Search

Opposition to Universal Basic Income (UBI) is encapsulated by Martinelli’s claim that ‘an affordable basic income would be inadequate, and an adequate basic income would be unaffordable’. In this article, we present a model of health impact that transforms that assumption. We argue that UBI can affect higher level social determinants of health down to individual determinants of health and on to improvements in public health that lead to a number of economic returns on investment. Given that no trial has been designed and deployed with that impact in mind, we present a methodological framework for assessing prospective costs and returns on investment through modelling to make the case for that trial. We begin by outlining the pathways to health in our model of change in order to present criteria for establishing the size of transfer capable of promoting health. We then consider approaches to calculating cost in a UK context to estimate budgetary burdens that need to be met by the state. Next, we suggest means of modelling the prospective impact of UBI on health before asserting means of costing that impact, using a microsimulation approach. We then outline a set of fiscal options for funding any shortfall in returns. Finally, we suggest that fiscal strategy can be designed specifically with health impact in mind by modelling the impact of reform on health and feeding that data cyclically back into tax transfer module of the microsimulation.

Background: Early chronic kidney disease (CKD) diagnosis in patients with type 2 diabetes (T2D) followed by guideline-recommended interventions are key to slowing CKD progression, but adherence to screening recommendations is suboptimal. Inside CKD models the global clinical and economic burden of CKD using country-specific, patient-level microsimulation models. We model the effects of targeted implementation of urine albumin:creatinine ratio (UACR) measurement and intervention in patients with T2D. Methods: We used the Inside CKD microsimulation to model the impact of measuring UACR during routine primary care visits with subsequent intervention in patients with T2D aged ≥45 years, versus current practice. Virtual populations were constructed using published country-specific data on demographics, CKD, T2D, comorbidities and complications. Results: Preliminary data for three countries show that in 2020-2025, measurement of UACR in patients with T2D would prevent CKD progression to stages 3b-5 in 80 000 patients in the UK, 350 000 in the US and 70 000 in Canada (Figure). Associated cost savings would be £90M, $5B and C$1.7B. More countries will be analysed. Conclusion: Preliminary data show that routine UACR measurement with subsequent intervention could potentially reduce the global burden of CKD and healthcare costs in patients with T2D, and improve outcomes. Disclosure S. T. Nolan: Employee; Self; AstraZeneca, Employee; Spouse/Partner; Biomarin, Stock/Shareholder; Self; AstraZeneca, Stock/Shareholder; Spouse/Partner; Biomarin. J. Sanchez: Employee; Self; AstraZeneca, Stock/Shareholder; Self; AstraZeneca. J. Halimi: None. E. Kanda: Speaker’s Bureau; Self; AstraZeneca K. K. G. Li: None. F. Mennini: None. J. Navarro-gonzalez: None. A. Power: Advisory Panel; Self; AstraZeneca, Bayer U. S., Napp Pharmaceuticals, Vifor Pharma Management Ltd., Consultant; Self; AstraZeneca, Speaker’s Bureau; Self; Alexion Pharmaceuticals, Inc., AstraZeneca, Napp Pharmaceuticals, Vifor Pharma Management Ltd. L. Retat: Employee; Self; HealthLumen. N. Tangri: Consultant; Self; AstraZeneca, Boehringer Ingelheim (Canada) Ltd., ClinPredict Inc, Eli Lilly and Company, Mesentech, Otsuka America Pharmaceutical, Inc., PulseData, Roche Pharma, Tricida, Inc., Research Support; Self; Janssen Pharmaceuticals, Inc. L. Webber: Employee; Self; HealthLumen. A. Sultan: Employee; Self; AstraZeneca, Stock/Shareholder; Self; AstraZeneca. J. Wish: Advisory Panel; Self; Akebia Therapeutics, Inc., AstraZeneca, Rockwell Medical, Vifor Pharma Management Ltd., Speaker’s Bureau; Self; Akebia Therapeutics, Inc., AstraZeneca. M. Xu: Employee; Self; HealthLumen. J. Arnlov: Advisory Panel; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Other Relationship; Self; Novartis AG. M. C. Batista: None. C. Cabrera: Employee; Self; AstraZeneca, Stock/Shareholder; Self; AstraZeneca. J. Card-gowers: Employee; Self; HealthLumen. S. Chadban: Advisory Panel; Self; Astellas Pharma Inc., AstraZeneca, Novartis Pharmaceuticals Corporation. G. M. Chertow: Advisory Panel; Self; Ardelyx, Baxter, Cricket Health, DURECT Corporation, Gilead Sciences, Inc., Reata Pharmaceuticals, Inc., Other Relationship; Self; Akebia Therapeutics, Inc., AstraZeneca, Vertex Pharmaceuticals Incorporated. L. Denicola: Consultant; Self; AstraZeneca, Mundipharma International, Novo Nordisk. Funding AstraZeneca

