulation Milestones ............................................................................................................ 31
2.3 SOME DEFINTIONS AND CONVENTIONS ............................................................................ 32
2.3.1 Obese/overweight child .......................................................................................................... 32
2.3.2 Reductions in childhood obesity/overweight ......................................................................... 33
2.3.3 Working ages and benefits eligibility ...................................................................................... 33
2.4 EXCESS AND EFFECT METRICS ........................................................................................... 45
2.4.1 Impacts and costs indicators .................................................................................................. 45
2.4.2 Excess metrics ......................................................................................................................... 47
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 12
2.4.3. Effect metrics ......................................................................................................................... 47
2.5 OBESITY-RELATED DISEASES ............................................................................................. 48
2.5.1 Global Disease List from the Evidence Reviews...................................................................... 48
2.5.2 Data requirements to be included in a country’s costing model ........................................... 50
2.6 SOFTWARE IMPLEMENTATION ......................................................................................... 50
2.6.1 Existing UKHF software ........................................................................................................... 50
2.6.2 Modification of existing UKHF software ................................................................................. 51
2.7 SOME STATISTICAL AND COSTING ISSUES .......................................................................... 53
2.7.1 Uncertainty intervals .............................................................................................................. 53
2.7.2 Other statistical issues ............................................................................................................ 54
2.7.3 Discounting future costs ......................................................................................................... 54
2.7.4 Approach to estimating productivity losses ........................................................................... 55
2.7.5 Valuing post-retirement productivity ..................................................................................... 55
2.7.6 Other costing issues ................................................................................................................ 55
3. WORKFLOW ................................................................................................................ 56
3.1 PHASE 1: DATA COLLATION .............................................................................................. 57
3.1.1 Identifying data sources .......................................................................................................... 57
3.1.2 Calculating per case treatment costs...................................................................................... 58
3.1.3 Data handling issues ............................................................................................................... 59
3.2 PHASE 2: PRE-SIMULATION DATA PROCESSING ................................................................. 59
3.2.1 Modelling lifetime BMI trajectories ........................................................................................ 60
3.2.2 Estimating disease parameters ............................................................................................... 60
3.3 PHASE 3: DISEASE MODELLING.......................................................................................... 60
3.3.1 Details of the simulations ....................................................................................................... 60
3.3.2 Simulating disease processes ................................................................................................. 61
3.4 PHASE 4: COST ESTIMATION ............................................................................................. 63
3.4.1 Model Outputs ........................................................................................................................ 64
3.5 PHASE 5: POST-SIMULATION REVIEW ............................................................................... 65
3.6 PHASE 6: REPORTING ........................................................................................................ 65
3.6.1 Data documentation ............................................................................................................... 66
3.7 JANPA COSTING MODEL TOOLBOX .................................................................................... 66
4. DATA REQUIREMENTS ................................................................................................. 68
4.1 DATA DOMAINS .............................................................................................................. 68
5. LIFETIME IMPACTS & COSTS OF CHILDHOOD OBESITY IN REPUBLIC OF IRELAND .......... 71
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 13
5.1 LOCAL CONTEXT ............................................................................................................... 71
5.2 LOCAL EVIDENCE .............................................................................................................. 74
5.2.1 Childhood Obesity / Overweight ........................................................................................... 74
5.2.2 Childhood and adulthood Impacts ......................................................................................... 75
5.2.3 Inequalities ............................................................................................................................. 75
5.3 COHORT DETAILS .............................................................................................................. 76
5.3.1 Profile of Irish Children ........................................................................................................... 76
5.3.2 Details of follow-up ................................................................................................................. 77
5.4 LIFETIME IMPACTS & COSTS IN REPUBLIC OF IRELAND ...................................................... 78
5.4.1 Adult Obesity / Overweight .................................................................................................... 78
5.4 .2. Morbidity .............................................................................................................................. 79
5.4.3 Mortality ................................................................................................................................. 83
5.4.4 Republic of Ireland summary .................................................................................................. 89
IRISH AND NORTHERN IRISH REFERENCES ............................................................................... 90
6. LIFETIME IMPACTS AND COSTS OF CHILDHOOD OBESITY IN NORTHERN IRELAND (NIR)93
6.1 COHORT DETAILS .............................................................................................................. 93
6.1.1 Profile of Northern Irish children ............................................................................................ 93
6.1.2 Details of follow-up ................................................................................................................. 94
6.2 LIFETIME IMPACTS & COSTS IN NORTHERN IRELAND ......................................................... 95
6.2.1. Adult Obesity / Overweight ................................................................................................... 95
6.2.2. Morbidity ............................................................................................................................... 96
6.2.3 Mortality ............................................................................................................................... 100
6.2.4 Northern Ireland summary ................................................................................................... 105
6.2.5 Comparison between the Republic of Ireland and Northern Ireland ................................... 106
7. LIMITATIONS AND RECOMMENDATIONS ................................................................ 109
7.1 LIMITATIONS ...................................................................................................................109
7.2 RECOMMENDATIONS ......................................................................................................112
7.2.1 Modelling Methodology ....................................................................................................... 112
7.2.2 Data and Research Gaps ....................................................................................................... 112
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 14
SUMMARY
JANPA WP4 was a very ambitious project. It is the first lifetime costing study of childhood
obesity/overweight that developed and applied standard modelling methodology in more than one
country (eight European countries).
The modelling methodology for the JANPA costing model is applicable to other childhood risk factors,
like childhood obesity/overweight, that have significant short term and long term consequences that
are, in part, mediated through a similar adult risk factor, like adult obesity/overweight.
In this document we outline the modelling methodology; describe the data and research
requirements; and present the final results for the Republic of Ireland (IRL) and Northern Ireland (NIR).
MODELLING METHODOLOGY
The evidence reviews on childhood obesity/overweight that were published in the Deliverable D4.1
“Evidence Paper and Study Protocols” were used to develop the JANPA (childhood obesity) costing
model that can be used to estimate the lifetime impacts and costs attributable to childhood
obesity/overweight as well as the effects of 1% and 5% reductions in mean childhood Body Mass Index
(BMI) in participating countries.
Multiple logistic regression was used to forecast BMI distributions and generate lifetime BMI
trajectories. These were incorporated into Semi-Markov processes that were used to model
independent disease processes. The project proceeded in six inter-connected phases: Data Collation,
Pre-modelling Data Processing, Simulation Modelling, Cost Estimation, Post-Modelling Review and
Reporting that were undertaken by WP4 Lead Team, participating countries and UK Health Forum
(UKHF) (sub-contractor to IPH-IRL).
Eight countries (Croatia, Greece, Republic of Ireland, Italy, Northern Ireland, Portugal, Romania and
Slovenia) participated in either “advanced” or “basic” studies. Advanced studies included societal costs
(lifetime income loss (the “income penalty”) and productivity losses due to premature death and
absenteeism) as well as direct healthcare costs, whereas basic studies included only direct healthcare
costs.
Materials relating to the Data Collation, Pre-modelling Data Processing, Simulation, Modelling, Cost
Estimation, Post-Modelling Review and Reporting phases that can be used by other countries wanting
to deploy the JANPA costing model will be available in the Modelling ToolBox on the JANPA website
(www.janpa.eu) in early 2018.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 15
DATA REQUIREMENTS
Data was required across six domains: Population, BMI, Disease (prevalence, incidence, survival,
mortality), Direct Healthcare Costs (hospital, primary care, pharmaceuticals), Income, Work absences.
All data are required to be broken down by sex, age and disease (where relevant).
Except for Portugal, complete country data files are described in Deliverable D4.7.
IMPACTS AND COSTS IN THE REPUBLIC OF IRELAND AND NORTHERN IRELAND
The problem
The JANPA costing model quantified the large burden of childhood obesity/overweight:
The total lifetime financial costs (in 2015 values) are €4,518m (€16,036 per person) in Republic
of Ireland and €2,533.7m (€22,647 per person) in Northern Ireland. In Republic of Ireland this
accounts for 1.6% of GDP.
In Republic of Ireland, it is estimated that just over 55,000 of today’s children will die
prematurely as a result of childhood obesity/overweight (around 1 in 10 of all premature
deaths). In Northern Ireland it is 30,513 premature deaths.
Costs in the report are discounted to 2015 values using an annual discount rate of 5% (for most
countries). The “per person lifetime cost of childhood obesity” in the Republic of Republic of
Ireland is estimated to be €16,036 in 2015 values. These costs are incurred over each individual’s
lifetime. To cover those costs for one obese/overweight child; in 2015 you would have to lodge
€16,036 into a bank account that earns 5% per annum compound interest, and leave it in that
account for the lifetime of the child. If you only made withdrawals to cover costs when they occur;
at the end of their lifetime the account would be empty and the lifetime costs would have been
paid.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 16
Table A: Lifetime impacts and costs attributable to childhood obesity/overweight (2015 values)
SEX
DIRECT
HEALTH
CARE
COSTS
(€m)
LIFETIME
INCOME
LOSS
(€m)
PRODUCTIVITY
LOSS
(PREMATURE
MORTALITY)
(€m)
PRODUCTIVI
TY LOSS
(ABSENTEEIS
M
(€m)
TOTAL
COST
(€m)
COST PER
PERSON
COST
(€)
TOTAL
NUMBER OF
PREMATURE
DEATHS
REPUBLIC OF IRELAND
MALES €422.0m €151.7m €2,105.3m €223.5m €2,902.4m € 21,115 26,202
FEMALES €527.0m €104.3m €756.4m €299.6m €1,687.3m € 11,694 28,854
PERSONS €944.7m €256.1m €2,795.4m €521.9m €4,518.1m € 16,036 55,056
NORTHERN IRELAND
MALES €334.8m €69.8m €1,248.7m €59.2m €1,712.6m € 33,487 15,279
FEMALES €337.0m €46.4m €415.1m €68.4m €867.0m € 14,275
15,234
PERSONS €679.6m €116.3m €1,607.3m €130.6m €2,533.7m € 22,647
30,513
Total lifetime direct healthcare costs account for 4.8% of total public health expenditure in Republic of
Ireland.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 17
Childhood obesity/overweight affects citizens, the health and social care systems and (most
significantly) the economics of EU member states.
Towards a solution
The JANPA costing model confirmed that substantial savings could be achieved if mean childhood BMI
was reduced by 1% and 5%. With a 5% reduction, total lifetime savings were estimated to be over a
billion euros in Republic of Ireland and almost early €400m in Northern Ireland.
Lifetime healthcare costs were expected to fall by €245.7m in Republic of Ireland and €100.1m in
Northern Ireland. The savings resulting from a 5% reduction in mean childhood BMI mean were
approximately 4 – 5 times those for 1% reductions.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 18
Table B: Reductions in lifetime impacts and costs associated with 1% and 5% reductions in
population mean childhood BMI (2015 values)
REPUBLIC OF IRELAND
SEX
PERCENT
REDUCTION
IN MEAN
CHILDHOOD
BMI
DIRECT
HEALTH
CARE
(€m)
LIFETIME
INCOME
LOSS
(€m)
PRODUCTIVITY
LOSS
(PREMATURE
MORTALITY)
(€m)
PRODUCTIVIT
Y LOSS
(ABSENTEEIS
M)
(€m)
TOTAL COST
REDUCTION
(€m)
TOTAL COST
REDUCTION
PER PERSON
(€)
TOTAL
REDUCTION
IN NUMBER
OF
PREMATURE
DEATHS
MALES
1% €26.4m €8.6m €125.5m €16.1m €176.5m €1,284 1,272
5% €123.7m €38.8m €516.7m €70.4m €749.5m €5,453 5,948
FEMALES
1% €27.5m €5.0m €43.5m €17.4m €93.5m €648 683
5% €122.0m €22.7m €154.3m €78.6m €377.6m €2,617 3,321
PERSONS
1% €53.9m €13.5m €169.0m €33.5m €270.0m €958 1,955
5% €245.7m €61.4m €671.0m €149.0m €1,127.1m €4,000 9,269
NORTHERN IRELAND
MALES
1% €11.2m €2.6m €52.7m €2.1m €68.6m €1,341 269
5% €51.7m €12.7m €199.8m €10.4m €274.6m €5,369 1,267
FEMALES
1% €11.0m €1.5m €12.6m €2.2m €27.2m €448 295
5% €48.4m €7.4m €56.1m €10.3m €122.2m €2,012 1,252
PERSONS
1% €22.2m €4.0m €65.2m €4.4m €95.8m €856 563
5% €100.1m €20.1m €255.9m €20.7m €396.8m €3,546 2,519
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 20
As we have already noted, there are similarities in the broad features of the excess burden of
childhood obesity/overweight in the Republic of Ireland and Northern Ireland:
Lifetime total societal costs accounted for the majority of the total lifetime costs; accounting
for 79.1% of the total costs in Republic of Ireland and 73.2% in Northern Ireland.
Lifetime productivity losses due to premature mortality were the greatest single cost item
accounting for 61.9% and 63.4%, respectively, of total lifetime costs in Republic of Ireland
and Northern Ireland.
The total lifetime cost (and per person costs) attributed to childhood obesity/overweight is
much higher for males than it is for females.
Males incur higher total lifetime income losses and productivity losses due to premature
mortality while females incur higher lifetime healthcare costs and productivity losses due to
absenteeism.
These differences may be explained in part by higher risk of premature mortality and higher average
incomes amongst males and the greater tendency to seek care and respond to care amongst
females.
Table 6(o): Percentage of total morbidity-related and mortality-related burden attributable to
childhood obesity / overweight (PAFs)
PAFs
IRL NIR
M F P M F P
Direct Healthcare Cost 11.6% 15.9% 13.6% 15.0% 14.5% 14.9%
Productivity Losses (Absenteeism)
29.8% 29.0% 24.8% 15.6% 15.3% 15.8%
Premature Deaths 9.3% 11.2% 20.8% 19.9%
Productivity Losses (Premature Death)
20.0% 17.0% 18.9% 31.3% 25.9% 28.8%
However; the comparison of the Republic of Ireland and Northern Ireland also revealed that the
excess burden of childhood obesity/overweight is experienced differently by males and females in
the two countries:
In the Republic of Ireland, childhood obesity/overweight accounted for relatively more of
the morbidity-related burden amongst males than amongst females. In Northern Ireland, no
such gender difference was observed.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 21
In the Republic of Ireland, but not Northern Ireland, childhood obesity / overweight
accounted for relatively more premature mortality amongst females than males.
In both the Republic of Ireland and Northern Ireland, however, childhood
obesity/overweight accounted for relatively more of the productivity losses due to
premature death amongst males than amongst females
Moreover; the comparison of the Republic of Ireland and Northern Ireland also emphasised the
importance of local context:
Direct health care costs are relatively higher in Northern Ireland
Indirect (societal) costs are relatively higher in the Republic of Ireland
These differences may be explained in part by the fact that Northern Ireland operates a universal
health care system (NHS in the UK) while a two-tiered public – private health care system operates
in the Republic of Ireland.
Discussion
Given the large human impact and the financial cost of today’s childhood obesity/overweight, the
need for urgent action is clear. Specific recommendations are:
• Obesity strategies and action plans in the Republic of Ireland and Northern Ireland should be
implemented, supported with adequate resources,
• A population and life-course approach is necessary with a strong emphasis on the
obesogenic environment balanced with supports for parents and carers.
• There should be increased investment in data collection to provide accurate and reliable
data for cost-of-illness studies and related health economic analysis. Data collected must
include utilisation of health services and illness-related productivity loss and absenteeism
from school.
• Research into the psychosocial impacts of overweight and obesity on the island is warranted
given the information gap identified.
RECOMMENDATIONS
The following recommendations relate to the modelling methodology; data and research gaps.
Recommendations about future project development are included in Deliverable D4.7
MODELLING METHODOLOGY
We recommend that:
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 22
An independent scientific review of the JANPA costing model and how it was developed
should be undertaken
The detailed suggestions for enhancements of the modelling methodology that are outlined
in Chapter 7 should be incorporated into the future development of the model.
Stand-alone dedicated software, provided as open source code, to fully implement the
JANPA costing model should be developed and available to other researchers for
independent scrutiny and audit
Detailed sensitivity audit and validation of the JANPA costing model should be undertaken
once the open source code is available. This should include calculation of uncertainty
intervals and the validity of critical assumptions and inputs
DATA AND RESEARCH GAPS
The validity and reliability of final results depend on the data inputs. The availability and quality of
data across the countries varied greatly. We recommend that work continues to improve the co-
ordination, and quality of the national and pan-European health information systems, particularly:
Obesity surveillance (particularly early years, later years and adolescence)
Surveillance of obesity-related diseases (particularly incidence and survival)
Healthcare costs (particularly primary care and pharmaceutical)
Analytical methods for using data
The biggest gap in the impacts and costs included in the JANPA costing model relates to the
psychosocial consequences of childhood obesity and the inability to undertake a sensitivity analysis
of the model. We recommend that the JANPA costing model be refined by incorporating research
into the psychosocial impacts of childhood obesity and their implications for human capital and the
economy (effects on school attendance, educational performance and subsequent employability,
position in the labour market and productivity).
In addition we recommend that:
A comprehensive review of multi-morbidities and their effects on the JANPA costing
model’s excess and effect metrics should be undertaken and a work programme to
incorporate its finding into the model should be developed
Support continues for longitudinal studies with long term follow-up
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 23
1. INTRODUCTION
This chapter contains a brief overview of the international context and international
evidence of childhood obesity and overweight. This is supplemented by local materials
from each participating country described in Deliverable D4.1 “Evidence Paper and Study
Protocols” and the local context and local evidence in each participating country in
Deliverable D4.7 “The Lifetime Impacts And Costs Of Childhood Obesity/Overweight In
Europe. Part 2” .
1.1 INTERNATIONAL CONTEXT
The primary international bodies working to address the global obesity epidemic are the WHO and
the European Commission. There is some policy collaboration between these agencies and a
recognition of the complexity of the solution required to intervene in any affective way. Their
policies recognize the contributing roles of social and environmental factors, such as; community
norms shaped by a market-driven economy, marketing campaigns promoting high-calorie low-
nutrition foods, sedentary behaviour, passive leisure activities, and lack of physical activity.
The WHO classifies obesity as a non-communicable disease (NCD), alongside cardiovascular disease,
cancer, chronic obstructive pulmonary diseases, and diabetes with primary efforts aimed at reducing
exposure to risk factors and strengthening health care. Between 2010 and 2012, WHO investigated
the underlying social causes of obesity and other NCD and their common risk factors in the EU’s 53
Member States in order to develop an implementation plan for the European Strategy for the
Prevention and Control of Noncommunicable Diseases 2012−2016 (WHO, 2012). This strategy is
WHO’s primary plan for addressing obesity and other NCD in Europe and includes: the WHO
European Food and Nutrition Action Plan 2015-2020 that encourages action in a range of policy
areas through a whole-of-government, health-in-all-policies approach to improve food system
governance and overall quality of the population’s diet and nutrition to ultimately promote health
and well-being; and the Global Strategy on Diet, Physical Activity and Health that addresses physical
activity and diet, while complementing ongoing work on other nutrition-related risk factors for
noncommunicable diseases, including undernutrition, micronutrient deficiencies and infant- and
young-child feeding. WHO has developed similar Action Plans for its non-EU members, the Global
Action Plan for the Prevention and Control of NCDs 2013-2020.
The European Commission advocates an integrated approach, involving stakeholders at local,
regional, national, and European levels. This has been the approach since 2007 when the
Commission established a Community Strategy based upon the Strategy on Nutrition, Overweight,
and Obesity-related Health Issues white paper (Commission of the European Communities, 2007).
The strategy encompassed a range of Commission policies to facilitate improved nutrition and
prevent overweight and obesity in policy areas, including: health and food safety, agriculture,
information society, education and culture, research, transport, and regional policy. These actions
were advanced by the Commission’s governmental representatives on the issue with the 2014
adoption of the EU Action Plan on Childhood Obesity 2014-2020 aimed at stopping the rise of
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 24
childhood obesity by 2020 (European Commission, 2014), and by the European Council’s Joint Action
policy designed to promote actions contributing to the implementation of the EU Action Plan on
Childhood Obesity (European Council, 2014), for example, the Joint Action on Nutrition and Physical
Activity (2015) that involves 25 Member States. In addition to setting policy, the EC provides funding
for projects that implement the EU health strategy, develops funding opportunities, organises
conferences, and identifies best practices. All the EC actions form the EC platform that was designed
to serve as an example of coordinated action by different parts of society to encourage national,
regional, and local initiatives across Europe.
1.2 INTERNATIONAL EVIDENCE
It is estimated that nearly 30% of the world population is overweight (Ng et al., 2014), resulting in a
burdensome public health issue that may prove to be among the most challenging for any nation to
address. Over the past three decades, the prevalence of overweight and obesity has increased
markedly worldwide and is described by the World Health Organization as a “global epidemic”
(WHO, 2017). Globally, adult obesity prevalence forecasts (2010–2030) that 32% of men and 30% of
women will be obese by 2020. By 2030, the model predicts that 44% of men and 40% of women will
be obese (WHO, 2013). The recent international prevalence of overweight and obesity in
adolescents is 41% of boys and 24% of girls aged 11 years (Currie et al., 2012) with European
childhood prevalence rates at 38.1% for boys and 39.9% for girls aged 7 years and at 45.1% for boys
and 42.3% for girls aged 9 years (Wijnhoven et al., 2014).
Overall, prevalence of childhood excess weight is a growing problem in most European countries and
the countries that is the focus of this investigation. In the Republic of Ireland, it is currently
estimated that 60% of adults and 25% of children are overweight or obese. Among children in
Northern Ireland aged 4-13, the prevalence of overweight and obesity is estimated at 22% for boys
and 27% for girls. Collectively, the findings of our updated review indicate that the prevalence of
childhood overweight and obesity is plateauing in the Republic of Ireland, and may be decreasing in
primary school-aged children, with the greatest reduction in prevalence observed among 5-year-
olds. Among children in Greece aged 1-12, it was estimated that 10.2% were obese, 23.7% were
overweight, and the combined prevalence of overweight and obesity was approximately 34%
(Kotanidou et al., 2013). Trends in the prevalence of child overweight and obesity in Greece show
rapid increases in both children and adolescents during the 1990s and early 2000s, followed by a
slowing down of increases in prevalence with some evidence of stabilisation in young children but
not in adolescents since around 2004. A Romanian survey reported that 20% of children aged 6-7
years were overweight or obese and that 18% of children aged 13-14 were overweight or obese
(Ardeleanu et al., 2015). Romanian trend investigations have reported a slight increase in the
prevalence of increased weight for height in children 0-24 months old in 2010 compared with 2004
(Nanu, Stativa, Moldovanu, Stoicescu, et al., 2011). In contrast to other JANPA participants, this
research has also highlighted the relatively high prevalence of underweight children, noting
relatively stable trends in underweight over time. A 2014 Slovenian study found 26.4% of boys and
22.2% of girls aged 7 to 18 were classified as overweight or obese, with trends suggesting that rates
of overweight and obesity have remained quite stable in recent years with some evidence of a
decline in overweight and obesity since around 2010.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 25
Childhood obesity is strongly linked to mortality and morbidity in adulthood. Since obesity often
begins in childhood, many obese children grow up to become obese adults. Childhood obesity has
been linked to a number of serious health conditions in adulthood, including: asthma, hypertension,
type 2 diabetes, sleep apnoea, non-alcoholic fatty liver disease, cancer, and depressive disorders. A
review by Park, Falconer, Viner, et al. (2012) reported that the risk of all-cause mortality in
adulthood increased by 40-60% in people who had a high BMI between the ages of 2 and 19. Our
review of relevant research suggests childhood obesity is a strong predictor of adult obesity with
obese children in the 7-11 age group and the 12-18 age group, 5 times more likely than their non-
obese counterparts to be obese adults. Prospective research suggests that approximately 55% of
obese children will remain obese into adolescence and approximately 80% of obese adolescents will
remain obese into adulthood. Seventy per cent of obese adolescents will remain obese over the age
of 30 (Datar, Sturm, & Magnabosco, 2004; Canning & Mayer, 1967). However, when obese children
become normal weight by adulthood, the risks of developing many outcomes are similar to the risks
for children who were never obese. It should also be noted that the majority of cases of obesity-
related disease in adult life arise in individuals who were of healthy weight during childhood, which
is the majority of children and not the smaller group who were overweight or obese in childhood.
The lifetime costs of childhood overweight and obesity are high. Cost-of-illness studies have
repeatedly shown that obesity during adulthood causes substantial direct and indirect costs (Tsai,
Williamson, & Glick, 2011). A review of the global literature since 2000 estimated an average lifetime
cost (direct healthcare cost and indirect productivity loss) of €54,663 (range, €45,014 to €74,244)
for males and €36,053 (range, €24,433 to €61,700) for females (Safefood, 2017). Medical costs alone
have been estimated at over €16,000 for an obese child who becomes an obese adult and at
€11,000 for a healthy weight child who becomes overweight or obese in adulthood (Finkelstein,
Graham, & Malhotra, 2014). It remains a challenge to understand the risk factors predisposing a
child to become overweight or obese and further challenging to evaluate the increased risk of
mortality and obesity-related diseases associated with childhood obesity.
Due to the challenges of research on this topic, data quality, reliability, and generalizability has been
lacking. The quality of the available evidence on obesity related co-morbidity in childhood is poor
due to inconsistencies across studies in the definitions and thresholds for overweight and obesity,
and the preponderance of cross-sectional studies which limit assessment of temporal relations, for
example, whether obesity is a cause or consequence of asthma. A challenge to the call for
prospective studies is the length of time between a child’s diagnosis as overweight or obese and the
appearance of co-morbidities, with some conditions not diagnosed until later adulthood. Also
challenging is the age at which a child becomes overweight or obese and when the condition begins
to influence the child’s future. Complications with investigation and unreliable evidence have been
noted by others (Department of Health, 2005).
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 26
1.3 JANPA WP4
An expert International Scientific Advisory Group (ISAG) guided the scientific aspects of JANPA WP4.
The ISAG:
Gave scientific advice to WP4 Lead Team.
Reviewed background materials and draft reports
Attended face-to-face meetings
1.3.1 Aims
Effective and sustainable political decision-making is an essential prerequisite for the
implementation of actions to achieve the objective. Estimating short- and long-term health and
social costs and determining the avoidable costs are essential to the prioritisation process for
governmental decisions. Apart from long term longitudinal studies, simulation modelling is the best
way to comprehensively estimating the lifetime impacts and costs of childhood obesity/overweight.
The modelling objectives of JANPA WP4 were to:
1. Estimate the lifetime impacts and costs of childhood obesity/overweight in eight European
countries
2. Describe how these impacts and costs are expected to occur over time.
3. Assess the effect of reducing the mean population childhood BMI by 1% and 5%.
The incorporation of inequalities into costing studies of obesity was taken up in the EU
commissioned “Health Equity Pilot Project” (HEPP) .
Four evidence reviews of the international literature on the prevalence, childhood and adult
consequences, and lifetime costs of childhood obesity/overweight were conducted by the Irish Team
with additional funding from safefood (www.safefood.eu). These were supplemented by local
research and data collected in a survey of partners from the participating countries (Croatia, Greece,
Republic of Ireland, Italy, Northern Ireland, Portugal, Romania and Slovenia) and summarised in
Deliverable D4.1 ”Evidence Paper and Study Protocols” (www.janpa.eu).
These evidence reviews guided the development of the JANPA costing model.
1.3.2 Modelling Principles
The following Principles guided the direction and conduct of JANPA WP4:
Relevance to each country and EU
A societal economic perspective that includes societal (non-health) impacts and costs as well
as direct healthcare costs
Transparency for interpretability and generalisability
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 27
Making best use of available research and data
Identifying gaps and stimulating further research
Building capacity – data, research and modelling
1.3.3 “Basic” and “advanced” studies
Participating countries could choose to participate in JANPA WP4 in one of two types of costing
studies: “basic” and “advanced”. Differences between basic and advanced studies are described in
the table below:
Table 1(a): Summary of basic and advanced studies.
BASIC STUDIES ADVANCED STUDIES
Direct healthcare costs only Also include societal impacts and costs
Major clinical conditions only Wider range of clinical conditions
Focus on core pan-European data Also include country-specific data
Focus on “Top down” approaches
using international inputs (and
possibly) local inputs
Focus on “Bottom up” approaches
using local inputs
Basic studies were conducted in Croatia, Italy and Portugal. Advanced studies were conducted in
Greece, Republic of Ireland, Northern Ireland, Romania and Slovenia.
1.3.4 Deliverables
This report, Deliverable D4.6 “The Lifetime Impacts and Costs Of Childhood Obesity Overweight In
Europe. Part 1”, describes
Modelling methodology
Data and research requirements
Final results for Republic of Ireland and Northern Ireland
Deliverable D4.7 “The Lifetime Impacts And Costs Of Childhood Obesity Overweight In
Europe. Part 2” describes
Collated Data
Challenges and lessons
Future projects
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 28
1.4 OUTLINE OF THE DOCUMENT
Following an overview of the international context for JANPA WP4 regarding childhood
obesity/overweight in Chapter 1;
The modelling methodology for the JANPA (childhood obesity/.overweight) costing model is
given in Chapter 2
The workflow followed during the work package is described in Chapter 3.
Chapter 4 specifies the data and research required to deploy the JANPA costing model in a
country.
Chapter 5 and Chapter 6 present the final modelling results for the Republic of Ireland and
Northern Ireland.
Chapter 7 which reflects on the limitations of the modelling methodology and
recommendations regarding improvements of the methodology.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 29
2. MODELLING METHODOLOGY
The evidence reviews in Deliverable D4.1 were used to develop the JANPA (childhood obesity)
costing model that estimates the lifetime impacts and costs (direct healthcare costs and societal
costs) attributable to childhood obesity/overweight as well as the effects of 1% and 5% reductions in
mean childhood BMI in each participating country.
2.1 CONCEPTUAL FRAMEWORK
The conceptual framework for the JANPA costing model extends that used by Fernandes (2010) to
model the direct healthcare costs by incorporating three societal costs:
Lifetime income loss (also called the “income penalty”) experienced by all individuals who
were obese/overweight as children
Productivity losses due to premature death
Productivity losses due to absenteeism
Figure 2 (a): Conceptual Framework (adapted from Fernandes (2010))
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 30
The Janpa WP4 evidence reviews summarised in Deliverable D4.1 confirmed Fernandes (2010)
description of the evidence-base given in the figure above.
The modelling methodology for the JANPA costing model is applicable to other childhood risk
factors, like childhood obesity/overweight, that have significant short term and long term
consequences that are, in part, mediated through a similar adult risk factor, like adult
obesity/overweight.
2.2 CLOSED COHORT SIMULATION MODELS
At the core of operationalising the conceptual framework are microsimulations.
Figure 2 (b): Cohort simulations underpinning the JANPA costing model
In such cohort simulations, an initial cohort of virtual children representative of the childhood
population living in a country in 2015 is created; their lifetime BMI trajectories are modelled using
historical BMI data; they are allowed to age and the morbidity and mortality, (direct) healthcare
costs and societal costs they experience over their lifetimes as a result of their modelled BMI
trajectories are recorded.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 31
These cohort simulations can be used to describe either:
1. The experiences of a population alive in some future year (we call such models “Open
Cohort Simulation Models (OCSM)”); or
2. The lifetime experiences of a particular population as they age (we call such models “Closed
Cohort Simulation Models (CCSM)”).
The cohort simulations underpinning these purposes are implemented differently;
• They are conducted differently: OCSMs allow into the cohort new entries (through births
and immigration) and additional exits (through emigration) in order to ensure that, in any
future year, the surviving cohort members are representative of the population living in that
year. The surviving members of a cohort in a CCSM, on the other hand, become less
representative of the resident population from which they were originally drawn.
They require different data: OCSMs, for example, require forecasts of population, disease
occurrence and mortality to ensure that the experiences of the cohort in any future year
matches the experiences of the resident population in those years. These data are not
required for CCSMs.
• Are reported differently: For example, in a CCSM the focus is on the cohort’s experiences
accumulated up to a future calendar year of interest while the focus of an OCSM will be their
experience in that calendar year. Thus the base population used as the denominator for
risks, etc. in a CCSM is the original population while for an OCSM it is the resident population
future calendar year of interest.
Many of us would be familiar with Open Cohort Simulation Models designed to provide population-
level obesity forecasts or the burden of obesity-related disease in a population in some future year.
The JANPA costing model looks at the lifetime experiences of a closed cohort of children as they age
and is a Closed Cohort Simulation Model.
2.2.1 Simulation Milestones
Table 2: Simulation milestones
0-5 year olds 6-11 year olds 12-17 year olds
Reach adulthood At start of: 2028 (5 yo) – 2033 (0 yo)
At start of: 2022 (11 yo) – 2027 (6 yo)
At start of : 2016 (17 yo) – 2021 (12 yo)
First year no children left in cohort
2033
Period 1: all children
2015
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 32
Period 2: children plus adults
2016 - 2032
Period 3: all adults 2033 - 2105
Life expectancies at birth (females)
2010 (5 yo) - 2015 (0 yo) 82.6 - 83.6
2004 (11 yo) - 2009 (6 yo) 81.0 - 82.3
1998 (17 yo) – 2003 (12 yo) 79.1 - 80.6
Life expectancies at birth (males)
2010 (5 yo) - 2015 (0 yo) 78.1 - 79.6
2004 (11 yo) - 2009 (6 yo) 76.0 - 77.8
1998 (17 yo) – 2003 (12 yo) 73.7 - 75.5
Last year all deaths are premature deaths
2078 (females) 2072 (males)
First year all deaths are mature deaths
2099 (females) 2095 (males)
Period 1: all premature deaths
2015-2078 (females) 2015-2072 (males)
Period 2: mix of premature and mature deaths
2079-2098 (females) 2073 – 2095 (males)
Period 3: all mature deaths
2099-2105 (females) 2095-2105 (males)
In the adapted UKHF model, individuals die automatically when they turn 110 years
2120 - 2125 2114 - 2119 2108 - 2113
Period 1: all natural deaths
2015 – 2106 (useable data)
2015 - 2119 2015 - 2113 2015 - 2107
Period 2: mix of natural and unnatural deaths
2107 - 2124 2120 - 2124 2114 - 2118 2108 - 2112
Period 3: all unnatural deaths
2125 2125 (0 yo turn 110)
2119 (6 yo turn 110)
2113 (12 yo turn 110)
2.3 SOME DEFINTIONS AND CONVENTIONS
2.3.1 Obese/overweight child
For the JANPA costing model, a child is an individual aged 0 – 17 years.
Because of the lack of the required details in available data and research, we combine “obese” and “overweight” and use the term “obese/overweight” to refer to BMI ≥ 25.0 according to IOTF definition.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 33
.
To address JANPA WP4’s modelling objectives, we first classify individuals as either
“obese/overweight as a child” or “healthy weight as a child”. There are many ways of doing this.
Because of the greater association with later life adult health consequences, an individual’s
modelled BMI on their 18th birthday is used to classify them as having been either an
“obese/overweight child” or a “healthy weight child”. During their childhood years, their
classification is updated if they die in childhood or develop a childhood obesity-related disease. In
the first calendar year in which either of these occurs, their classification was revised using their
modelled BMI in that calendar year. Thereafter, their classification does not change.
2.3.2 Reductions in childhood obesity/overweight
The second part of JANPA WP4’s objectives concerns the effect of reductions in mean childhood
BMI in a participating country. We consider two scenarios:
A one percent reduction in mean childhood BMI in which the means of the sex-age specific
childhood BMI distributions in 2015 (taken from the current BMI distributions in the
country) are reduced by 1% before the initial virtual children are selected.
A 5% percent reduction in mean childhood BMI in which the means of the sex-age specific
childhood BMI distributions in 2015 (taken from the current BMI distributions in the
country) are reduced by 5% before the initial virtual children are selected
In each scenario, the standard deviations are not changed.
2.3.3 Working ages and benefits eligibility
CROATIA
Minimum age for admission to employent
15 http://r2e.gn.apc.org/country-node/327/country-minimum
VI. Old-age Conditions Legal retirement age Standard pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABA
The pensionable age is currently: Men: 65 years Women: 61 years and 6 months Men and women long-insured persons with 41 years of insurance or more: 60 years. The pensionable age for women is being gradually increased by 3
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 34
SE/comparativeTableSearch.jsp
months per calendar year from 1 November 2010 onwards, to reach 65 in 2030. The pensionable age for both women and men will be gradually increased by 3 months per calendar year from 2031 onwards, to reach 67 in 2038.
VI. Old-age Conditions Legal retirement age Early pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Men: age of 60 years and qualifying period of 35 years. Women: age of 56 years and 6 months, and qualifying period of 31 years and 6 months. Age and qualifying period for women are being gradually increased by 3 months per calendar year from 1 November 2010 onwards, to reach 60 and 35 in 2030 respectively. The age limit for early pension (women and men) will be gradually increased by 3 months per calendar year from 2031 onwards, to reach 62 in 2038. The same conditions apply to persons unemployed for at least 2 years before fulfilling the early pension requirements due to enterprise bankruptcy.
Any laws which impose a mandatory retirement age? Reference: http://ec.europa.eu/justice/discrimination/files/age_and_employment_en.pdf Section 7.3
65 but can be extended by agreement
during what ages can a person apply for sickness benefit for work absences
employed persons http://ec.europa.eu/social/main.jsp?catId=1104&langId=en&intPageId=4459
III. Sickness - cash benefits Basic principles Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Compulsory social insurance scheme covering the active population and providing earnings-related benefits. Continued payment by the employer.
III. Sickness - cash benefits Conditions 2. Qualifying period Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Minimum period of insurance required: 9 months of consecutive insurance or 12 with interruptions during the last two years. If this condition is not fulfilled, the insured person is entitled to the minimum sickness benefit, see below "Benefits, 2. Benefits of social protection, Amount of the benefit".
included in the income files Mean equivalised net income
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 35
sent to UKHF
GREECE
Minimum age for admission to employent
15 http://r2e.gn.apc.org/country-node/348/country-minimum (article 2 of Law 1837/89)
VI. Old-age Conditions Legal retirement age Standard pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
67 years (if 15 years of insurance). 62 years (if 40 years of insurance).
VI. Old-age Conditions Legal retirement age Early pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Persons insured before 1/1/1993: Full amount: For men and women, from the age of 62, if they have completed 10,500 insurance days (of which 7,500 must have been spent doing arduous and unhealthy work). Reduced amount: from 62 years for men and women if 15 insurance years or 4,500 insurance days (of which 100 days have been worked during the last 5 years), from 62 years of age and 10,000 insurance days for men (60 years and 12,000 insurance days for women, increasing by 6 months every year until the age of 62 is reached in 2017) of which 100 per year during the last five years, from 60 years for men and women if 35 working years or 10,500 insurance days (of which 7,500 days must have been worked under arduous or unhealthy conditions), from 62 years for mothers and widowed fathers with a minor or disabled child if 18 insurance years or 5,500 working days. Persons insured since 1/1/1993: Reduced amount: from 62 years for mothers with a minor or disabled child if 20 years of insurance or 6,000 working days.
Any laws which impose a mandatory retirement age? Reference:
None
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 36
http://ec.europa.eu/justice/discrimination/files/age_and_employment_en.pdf Section 7.3
during what ages can a person apply for sickness benefit for work absences
employed persons If you are too sick or ill to do your job and if you are under 66, you may be entitled to Illness Benefit. http://ec.europa.eu/social/main.jsp?catId=1112&langId=en&intPageId=4563
III. Sickness - cash benefits Basic principles Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Compulsory social insurance scheme for employees with earnings-related benefits. No continuation of payment by the employer.