Background: Inside CKD aims to model the future global clinical and economic burden of chronic kidney disease (CKD). Type 2 diabetes (T2D) is a leading cause of CKD, and concomitant CKD and T2D place a significant burden on healthcare systems worldwide. Methods: We used the Inside CKD country-specific, patient-level microsimulation to model global healthcare costs for patients with concomitant CKD and T2D from 2020 to 2025. We constructed virtual populations using country-specific data including demographics, prevalence of CKD (by stage), T2D and complications, and direct costs, from multiple published sources (e.g., NHANES for US; HSE for UK). Results: Preliminary results from three countries show that annual healthcare costs for patients with both CKD and T2D are expected to increase from 2020 to 2025 (US, $51.1B-95.3B; Canada, C$6.5B-11.5B; UK, £2.3B-2.7B) (Figure). Costs attributable to CKD stage 4 are expected to increase the most (US, 4-9% of overall costs; Canada, 9-13%; UK, 7-11%). Conclusion: Healthcare costs for patients with both CKD and T2D are projected to increase in the UK, US and Canada from 2020 to 2025. Later CKD stages are associated with more pronounced cost increases, likely due to both increased prevalence and greater treatment complexity. Early diagnosis and interventions to slow CKD progression are needed to reduce the economic burden of concomitant stage 3-5 CKD and T2D. Disclosure J. Sanchez: Employee; Self; AstraZeneca, Stock/Shareholder; Self; AstraZeneca. J. Halimi: None. E. Kanda: Speaker’s Bureau; Self; AstraZeneca K. K. G. Li: None. F. Mennini: None. J. Navarro-gonzalez: None. S. T. Nolan: Employee; Self; AstraZeneca, Employee; Spouse/Partner; Biomarin, Stock/Shareholder; Self; AstraZeneca, Stock/Shareholder; Spouse/Partner; Biomarin. A. Power: Advisory Panel; Self; AstraZeneca, Bayer U. S., Napp Pharmaceuticals, Vifor Pharma Management Ltd., Consultant; Self; AstraZeneca, Speaker’s Bureau; Self; Alexion Pharmaceuticals, Inc., AstraZeneca, Napp Pharmaceuticals, Vifor Pharma Management Ltd. L. Retat: Employee; Self; HealthLumen. N. Tangri: Consultant; Self; AstraZeneca, Boehringer Ingelheim (Canada) Ltd., ClinPredict Inc, Eli Lilly and Company, Mesentech, Otsuka America Pharmaceutical, Inc., PulseData, Roche Pharma, Tricida, Inc., Research Support; Self; Janssen Pharmaceuticals, Inc. L. Webber: Employee; Self; HealthLumen. A. Sultan: Employee; Self; AstraZeneca, Stock/Shareholder; Self; AstraZeneca. J. Wish: Advisory Panel; Self; Akebia Therapeutics, Inc., AstraZeneca, Rockwell Medical, Vifor Pharma Management Ltd., Speaker’s Bureau; Self; Akebia Therapeutics, Inc., AstraZeneca. M. Xu: Employee; Self; HealthLumen. J. Arnlov: Advisory Panel; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Other Relationship; Self; Novartis AG. M. C. Batista: None. C. Cabrera: Employee; Self; AstraZeneca, Stock/Shareholder; Self; AstraZeneca. J. Card-gowers: Employee; Self; HealthLumen . S. Chadban: Advisory Panel; Self; Astellas Pharma Inc., AstraZeneca, Novartis Pharmaceuticals Corporation. G. M. Chertow: Advisory Panel; Self; Ardelyx, Baxter, Cricket Health, DURECT Corporation, Gilead Sciences, Inc., Reata Pharmaceuticals, Inc., Other Relationship; Self; Akebia Therapeutics, Inc., AstraZeneca, Vertex Pharmaceuticals Incorporated. L. Denicola: Consultant; Self; AstraZeneca, Mundipharma International, Novo Nordisk. Funding AstraZeneca

Background and Aims Anaemia is a common complication in patients with chronic kidney disease (CKD) and is associated with increased mortality, cardiovascular complications, reduced quality of life and increased use of healthcare resources. Mathematical modelling based on robust epidemiological and clinical data is a useful approach for predicting the future burden of disease and the impact of different intervention scenarios; this is important for health service planning. This analysis uses a microsimulation model, Inside ANEMIA of CKD, to predict the effects of a hypothetical intervention scenario that reduces the prevalence of anaemia of CKD on related healthcare costs in the USA from 2020 to 2025. Method A virtual cohort representing the US population was created within the Inside ANEMIA of CKD microsimulation model framework using demographics and epidemiological data drawn from the US Census Bureau, the Centers for Disease Control and Prevention, and the National Health and Nutrition Examination Survey. In the cohort, virtual individuals were ascribed an age–sex-stratified CKD status (defined by estimated glomerular filtration rate and albuminuria levels, as per international guidelines) and anaemia status (defined by haemoglobin level as mild, moderate or severe, as per WHO criteria) based on US prevalence data. Key comorbidities (type 2 diabetes, heart failure and hypertension) were also assigned, reflecting US-specific population statistics. Healthcare costs related to CKD and anaemia of CKD were taken from the published literature. The study modelled the effects on healthcare costs of a hypothetical intervention scenario in which the prevalence of moderate and severe anaemia is reduced by 20% per year from 2020 to 2025 compared with no intervention (baseline). In each scenario (i.e. intervention or baseline), the modelling analysis estimated healthcare costs related to CKD and anaemia (including inpatient, outpatient, pharmacy costs) for patients with moderate or severe anaemia of CKD. The model did not adjust for the potential costs of the intervention. Results Preliminary results predict that, with the hypothetical intervention, there could be 1.40 million fewer patients with moderate or severe anaemia of CKD in the USA in 2025 compared with no intervention (1.45 million versus 2.85 million). This represents a 49% reduction in cases of moderate or severe anaemia of CKD in 2025 with the intervention versus no intervention. The intervention is projected to lead to a reduction of approximately US$18 billion in annual direct healthcare costs in 2025 for patients with moderate or severe anaemia of CKD compared with no intervention (US$26 billion versus US$44 billion). Conclusion The Inside ANEMIA of CKD microsimulation model predicts that a hypothetical intervention which reduces the prevalence of moderate and severe anaemia of CKD would reduce direct healthcare costs. This suggests that interventions effective at reducing the prevalence of anaemia of CKD would help to reduce the economic burden on healthcare services.

Background and Aims Chronic kidney disease (CKD) is a debilitating and costly condition, affecting approximately 10% of people globally. Progression of CKD is associated with an increased incidence of adverse renal and cardiovascular outcomes, and premature mortality, as well as increased requirement for renal replacement therapies (RRTs), which are associated with significant healthcare costs and resource use. The trajectories of CKD prevalence, progression, outcomes and the related costs are therefore critical considerations for public health and policy planning. Using country-specific, patient-level microsimulation, Inside CKD aims to model the global clinical and economic burden of CKD from 2020 to 2025. Method We used the Inside CKD microsimulation to model the economic burden of CKD in Europe. A virtual general population was developed for each country using national survey data and relevant data from published literature. Data inputs included country demographics, the prevalence of CKD and RRT, comorbidities and complication rates, as well as associated healthcare costs. CKD stages were defined according to Kidney Disease Improving Global Outcomes (KDIGO) 2012 recommendations and patients were categorized according to estimated glomerular filtration rate and albuminuria status. RRT modelling was calibrated against historical trends from country-specific renal registries. Model validation and calibration were conducted following established methods for health economic modelling. Here, we report the initial results from the UK analysis, with further analyses currently underway for additional European countries. Results The UK analysis revealed that annual healthcare costs associated with CKD will increase linearly from £12.51B to £13.99B between 2020 and 2025. The largest absolute increase in cost was observed in CKD stage 3b (£0.75B); however, CKD stage 5 had the largest relative increase in cost with an approximately three-fold increase (£0.14B to £0.41B). By 2025, costs associated with CKD will increase across all age categories (18–34, 35–64 and 65+ years); the 35–64 age group had the largest absolute increase in costs with an increase of £1.14B (£2.02B to £3.16B). The largest relative increase in cost was observed in the 18–34 age category, with a three-fold increase in costs (£0.09B to £0.27B). Conclusion Initial results from Inside CKD demonstrate that CKD poses a significant economic burden over the next 5 years. CKD stages 3b and 5 were associated with the most pronounced cost increases, likely due to increased prevalence for stage 3b and greater treatment cost for stage 5. Notably, the largest increase in CKD costs was observed in the 35–64-year-old ‘working’ population. Further policy interventions aimed at early diagnosis and proactive management should be considered to slow disease progression, improve patient outcomes and reduce the economic burden associated with CKD.