III. Sickness - cash benefits Conditions 2. Qualifying period Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
* 120 days of work subject to contributions during the previous year or the 12 first months of the 15 months preceding the illness (100 for those employed in construction). Duration of benefit: 182 days for one or more illnesses within one year. * 300 days subject to contributions during the 2 years, or 27 months of the 30, preceding the illness (duration of benefit: 360 days for the same illness, within one year). * 1,500 days of insurance, 600 of which during the last 5 years preceding the incapacity for work due to the same illness (duration of benefit: 720 days). * 4,500 days of insurance before the declaration of the illness (duration of benefit: 720 days). * Depending on the patient’s age and insurance record, a 720 days’ benefit can be paid in case the requirement of the 1,500 or the 4,500 days is not fulfilled.
included in the income files sent to UKHF
Mean equivalised net income
IRELAND
Minimum age for admission to employent
15 http://r2e.gn.apc.org/country-node/348/country-minimum (article 2 of Law 1837/89)
VI. Old-age Conditions
67 years (if 15 years of insurance). 62 years (if 40 years of insurance).
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 37
Legal retirement age Standard pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
VI. Old-age Conditions Legal retirement age Early pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Persons insured before 1/1/1993: Full amount: For men and women, from the age of 62, if they have completed 10,500 insurance days (of which 7,500 must have been spent doing arduous and unhealthy work). Reduced amount: from 62 years for men and women if 15 insurance years or 4,500 insurance days (of which 100 days have been worked during the last 5 years), from 62 years of age and 10,000 insurance days for men (60 years and 12,000 insurance days for women, increasing by 6 months every year until the age of 62 is reached in 2017) of which 100 per year during the last five years, from 60 years for men and women if 35 working years or 10,500 insurance days (of which 7,500 days must have been worked under arduous or unhealthy conditions), from 62 years for mothers and widowed fathers with a minor or disabled child if 18 insurance years or 5,500 working days. Persons insured since 1/1/1993: Reduced amount: from 62 years for mothers with a minor or disabled child if 20 years of insurance or 6,000 working days.
Any laws which impose a mandatory retirement age? Reference: http://ec.europa.eu/justice/discrimination/files/age_and_employment_en.pdf Section 7.3
None
during what ages can a person apply for sickness benefit for work absences
employed persons If you are too sick or ill to do your job and if you are under 66, you may be entitled to Illness Benefit. http://ec.europa.eu/social/main.jsp?catId=1112&langId=en&intPageId=4563
III. Sickness - cash benefits Compulsory social insurance scheme for employees with earnings-
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 38
Basic principles Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
related benefits. No continuation of payment by the employer.
III. Sickness - cash benefits Conditions 2. Qualifying period Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
* 120 days of work subject to contributions during the previous year or the 12 first months of the 15 months preceding the illness (100 for those employed in construction). Duration of benefit: 182 days for one or more illnesses within one year. * 300 days subject to contributions during the 2 years, or 27 months of the 30, preceding the illness (duration of benefit: 360 days for the same illness, within one year). * 1,500 days of insurance, 600 of which during the last 5 years preceding the incapacity for work due to the same illness (duration of benefit: 720 days). * 4,500 days of insurance before the declaration of the illness (duration of benefit: 720 days). * Depending on the patient’s age and insurance record, a 720 days’ benefit can be paid in case the requirement of the 1,500 or the 4,500 days is not fulfilled.
included in the income files sent to UKHF
Average disposable income
ITALY
Minimum age for admission to employent
varies between 14 and 18 depending on job type http://r2e.gn.apc.org/country-node/443/country-minimum
VI. Old-age Conditions Legal retirement age Standard pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Male employees of the private sector, self-employed and para-subordinate workers: 66 years and 7 months; Male and female civil servants: 66 years and 7 months; Female employees of the private sector: 65 years and 7 months; Female self-employed and para-subordinate workers: 66 years and 1 month (see Annex on the social protection of the self-employed). The retirement age is being gradually increased according to the increase in life expectancy. As of January 2021, the retirement age cannot be lower than 67 (it will reach 69 and 9 months by the year 2050). The pension payment deferment scheme no longer applies except for certain duly certified categories of hard jobs to which the
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 39
previous “Quota system” still applies. Such categories include: miners, workers engaged in asbestos removal, night-shift workers, public transport heavy-vehicles’ drivers, etc.
VI. Old-age Conditions Legal retirement age Early pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
From January 2012 the former seniority pension (pensione di anzianità) has been replaced by the Early retirement pension (pensione anticipata). If the person has accrued the conditions for drawing full pension: 42 years + 10 months for men and 41 years + 10 months for women, as from January 2016, the benefit shall not be subject to a permanent reduction in amount even though the pension is claimed before the age of 62, until 31st December 2017. Persons first insured after 1/1/1996 who have accrued a work insurance of at least 20 years, may retire at the age of 63 years and 7 months upon condition that the amount of the pension they would be entitled to is at least equal to 2.8 times the monthly amount of the welfare-based social allowance (assegno sociale) equal to €448.07 in 2016 (see also Table XI, “Guaranteed Minimum Resources”). Since January 2012, the pension payment deferment schemes (the so-called “windows”) and the “quota system” (based on the sum of contributions and age) no longer apply except for certain categories of hard jobs.
Any laws which impose a mandatory retirement age? Reference: http://ec.europa.eu/justice/discrimination/files/age_and_employment_en.pdf Section 7.3
women can ask to postpone retirement to 65
during what ages can a person apply for sickness benefit for work absences
employed persons http://ec.europa.eu/social/main.jsp?catId=1116&langId=en&intPageId=4620
III. Sickness - cash benefits Basic principles Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Compulsory social insurance scheme for employees and assimilated groups with earnings-related benefits generally provided by the employer at the expense of the National Institute for Social Security (Istituto Nazionale della previdenza sociale, INPS).
III. Sickness - cash benefits Conditions 2. Qualifying period Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABA
Generally, no qualifying period. Exceptions: farming industry employees on fixed-term contracts must have been in their occupation for at least 51 days prior to the onset of the illness in the current or preceding year; show-business employees must have accrued at least 100 days of contributions as of 1 January of the year prior to the onset of the
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 40
SE/comparativeTableSearch.jsp
illness.
included in the income files sent to UKHF
Mean equivalised net income
PORTUGAL
Minimum age for admission to employent
16 http://r2e.gn.apc.org/country-node/385/country-minimum
VI. Old-age Conditions Legal retirement age Standard pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
66 years and 2 months for men and women in 2016 (after 2015, the normal age for access to a pension varies depending on the average life expectancy at the age of 65. 65 years for beneficiaries legally prevented from working beyond that age (e.g., pilots, drivers of heavy vehicles). When the beneficiary reaches the age of 65, the normal pensionable age is reduced by four months for each calendar year after the contribution period of 40 years, with a 65-year threshold.
VI. Old-age Conditions Legal retirement age Early pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Insured persons aged at least 60 who have completed a contribution period of 40 calendar years or more with registered earnings may claim an early pension. In this case the pension amount is reduced. Beneficiaries aged between 55 and 60 years that have contributed over a career of 30 or more years with registered earnings may also claim an early pension on condition that they have submitted a request by 9 March 2016. Unemployed: Early pension from the age of 62, provided that they were aged 57 at the beginning of their unemployment and have completed the qualifying period. For those who have contributed for 22 calendar years and are aged 52 or more when becoming unemployed, it is also possible from the age of 57. In this case the pension amount is reduced. For heavy or unhealthy work, as a general rule, from 55 years of age (only for the professions legally provided for). From 55 years in case of specific measures to protect economic activities or companies.
Any laws which impose a mandatory retirement age? Reference: http://ec.europa.eu/justice/discrimination/files/age_and_employment_en.pdf Section 7.3
None
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 41
during what ages can a person apply for sickness benefit for work absences
employed persons http://ec.europa.eu/social/main.jsp?catId=1125&langId=en&intPageId=4738
III. Sickness - cash benefits Basic principles Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Compulsory social insurance scheme financed by contributions covering employees and self-employed, with benefits depending on the registered earnings and on the duration of incapacity. No continuation of payment of wage by the employer.
III. Sickness - cash benefits Conditions 2. Qualifying period Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
6 months affiliation with registered remuneration of which 12 days of actual work during the 4 months prior to the one preceding the day of incapacity.
included in the income files sent to UKHF
Mean equivalised net income
ROMANIA
Minimum age for admission to employent
16 http://r2e.gn.apc.org/country-node/387/country-minimum
VI. Old-age Conditions Legal retirement age Standard pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Old-Age Pension (pensie pentru limita de varsta): Men: 65 years. Women: 60 years and 4 months on 1 July 2016, gradually increasing to 63 years by 1 January 2030. The pace of increase varies: the rule is one month increase at every three or five or eleven months.
VI. Old-age Conditions Legal retirement age Early pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPA
Old-Age Pension with Reduced Standard Retirement Age (pensie pentru limita de varsta cu reducerea varstelor standard de pensionare): There is an assortment of Standard Retirement Age reductions for: * persons who contributed under special, difficult or other specific working conditions,
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 42
RATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
* persons who have had a disability prior to obtaining the insured person status, * persons persecuted for political reasons by the regime in power after 6 March 1945, deported abroad or taken prisoners of war, * blind persons, * other categories of persons, defined by other legal acts. Early Retirement Pension (pensie anticipata): Granted up to 5 years before the Standard Retirement Age to a person who exceeds the Full Contribution Period by at least 8 years. Partial Early Retirement Pension (pensie anticipata partiala): Granted up to 5 years before the Standard Retirement Age to a person who exceeds the Full Contribution Period by up to 8 years.
Any laws which impose a mandatory retirement age? Reference: http://ec.europa.eu/justice/discrimination/files/age_and_employment_en.pdf Section 7.3
None
during what ages can a person apply for sickness benefit for work absences
employed persons http://ec.europa.eu/social/main.jsp?catId=1126&langId=en&intPageId=4750
III. Sickness - cash benefits Basic principles Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Compulsory social insurance scheme for employees and self-employed providing an earnings-related benefit. Payment of a Benefit for incapacity to work (Beneficiu pentru incapacitate de munca) by the employer.
III. Sickness - cash benefits Conditions 2. Qualifying period Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
At least 1 month of contribution.
included in the income files sent to UKHF
Gross achieved income
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 43
SLOVENIA
Minimum age for admission to employment
16 http://r2e.gn.apc.org/country-node/519/country-minimum
VI. Old-age Conditions Legal retirement age Standard pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Legal full retirement age is 65 years for both women and men.
VI. Old-age Conditions Legal retirement age Early pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
An insured person is entitled to early pension (predčasna pokojnina) at 60 years of age, if he or she has completed 40 years of qualifying period (pokojninska doba). More stringent early pension entitlement conditions are being introduced gradually, with the transitional period ending in 2018.
Any laws which impose a mandatory retirement age? Reference: http://ec.europa.eu/justice/discrimination/files/age_and_employment_en.pdf Section 7.3
None
during what ages can a person apply for sickness benefit for work absences
employed persons http://ec.europa.eu/social/main.jsp?catId=1128&langId=en&intPageId=4777
III. Sickness - cash benefits Basic principles Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABA
Compulsory social insurance scheme financed by contributions for employees and self-employed with earnings-related benefits. Continuation of payment of wages and salaries paid by the employer.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 44
SE/comparativeTableSearch.jsp
III. Sickness - cash benefits Conditions 2. Qualifying period Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
No qualifying period required.
included in the income files sent to UKHF
Average yearly disposable income
NORTHERN IRELAND (UK)
Minimum age for admission to employent
age 13 and the minimum school leaving age (16) may work http://r2e.gn.apc.org/country-node/570/country-minimum
VI. Old-age Conditions Legal retirement age Standard pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
State Pension and New State Pension age: Men: 65 years Women: 60 years (up until 5 April 2010). From 6 April 2010 women’s State Pension age is gradually rising until it reaches age 65 in November 2018. From December 2018 the State Pension age for both men and women will start to increase to reach 66 by October 2020. The government is planning further increases, which will raise the state pension age from 66 to 67 between 2026 and 2028. They will then review it every five years in line with life expectancy.
VI. Old-age Conditions Legal retirement age Early pension Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
No early State Pension or New State Pension.
Any laws which impose a mandatory retirement age? Reference: http://ec.europa.eu/justice/dis
None
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 45
crimination/files/age_and_employment_en.pdf Section 7.3
during what ages can a person apply for sickness benefit for work absences
employed persons http://ec.europa.eu/social/main.jsp?catId=1132&langId=en&intPageId=4839
III. Sickness - cash benefits Basic principles Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
* Statutory Sick Pay (SSP) paid by the employer for up to 28 weeks; * Employment and Support Allowance: Provides financial help to people who are unable to work because of illness or disability.
III. Sickness - cash benefits Conditions 2. Qualifying period Source http://www.missoc.org/MISSOC/INFORMATIONBASE/COMPARATIVETABLES/MISSOCDATABASE/comparativeTableSearch.jsp
Statutory Sick Pay: Employees' earnings before sickness must have reached the Lower Earnings Limit (LEL) for National Insurance contribution purposes. Employees must satisfy the contribution conditions where they claim Employment and Support Allowance on cessation of Statutory Sick Pay. Employment and Support Allowance (ESA): payable to claimants who either meet National Insurance-related contribution conditions, meet income and capital tests or meet both.
included in the income files sent to UKHF
Average annual gross pay
2.4 EXCESS AND EFFECT METRICS
2.4.1 Impacts and costs indicators
The human impacts and financial costs included in the JANPA costing model are listed below.
Table 2 (a) : Obesity-related impacts and costs indicators
HUMAN IMPACTS
FINANCIAL COSTS
ADULT OBESITY /OVERWEIGHT Prevalence
Lifetime Income Losses
MORBIDITY Incidence
Prevalence
Years Lost due to Disability (YLD)
Quality Adjusted Life Years (QALY )
Direct healthcare costs
Productivity losses due to
absenteeism
MORTALITY Premature death Productivity losses due to
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 46
Years of Life Lost (YLL)
premature mortality
Adult productivity losses due to absenteeism are assumed to commence when a person develops an
obesity-related disease and last until after national retirement age. Lifetime income losses (the
“income penalty”) is assumed to commence on the 18th birthday for individuals who are classified as
“obese/overweight at age 18 years”.
Table below describes how these impact and cost indicators are handled in the JANPA costing
model.
Table 2(b): Handling of impact – cost indicators
Impact and cost indicators Distribution of impact-cost Discounted
Adult Obesity / Overweight No No
Mortality
Death To Year of Occurrence (YoO) No
Premature death To YoO No
Potential Years of Life Lost (PYLL) To YoO (to the year of premature death)
Years of Life Lost (YLL) To each Year to Life Lost (starting from year to premature death to year of life expectancy (at birth)) (YoLL)
Yes
Morbidity
Incidence To YoO
Prevalence To YoO
Years Lost due to Disability (YLD) To each Year to Life Lost (starting from year to premature death to year of life expectancy (at birth)) (YoLL)
Yes
Quality Adjusted Life Years (QALY)
Direct healthcare costs To YoLL (starting year that disease to year of death)
Yes
Societal costs
Productivity losses due to absenteeism
To YoLL (from year that disease developed to “retirement”)
Yes
Productivity losses due to premature mortality
To YoO (to the year of premature death) Yes
Lifetime income losses (applies only to those who are obese / overweight at 18 years)
To YoO (to the 18 years birth year) Yes
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 47
2.4.2 Excess metrics
To estimate the excess burden attributable to childhood obesity/overweight we compare the value
of an impact/cost indicator amongst individuals who were “obese/overweight as a child” to its value
amongst individuals who were “healthy weight as a child”:
An example of an excess metric is the number of diabetes cases that are attributable to childhood
obesity/overweight.
2.4.3. Effect metrics
To assess the effect of a 1% (or 5% ) reduction in (sex-age specific) mean childhood BMIs, the BMI
distributions of the initial cohort of children is changed appropriately and the modelling software
rerun. The effect of a 1% (or 5%) reduction in mean BMIs is then estimated by taking the difference
between total impacts/costs in the original model and impacts/costs in the changed model.
The current value of an excess metric thus serves as the base case for the assessment of the effect of
a reduction in mean childhood BMI. Increases in all impacts and costs (except QALYs) represent
greater burden. Therefore, for all impacts and costs except QALYs, a positive effect represents an
improvement (i.e. a reduction in a burden attributable to childhood obesity/overweight).
An example of an effect metric is the effect of a 1% reduction in the mean childhood BMI on the
excess number of diabetes cases that are attributable to childhood obesity/overweight. Another
Excess costs attributable to childhood obesity/overweight
Impact/Cost (Obese/Overweight as child) – Impact/Cost (Healthy weight as child)
Effect of reductions in mean childhood BMI
Total impact/cost (current BMI) – Total impact/cost (reduced BMI)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 48
would be the effect that a 5% reduction in mean childhood BMI on the lifetime excess direct
healthcare costs that are attributable to childhood obesity/overweight.
2.5 OBESITY-RELATED DISEASES
To be incorporated into a country’s JANPA costing model, a disease or a societal impact must satisfy
two criteria:
It must be significantly related to childhood obesity in the evidence review; and
The necessary data must be available in the country
The global list of diseases and societal impacts that are significantly related to obesity and
overweight is identified from the evidence reviews of the international literature and local materials.
Diseases and societal impacts for which there is inadequate local data or acceptable proxy data are
removed from the country’s model.
2.5.1 Global Disease List from the Evidence Reviews
The evidence reviews confirmed Fernandes (2010) summary of the strength of the evidence
regarding the consequences of childhood obesity. The reviews revealed a substantial evidence base
on the link between childhood obesity/overweight and childhood diseases. However, studies of the
link between childhood obesity/overweight and adult diseases are more difficult and costly and the
evidence base regarding adult diseases is much weaker.
The sources from the evidence review of childhood consequences was combined with an updated
international literature review of adult consequences that was used in the safefood “Economic Cost
of Adult Obesity in Republic of Ireland” conducted in 2012 (ref). Relative risks of developing diseases
that were associated with childhood and adult obesity/overweight and childhood and adult diseases
were then extracted from these combined sources. The childhood obesity-related diseases were
used in the childhood years of the disease modelling and the adult obesity-related diseases were
used in the adult years.
Table 2 (c): Global Disease List (Diseases known to be associated with obesity and overweight)
Childhood (only) diseases Chronic pain, Wheezing disorders
Diseases in childhood and adulthood Asthma, Colorectal cancer, Deep Vein Thrombosis (DVT),
Depression, (Type 2) Diabetes, Hypertension, Kidney
Cancer, Liver Cancer, Multiple Sclerosis (MS), Non-
alcoholic Fatty Liver Disease (NAFLD), Obstructive sleep
apnoea, Oesophageal cancer, Psoriasis, Pulmonary
embolism, Stroke, Thyroid cancer.
Adult (only) diseases Chronic Back Pain, Endometrial cancer (females),
Gallbladder cancer, Gallbladder disease, Gout,
Hypertension in pregnancy, Ischaemic Heart Disease,
Osteoarthritic knee, Ovarian cancer (females),
Pancreatic cancer, Polycystic Ovarian Syndrome
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 49
(females), Breast cancer (females aged 50+ years),
Prostate cancer (males), Urothelial Cancer (males)
The characteristics of these diseases and the way they were handled in the disease modelling are
given in the table below.
Table 2 (d): Disease characteristics and their use in the disease modelling
DISEASE ICD-10 AM, 6th edition ADULT CHILD TERMINAL ACUTE GENDER
Asthma J45.1, J45.8, J45.9, J46 Yes Yes No No Both
Bladder cancer
(or Urothelial Cancer) C67 Yes No Yes No Males
Breast cancer C50 Yes No Yes No Females
CHD
(or Ischaemic Heart Disease) I20, I21, I22, I23, I24, I25, I46, I50 Yes No Yes No Both
Chronic back pain M54.3, M54.4, M54.5 Yes No No No Females
Chronic pain
No Yes No No Both
Colorectal cancer C18, C19, C20 Yes No Yes No Both
Depression
No Yes No No Both
Diabetes E11 Yes Yes No No Both
DVT I80.1, I80.2, I80.3 Yes No No Yes Both
Endometrial cancer C54, C55 Yes No Yes No Both
Gallbladder cancer C23 Yes No Yes No Both
Gallbladder disease K80, K81, K85.1 Yes No No Yes Both
Gout M10.0, M10.9 Yes No No No Both
Hypertension I10, I11, I12, I13 Yes Yes No No Both
Kidney cancer C64 Yes No Yes No Both
Knee osteoarthritis M17.0, M17.1, M17.9 Yes No No No Females
Liver cancer C22.0 Yes No Yes No Both
Multiple sclerosis G35 Yes No No No Males
NAFLD K76.0 No Yes No No Both
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 50
Oesophageal cancer C15 Yes No Yes No Both
Ovarian cancer C56 Yes No Yes No Both
Pancreatic cancer C25 Yes No Yes No Both
Prostate cancer C61 Yes No Yes No Both
Psoriasis L40 Yes No No No Both
Pulmonary embolism I26 Yes No No Yes Both
Sleep Apnoea
No Yes No No Both
Stroke G45, G46, I63,I64 Yes No Yes No Both
Thyroid cancer C73 Yes No Yes No Both
2.5.2 Data requirements to be included in a country’s costing model
A disease associated with obesity/overweight could be included in a country’s CCSM only if the
required detailed data was available. No country model included all diseases in the Table above.
2.6 SOFTWARE IMPLEMENTATION
2.6.1 Existing UKHF software
Disease modelling and cost estimation were undertaken by the UKHF (sub-contractor to IPH-IRL)
through its Public Health Modelling Unit that uses closed source software.
The UKHF has developed extensive software which has been used by WHO for their population
obesity forecasts and population-level burden of disease reports.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 51
UKHF software is modularised; the modules are described in the figure below.
Figure 2 (c): Modules of UKHF’s software
Construction of individual lifetime BMI trajectories is undertaken in the Risk Module; disease
modelling of disease occurrence is undertaken in the Disease Modules and cost estimation was
undertaken in the Economic Module.
2.6.2 Modification of existing UKHF software
To implement the CCSMs required for the JANPA costing model, the WP4 Lead Team worked with
the UKHF to modify their OCSM-oriented software. This involved:
Adapting the Risk Module, Disease Module and Economic Module
Introducing a number of innovations into these modules
Integrating these modules in order to produce to the necessary Model Outputs Workbook
This presentation is part of the Joint Action JANPA (Grant agreement n°677063) which has received funding from the European Union’s Health Programme (2014-2020)
Example3:ForesightObesityModel
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 52
The table below lists the main modifications that were needed to existing UKHF software:
Table 2 (e): Modifications made to existing UKHF software
MODIFICATION COMMENTS
Incorporating children
Extending age ranges
Incorporating childhood impacts and costs that are
associated with childhood obesity/overweight
Excluding adults from initial cohort
“Closing the cohort”
Excluding new entries by births and immigration
Excluding exits by emigration
Incorporating the definition of an
overweight/obese child
Comparisons based on BMIs on 18th
birthday rather BMI
in a particular future year
Complications associated with the occurrence of
childhood diseases and deaths
Incorporating a number of other chronic obesity-related diseases
Incorporating acute conditions into a chronic
disease model
Acute conditions and costs are assumed to last one year
Incorporating three types of societal costs Lifetime income losses (associated with being
obese/overweight at 18 years of age)
Productivity losses due to premature death (associated
with an early death)
Productivity losses due to absenteeism (associated with
developing an obesity-related disease)
Incorporating post-retirement productivity into
productivity loss metrics
Introducing new metrics
Impact and cost indicators for the possible
consequences of burdens attributable to childhood
obesity/overweight
Excess metrics for the impacts and costs attributable to
childhood obesity/overweight
Effect metrics for the effects of 1% and 5% reductions in
mean childhood BMI
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 53
2.7 SOME STATISTICAL AND COSTING ISSUES
2.7.1 Uncertainty intervals
The uncertainty intervals that accompany the Model Outputs incorporate variation associated from
the simulation (stochastic or aleatoric uncertainty) and are derived from the various probabilistic
distributions that are used in the software.
Example equations for calculating the Monte Carlo errors
Annual incidence outputs
The annual incidence (I) per 100,000 is calculated with the following formula:
per 100,000 *100,000population
nI
N (0.1)
Where n refers to the number of new cases of a disease in a given year and Npopulation is the total
number of people alive in the simulation at a given year.
Calculating 95% confidence intervals
95% CI for epidemiological outputs
(1 )
95% CI per 100,000 1.96 *100,000population
p p
N
(0.2)
Where Npopulation relates to the number of individuals alive in the year (population size) and p (per 1)
is the rate of an event an occurring in the population (p=n/NP).
Direct costs
The annual costs for each disease (CTotal) per 100,000 are calculated in each year by multiplying the
cost per case (Ccase) by the prevalence of the disease (PD) (0.3).
*P
per 100,000 *100,000case DTotal
trials
CC
N (0.3)
95% CI for direct and absenteeism costs
(1 )
95% CI per 100,000 costs 1.96 * *100,000case
trials
p pC
N
(0.4)
The rate p corresponds to the prevalence rate per individual.
These only apply to the random processes incorporated into the microsimulation and ignore lots of
sources of variation:
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 54
BMI trajectories
Sampling of initial cohort
Prevalence, incidence, survival inputs
Proxy data
Cost estimation procedures
etc
The example equations do not attach meaningful uncertainty intervals to final Model Outputs. These
can only be derived from large scale sensitivity analyses.
2.7.2 Other statistical issues
In the Model Output Workbooks, a “premature” death is defined as one that occurs before their life
expectancy at birth. However, because life expectancy at birth is greater for females than it is for
males, female deaths are classified as “premature” for a greater number of calendar years.
Therefore, risk of “premature” deaths can appear higher amongst females. Therefore in the RE ADJ
Model Output Workbooks, the female premature mortality calculations are adjusted to take this into
account. In the RE ADJ Model Output Workbooks, a “premature” death in one that occurs before life
expectancy of the appropriate male.
2.7.3 Discounting future costs
All impacts and costs (except number of premature deaths) are discounted to 2015 euro values. The
annual discount used in each country to convert future values to current 2015 values are shown in
the table below.
Table 2(f): Annual Discount Rates
Country Annual discount rate
Croatia (HRV) 5%
Greece (GRC) 5%
Republic of Ireland (IRL) 5%
Italy (ITA) 3.5%
Northern Ireland (NIR) 3.5%
Portugal (PTG) not applicable
Romania (ROM) 5%
Slovenia (SVN) 5%
Discounting is a technique used to reflect people's time preferences to receive benefits now and pay
costs later. Discounting at the annual rate of 5% per annum is almost the opposite of compounding
interest at 5% per annum. So, for example, in the Republic of Ireland the JANPA costing model
estimates that the total lifetime costs of childhood obesity/overweight is €4,518.1 M in 2015 values.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 55
These costs are incurred over the lifetimes of today’s children. To pay for these costs; in 2015 you
would have to lodge €4,4518.1 M into a bank account that earns 5% compound interest per annum
and leave it in that account only making withdrawals as those costs are incurred. At the end of the
children’s lifetimes the account would be empty (principal plus interest) and the lifetime costs would
have been paid.
2.7.4 Approach to estimating productivity losses
In each JANPA WP4 country, an estimate of the (per case) annual costs of adult productivity losses is
required. For this type of calculation, economists use either a Human-Capital approach or a Friction-
Cost approach although it is unclear which is the most appropriate application of the Friction-Cost
approach when an accumulation over many years is used. Therefore, like the majority of cost
studies, we will use the Human-Capital approach.
2.7.5 Valuing post-retirement productivity
To incorporate a value for productivity losses associated with the post-retirement age, their
calculation continues until 10 year after the national retirement age along with a scaling factor listed
below:
By 100% if death occurs before national retirement age.
By 30% if death occurs after but within 10 years of national retirement age
By 0% if death occurs thereafter
2.7.6 Other costing issues
Indirect healthcare costs that are incurred by patients, their families and communities are
omitted from the modelling because of the lack of data and research.
Acute diseases are modelled as lasting one year and use annual per case treatment costs
although their duration may be considerably shorter. This probably leads to overestimation
of healthcare costs.
The evidence reviews found that the cost of treatment for diseases that are not related to
obesity/overweight can be higher amongst obese/overweight patients than amongst
patients with healthy weight. This means that cost–related excess metrics will be
underestimated
Adult productivity losses due to absenteeism are assumed to commence when an individual
develops an obesity-related disease and last until retirement or death. They may be
overestimated.
No adjustments have been made for different purchasing powers in the different countries.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 56
3. WORKFLOW
Six broad phases are involved in the deployment of the JANPA costing model in a country: Data
Collation, Pre-modelling Data Processing, Disease modelling, Cost estimation, Post-Modelling Review
and Reporting. These inter-related phases and the feedback loops between them are described in
the Figure blow:
Figure 3(a): JANPA costing model workflow3
3 UKHF were principally subcontracted for Phases 1 and 2.
1. Data
collation
2. Pre-
simulation
data
processing
3.
Simulation
modelling
5. Post-
simulation
review
6.
Reporting
4. Cost
estimation
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 57
3.1 PHASE 1: DATA COLLATION
Data collation was conducted by the JANPA WP4 Teams in the participating countries and overseen
by the WP4 lead Team in IPH-IRL. Standardised Excel workbooks were used to identify possible data
sources and collate the data required for the modelling (see Section 3.7).
A systematic approach was developed to collate the required data.
Figure 3(b): Data collation workflow
3.1.1 Identifying data sources
Identification of potential data sources, collation of data from these sources and final decisions
about data sources to use were undertaken jointly by the participating country and the WP4 lead
Team.
The availability and quality of data varied greatly across the countries. In all countries, multiple data
sources had to be used.
In the case of disease parameters (prevalence, incidence, survival, mortality), a modification of the
DISMOD software (ref) is used by UKHF to “regularise” these parameters and estimate the value of
missing parameters.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 58
In all participating countries, data imputation may be necessary because:
Required data are not available and it is necessary to impute data from other sources
Some required data are available but not at the optimal level of detail and it is necessary to
collapse BMI, age, etc. categories.
When the required data, from any domain, is unavailable in a participating country, the most
appropriate proxy data was used. Decisions about data imputation were made by participating
countries in consultation with the WP4 Lead Team and the UKHF; and appropriately documented.
The table below describes the types of data sources used, the ranking given to in the decision
making, and who was responsible for collating the data:
Table 3(a): Potential data sources for participating country
RANKING TYPE RESPONSIBLE PERSON
1a
National source Participating country
1b
International source (national data) WP4 Lead Team
2 Regional source (extrapolation to national level)
Participating country
3
National source for another country (proxy data) WP4 lead team
4 International source (regional proxy data)
WP4 lead team
5 Regional source for another country
(extrapolated to national level)
WP4 lead team
3.1.2 Calculating per case treatment costs
We aimed to gather direct health care costs (costs to the state) covering hospital costs, primary care
costs and pharmaceutical cost. Indirect costs borne by a patient, their family or community are not
included. Specialist services for morbidly obese children or adults is not included.
Treatment costs for a particular disease in any year are obtained by multiplying the (sex-age)
number of prevalent cases at the beginning of that year by the (sex-age specific) annual per case
treatment costs.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 59
A mixture of two approaches are used to calculate the annual cost per case for the management and
treatment of obesity-related diseases that are included in the Collated Data Workbook :
• “Top down” approach based on estimation of Population Attributable Fractions (PAFs) and
their application to national healthcare data
• “Bottom up” approaches based on analysis of healthcare utilisation in cross-sectional studies
or longitudinal studies that also include BMI data
The approach varies from one country to another and from one disease to another. Details are given
in the data documentation.
Ideally, all model inputs and outputs for a participating country would be calculated using a bottom-
up approach based to local research and/or data. Failing this, a top-down method applied to local
research and/or data is the next preferred approach. The least preferred approach is the use of a
top-down method with international inputs.
3.1.3 Data handling issues
Significant methodological challenges are associated with combining data from the different global,
international and regional sources used in the Data Collation and Pre-simulation Data Processing
phases. These include:
Significant data imputation involving sex-age extrapolation and interpolation of collated data
into early childhood years, adolescence and later adult years
Calculation of annual disease parameters from those relating to other periods (ten-year
incidence rates, five-year relative risks)
Appropriate data handling protocols with such complex collections of data gathered across a
large number of data domains
Challenges of estimating missing disease parameters
Mismatch between disease definitions used in the evidence reviews and those used in data
available.
3.2 PHASE 2: PRE-SIMULATION DATA PROCESSING
A country’s Collated Data Workbook was then sent to the UKHF (sub-contractor to IPH-IRL) who, in
collaboration with the WP4 Lead Team and the participating country, prepared it for inputting into
the modified simulation software. A description of these data processes is provided in the Model
Toolbox although the final data input file (“Input Data File”) is not provided by UKHF.
This stage involved several important procedures:
Obesity forecasting and the modelling of virtual individual lifetime BMI trajectories
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 60
“Regularising” and estimating values of missing disease parameters (prevalence, incidence,
survival and mortality)
3.2.1 Modelling lifetime BMI trajectories
Implementation software currently uses (sex, age, year) regression-based forecasts of
obesity/overweight prevalence plus a constant lifetime BMI percentile assumption to model
individual lifetime BMI trajectories .
3.2.2 Estimating disease parameters
A consistent set of disease parameters (prevalence, incidence, survival, mortality) is required.
Using the relationships that exist between these four disease parameters, a modified version of
DISMOD is used to estimate missing parameters and produce a consistent set of all parameters for
use in the simulation modelling.
3.3 PHASE 3: DISEASE MODELLING
3.3.1 Details of the simulations
A range of impacts and costs are recorded over a period of 90 years of follow-up from 2015 to 2105.
The initial cohort in a participating country’s simulation model consists of a random sample of 20
million virtual children selected to have the same sex-age-BMI distribution as the children living in
that country in 2015. In the Model Output Workbooks for a participating country include the counts
and totals for the 20 million initial cohort members as well as the counts and totals that have been
scaled to the childhood population size living in the country in 2015.
The virtual lives of the initial cohort of virtual children are simulated for 110 years: all cohort
members who survive until their 110th birthday automatically experience death at the end of their
110th year. In any calendar year in which there is at least one such individual, the simulation of
disease and mortality experience of the survivors in that year is biased and excluded from the Model
Outputs. Theoretically, this bias begins in 2108 when individuals who are 17 years old in 2015 turn
110 years of age. For this reason, follow-up is stopped in 2105 when there are individuals as young
as 93 years of age. At the beginning of 2106, surviving individuals will be aged 90-107 years
(estimated to be up to 5% of the initial cohort members) and their subsequent living experiences
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 61
are excluded from the Model Outputs. They are predominantly females who were healthy weight as
a child so this will probably underestimate the lifetime disease, mortality and healthcare costs of
female healthy weight children.
3.3.2 Simulating disease processes
Independent disease process
Each obesity-related disease that is included in a participating country’s model is modelled
independently. These independent disease process will probably underestimate disease incidence
and prevalence by ignoring multi-morbidities and overestimate healthcare cost estimates by
ignoring savings that might accrue from managed care. Checks are put in place to ensure that an
individual cannot develop a disease more than once and cannot continue to develop further diseases
after death. The order that the diseases are modelled is the order on which they appear in the
Collated Data Workbook.
Annual disease modelling
For each obesity-related disease in a country’s costing model, the disease experience of the virtual
individuals are modelled year-by-year using a semi-Markov process that has four states defined by
whether or not the individual has the disease and whether or not the individual is alive.
Figure 3(b): State transition probability matrix
END OF A YEAR
START OF A YEAR
ALIVE DEAD
WITHOUT DISEASE
WITH DISEASE
WITHOUT DISEASE
WITH DISEASE
ALIVE
WITHOUT DISEASE P 11 P12 P13 P14
WITH DISEASE P21 P22 P23 P24
DEAD
WITHOUT DISEASE P31 P32 P33 P34
WITH DISEASE P41 P42 P43 P44
In this table, PIJ = Probability {end of year state = J | start of year state = I} for I,J = 1,2,3,4.
This figure relates to chronic diseases which are assumed to last until death.
Acute diseases are assumed to last for one year.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 62
Table 3(c): Calculation
of state transition
probabilities
Separate state
transition probability
matrices are used for
individuals who are
obese/overweight at
the start of the year
and those who are of
healthy weight.
The transition
probability matrix that
is applied to a
particular individual at
the beginning of a year is the one that matches their sex, age and BMI at the beginning of that year.
Some notes on the transition probability matrix used in the semi-Markov disease process:
1. The probabilities do not change over time. For example:#
They do not account for any possible changes in survival due to new medications
and treatments
2. The probabilities do not take into account how long a person who is obese/overweight at
the beginning of a year has been obese/overweight (duration of risk exposure)
3. Deaths from other causes are driven by underlying sex-age specific mortality rates. No
breakdown into finer (not obesity-related) causes of death categories is used.
In these calculations; diseases are developed towards the beginning of a calendar year and deaths
occur towards the end of a calendar year.
TRANSITION PROBABILITY
DATA REQUIREMENT
P11 Annual incidence
P12 Annual incidence
P13 All causes mortality
P14 0 (develop disease and die in one year)
P21 0
P22 Annual survival
P23 0
P24 Annual survival
P31 0
P32 0
P33 1
P34 0
P41 0
P42 0
P43 0
P44 1
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 63
Figure 3(c): Timing of process in Disease Module
The figure above shows the main model processes which take place for each individual in a given
year in the disease modelling. The outputs summarise at which time points the outputs are
generated.
3.4 PHASE 4: COST ESTIMATION
Cost estimation is done in the Economics Module of the implementation software using the disease
trajectories produced by the Disease Module and annual per case treatment cost estimates. The
calculations could thus also have been performed using the cost data supplied in the Data Collation
Workbooks and the counts and totals in Model Output Workbooks.
Three types of costs are calculated in each year of the simulation:
For each obesity-related disease; annual per case treatment costs are applied to the number
of prevalent cases in a year to obtain the direct healthcare cost estimates for that disease in
that year.
For each obesity-related disease, the annual per case cost of work absences (number of days
per year) associated with the disease and the absenteeism and the per case treatment costs
for each obesity-related disease are applied to the number of prevalent cases in that year.
Income losses are calculated by applying annual average incomes (adjusted for the income
penalty) to the number of individuals at the beginning of the year who are classified as
obese/overweight children
The assumption that the different disease processes are modelled independently probably means
that total direct healthcare costs and productivity losses due to absenteeism may be overestimated.
Discounted and undiscounted costs are included in the Model Output Workbooks.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 64
3.4.1 Model Outputs
In order to contain sub-contracting costs, the Reporting phase was undertaken by the WP4 Lead
Team in IPH-IRL. For this, WP4 Lead Team and UKHF agreed a standard format for the Model
Outputs Workbook that consisted of annual counts and costs for a country.
The variables included in the Model Outputs Workbook for a country are listed in the table below:
Table 3(d): Counts and costs in the Models Outputs Workbook
Disease-related outputs
Model output Description
1. Population counts Number of individuals alive at the beginning of the year
2. Incidence counts Number of new cases of each disease to appear in the year
3. Prevalence counts Number of cases of each disease existing in the individuals alive at the
end of the year
4. Death counts Number of deaths that occur in each year
5. Premature death
counts
Number of people who die before their Life expectancy (LE) (at birth)
during the year
6. Years of Life Lost
(YLL) counts
The number of years of life lost during the year (due to premature
death) associated with individuals who died in the year or a previous
year This is the same as the number of people who died prematurely
during the year plus the number of people who died prematurely in a
previous year but would not have reached their LE (at birth) in the
year (had they lived)
7. Years Lost due to
Disability (YLD) counts
The number of years of life lived with disability during the year by all
individuals alive at the end of the year
8. QALY counts The number of quality adjusted years of life lived during the year
QALY by all individuals alive at the end of the year
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 65
Cost outputs
Model output Description
Direct healthcare costs Total direct healthcare costs in the year
Total Productivity Losses
due to Absenteeism
Total productivity losses due to absenteeism incurred in the year
Total Productivity Losses
due to premature
mortality
Total productivity losses due to premature mortality incurred in the
year
Total Life income losses
Total life income losses incurred in the year
3.5 PHASE 5: POST-SIMULATION REVIEW
Model outputs were provided to the WP4 Lead Team in a standardised Model Outputs Workbook
(see Model Toolbox). The WP4 Lead Team then restructured the Model Outputs Workbook into a
classical data analytical format. These are referred to as RE ADJ Model Output Workbooks.