Background and Aims Anaemia is common in patients with chronic kidney disease (CKD) and is associated with increased mortality, cardiovascular complications, reduced quality of life and increased use of healthcare resources. Based on robust epidemiological and clinical data, mathematical modelling is a useful approach for predicting the future burden of disease and the effects of different intervention scenarios, which is essential for health service planning. This analysis uses a microsimulation model, Inside ANEMIA of CKD, to project the impact of a hypothetical intervention scenario that reduces the prevalence of anaemia of CKD on related healthcare costs in Canada from 2020 to 2025. Method A virtual cohort representing the Canadian population was created within the Inside ANEMIA of CKD microsimulation model framework using national demographics and epidemiological data drawn from Statistics Canada and a provincial renal database. In the cohort, virtual individuals were ascribed an age- and sex-stratified CKD status (defined by estimated glomerular filtration rate and albuminuria levels, as per international guidelines) and anaemia status (defined as mild, moderate or severe based on haemoglobin level, as per WHO criteria) based on Canadian prevalence data. Key comorbidities (type 2 diabetes, heart failure and hypertension) were also assigned, reflecting Canada-specific population statistics. Costs related to the treatment of CKD were taken from the published literature, and are shown in Canadian dollars (C$). This modelling analysis evaluated the effects on healthcare costs of a hypothetical intervention scenario in which the prevalence of moderate and severe anaemia is reduced by 20% per year from 2020 to 2025 compared with no intervention (baseline). In each scenario (i.e. intervention or baseline), the modelling analysis estimated CKD-related healthcare costs for patients with moderate or severe anaemia of CKD. The modelling analysis did not adjust for the potential costs of the intervention. Results Preliminary results predict that, with the hypothetical intervention, there could be approximately 435,000 fewer patients with moderate or severe anaemia of CKD in Canada in 2025 compared with no intervention (approximately 497,000 versus 932,000). The intervention is projected to lead to a reduction of C$4.4 billion in annual direct healthcare costs in 2025 for patients with moderate or severe anaemia of CKD compared with no intervention (C$9.1 billion versus C$13.5 billion), assuming that all eligible patients are diagnosed and treated. Conclusion The Inside ANEMIA of CKD microsimulation model predicts that a hypothetical intervention which reduces the prevalence of moderate and severe anaemia of CKD would produce reductions in direct healthcare costs. This suggests that interventions effective at reducing the prevalence of anaemia of CKD would help to reduce the economic burden on healthcare services.

Background and Aims With an estimated global prevalence of 10%, chronic kidney disease (CKD) and its associated complications place a substantial strain on healthcare systems worldwide, which is compounded by the burden of undiagnosed CKD. Early CKD diagnosis followed by guideline-recommended interventions can improve patient outcomes and reduce associated healthcare-related costs, particularly by delaying or preventing the development of complications and progression to kidney failure. Urinary albumin-to-creatinine ratio (UACR) can be used to screen for CKD, but adherence to screening recommendations is suboptimal in routine care. Inside CKD aims to model the global clinical and economic burden of CKD using country-specific, patient-level microsimulation models. We used the Inside CKD microsimulation to model the potential clinical and economic impacts of routine measurement of UACR followed by appropriate intervention in patients aged 45 years and over in the US and Canada. Method The Inside CKD microsimulation model was used to model the clinical and economic impacts associated with measurement of UACR with subsequent appropriate intervention during routine primary care visits versus current practice in individuals aged 45 years and over. The model covers the period 2020–2025. In preliminary analyses, virtual populations representing the general populations of the US and Canada were constructed using published country-specific data, including demographics, prevalence of CKD and comorbidities (type 2 diabetes, uncontrolled hypertension and heart failure), incidence of complications (heart failure, myocardial infarction, stroke and acute kidney injury) and costs associated with CKD. The model also included parameters relating to the proportion of patients who visit a primary care physician at least once a year, the proportion of patients who agreed to UACR measurements, and the diagnostic sensitivity and specificity of UACR measurements. The modelling is being expanded to additional countries in the Americas and the Asia-Pacific region. Results Preliminary results from the US and Canada show that over the 2020–2025 period routine measurement of UACR during primary care visits followed by appropriate intervention could prevent progression to CKD stages 3b–5 in approximately 1.3M patients in the US and 160 000 in Canada, compared with current clinical practice, with linear increases in the cumulative numbers of prevented cases (Figure). Associated savings in healthcare costs in 2025 are projected to be approximately US$16B in the US and C$2.5B in Canada, corresponding to a reduction in cost for that year of 4.4% and 7.4%, respectively, compared with current clinical practice. Conclusion Preliminary results from the Inside CKD microsimulation model in the US and Canada show that routine measurement of UACR with subsequent intervention in primary care would prevent progression to CKD stages 3b–5 in a substantial number of patients compared with current screening practices, and could therefore decrease associated healthcare costs considerably. This analysis is being extended to further countries in the Americas and the Asia-Pacific region.

Background and Aims Anaemia is a common complication in patients with chronic kidney disease (CKD). Prevalence of anaemia increases with CKD severity and ranges from 17% in patients with stage 3 disease to over 50% in patients with stage 5 CKD who are not on dialysis. Anaemia of CKD is associated with increased mortality, cardiovascular complications, reduced quality of life and increased use of healthcare resources. Mathematical modelling based on robust epidemiological and clinical data is a useful approach for predicting the future burden of disease, which is important for health service planning. This analysis uses a microsimulation model, Inside ANEMIA of CKD, to project the economic burden of anaemia of CKD in Canada from 2020 to 2025. Method A virtual cohort representing the Canadian population was created within the Inside ANEMIA of CKD microsimulation model framework, using Canadian demographics and epidemiological data drawn from Statistics Canada and a provincial renal database. In the cohort, virtual individuals were ascribed an age–sex-stratified CKD status (defined by estimated glomerular filtration rate and albuminuria levels, as per international guidelines) and anaemia status (defined as mild, moderate or severe based on haemoglobin level, as per WHO criteria) based on Canadian prevalence data. Key comorbidities (type 2 diabetes, heart failure and hypertension) were also assigned, reflecting Canada-specific population statistics. Incidence rates for acute kidney injury and cardiovascular complications (heart failure, myocardial infarction and stroke) were drawn from the literature. Costs related to CKD, anaemia of CKD and associated complications were taken from Canadian government sources and the literature, and are shown in Canadian dollars (C$). Results Preliminary results show that, in Canada, the number of individuals with anaemia of CKD is projected to increase by approximately 0.8 million between 2020 and 2025 (from 1.8 million to 2.6 million). Annual healthcare costs for patients with anaemia of CKD are projected to increase by 17% by 2025 (from C$19.3 billion to C$22.5 billion). Between 2020 and 2025, the costs associated with cardiovascular complications in patients with anaemia of CKD are projected to increase by 28% for heart failure (from C$1.13 billion to C$1.45 billion), 26% for myocardial infarction (from C$0.83 billion to C$1.05 billion) and 29% for stroke (from C$0.99 billion to C$1.29 billion). Conclusion Inside ANEMIA of CKD is the first microsimulation model to project the economic burden of anaemia of CKD in Canada. Based on the modelling projections, the increase in the number of individuals with anaemia of CKD over the next 5 years will be accompanied by a parallel increase in associated healthcare costs and a marked rise in the cost of cardiovascular complications. Evidence-based therapies for anaemia of CKD that lower cardiovascular complications are needed to reduce the economic burden on healthcare services.