Data and modelling issues needed to be treated sequentially because of their inter-relationship and
lack of access to software code.
The review considered:
survival at the end of 2105 after 91 years of follow up
3.6 PHASE 6: REPORTING
The WP4 Lead Team at IPH-IRL developed Excel macros and SAS programmes to calculate each
impact and cost indicator as well as the corresponding excess metric and effect metric from the total
counts and total costs provided in the Model Outputs Workbook. Standardised templates were then
produced to present the core tables and graphs need for reporting (see Model Toolbox).
Two versions of the core tables and graphs are available:
Accumulating impacts and costs using 2015 population as denominators for rates and
percentages.
Annual impacts and costs using current populations as denominators for rates and
percentages.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 66
Core tables are broken down by sex, childhood age group (0-5 years, 6 -11 years and 12 -17 years)
and calendar year.
3.6.1 Data documentation
To document the availability and quality of data available across the required domains, and to help
identify data gaps in each country, a number of data quality scales were developed and used the
describe the data collated. These included a Disease data Quality Score for prevalence, incidence,
survival and mortality data.
Disease Data Quality Score
1. No acceptable data
2. Must be estimated from other data (for disease parameters: prevalence, incidence, survival
mortality).
3. International proxy
4. "Approximate" data only:
5. Not applicable (non-fatal disease)
6. Acceptable data
1 2 3 4 5 6
“Approximate” data included cases where theoretical ICD codes mismatched those actually used;
hospital data was used for prevalence or incidence , self-reported BMI or regional (sub-national)
data was used.
3.7 JANPA COSTING MODEL TOOLBOX
Materials relating to each of the phases of the JANPA Costing Model workflow (Data Collation, Pre-
modelling Data Processing, Disease Modelling, Cost Estimation, Post-Modelling Review and
Reporting) that could be used by other countries wanting to deploy the JANPA costing model will be
available in the Modelling ToolBox on the JANPA website (www.janpa.eu) in early 2018.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 67
These resources include the following guidance documents and questionnaires and are described in
the table below:
Table 3(e): JANPA Costing Model Toolbox
WORKFLOW PHASE
RESOURCE
1. DATA COLLATION Local Materials Survey used to identify local reports and research to supplement the international literature Data Sources Survey to identify local and international data sources not captured by initial data scoping exercise Data Request Workbook to collate the required data for a country Collated Data workbook
2. PRE-SIMULATION DATA PROCESSING
Guide to Pre-modelling Data Processing and model inputs
3. SIMULATION MODELLING Model Outputs Workbook
4. COST ESTIMATION
5. POST – SIMULATION REVIEW Guide to Post-modelling Review
6. REPORTING SAS data file and codebook Core Table and Graph Workbook
OTHER RESOURCES Global list of child diseases significantly related to childhood obesity/overweight Global list of adult diseases significantly related to childhood obesity/overweight and/or adult obesity/overweight
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 68
4. DATA REQUIREMENTS
4.1 DATA DOMAINS
The data required for a model depends on the impact and costs that are included in the costing
study. Data requirements are described in the tables below.
Table 4(a): Data Requirements
1. Population
Current childhood population size estimates Broken down by sex-age.
(single year age groups preferred)
2. BMI
Current distribution and historical trends in BMI Broken down by year sex-age.
All ages required (single year age groups preferred)
Sample sizes required
3. Disease parameters
Current annual incidence rates for
Each obesity-related diseases
Broken down by sex-age (single year age groups
preferred)
Current annual prevalence rates for
Each obesity-related disease
Broken down by sex-age (single year age groups
preferred)
Current annual mortality rates for
Each obesity-related disease
All causes
Broken down by sex-age (single year age groups
preferable)
Current one-year survival probabilities for
Each obesity-related disease
Broken down by sex-age (single year age groups
preferable)
4. Direct healthcare costs
Current annual direct healthcare costs for case of:
Each obesity-related disease
Hospital costs, primary care costs, pharmaceutical
costs.
Either national annual total costs (if number of current
prevalent cases is known) or current annual per case
costs.
Broken down by sex-age (single year age groups
preferred)
5. Lifetime income losses and Productivity losses due to premature mortality
Current annual average income Broken down by sex-age (single year age groups
preferred)
Gross income perhaps better
6. Productivity losses due to absenteeism
Absenteeism rates (average number of days absent Broken down by sex-age (single year age groups
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 69
per year) or each obesity-related disease preferred)
Current social welfare payments for work
absences
Either national total annual costs (if current number of
prevalent cases is known) or current annual per case
costs.
Broken down by sex-age (single year age groups
preferred).
Table 4(b): Other parameter requirements
National BMI cut off-points and reference curves (if
they exist and are different than IOTF cut-off
points).
For classifying childhood BMI status
Disease risks for each obesity-related diseases Relative risks / odds ratios
Risks in healthy weight individuals
Broken down by sex-age (single year age groups
preferred)
National utility weights used in national studies (if
relevant) for:
Each obesity-related disease
EuroQOL’s EQ5D weights used by default in calculation
of QALYs.
Broken down by sex-age (single year age groups
preferred)
National disability weights used in national studies
(if relevant) for
Each obesity-related disease
GBD weights used by default in calculation of YLDs.
Broken down by sex-age (single year age groups
preferred)
Annual discounting rate used in national studies (if
relevant)
OECD recommendations used by default
Life expectancy at birth For each single-year from ages 0 to 17 at their year of
birth. Broken down by sex.
Minimum legal working age and retirement age
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 70
The figure below explains how data from these domains are used in the modules of the simulation
software.
Figure 4(a): Data use in software modules
Population Module
Risk Module
Disease Module
Economic Module
Model Outputs
Workbook
Initial childhood cohort
Virtual BMI trajectories
Virtual Diseases trajectories
Counts and totals
Current childhood
disease prevalence
Current childhood
sex-age distribution
Current childhood BMI
distribution
Current and historical
trends in BMI
RRs/ORs of disease
Disease one year survival
probabilities
All-cause mortality rates
Income penalties
Average annual income
Average work absences
Social services costs
Annual per case treatment
costs
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 71
5. LIFETIME IMPACTS & COSTS OF CHILDHOOD OBESITY IN REPUBLIC
OF IRELAND
5.1 LOCAL CONTEXT
This section should be read in conjunction with the international context outlined in Chapter 1.
The pictures of obesity-- its prevalence, causes, and human outcomes—are similar across the
Republic of Ireland and Northern Ireland, although their financial costs and losses differ. Each
government has responded to the epidemic with a similar multi-departmental, multi-sector strategy
policy that is aimed at prevention across the lifetime.
The government of the Republic of Ireland has very actively promoted partnership among
government bodies and across sectors. It has developed and funded internal programs and outside
agencies with a remit to address the obesity epidemic and has initiated and funded internal and
external: investigations into the scale of the problem in Republic of Ireland, into the best
interventions to address and prevent obesity, and into the financial and lifetime costs of overweight
and obesity to the person and society. The Government’s current range of initiatives rely on the
multi-sectorial approach outlined in Healthy Republic of Ireland (HI) – A Framework for Improved
Health and Well-Being 2013-2025 (Department of Health, 2013). The approach was adopted by the
Irish Government to serve as a tool to frame multi-sector action in response to not only the obesity
epidemic, but to Republic of Ireland’s changing health and wellbeing profile of increased life
expectancy, rising morbidity trends, and increasing associated costs. The framework includes
arrangements that promote cooperation among the health sector and other areas of Government
and public services. The framework also focuses on research and evidence to ensure goals,
programmes, policy, and programming decisions are based on robust evidence, best practice
approaches, and integrated with service delivery to maximise impact. The Healthy Republic of
Ireland team evaluated Republic of Ireland’s health status in the Healthy Republic of Ireland Survey
2015 and specifically evaluated Weight Management and found the same profound and rising
weight epidemic (Department of Health, 2015) that existed in 2013 when the program started.
The HSE has incorporated Healthy Republic of Ireland into the health services strategy. Healthy
Republic of Ireland in the Health Services – National Implementation Plan 2015-2017 describes a 3-
pronged strategy aimed at health service reform, reducing the burden of chronic disease, and
improving staff and well-being. Reducing overweight and obesity are listed among the plan’s
strategic priorities (HSE, 2015). The Government has continued its ideal of agency collaboration with
the 2016 Program for a Partnership Government that sets out the agreed government program
between Fine Gael, the Independent Alliance, and some Independent TDs. It lists the
implementation of a national obesity plan among the key public health interventions it will make.
The program will include a focus on child health and targeted investment in the early years that will
include a Prevention and Early Intervention Unit in the Department of Public Expenditure and
Reform/Finance focused on early intervention policies to improve life outcomes. The Government
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 72
developed the Obesity Policy and Action Plan 2016-2025 called A Healthy Weight for Republic of
Ireland aimed at assisting people to achieve better health and specifically reduce levels of
overweight and obesity. This approach is also based on the Government’s 2013 framework for
improved health and well-being, Healthy Republic of Ireland. A Healthy Weight for Republic of
Ireland covers a 10-year period (2016-2025) setting targets and actions to produce results and
includes: a sugar levy; a whole school approach; food establishments posting calorie content of
dishes; food industry reducing sugar, fat, and salt; and a code of practice for food and drink
marketing. (Department of Health, 2016) The critical point in the success of the plan relies on the
meaningful application of the Ten Steps Forward by government and non-government bodies. The
Ten Steps Forward:
1. Embed multi-sectoral actions on obesity prevention with the support of government
departments and public sector agencies.
2. Regulate for a healthier environment.
3. Secure appropriate support from the commercial sector to play its part in obesity
prevention.
4. Inform and empower change through a clear communications strategy.
5. The Department of Health will provide leadership.
6. Mobilise the health services with a focus on prevention.
7. Develop a service model for specialist care for children and adults.
8. Acknowledge the key role of physical activity in the prevention of overweight and obesity.
9. Allocate resources according to need, in particular children and disadvantaged groups.
10. Monitor research and review
The Government has partnered with non-government and external agencies across sectors to
actualize its policies and plans, to continue evaluation of the epidemic, and to advise on policy, and
regularly works with Republic of Ireland Department of Public Health (IPH) who assisted the
Government with policy development and implementation of A Healthy Weight for Republic of
Ireland. IPH contributed to the evidence base on a sugar sweetened drinks tax in 2012, when
commissioned by the Department of Health in the Republic of Republic of Ireland to undertake
a Health Impact Assessment. With the support of the EC, IPH is currently evaluating the lifetime
impact of childhood overweight and obesity as measured by body mass index (BMI), on the
individual and the society in terms of financial and human costs.
SafeFood has collaborated with IDPH, University College Cork, the European Commission and other
agencies to provide the first estimate of the financial costs of overweight and obesity to Republic of
Ireland in 2012, and are continuing to advance these investigations with a report of the Lifetime Cost
of Childhood Obesity (2017). In 2013, SafeFood worked with the Special Advisory Group on Obesity
(SAGO) and with the Regional Obesity Prevention Implementation Group (ROPIG) in Northern Ireland
on an obesity awareness public health campaign.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 73
Children and Young People's Services Committees (CYPSC) operate on a county level to secure better
outcomes for children and young people in their area through more effective integration of existing
services and interventions. The Government identified them as a key to plan and co-ordinate
services for children and young people in every country in Republic of Ireland. One of CYPSC’s
priorities is obesity prevention and is developing initiatives to raise awareness of the issue of
childhood obesity. (CYPSE, 2017)
The European Union designed the Action Plan on Childhood Obesity 2014-2020 that aims halting the
rise in people’s ages 0-18 by 2020, requiring the involvement of many stakeholders within each
member state to develop relevant policy.
The Irish Government’s understanding of the complexity of the causes and contributors to the
obesity epidemic has culminated into the multi-sector solution strategy and an active collaboration
stance with internal and external agencies. This has provided a welcoming environment to support
and nurture results-oriented investigations, policy, and programs to bring results.
Northern Ireland Context: The government of Northern Ireland has very actively developed and
implemented programs to address the obesity and overweight epidemic and regularly evaluates
program effectiveness and modifies programs based on program outcomes and new evidence. The
Government’s acknowledgement of the complex solution required to address overweight and
obesity, due to the obesogenic environment, resulted in the current evidence-based, integrated,
cross-sector, life course policy approach.
Leading up to the current approach, the Government had addressed obesity with Fit Futures, a
nutrition and exercise approach. The 2007 UK-wide Foresight Report, Tackling Obesities: Future
Choices, suggested policy ineffectiveness due to the obesogenic environment requiring
comprehensive interventions. The report also evaluated how to address obesity over the next 40
years. The Department of Health, Social Services and Public Safety (DHSSPS) established the cross-
sectoral Obesity Prevention Steering Group (OPSG) in 2008 to promote Fit Futures and develop a life
course framework to tackle obesity that would replace Fit Futures. A whole system approach to
health became the foundation for A Fitter Future for All - Framework for Preventing and Addressing
Overweight and Obesity in Northern Ireland 2012-2022 and for Making Life Better - A Whole System
Strategic Framework for Public Health 2013 -2023, which is aimed at overall health and wellbeing
and includes tackling obesity as one of its aims. Both programs involve steering committees to
oversee progress and the Public Health Agency to facilitate implementation and delivery. (DHSSPS
2012; 2013) In 2012, various efforts had accomplished: the development of public information
campaigns and supporting materials; delivery of relevant training and support; development of
nutritional guidelines in key settings, particularly schools; community based initiatives on food and
physical activity; the introduction of the curriculum sports programme for primary schools, which
enables pupils to develop their physical literacy skills working with coaches from the GAA and IFA;
support, advice and guidance for professionals; improved support in health care settings, including
physical activity referrals; strengthened code of conduct for advertising high fat, sugar, or salt foods
to children; improved evidence and research base; and work with industry, including progress on
reformulation and improved labelling (DHSSPS).
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 74
Additional action include: Healthy Child, Healthy Future (DHSSPS, 2010), a framework for the
Universal Child Health Promotion Programme that involves the family in adopting health-enhancing
behaviours for children age 0-19; Healthy Foods for Health Outcomes (DHSSPS & DE, 2013) that
advocates a whole school approach to all food provided in schools; and the Public Health Agency’s
Obesity Awareness Week. The government also partners with regional government and external
agencies to actualize and extend its policies, including: district councils; schools; leisure centres and
healthy living centres; Regional Obesity Prevention Implementation Group (ROPIG) who developed
an obesity awareness public health campaign; Republic of Ireland Department of Public Health, who
is currently evaluating the lifetime impact of childhood overweight and obesity as measured by body
mass index (BMI), on the individual and the society in terms of financial and human costs; the Food
Standards Agency (FSA); Safefoods, who investigated the financial and healthcare costs to the local
economy as a result of obesity (2011), collaborated with IDPH, UCC, the EC, and other agencies to
provide the first estimate of the financial costs of overweight and obesity to Republic of Ireland
(2012), and the Lifetime Cost of Childhood Obesity (2017); and the Chartered Institute of
Environmental Health (CIEH) to develop a healthier eating award for catering establishments across
Northern Ireland; and The European Union, who designed the Action Plan on Childhood Obesity
2014-2020 that aims halting the rise in peoples ages 0-18 by 2020, requiring the involvement of
many stakeholders within each member state to develop relevant policy.
The Government’s policies aimed at the obesity epidemic are many and varied to address the
multiple causal factors through interventions delivered from multiple sectors of most government
organizations. The integrated environment is hospitable to actualizing these programs.
5.2 LOCAL EVIDENCE
This section should be read in conjunction with the international evidence outlined in Chapter 1.
5.2.1 Childhood Obesity / Overweight
The literature from Republic of Ireland provided 18 sets of estimates of the prevalence of
overweight and obesity. Five are considered here. They come from four sources. The first is the
Growing Up in Republic of Ireland (GUI) study, a national longitudinal survey of representative
samples of children in two cohorts, and followed every 2-3 years. The Infant Cohort of about 11,150
children was first surveyed at age 9 months in 2008-2009, while the Child Cohort of about 8,550
children was first surveyed at age 9 years in 2007-2008. The second is the third round of COSI (2012).
Estimates for adolescents come from a study on second-level students’ participation in sport (Fahey
et al. 2005), while the most recent estimates, based on data collected in 2013-2014, come from the
Fluoride and Caring for Children’s Teeth (FACCT) study (McCarthy et al., 2016a)37.
Among infants aged 9 months who took part in GUI, on the basis of the UK-WHO growth charts,
24.8% of all children were classified as overweight and 15.7% as obese (Mangan & Zgaga, 2014). Also
based on GUI, at age 9, it was reported that 22% of boys and 30% of girls were overweight or obese
(Layte & McCrory, 2011). The FACCT study indicated that 21% of children aged 4-7 years (18% of
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 75
boys and 25% of girls), and 26% of adolescents (aged 11-14 years; 23% of boys and 28% of girls)
were overweight and obese.
The COSI results for Republic of Ireland for round 3, conducted in 2012 (Heinen et al., 2014)
indicated that among children aged 7, the prevalence of overweight and obesity was higher in girls
(22%) than in boys (17%). These estimates are lower than those from the FACCT study for children
aged 4-7 years but the gender difference is consistent. At age 9, COSI estimates indicated that
prevalence was similar for girls (22%) and boys (20%).
Fahey et al. (2005) surveyed a representative sample of adolescents aged 13 to 18 in 2004 and
estimated that about one in five (19.9% of boys and 20.4% of girls) was overweight or obese. The
pattern of prevalence followed a U-shape with age, being lowest among adolescents aged 15 and 16.
5.2.2 Childhood and adulthood Impacts
Three papers from Republic of Ireland examined aspects of cardio-metabolic health. Finucane et al.
(2008a) reported that 51% of boys and 49% of girls had systolic BP in hypertensive range (> 95th
percentile for age, sex and height). Results also showed a clear and continuous increase in systolic BP
with increasing BMI, particularly in boys. This is of significance, since 93% of this sample (aged 2-18
years) was obese. Finucane et al. (2008b) reported significant associations between degree of
obesity, insulin sensitivity and markers of liver steatosis among a sample of obese children and
adolescents (mean age 15.5 years). Carolan et al. (2013) reported that obese children showed
changes in immune cell frequency, inflammatory environment, and regulation of metabolic gene
expression compared to children of healthy weight. These changes have been causally linked to
adult onset of metabolic disease and suggest a future trajectory for the development of type 2
diabetes and premature cardiovascular disease.
Three further papers examined associations between overweight/obesity and muscular-
skeletal/motor function (O’Malley et al., 2012, 2015a, 2015b). For example, in a sample of obese
children and adolescents (mean age 12.2 years), O’Malley et al. (2012) reported moderate negative
correlations were found between body composition and range of motion, flexibility, and strength.
Genu valgum deformity was moderately positively correlated to body mass index.
One source from Republic of Ireland examined psychological/emotional impacts. On the basis of a
representative sample of 9 year-olds, Layte & McCrory (2011) reported that self-perceptions relating
to popularity and physical appearance were significantly negatively related to self-perceptions of
weight. The perception of overweight was also significantly associated higher levels of emotional
and behavioural problems.
5.2.3 Inequalities
Nine studies from Republic of Ireland that examined inequalities in prevalence were retrieved. One
(Williams et al., 2013) confirmed the presence of a socio-economic gradient at age 3 years, while
another study examining weight gain from birth to three years showed that lower SES was
associated with lower birth weights and highest gains in weight; higher gains in weight were
associated with higher maternal weight gain during pregnancy and no breastfeeding (Layte &
Biesma-Blanco, 2014). Multivariate analyses of children’s BMI at age 9 (Layte & McCrory, 2011;
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 76
Keane et al., 2012; Perry et al., 2015) indicated higher prevalence of overweight and obesity among
girls, one parent families, lower occupational class, lower parental education, lower rates of physical
activity, poorer dietary quality, and, in particular, among children with overweight or obese parents.