Background and Aims Chronic kidney disease (CKD) represents an important health policy concern due to a growing population and its associated morbidity and mortality. Predicting the future burden of CKD overall and in high-risk populations such as patients with elevated albuminuria, type 2 diabetes (T2D) or heart failure (HF) is important if healthcare services are to be resourced properly. Health economic policy models based on epidemiological and clinical outcomes data provide a useful way by which to make such predictions; different methods of varying complexity have been employed to do this. This study aims to compare two different analytical approaches to estimating the burden of CKD in the UK, and to estimate how this is predicted to change in the future. Method Analysis 1 and 2 characterised the prevalent and incident CKD population, disease progression, clinical outcomes, costs and quality of life sourced from published data over a 5-year horizon. Analysis 1 utilised an open cohort analysis based on a Markov framework, with health states defined by CKD stages. Disease progression was modelled through the application of published estimates of the rate of estimated glomerular filtration rate (eGFR) decline, stratified by the presence of T2D, HF and albuminuria. Results Conclusion

Aim The English NHS currently has a policy of providing Health Checks to all 40–74 year olds. Administered in primary care, they aim to identify patients at risk of a range of diseases, including diabetes and heart disease, and facilitate care. This study is the first to use observed data on the effectiveness of the Checks to consider whether they represent a cost-effective use of limited NHS resources. Subject and methods Using a publicly available evaluation tool we conducted an analysis of the Checks to establish the long-term cost and health-related outcomes of a cohort of patients. The primary focus of the analysis was to establish whether the impact of the Checks on BMI was sufficient to justify their cost. Results The Checks were associated with a reduction in mean BMI of 0.27 (95% CI 0.20 to 0.34) compared to no Check. When applied to the evaluative tool, a small but positive QALY gain of 0.05 per participant was observed, coupled with a reduction in disease-related care costs of £170 ($210 USD). When the estimated cost per Check (£179, $220 USD) is taken into account, we estimate an incremental cost-effectiveness ratio of £900/QALY ($1109 USD/QALY). Conclusions Much of the criticism of the Health Checks has focussed on the relatively small average change in risk factors such as BMI. However, this analysis suggests that the significant health and cost-saving benefits from even a modest reduction in mean BMI, coupled with the low costs of the Checks, combine to result in a potentially highly cost-effective policy. Electronic supplementary material The online version of this article (doi:10.1007/s10389-017-0801-8) contains supplementary material, which is available to authorized users.

In public health, model predictions are used by decision-makers to minimise health burdens and monetary costs of non-communicable diseases. Fully understanding the uncertainty underlying those predictions is thus crucial. One-parameter-at-a-time methods are typically used for model uncertainty analysis but are often impractical for large-scale nonlinear models containing a very large number of parameters and cannot be used to examine the uncertainty associated with parameter interaction. An individual-based chronic disease model was developed to model the impact of Body Mass Index (BMI) trends on the rates of non-communicable diseases. The model was simulated for overweight and obese male case studies and used to predict their life expectancy, disease-free life expectancy and quality-adjusted life years. Uncertainty was estimated by carrying out a global sensitivity analysis by assessing the contribution to the overall uncertainty from a selection of parameters individually and from their interactions. Results show that the uncertainty of the BMI input parameter had the greatest impact on the disease-free life expectancy and quality adjusted life year uncertainty compared to the relative risks of colorectal cancer and stroke. Life expectancy uncertainty was influenced by BMI and colorectal cancer relative risks. Global sensitivity analysis enables the assessment of the parametric uncertainty for individual parameters and their interaction. This allows the communication of the uncertainty of different policy options. A strategy for scaling-up uncertainty analysis from an individual to a population level is discussed.

Background The Brief Intervention for Weight Loss Trial enrolled 1882 consecutively attending primary care patients who were obese and participants were randomised to physicians opportunistically endorsing, offering, and facilitating a referral to a weight loss programme (support) or recommending weight loss (advice). After one year, the support group lost 1.4 kg more (95%CI 0.9 to 2.0): 2.4 kg versus 1.0 kg. We use a cohort simulation to predict effects on disease incidence, quality of life, and healthcare costs over 20 years. Methods Randomly sampling from the trial population, we created a virtual cohort of 20 million adults and assigned baseline morbidity. We applied the weight loss observed in the trial and assumed weight regain over four years. Using epidemiological data, we assigned the incidence of 12 weight-related diseases depending on baseline disease status, age, gender, body mass index. From a healthcare perspective, we calculated the quality adjusted life years (QALYs) accruing and calculated the incremental difference between trial arms in costs expended in delivering the intervention and healthcare costs accruing. We discounted future costs and benefits at 1.5% over 20 years. Results Compared with advice, the support intervention reduced the cumulative incidence of weight-related disease by 722/100,000 people, 0.33% of all weight-related disease. The incremental cost of support over advice was £2.01million/100,000. However, the support intervention reduced health service costs by £5.86 million/100,000 leading to a net saving of £3.85 million/100,000. The support intervention produced 992 QALYs/100,000 people relative to advice. Conclusions A brief intervention in which physicians opportunistically endorse, offer, and facilitate a referral to a behavioural weight management service to patients with a BMI of at least 30 kg/m2 reduces healthcare costs and improves health more than advising weight loss.