Walsh and Cullinan (2015) conducted an analysis of the relative contributions of a range of child and
parent characteristics to the socio-economic gradient at age 9 and found that parental
characteristics accounted for a large majority of this gradient, while child-related measures were not
statistically significant. Other studies confirmed an association between socio-economic deprivation
and child overweight/obesity (Heinen et al., 2014; O’Shea et al., 2014). One study (Fahey et al.,
2005) did not find a significant association between SES and rates of overweight or obesity among
adolescents. However, Fahey et al.’s (2005) analysis was bivariate and used a rather broad measure
of SES (parental occupation, split into 9 groups by sector).
5.3 COHORT DETAILS
5.3.1 Profile of Irish Children
The table below gives the profile of children (age 0-17 years), living in Republic of Ireland in 2015.
Most (76.5%) children are healthy weight with 23.5% either obese or overweight. Percent who are
obese/overweight increases with age. In the 0-5 age group, slightly higher percent of males are
obese/overweight than females. However, this changes in 6-11 year old group and persists in the
12-17 year old group with relatively more obese/overweight females than males.
Table 5(a): Profile of Irish Children (2015)
REPUBLIC OF IRELAND
AGE SEX BMI AT AGE 18 NUMBER PERCENTAGE
0-17 YEARS PERSONS OBESE/OVERWEIGHT 281,751 23.5%
HEALTHY WEIGHT 917,569 76.5%
ALL 1,199,320 100.0%
FEMALES OBESE/OVERWEIGHT 144,292 24.6%
HEALTHY WEIGHT 442,234 75.4%
ALL 586,526 100.0%
MALES OBESE/OVERWEIGHT 137,459 22.4%
HEALTHY WEIGHT 475,335 77.6%
ALL 612,794 100.0%
0-5 YEARS PERSONS OBESE/OVERWEIGHT 86,060 19.9%
HEALTHY WEIGHT 345,532 80.1%
ALL 431,592 100.0%
FEMALES OBESE/OVERWEIGHT 40,129 19.0%
HEALTHY WEIGHT 171,030 81.0%
ALL 211,159 100.0%
MALES OBESE/OVERWEIGHT 45,931 20.8%
HEALTHY WEIGHT 174,502 79.2%
ALL 220,433 100.0%
6-11 YEARS PERSONS OBESE/OVERWEIGHT 95,224 23.3%
HEALTHY WEIGHT 312,982 76.7%
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 77
ALL 408,206 100.0%
FEMALES OBESE/OVERWEIGHT 51,495 25.7%
HEALTHY WEIGHT 148,931 74.3%
ALL 200,426 100.0%
MALES OBESE/OVERWEIGHT 43,729 21.0%
HEALTHY WEIGHT 164,051 79.0%
ALL 207,780 100.0%
12-17 YEARS PERSONS OBESE/OVERWEIGHT 100,467 27.9%
HEALTHY WEIGHT 259,055 72.1%
ALL 359,522 100.0%
FEMALES OBESE/OVERWEIGHT 52,668 30.1%
HEALTHY WEIGHT 122,274 69.9%
ALL 174,941 100.0%
MALES OBESE/OVERWEIGHT 47,799 25.9%
HEALTHY WEIGHT 136,782 74.1%
ALL 184,581 100.0%
5.3.2 Details of follow-up
At the end of 2105 after 90 years of follow-up, 4.9% of the initial cohort will be alive.
Table 5(b): Details of the follow-up of Irish children (2015 – 2105)
REPUBLIC OF IRELAND
SEX BMI AT AGE 18 NUMBER ALIVE AT
BEGINNING 2015
NUMBER ALIVE AT
END 2015
PERCENTAGE ALIVE
AT END 2015
PERSONS OBESE/OVERWEIGHT 281,751 12,522 4.4%
HEALTHY WEIGHT 917,569 45,812 5.0%
TOTAL 1,199,320 58,334 4.9%
FEMALES OBESE/OVERWEIGHT 144,292 9,552 6.6%
HEALTHY WEIGHT 442,234 31,456 7.1%
TOTAL 586,526 41,008 7.0%
MALES OBESE/OVERWEIGHT 137,459 2,970 2.2%
HEALTHY WEIGHT 475,335 14,356 3.0%
TOTAL 612,794 17,326 2.8%
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 78
5.4 LIFETIME IMPACTS & COSTS IN REPUBLIC OF IRELAND
5.4.1 Adult Obesity / Overweight
Lifetime income loss
The problem
The total lifetime income loss attributable to childhood obesity/overweight is €256.1m; per person
losses males losing 50% more than females.
Table 5(c): Lifetime income losses attributable to childhood obesity/overweight in Republic of
Ireland (2015 values)
REPUBLIC OF IRELAND
SEX NUMBER OF OBESE /
OVERWEIGHT CHILDREN
IN 2015
TOTAL LIFETIME INCOME
LOSS (€m)
PER PERSON LIFETIME
INCOME LOSS (€)
MALES 137,459 €151.7m €1,104
FEMALES 144,292 €104.3m €723
PERSONS 281,751 €256.1m €909
Towards a solution
If mean childhood BMI is reduced by 1% and 5% then it is expected that lifetime income losses will
be reduced by €13.5m and €61.4m, respectively. Male savings greatly exceed female savings.
Table 5(d): Reductions in lifetime income losses associated with 1% and 5% reductions in
population mean childhood BMI in Republic of Ireland (2015 values)
REPUBLIC OF IRELAND
SEX PERCENT
REDUCTION IN
MEAN CHILDHOOD
BMI
NUMBER OF
OBESE /
OVERWEIGHT
CHILDREN IN 2015
TOTAL LIFETIME
INCOME LOSS
(€m)
REDUCTION IN
LIFETIME INCOME
LOSS
(€m)
MALES
Base (2015) 137,459 €151.7m
1% 131,372 €143.2m €8.6m
5% 112,840 €113.0m €38.8m
FEMALES Base (2015) 144,292 €104.3m
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 79
1% 138,344 €99.4m €5.0m
5% 119,588 €81.7m €22.7
PERSONS Base (2015) 281,751 €256.1m
1% 269,717 €242.5m €13.5m
5% 232,429 €194.6m €61.4m
5.4 .2. Morbidity
(Direct) Healthcare Costs
The problem
In the Republic of Ireland, the excess lifetime direct healthcare costs attributable to childhood
obesity/overweight is estimated to be €944.7m (2015 values) or € 3,353 per person; accounting for
13.6% of all lifetime healthcare costs. Whether referring to total lifetime costs or per person cost,
female costs attributable to childhood obesity/overweight were higher than male costs.
Table 5(e): Lifetime direct healthcare costs for Republic of Ireland's childhood population (2015
values)
REPUBLIC OF IRELAND
SEX BMI AT 18 YEARS NUMBER OF
CHILDREN IN 2015
LIFETIME COST PER
PERSON
(€)
TOTAL LIFETIME
COST
(€m)
MALES OBESE/OVERWEIGHT
137,459 €8,335 €1,145.8m
HEALTHY WEIGHT 475,335 €5,265 €2,502.9m
ALL 612,794 €5,954 €3,648.6m
Lifetime cost attributable to childhood
obesity/overweight
€ 3,070 €422.0m
(PAF = 11.6%)
FEMALES OBESE/OVERWEIGHT 144,292 €8,420 €1,214.9m
HEALTHY WEIGHT 442,234 €4,768 €2,108.4m
ALL 586,526 €5,666 €3,323.3m
Lifetime cost attributable to childhood
obesity/overweight
€ 3,652 €527.0m
(PAF = 15.9%)
PERSONS OBESE/OVERWEIGHT 281,751 € 8,379 €2,360.7m
HEALTHY WEIGHT 917,569 € 5,025 €4,611.2m
ALL 1,199,320 € 5,813 €6,971.9m
Lifetime cost attributable to childhood
obesity/overweight
€ 3,353 €944.7m
(PAF = 13.6%)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 80
Towards a solution
Lifetime healthcare costs were greatly reduced with a 1% and 5% reduction in BMI, with €53.9m
and €245.7m reduction in costs respectively. Cost reductions were substantially greater at 5%
childhood BMI reduction.
Table 5(f): Reduction in lifetime direct healthcare costs that are associated with 1% and 5%
reductions in mean childhood BMI in Republic of Ireland (2015 values)
REPUBLIC OF IRELAND
SEX PERCENT
REDUCTION IN
MEAN
CHILDHOOD BMI
NUMBER OF OBESE /
OVERWEIGHT
CHILDREN IN 2015
TOTAL LIFETIME
HEALTH CARE
COSTS (€m)
REDUCTION IN TOTAL
LIFETIME HEALTH CARE
COSTS (€m)
MALES Base (2015) 137,459 €3,649m
1% 131,372 €3,622m €26.4m
5% 112,840 €3,525m €123.7m
FEMALES Base (2015) 144,292 €3,323m
1% 138,344 €3,296m €27.5m
5% 119,588 €3,201m €122.0m
PERSONS Base (2015) 281,751 €6,972m
1% 269,717 €6,918m €53.9m
5% 232,429 €6,726m €245.7m
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 81
Productivity losses due to absenteeism
The problem
Over a lifetime, the excess productivity losses due to absenteeism attributed to childhood
obesity/overweight is estimated to be €521.9m. Female productivity losses (€299.6m) were larger
than male losses (€223.5m).
Table 5(g): Lifetime productivity losses due to absenteeism for Republic of Ireland's childhood
population (2015 values)
REPUBLIC OF IRELAND
SEX BMI AT 18 YEARS NUMBER OF CHILDREN IN
2015
PER PERSON
LOSS (€)
TOTAL LIFETIME
LOSSES (€m)
MALES OBESE/OVERWEIGHT 137,459 €3,011 €413.9m
HEALTHY WEIGHT 475,335 €1,386 €658.6m
ALL 612,794 €1,750 €1,072.5m
Lifetime loss attributable to childhood
obesity/overweight
€1,626 €223.5m
(PAF = 20.8%)
FEMALES OBESE/OVERWEIGHT
144,292 €3,326 €479.9m
HEALTHY WEIGHT 442,234 €1,250 €552.6m
ALL 586,526 €1,760 €1,032.5m
Lifetime loss attributable to childhood
obesity/overweight
€2,076 €299.6m
(PAF = 29.0%)
PERSONS OBESE/OVERWEIGHT
281,751 €3,172 €893.8m
HEALTHY WEIGHT 917,569 €1,320 €1,211.2m
ALL 1,199,320 €1,755 €2,105.0m
Lifetime loss attributable to childhood
obesity/overweight
€1,852 €521.9m
(PAF = 24.8%)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 82
Towards a solution
As mean childhood BMI is reduced by 1% and 5%, there is expected to be a €33.5m and a €149.0m
reduction in lifetime productivity losses due to absenteeism, respectively. Reductions in productivity
losses were similar for males and females.
Table 5(h): Reductions in lifetime productivity losses due to absenteeism that are associated with
1% and 5% reductions in mean childhood BMI in Republic of Ireland (2015 values)
REPUBLIC OF IRELAND
SEX PERCENT
REDUCTION IN
MEAN CHILDHOOD
BMI
NUMBER OF OBESE /
OVERWEIGHT
CHILDREN IN 2015
TOTAL LIFETIME
PRODUCTIVITY
LOSSES
(ABSENTEEISM) (€m)
REDUCTION IN
LIFETIME
PRODUCTIVITY
LOSSES
(ABSENTEEISM)
(€m)
MALES Base (2015) 137,459 €1,073m
1% 131,372 €1,056m €16.1m
5% 112,840 €1,002m €70.4m
FEMALES Base (2015) 144,292 €1,032m
1% 138,344 €1,015m €17.4m
5% 119,588 €954m €78.6m
PERSONS Base (2015) 281,751 €2,105m
1% 269,717 €2,072m €33.5m
5% 232,429 €1,956m €149.0m
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 83
5.4.3 Mortality
Premature mortality
The problem
The excess risk of premature death that is attributed to childhood obesity/overweight in the
Republic of Ireland is 19.1% in males and 22.7% in females. This equate to an excess of 26,202
premature male deaths and 32,796 excess premature female deaths attributable to childhood
obesity/overweight.
Table 5(i): Premature deaths amongst Republic of Ireland’s childhood population
REPUBLIC OF IRELAND
SEX BMI AT 18 YEARS
NUMBER OF
CHILDREN IN
2015
TOTAL NUMBER OF
PREMATURE DEATHS
LIFETIME RISK OF
PREMATURE DEATH (%)
MALES
OBESE/OVERWEIGHT
137,459 83,587 60.8%
HEALTHY WEIGHT 475,335 198,438 41.7%
ALL 612,794 282,026 46.0%
Risk attributable to childhood obesity/overweight 19.1%
Number attributable to childhood
obesity/overweight
26,202
(PAF = 9.3%)
FEMALES
OBESE/OVERWEIGHT
144,292 85,128 59.0%
HEALTHY WEIGHT 442,234 172,471 39.0%
ALL 586,526 257,599 43.9%
Risk attributable to childhood obesity/overweight 20.0%
Number attributable to childhood 28,854
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 84
obesity/overweight (PAF = 11.2%)
For males and females, amongst those who were healthy weight and obese/overweight as children,
the risk of premature death increases with age. At all ages, the risk is higher amongst males. In both
males and females, and at all ages the risk is higher amongst individuals who were obese/overweight
as a child.
For calculation purposes, all children in the 0-5 years age group in 2015 are assumed to be aged 2 ½
years in 2015
Towards a solution
Table 5(j): Reductions in premature death that are associated with 1% and 5% reductions in mean
childhood BMIs in Republic of Ireland
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 85
SEX
PERCENT REDUCTIONS
IN MEAN CHILDHOOD
BMI
TOTAL NUMBER OF
CHILDREN IN 2015
TOTAL NUMBER
OF PREMATURE
DEATHS
REDUCTION IN NUMBER
OF PREMATURE DEATHS
MALES
Base (2015) 612,794 282,026
1% 612,839 280,754 1,272
5% 612,721 276,078 5,948
FEMALES
Base (2015) 586,526 257,599
1% 586,481 256,916 683
5% 586,599 254,278 3,321
PERSONS
Base (2015) 1,199,320 539,625
1% 1,199,320 537,669 1,955
5% 1,199,320 530,356 9,269
Years of Life Lost (YLL)
The problem
An excess of 46,737 years of life lost (YLL) are attributable to childhood obesity/overweight;
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 86
26,379.1 in males and 21,170.1 in females
Table 5(k): Years of Life Lost (YLL) over the lifetime of Republic of Ireland’s childhood population4
REPUBLIC OF IRELAND
SEX BMI AT 18 YEARS NUMBER OF
CHILDREN IN 2015 YLL PER PERSON
TOTAL NUMBER OF
YLL
MALES
OBESE/OVERWEIGHT 137,459 0.57 78,881.6
HEALTHY WEIGHT 475,335 0.38 181,554.1
ALL 612,794 0.42 260,435.7
YLL per person attributable to childhood obesity/overweight
0.2
Total YLL years attributable to childhood
obesity/overweight
26,379.1
(PAF = 10.1%)
FEMALES
OBESE/OVERWEIGHT 144,292 0.43 62,497.4
HEALTHY WEIGHT 442,234 0.29 126,662.0
ALL 586,526 0.32 189,159.4
YLL per person attributable to childhood obesity/overweight 0.1
Total YLL years attributable to childhood
obesity/overweight
21,170.1
(PAF = 11.2%)
PERSONS
OBESE/OVERWEIGHT 281,751 0.50 141,379.0
HEALTHY WEIGHT 917,569 0.34 308,216.1
ALL 1,199,320 0.37 449,595.1
YLL per person attributable to childhood obesity/overweight
0.2
Total YLL years attributable to childhood
obesity/overweight
46,737.3
(PAF = 10.4%)
Towards a solution
A 1% and 5% reduction in childhood BMI reduces the total number of premature deaths by 1,875
and 7,180. There are larger reductions in premature deaths for males than for females.
4 Discounting has been applied to these figures
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 87
Table 5(l): Reduction in Years of Life Lost (YLL) associated with 1% and 5% reductions in mean
childhood BMI in Republic of Ireland
REPUBLIC OF IRELAND
SEX PERCENT REDUCTION IN
MEAN CHILDHOOD BMI
TOTAL NUMBER OF
OBESE / OVERWEIGHT
CHILDREN IN 2015
TOTAL NUMBER OF
YEARS OF LIFE LOST
TOTAL REDUCTION
IN YEARS OF LIFE
LOST
MALES
Base (2015) 137,459 260,455
1% 131,372 259,446 1,010
5% 112,840 256,050 4,406
FEMALES
Base (2015) 144,292 189,159
1% 138,344 188,294 866
5% 119,588 186,385 2,775
PERSONS
Base (2015) 281,751 449,615
1% 269,717 447,739 1,875
5% 232,429 442,434 7,180
Productivity losses due to premature mortality
The problem
Total excess lifetime productivity loss attributable to childhood obesity/overweight is estimated to
be €2,975.4m, with excess male losses more than double female losses.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 88
Table 5(m): Lifetime productivity losses due to premature mortality amongst Republic of Ireland’s
childhood population (2015 values)
REPUBLIC OF IRELAND
SEX BMI AT 18 YEARS NUMBER OF
CHILDREN IN
2015
LIFETIME LOSS
PER PERSON (€)
TOTAL LIFETIME COST
(€m)
MALES OBESE/OVERWEIGHT
137,459 € 29,098 €4,000m
HEALTHY WEIGHT 475,335 € 13,783 €6,551m
ALL 612,794 € 17,218 €10,551m
Lifetime loss per person attributable
to childhood obesity/overweight
€15,316
Total lifetime loss attributable
to childhood obesity/overweight
€2,105.3m
(PAF = 20.0%)
FEMALES OBESE/OVERWEIGHT 144,292 € 11,225 €1,620m
HEALTHY WEIGHT 442,234 € 5,984 €2,646m
ALL 586,526 € 7,273 €4,266m
Lifetime loss per person attributable
to childhood obesity/overweight
€5,242
Total lifetime loss attributable
to childhood obesity/overweight
€756.4m
(PAF = 17.7%)
PERSONS OBESE/OVERWEIGHT 281,751 € 19,945 €5,620m
HEALTHY WEIGHT 917,569 € 10,024 €9,198m
ALL 1,199,320 € 12,355 €14,817m
Lifetime loss per person attributable
to childhood obesity/overweight
€9,921
Total lifetime loss attributable
to childhood obesity/overweight
€2,795.4m
(PAF = 18.9%)
Towards a solution
With a 1% and 5% reduction in mean childhood BMI, reductions in excess productivity losses due to
premature mortality are estimated to be €169.0m and €1671.0m respectively. Male reductions in
productivity losses are estimated to be about three times greater than those for females.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 89
Table 5(n): Reductions in lifetime productivity losses due to premature death that are associated
with 1% and 5% reductions in mean childhood BMIs in Republic of Ireland (2015 values)
REPUBLIC OF IRELAND
SEX PERCENT REDUCTION
IN MEAN CHILDHOOD
BMI
TOTAL NUMBER OF
OBESE / OVERWEIGHT
CHILDREN IN 2015
TOTAL
PRODUCTIVITY
LOSSES (€m)
TOTAL REDUCTION
IN PRODUCTIVITY
LOSSES (€m)
MALES Base (2015) 137,459 €10,551.3m
1% 131,372 €10,425.8m €125.5m
5% 112,840 €10,034.6m €516.7m
FEMALES Base (2015) 144,292 €4,265.9m
1% 138,344 €4,222.3m €43.5m
5% 119,588 €4,111.6m €154.3m
PERSONS Base (2015) 281,751 €14,817.2m
1% 269,717 €14,648.2m €169.0m
5% 232,429 €14,146.2m €671.0m
5.4.4 Republic of Ireland summary
Childhood obesity/overweight affects citizens, the health and social care systems and (most
significantly) the economics of EU member states. These estimates are likely to be underestimates
because data limitations restricted what impacts and costs could be included.
All monies are in 2015 values. And future costs are discounted by an annual discount rate of 5% per
annum.
Impacts and costs (2015 values) attributable to childhood obesity/overweight in
the Republic of Ireland Total financial costs (€4,518.1M) account for 1.6% of GDP in 2015 Lifetime financial cost is €16,036 per person
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 90
Direct healthcare costs (€944.7M) account for 4.8% of public health expenditure in 2015. Premature deaths (55,056) account for 1 in 10 of all premature deaths Societal costs are larger than direct healthcare costs Premature death is a larger cause of productivity loss than absenteeism (€2,795.4M vs €521.9M) Gender differences:
Male productivity losses due to premature mortality and lifetime income losses are higher
Female direct healthcare costs and productivity losses due to absenteeism are higher
Large savings (€1,127M) with modest changes in mean childhood BMI
Figure 5(c): Lifetime impacts and costs attributable to childhood obesity/overweight in the
Republic of Ireland
IRISH AND NORTHERN IRISH REFERENCES
Carolan, E., Hogan, A.E., Corrigan, M., Gaotswe, G., O'Connell, J., Foley, N., O'Neill, L.A., Cody, D., & O'Shea, D.
(2013). "The impact of childhood obesity on inflammation, innate immune cell frequency, and metabolic
microRNA expression." The Journal of Clinical Endocrinology & Metabolism 99(3): E474-E478.
0 €
500 €
1 000 €
1 500 €
2 000 €
2 500 €
3 000 €
3 500 €
4 000 €
4 500 €
5 000 €
Male Female Persons
Mill
ion
s
PRODUCTIVITY LOSS(ABSENTEEISM
PRODUCTIVITY LOSS(PREMATURE MORTALITY)
LIFETIME INCOME LOSS
DIRECT HEALTH CARE
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 91
Fahey, T., Delaney, L., & Gannon, B. (2005). School children and sport in Republic of Ireland. Dublin: ESRI.
Finucane, F., Pittock, S., Fallon, M., Hatunic, M., Ong, K., Burns, N., Costigan, C., Murphy, N., & Nolan, J.
(2008a). "Elevated blood pressure in overweight and obese Irish children." Irish Journal of Medical Science
177(4): 379-381.
Finucane, F., Teong, L., Pittock, S., Fallon, M., Hatunic, M., Costigan, C., Murphy, N., Crowley, V., & Nolan, J.
(2008b). "Adverse metabolic profiles in a cohort of obese Irish children." Annals of Clinical Biochemistry 45(2):
206-209.
Heinen, M., Murrin, C. Daly, L., O’Brien, J., Heavey, P., Kilroe, J., O’Brien, M., Scully, H., Mulhern, L.M., Lynam,
A., Hayes, C., O’Dwyer, U., Eldin, N., & Kelleher, C. (2014). The Childhood Obesity Surveillance Initiative (COSI)
in the Republic of Republic of Ireland: Findings from 2008, 2010 and 2012. Dublin: Health Service Executive and
Department of Health.
Keane, E., Layte, R., Harrington, J., Kearney, P.M., & Perry, I.J. (2012). "Measured parental weight status and
familial socio-economic status correlates with childhood overweight and obesity at age 9." PloS One 7(8):
e43503.
Layte, R., & Biesma-Blanco, R. (2014). “Social class differences in weight gain from birth to three years.” Paper
presented at the Growing Up in Republic of Ireland Research Conference 2014: Dublin, November.
Layte, R. & McCrory, C. (2011). Growing Up in Republic of Ireland-National Longitudinal Study of Children:
Overweight and Obesity Among 9-Year-Olds. Dublin: Department of Children and Youth Affairs.
McCarthy, L., Keane, E., Geaney, F., O’Sullivan, M., & Perry, I.J. (2016a). Trends and prevalence of overweight
and obesity in primary school aged children in Republic of Ireland from 2002-2015: An update on the existing
literature. Report commissioned by safefood Republic of Ireland. Cork: safefood.
Mangan, L., & Zgaga, L. (2014). “Exploring the association between sleep duration and overweight and obesity
in infants.” Paper presented at the Growing Up in Republic of Ireland Research Conference 2014: Dublin,
November.
O'Malley, G., Hussey, J., & Roche, E. (2012). "A pilot study to profile the lower limb musculoskeletal health in
children with obesity." Pediatric Physical Therapy 24(3): 292-298.
O’Malley, G., Elmes, M., Keating, R., Killeen, S., Doyle, S., Murphy, S., & Lennon, O. (2015a). “Exploring the
prevalence of musculoskeletal impairments in children and adolescents attending an obesity management
service.” Appetite 89: 309.
O’Malley, G., Keating, R., Elmes, M., Killeen, Sheridan, N., Murphy, S., & Brinkley, A. (2015b). “Standing balance
and health-related quality of life in children who are obese.” Appetite 89: 309.
O’Shea, B., Ladewig, E.L., Kelly, A., Reulbach, U., & O’Dowd, T. (2014). “Weighing children; parents agree, but
GPs conflicted.” Archives of Disease in Childhood 99: 543-545.
Perry, C., Keane, E., Fitzgerald, A.P., Layte, R., Perry, I.J., & Harrington, J.A. (2015). “The use of a Dietary Quality
Score as a predictor of childhood overweight and obesity.” BMC Public Health 15: 581.
Walsh, B., & Cullinan, J. (2015). “Decomposing socioeconomic inequalities in childhood obesity: Evidence from
Republic of Ireland.” Economic & Human Biology 16: 60-72.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 93
6. LIFETIME IMPACTS AND COSTS OF CHILDHOOD OBESITY IN
NORTHERN IRELAND (NIR)
6.1 COHORT DETAILS
6.1.1 Profile of Northern Irish children
The table below gives the profile of children (age 0-17 years), living in Northern Ireland in 2015.
Most (74.2%) children are healthy weight with 25.8% either obese or overweight. Percent who are
obese/overweight increases with age. In the 0-5 years age group, 6-11 years age group 12-17 years
age group, there are higher percentages of females who are obese/overweight than males.
However, this difference reduces with age.
Table 6(a): Profile of Northern Irish Children
NORTHEN IRELAND
AGE SEX BMI AT AGE 18 NUMBER PERCENTAGE
ALL PERSONS OBESE/OVERWEIGHT 111,875 25.8%
HEALTHY WEIGHT 320,916 74.2%
TOTAL 432,791 100.0%
FEMALES OBESE/OVERWEIGHT 60,735 28.8%
HEALTHY WEIGHT 149,981 71.2%
TOTAL 210,716 100.0%
MALES OBESE/OVERWEIGHT 51,140 23.0%
HEALTHY WEIGHT 170,935 77.0%
TOTAL 222,075 100.0%
0-5 YEARS PERSONS OBESE/OVERWEIGHT 33,600 22.4%
HEALTHY WEIGHT 116,586 77.6%
TOTAL 150,187 100.0%
FEMALES OBESE/OVERWEIGHT 19,561 26.6%
HEALTHY WEIGHT 53,867 73.4%
TOTAL 73,429 100.0%
MALES OBESE/OVERWEIGHT 14,039 18.3%
HEALTHY WEIGHT 62,719 81.7%
TOTAL 76,758 100.0%
6-11 YEARS PERSONS OBESE/OVERWEIGHT 35,254 24.8%
HEALTHY WEIGHT 106,891 75.2%
TOTAL 142,145 100.0%
FEMALES OBESE/OVERWEIGHT 19,332 28.0%
HEALTHY WEIGHT 49,739 72.0%
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 94
TOTAL 69,071 100.0%
MALES OBESE/OVERWEIGHT 15,922 21.8%
HEALTHY WEIGHT 57,152 78.2%
TOTAL 73,074 100.0%
12-17 YEARS PERSONS OBESE/OVERWEIGHT 43,021 30.6%
HEALTHY WEIGHT 97,438 69.4%
TOTAL 140,459 100.0%
FEMALES OBESE/OVERWEIGHT 21,842 32.0%
HEALTHY WEIGHT 46,375 68.0%
TOTAL 68,217 100.0%
MALES OBESE/OVERWEIGHT 21,179 29.3%
HEALTHY WEIGHT 51,064 70.7%
TOTAL 72,243 100.0%
6.1.2 Details of follow-up
At the end of 2105 after 90 years of follow-up, 6.1% of the initial cohort will be alive.
Table 6(b): Details of the follow-up of Northern Irish children (2015 – 2105)
NORTHERN IRELAND
SEX BMI AT AGE 18 NUMBER ALIVE AT
BEGINNING 2015
NUMBER ALIVE AT
END 2015
PERCENTAGE ALIVE
AT END 2015
Persons Obese/Overweight 111,875 9,298 8.3%
Healthy weight 320,916 16,986 5.3%
Total 432,791 26,283 6.1%
Females Obese/Overweight 60,735 6,033 9.9%
Healthy weight 149,981 10,229 6.8%
Total 210,716 16,262 7.7%
Males Obese/Overweight 51,140 3,265 6.4%
Healthy weight 170,935 6,756 4.0%
Total 222,075 10,021 4.5%
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 95
6.2 LIFETIME IMPACTS & COSTS IN NORTHERN IRELAND
6.2.1. Adult Obesity / Overweight
Lifetime income loss
The problem
In Northern Ireland the total lifetime income losses attributable to childhood obesity/overweight is
estimated to be €116.3m, with total male losses being about 50% higher than total female losses.
Table 6(c): Lifetime income losses attributable to childhood obesity/ overweight in Northern
Ireland (2015 values)
NORTHERN IRELAND
SEX NUMBER OF OBESE / OVERWEIGHT
CHILDREN IN 2015
TOTAL LIFETIME INCOME
LOSS (€m)
PER PERSON LIFETIME
INCOME LOSS (€)
MALES 51,140 €69.8m €1,365
FEMALES 60,735 €46.4m €764
TOTAL 111,875 €116.3m €1,039
Towards a solution
If mean childhood BMI is reduced by 1% and 5% in Northern Ireland, it is estimated that total
lifetime income loss attributable to childhood obesity would be reduced by €4.0m and a €20.1m,
respectively. Total reductions for males are expected to be about 50% higher than reductions for
females.
Table 6(d): Reductions in lifetime income losses that is associated with 1% and 5% reductions in
population mean childhood BMI in Northern Ireland (2015 values)
NORTHERN IRELAND
SEX PERCENT REDUCTION IN
MEAN CHILDHOOD BMI
NUMBER OF OBESE /
OVERWEIGHT
CHILDREN IN 2015
TOTAL LIFETIME
INCOME LOSS (€m)
REDUCTION IN
LIFETIME INCOME
LOSS (€m)
MALES
Base (2015) 51,140 €69.8m
1% 49,218 €67.3m €2.6m
5% 43,168 €57.2m €12.7m
FEMALES Base (2015) 60,735 €46.4m
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 96
1% 58,789 €45.0m €1.5m
5% 51,842 €39.1m €7.4m
PERSONS
Base (2015) 111,875 €116.3m
1% 108,007 €112.3m €4.0m
5% 95,010 €96.2m €20.1m
6.2.2. Morbidity
(Direct) Healthcare costs
The problem
The total excess lifetime direct healthcare costs attributable to childhood obesity/overweight in
Northern Ireland is estimated to be €679.6m. The excesses for males and females were similar.
Table 6(e): Lifetime direct healthcare costs for Northern Ireland's childhood population (2015
values)
NORTHERN IRELAND
SEX BMI AT 18 YEARS NUMBER OF
CHILDREN IN 2015
COST PER
PERSON TOTAL COST
(€) (€m)
MALES
OBESE/OVERWEIGHT 51,140 €15,084 €771.4m
HEALTHY WEIGHT 170,935 €8,537 €1,459.2m
ALL 222,075 €10,044 €2,230.6m
Lifetime cost attributable to childhood
obesity/overweight € 6,547
€334.8m
(PAF = 15.0%)
FEMALES
OBESE/OVERWEIGHT 60,735 €15,001 €911.1m
HEALTHY WEIGHT 149,981 €9,452 €1,417.6m
ALL 210,716 €11,051 €2,328.7m
Lifetime cost attributable to childhood
obesity/overweight € 5,549
€337.0m
(PAF = 14.5%)
PERSONS
OBESE/OVERWEIGHT 111,875 € 15,039 €1,682.5m
HEALTHY WEIGHT 320,916 € 8,964 €2,876.8m
ALL 432,791 € 10,535 €4,559.3m
Lifetime cost attributable to childhood
obesity/overweight € 6,074
€679.6m
(PAF = 14.9%)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 97
Towards a solution
Total excess lifetime healthcare costs in Northern Ireland are expected to be reduced by €22.2m
and €100.1m with 1% and 5% reductions in mean childhood BMI, respectively. Male and female
reductions are similar and total direct healthcare cost reductions were substantially greater at 5%
childhood BMI reduction.
Table 6(f): Reduction in direct lifetime healthcare costs that are associated with 1% and 5%
reductions in mean childhood BMI in Northern Ireland (2015 values)
NORTHEN REPUBLIC OF IRELAND
SEX
PERCENT
REDUCTION IN
MEAN CHILDHOOD
BMI
NUMBER OF OBESE /
OVERWEIGHT
CHILDREN IN 2015
TOTAL LIFETIME
HEALTH CARE
COSTS (€m)
REDUCTION IN
TOTAL LIFETIME
HEALTH CARE
COSTS (€m)
MALES
Base (2015) 51,140 €2,231m
1% 49,218 €2,219m €11.2m
5% 43,168 €2,179m €51.7m
FEMALES
Base (2015) 60,735 €2,329m
1% 58,789 €2,318m €11.0m
5% 51,842 €2,280m €48.4m
TOTAL
Base (2015) 111,875 €4,559m
1% 108,007 €4,537m €22.2m
5% 95,010 €4,459m €100.1m
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 98
Productivity losses due to absenteeism
The problem
The lifetime excess productivity losses due to absenteeism that are attributed to childhood
obesity/overweight was €130.6m. Male excess productivity losses were slightly less than those for
females.
Table 6(g): Lifetime productivity losses due to absenteeism amongst Northern Ireland's childhood
population (2015 values)
NORTHERN IRELAND
SEX BMI AT 18 YEARS NUMBER OF
CHILDREN IN 2015
PER PERSON LOSS
(€)
TOTAL LIFETIME LOSSES
(€m)
MALES
OBESE/OVERWEIGHT 51,140 €2,601 €133.0m
HEALTHY WEIGHT 170,935 €1,443 €246.7m
ALL 222,075 €1,710 €379.7m
Lifetime loss attributable to childhood
obesity/overweight €1,157
€59.2m
(PAF = 15.6%)
FEMALES
OBESE/OVERWEIGHT 60,735 €2,920 €177.4m
HEALTHY WEIGHT 149,981 €1,794 €269.1m
ALL 210,716 €2,119 €446.4m
Lifetime loss attributable to childhood
obesity/overweight €1,126
€68.4m
(PAF = 15.3%)
PERSONS
OBESE/OVERWEIGHT 111,875 €2,774 €310.4m
HEALTHY WEIGHT 320,916 €1,607 €515.8m
ALL 432,791 €1,909 €826.2m
Lifetime loss attributable to childhood
obesity/overweight €1,167
€130.6m
(PAF = 15.8%)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 99
Towards a solution
If mean childhood BMI in Northern Ireland is reduced by 1% and 5%, it is estimated that lifetime
productivity losses attributable to childhood obesity will be reduced by €4.4m and €20.7m
respectively. Reductions in losses were similar for males and females.
Table 6(h): Reductions in lifetime productivity losses due to absenteeism that are associated with
1% and 5% reductions in mean childhood BMI in Northern Ireland (2015 values)
NORTHERN IRELAND
SEX
PERCENT
REDUCTION IN
MEAN
CHILDHOOD BMI
NUMBER OF OBESE /
OVERWEIGHT
CHILDREN IN 2015
TOTAL LIFETIME
PRODUCTIVITY LOSSES
(ABSENTEEISM) (€m)
REDUCTION IN LIFETIME
PRODUCTIVITY LOSSES
(ABSENTEEISM) (€m)
MALES
Base (2015) 51,140 €380m
1% 49,218 €378m €2.1m
5% 43,168 €369m €10.4m
FEMALES
Base (2015) 60,735 €446m
1% 58,789 €444m €2.2m
5% 51,842 €436m €10.3m
TOTAL
Base (2015) 111,875 €826m
1% 108,007 €822m €4.4m
5% 95,010 €805m €20.7m
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 100
6.2.3 Mortality
Premature mortality
The problem
The excess risk of premature death that is attributed to childhood obesity/overweight in Northern
Ireland is 29.9% in males and 25.1% in females. This equates to an excess of 15,279 premature male
deaths and 15,234 excess premature female deaths.
Table 6(i): Premature deaths amongst Northern Ireland’s childhood population
NORTHEN REPUBLIC OF IRELAND
SEX BMI AT 18 YEARS NUMBER OF
CHILDREN IN 2015
TOTAL NUMBER OF
PREMATURE
DEATHS
LIFETIME RISK OF
PREMATURE DEATH (%)
MALES
OBESE/OVERWEIGHT 51,140 28,701 56.1%
HEALTHY WEIGHT 170,935 44,864 26.2%
ALL 222,075 73,565 33.1%
Risk attributable to childhood
obesity/overweight 29.9%
Number attributable to childhood
obesity/overweight
15,279
(PAF = 20.8%)
FEMALES
OBESE/OVERWEIGHT 60,735 32,942 54.2%
HEALTHY WEIGHT 149,981 43,727 29.2%
ALL 210,716 76,669 36.4%
Risk attributable to childhood obesity/overweight 25.1%
Number attributable to childhood
obesity/overweight
15,234
(PAF = 19.9%)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 101
For males and females, amongst those who were healthy weight and obese/overweight as children,
the risk of premature death increases with age. At all ages, the risk is higher amongst males. In both
males and females, and at all ages the risk is higher amongst individuals who were obese/overweight
as a child.
The risk of premature death amongst Northern Ireland’s 0-5 year old children as they age
Towards a solution
A 1% and 5% reduction in mean childhood BMI in Northern Ireland is estimated to reduce the total
number of premature deaths by 563 and 2,519 respectively, with substantially less deaths due to a
5% reduction in BMI.
Table 6(j): Reductions in premature death that are associated with 1% and 5% reductions in mean
childhood BMIs in Northern Ireland
NORTHERN IRELAND
SEX
PERCENT
REDUCTIONS IN
MEAN BMI
TOTAL NUMBER OF
CHILDREN IN 2015
TOTAL NUMBER OF
PREMATURE DEATHS
REDUCTION IN
NUMBER OF
PREMATURE DEATHS
MALES
Base (2015) 222,075 73,565
1% 222,006 73,296 269
5% 222,040 72,297 1,267
FEMALES Base (2015) 210,716 76,669
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 102
1% 210,785 76,375 295
5% 210,751 75,418 1,252
PERSONS
Base (2015) 432,791 150,234
1% 432,791 149,671 563
5% 432,791 147,715 2,519
Years of Life Lost (YLL)
The problem
An excess of 59,618.5 years of Life Lost (YLL) were attributable to childhood obesity/overweight .The
total excess is greater amongst males than it is amongst females.
Table 6(k): Years of life lost (YLL) over the lifetime of Northern Ireland’s childhood population
NORTHERN IRELAND
SEX BMI AT 18 YEARS
NUMBER OF
CHILDREN IN
2015
YLL PER PERSON TOTAL NUMBER OF
YLL
MALES
OBESE/OVERWEIGHT 51,140 1.25 63,995.7
HEALTHY WEIGHT 170,935 0.59 101,169.8
ALL 222,075 0.74 165,165.5
YLL per person attributable to childhood obesity/overweight 0.7
Total YLL attributable to childhood
obesity/overweight
33,727.5
(PAF = 20.4%)
FEMALES
OBESE/OVERWEIGHT 60,735 0.97 58,926.6
HEALTHY WEIGHT 149,981 0.54 80,417.5
ALL 210,716 0.66 139,344.1
YLL per person years attributable to childhood obesity/overweight 0.4
Total YLL attributable to childhood
obesity/overweight
26,361.4
(PAF = 18.9%)
PERSONS
OBESE/OVERWEIGHT 111,875 1.10 122,922.3
HEALTHY WEIGHT 320,916 0.57 181,587.4
ALL 432,791 0.70 304,509.6
YLL per person years attributable to childhood obesity/overweight 0.5
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 103
Total YLL attributable to childhood
obesity/overweight
59,618.5
(PAF = 19.6%)
Towards a solution
A 1% and 5% reduction in mean childhood BMI is expected to reduce total excess YLL by 963 years
and 3,869 years respectively, with many more lives saved with a 5% BMI reduction.
Table 6(l): Reduction in years of life lost (YLL) due to premature mortality that is associated with
1% and 5% reductions in mean childhood BMIs in Northern Ireland
SEX
PERCENT
REDUCTIONS IN
MEAN CHILDHOOD
BMI
TOTAL NUMBER OF
OBESE / OVERWEIGHT
CHILDREN IN 2015
TOTAL NUMBER OF
YEARS OF LIFE
LOST
TOTAL REDUCTION
IN YEARS OF LIFE
LOST
MALES
Base (2015) 51,140 165,172
1% 49,218 164,552 620
5% 43,168 163,123 2,049
FEMALES
Base (2015) 60,735 139,344
1% 58,789 139,001 343
5% 51,842 137,524 1,820
PERSONS
Base (2015) 111,875 304,516
1% 108,007 303,553 963
5% 95,010 300,647 3,869
Productivity losses due to premature mortality
The problem
Total lifetime productivity loss due to premature death that is attributable to childhood
obesity/overweight is estimated to be €1,607.3m in Northern Ireland. The total losses amongst
males (€1,248.7m) is almost treble the total losses amongst females (€415.1m)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 104
Table: 6(m) Lifetime productivity losses due to premature mortality amongst Northern Ireland’s
childhood population (2015 values)
NORTHERN IRELAND
SEX BMI AT 18 YEARS NUMBER OF
CHILDREN IN 2015
LIFETIME LOSS PER
PERSON (€)
TOTAL LIFETIME
LOSS (€m)
MALES
OBESE/OVERWEIGHT 51,140 € 36,736 €1,879m
HEALTHY WEIGHT 170,935 € 12,319 €2,106m
ALL 222,075 € 17,942 €3,984m
Lifetime loss per person cost attributable to childhood
obesity/overweight €24,417
Total lifetime loss attributable to childhood
obesity/overweight
€1,248.7m
(PAF = 31.3%)
FEMALES
OBESE/OVERWEIGHT 60,735 € 12,461 €757m
HEALTHY WEIGHT 149,981 € 5,625 €844m
ALL 210,716 € 7,595 €1,600m
Lifetime loss per person cost attributable to childhood
obesity/overweight €6,835
Total lifetime loss attributable to childhood
obesity/overweight
€415.1m
(PAF = 25.9%)
PERSONS
OBESE/OVERWEIGHT 111,875 € 23,557 €2,636m
HEALTHY WEIGHT 320,916 € 9,191 €2,949m
ALL 432,791 € 12,904 €5,585m
Lifetime loss per person cost attributable to childhood
obesity/overweight €14,367m
Total lifetime loss attributable to childhood
obesity/overweight
€1,607.3m
(PAF = 28.8%)
Towards a solution
With a 1% and 5% reduction in mean childhood BMI, excess productivity losses due to premature
mortality are expected to reduce were substantially by €65.2m and €255.9m respectively. Male
reductions in total losses were around four times the reduction in total losses amongst females.
Table 6(n): Reduced productivity losses due to premature mortality that are associated with 1%
and 5% reductions in mean childhood BMIs in Northern Ireland (2015 values)
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 105
NORTHERN IRELAND
SEX PERCENT
REDUCTIONS IN
MEAN CHILDHOOD
BMI
TOTAL NUMBER OF
OBESE / OVERWEIGHT
CHILDREN
TOTAL
PRODUCTIVITY
LOSSES (€m)
TOTAL REDUCTION
IN PRODUCTIVITY
LOSSES (€)
MALES
Base (2015) 51,140 €3,984.4m
1% 49,218 €3,931.8m €52.7m
5% 43,168 €3,784.6m €199.8m
FEMALES
Base (2015) 60,735 €1,600.5m
1% 58,789 €1,587.9m €12.6m
5% 51,842 €1,544.4m €56.1m
PERSONS
Base (2015) 111,875 €5,584.9m
1% 108,007 €5,519.7m €65.2m
5% 95,010 €5,329.0m €255.9m
6.2.4 Northern Ireland summary
All monies are in 2015 values. Future costs are discounted by an annual discount rate of 5% per
annum.
Impacts and costs (2015 values) attributable to childhood obesity/overweight in
Northern Ireland Premature deaths (30,513) Lifetime financial costs (€2,533.7M) Lifetime financial costs are €22,647 per person Lifetime direct healthcare costs (€679.6M) Societal costs (€1,854.2M) are much larger than direct healthcare costs Premature death is a larger cause of productivity loss than absenteeism (€1,607.3M vs €130.6M) Gender differences:
Productivity losses due to premature mortality and lifetime income losses are higher amongst males
Direct healthcare costs and productivity losses due to absenteeism are higher amongst females
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 106
Large savings (€396.2M) with modest changes (5%) in mean childhood BMI5
Figure 6(c): Lifetime impacts & costs attributable to childhood obesity/overweight in Northern
Ireland
6.2.5 Comparison between the Republic of Ireland and Northern Ireland
As we have already noted, there are similarities in the broad features of the excess burden of
childhood obesity/overweight in the Republic of Ireland and Northern Ireland:
Lifetime total societal costs accounted for the majority of the lifetime total costs; accounting
for 79.1% of the total costs in Republic of Ireland and 73.2% in Northern Ireland.
Lifetime productivity losses due to premature mortality were the greatest single cost item
accounting for 61.9% and 63.4%, respectively, of total lifetime costs in Republic of Ireland
and Northern Ireland.
The total lifetime cost (and per person costs) attributed to childhood obesity/overweight is
much higher for males than it is for females.
Males incur higher total lifetime income losses and productivity losses due to premature
mortality while females incur higher lifetime healthcare costs and productivity losses due to
absenteeism.
5 All monies in 2015 values. Future costs discounted by annual discount rate of 5% per annum.
€0
€500
€1 000
€1 500
€2 000
€2 500
€3 000
Male Female Persons
Mill
ion
s
PRODUCTIVITY LOSS (ABSENTEEISM
PRODUCTIVITY LOSS (PREMATUREMORTALITY)
LIFETIME INCOME LOSS
DIRECT HEALTH CARE
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 107
These differences may be explained in part by higher risk of premature mortality and higher average
incomes amongst males and the greater tendency to seek care and respond to care amongst
females.
Table 6(o): Percentage of total morbidity-related and mortality-related burden attributable to
childhood obesity / overweight (PAFs)
PAFs
IRL NIR
M F P M F P
Direct Healthcare Cost 11.6% 15.9% 13.6% 15.0% 14.5% 14.9%
Productivity Losses (Absenteeism)
29.8% 29.0% 24.8% 15.6% 15.3% 15.8%
Premature Deaths 9.3% 11.2% 20.8% 19.9%
Productivity Losses (Premature Death)
20.0% 17.0% 18.9% 31.3% 25.9% 28.8%
However; the comparison of the Republic of Ireland and Northern Ireland revealed that the excess
burden of childhood obesity/overweight is experienced differently by males and females in the two
countries:
In the Republic of Ireland, childhood obesity/overweight accounted for relatively more of
the morbidity-related burden amongst males than amongst females. In Northern Ireland, no
such gender difference was observed.
In the Republic of Ireland, but not Northern Ireland, childhood obesity/overweight
accounted for relatively more premature mortality amongst females than amongst males.
In both the Republic of Ireland and Northern Ireland, childhood obesity/overweight
accounted for relatively more of the productivity losses due to premature mortality amongst
males than amongst females.
Moreover; the comparison of the Republic of Ireland and Northern Ireland also emphasised the
importance of local context:
Direct health care costs are relatively higher in Northern Ireland
Indirect (societal) costs are relatively higher in the Republic of Ireland
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 108
These differences may be explained in part by the fact that Northern Ireland operates a universal
health care system (NHS in the UK) while a two-tiered public – private health care system operates
in the Republic of Ireland.
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 109
7. LIMITATIONS AND RECOMMENDATIONS
7.1 LIMITATIONS
This section lists the limitations of the JANPA costing model and enhancements. Many of these
limitations arise out of the availability and quality of data and are shared by all costing models
LIMITATIONS REMEDIES
Population
The burden of childhood obesity is
unequally shared across our community.
Work programme to incorporate racial, ethnicity
and migrant /asylum seeker status into the
costing model.
Work programme to incorporate differences
between individuals in care and those not in care
into the costing model.
Linking with the EU commissioned “Health Equity
Pilot Project” (HEPP) to incorporate an equity
dimension to the costing model
BMI
Future age-sex specific BMI distributions of
today’s children may not follow historical
trends
Improvement in obesity surveillance (particularly
early childhood years, adolescence and later
adult years) across all sex, age and BMI groups
Strong population trends in some countries
towards increased prevalence of morbid and
severe obesity with their more severe
consequences
Incorporate sub-division of obese category into
morbidly obese and severely obese sub-
categories
Obesity and overweight are not
distinguished in many studies because of
lack of requisite data
Incorporate separation of obese and overweight
categories
The measurement of overweight and
obesity in epidemiological studies of RRs
may not match the BMI categorisations used
in the JANPA costing model. For example,
measure of central adiposity or the use of
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 110
different reference curves for BMI
Different BMI percentile cut-offs are used
for individual children in clinical settings (for
example, >98th percentile with UK90) and in
population studies (for example, >95th
centile with UK90).
Disease data
Improvements in surveillance of obesity-related
diseases (particularly incidence and survival)
across sex, age and BMI groups
Healthcare Costs
Improvements in collection of healthcare costs
data (particularly primary care and drug
prescription costs) across sex, age and BMI
groups
The international literature shows that the
cost of treatment for conditions not related
to obesity/overweight can be higher
amongst obese/overweight patients than
amongst patients with healthy weight
(Hamilton et al (2016) – in preparation).
This means that excess (direct) healthcare
cost may be underestimated.
No other specific diseases unrelated to
overweight and obesity are considered
Most studies only consider direct healthcare
costs making comparisons across countries
with different healthcare and social care
model difficult
Incorporate indirect healthcare costs (out of
pocket costs incurred by patients, their families
or communities) into the model
Specialist services for morbidly obese
children or adults is not included.
Incorporate specialist services for morbidly obese
children or adults into the model (ECOG and
EASO clinical networks)
Societal Costs
Carers of morbidly obese individuals and
carers of individuals who develop obesity-
related diseases experience reduced lifetime
earnings
Incorporate these associated secondary costs
Pension costs are not included in the
modelling. Ignoring socio-economic
differences, these will tend to higher
amongst individuals who are of healthy
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 111
weight than amongst individuals who are
obese or overweight because of premature
mortality in the latter.
Incorporate adult productivity losses due to:
Reduced productivity at work
(presenteeism)
Short term absences
Early retirement
Statistical issues
The uncertainty limits that accompany the
Model Outputs incorporate variation
associated from the simulation (stochastic
or aleatoric uncertainty) and is derived from
the various probabilistic distributions that
guide the simulations. However, variation
associated with the Collated Data is not
included. Because this source of variation is
expected to be very much larger than that
associated with the simulations, it is
impossible to attach meaningful uncertainty
intervals to the final Model Outputs. These
can probably only be derived from large
scale sensitivity analyses.
Sensitivity analyses
In-depth assessment of validity was not
possible
Incorporate comprehensive sensitivity audit
addressing:
Method of constructing lifetime BMI
trajectories
Definitions of childhood obesity - being
“obese/overweight” as a child
Bottom-up approaches that may use
different measures of adiposity
(measurement vs self-reports)
Incorporate comparison of model-based lifetime
risk of obesity-related diseases and research-
based risks
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 112
7.2 RECOMMENDATIONS
7.2.1 Modelling Methodology
We recommend that:
An independent scientific review of the JANPA costing model and how it was developed
should be undertaken
The detailed suggestions for enhancements of the modelling methodology that are outlined
in Chapter 7 should be incorporated into the future development of the model.
Stand-alone dedicated software, provided as open source code, to fully implement the
JANPA costing model should be developed and available to other researchers for
independent scrutiny and audit
Detailed sensitivity audit and validation of the JANPA costing model should be undertaken
once the open source code is available . This should include calculation of uncertainty
intervals and the validity of critical assumptions and inputs
7.2.2 Data and Research Gaps
The validity and reliability of final results depend on the data inputs. The availability and quality of
data across the countries varied greatly. We recommend that work continues to improve the co-
ordination, and quality of the national and pan-European health information systems, particularly:
Obesity surveillance (particularly early years, later years and adolescence)
Surveillance of obesity-related diseases (particularly incidence and survival)
Healthcare costs (particularly primary care and pharmaceutical)
Analytical methods for using data
The biggest gap in the impacts and costs included in the JANPA costing model relates to the
psychosocial consequences of childhood obesity and the inability to undertake a sensitivity analysis
of the model. We recommend that the JANPA costing model be refined by incorporating research
into the psychosocial impacts of childhood obesity and their implications for human capital and the
economy (effects on school attendance, educational performance and subsequent employability,
position in the labour market and productivity).
In addition we recommend that:
A comprehensive review of multi-morbidities and their effects on the JANPA costing
model’s excess and effect metrics should be undertaken and a work programme to
incorporate its finding into the model should be developed
Support continues for longitudinal studies with long term follow-up
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 113
REFERENCES
Ardeleanu, I.S., Nanu, M., Moldovanu, F., Bacalearos, C., & Moculescu, C. (2015). Overweight and obesity
screening of 6-7 years old and 13-14 years old children in 14 countries from Romanis. Paper presented
at IOMC days. December, Bucharest.
Canning, H. & Mayer, J. (1967). Obesity: An influence on high school performance? American Journal of Clinical
Nutrition. 20(4), 352–354.
Commission of the European Communities. (2007). A Strategy for Europe on Nutrition, Overweight and
Obesity Related Health Issues. [White Paper] Brussels.
http://ec.europa.eu/health/archive/ph_determinants/life_style/nutrition/documents/nutrition_wp_en.
pdf (accessed 20 October 2017).
Currie, C., Zanotti, C., Morgan, A., Currie, D., de Looze, M., Roberts, C., et al., (Eds.). (2012). Social
determinants of health and well-being among young people: Health Behavior in School-Aged Children
(HBSC) study: International report from the 2009/2010 survey. Copenhagen: WHO Regional Office for
Europe (ISBN 978 92 890 1423 6)
http://www.euro.who.int/__data/assets/pdf_file/0003/163857/Social-determinants-of-health-and-
well-being-among-young-people.pdf (accessed 02 October 2017).
Datar, A., Sturm, R. & Magnabosco, J. L. (2004). Childhood overweight and academic performance: national
study of kindergartners and first-graders. Obesity Research, 12, 58– 68.
Department of Health. (2005). Report of the National Taskforce on Obesity: Obesity – The Policy Challenges.
http://health.gov.ie/blog/publications/report-of-the-national-taskforce-on-obesity-obesity-the-policy-
challenges/. (accessed 10 October 2017).
European Commission. (2014). EU Action Plan on Childhood Obesity 2014-2020.
https://ec.europa.eu/health/sites/health/files/nutrition_physical_activity/docs/childhoodobesity_actionplan_
2014_2020_en.pdf (accessed 20 October 2017).
European Council. (2014). Council Conclusions on Nutrition and Physical Activity. http://eur-
lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:52014XG0708%2801%29&rid=14 (accessed 20
October 2017).
Finkelstein, E.A., Graham, W.C.K., & Malhotra, R. (2014). Lifetime Direct Medical Costs of Childhood Obesity.
Pediatrics, Apr 0063; DOI: 10.1542/peds.2014-0063
Kotanidou, E.P., Grammatikopoulou, M.G., Spiliotis, B.E., Kanaka-Gantenbein, C., Tsigga, M., & Galli-
Tsinopoulou, A. (2013). Ten-year obesity and overweight prevalence in Greek children: A systematic
review and meta-analysis of 2001-2010 data. Hormones. 12(4): 537-549.
Kovac, M., Jurak, G., & Leskosek, B. (2012). "The prevalence of excess weight and obesity in Slovenian children
and adolescents from 1991 to 2011." Anthropological Notebooks 18(1): 91-103.
Leskosek, B., Strel, J., & Kovac, M. (2007). “Differences in physical fitness between normal-weight, overweight
LIFETIME IMPACT AND COST OF CHILDHOOD OBESITY IN EUROPE (PART 1) 114
and obese children and adolescents.” Kinesiologia Slovenica 13(1): 21-30.
Matejek, C., Planincec, J., Fosnaric, S., & Pisot, R. (2014). “Relations of weight status and physical fitness of
children in Slovenia.” Zdrav Var 53: 11-16.
Mocnik, M., Nikolic, S., & Varda, N.M. (2015). “Arterial Compliance Measurement in Overweight and
Hypertensive Children.” Indian Journal of Pediatrics DOI 10.1007/s12098-015-1965-2.
Nanu., M.I., Stativa, E., Moldovanu, F., Stoicescu, S., & Novak, C. (2011). Growth and development. Evaluation
of Interventions’ Efficacy of the National Programs Regarding Nutrition of Children under 2 Years.
[chapter translation provided by Nanu, M.I.]
Ng, M., Fleming, T., Robinson, M., Thomson, B., Graetz, N., Margono, C., et al., (2014). Global, regional, and
national prevalence of overweight and obesity in children and adults during 1980-2013: A systematic
analysis for the Global Burden of Disease Study. Lancet, Aug 30;384(9945):746.
Park, M., Falconer, C., Viner, R., & Kinra, S. (2012). The impact of childhood obesity on morbidity and mortality
in adulthood: A systematic review. Obesity Reviews 13: 985-1000.
SafeFood (2017). Lifetime Cost of Childhood Obesity. Currently unpublished.
Sedej, K., Kotnik, P., Avbelj Stefanija, M., Groselj, U., Sirca Campa, A., Lusa, L., Battelino, T., & Bratina, N.
(2014). "Decreased prevalence of hypercholesterolaemia and stabilisation of obesity trends in 5-year-
old children: possible effects of changed public health policies." European Journal of Endocrinology
170(2): 293-300.
Tsai, A.G., Williamson, D.F., & Glick, H.A., (2011). Direct medical cost of overweight and obesity in the USA: A
quantitative systematic review. Obesity Review. 12, 50–61.
Wijnhoven, T. M., van Raaij, J.M., Spinelli, A., Starc, G., Hassapidou, M., Spiroski, I., Rutter, H., Martos, E., Rito,
A.I., Hovengen, R., Peréz-Farinós, N., Petrauskiene, A., Eldin, N., Braeckevelt, L., Pudule, I., Kunesova,
M., & Breda, J. (2014a). "WHO European Childhood Obesity Surveillance Initiative: Body mass index and
level of overweight among 6-9-year-old children from school year 2007/2008 to 2009/2010." BMC
Public Health 14.
Wijnhoven, T., van Raaij, J., Spinelli, A., Starc, G., Hassapidou, M., Spiroskii, I., et al. (2014). WHO European
Childhood Obesity Surveillance Initiative: Body mass index and level of overweight among 6–9-year-old
children from school year 2007/2008 to school year 2009/2010. BMC Public Health, 14:806.
https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-806 (accessed 02 October
2017).
WHO. (2012). European Strategy for the Prevention and Control of Noncommunicable Diseases 2012−2016.
Copenhagen: WHO Regional Office for Europe. ISBN 978 92 890 0268 4.
http://www.euro.who.int/__data/assets/pdf_file/0019/170155/e96638.pdf (accessed 20 October
2017).
World Health Organization (2013). Global Health Observatory Data Repository. Geneva [online database].