Background Adults with severe obesity [body mass index (BMI) of ≥ 35 kg/m2] have an increased risk of comorbidities and psychological, social and economic consequences. Objectives Systematically review bariatric surgery, weight-management programmes (WMPs) and orlistat pharmacotherapy for adults with severe obesity, and evaluate the feasibility, acceptability, clinical effectiveness and cost-effectiveness of treatment. Data sources Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials and the NHS Economic Evaluation Database were searched (last searched in May 2017). Review methods Four systematic reviews evaluated clinical effectiveness, cost-effectiveness and qualitative evidence for adults with a BMI of ≥ 35 kg/m2. Data from meta-analyses populated a microsimulation model predicting costs, outcomes and cost-effectiveness of Roux-en-Y gastric bypass (RYGB) surgery and the most effective lifestyle WMPs over a 30-year time horizon from a NHS perspective, compared with current UK population obesity trends. Interventions were cost-effective if the additional cost of achieving a quality-adjusted life-year is Results A total of 131 randomised controlled trials (RCTs), 26 UK studies, 33 qualitative studies and 46 cost-effectiveness studies were included. From RCTs, RYGB produced the greatest long-term weight change [–20.23 kg, 95% confidence interval (CI) –23.75 to –16.71 kg, at 60 months]. WMPs with very low-calorie diets (VLCDs) produced the greatest weight loss at 12 months compared with no WMPs. Adding a VLCD to a WMP gave an additional mean weight change of –4.41 kg (95% CI –5.93 to –2.88 kg) at 12 months. The intensive Look AHEAD WMP produced mean long-term weight loss of 6% in people with type 2 diabetes mellitus (at a median of 9.6 years). The microsimulation model found that WMPs were generally cost-effective compared with population obesity trends. Long-term WMP weight regain was very uncertain, apart from Look AHEAD. The addition of a VLCD to a WMP was not cost-effective compared with a WMP alone. RYGB was cost-effective compared with no surgery and WMPs, but the model did not replicate long-term cost savings found in previous studies. Qualitative data suggested that participants could be attracted to take part in WMPs through endorsement by their health-care provider or through perceiving innovative activities, with WMPs being delivered to groups. Features improving long-term weight loss included having group support, additional behavioural support, a physical activity programme to attend, a prescribed calorie diet or a calorie deficit. Limitations Reviewed studies often lacked generalisability to UK settings in terms of participants and resources for implementation, and usually lacked long-term follow-up (particularly for complications for surgery), leading to unrealistic weight regain assumptions. The views of potential and actual users of services were rarely reported to contribute to service design. This study may have failed to identify unpublished UK evaluations. Dual, blinded numerical data extraction was not undertaken. Conclusions Roux-en-Y gastric bypass was costly to deliver, but it was the most cost-effective intervention. Adding a VLCD to a WMP was not cost-effective compared with a WMP alone. Most WMPs were cost-effective compared with current population obesity trends. Future work Improved reporting of WMPs is needed to allow replication, translation and further research. Qualitative research is needed with adults who are potential users of, or who fail to engage with or drop out from, WMPs. RCTs and economic evaluations in UK settings (e.g. Tier 3, commercial programmes or primary care) should evaluate VLCDs with long-term follow-up (≥ 5 years). Decision models should incorporate relevant costs, disease states and evidence-based weight regain assumptions. Study registration This study is registered as PROSPERO CRD42016040190. Funding The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit and Health Economics Research Unit are core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.

Objective: To project the prevalence of obesity across the WHO European region and examine whether the WHO target of halting obesity at 2010 levels by 2025 is achievable. Methods: BMI data were collected from online databases and the literature. Past and present BMI trends were extrapolated to 2025 using a non-linear categorical regression model fitted to nationally representative survey data. Where only 1 year of data was available, a flat trend was assumed. Where no data were available, proxy country data was used adjusted for demographics. Results: By 2025, obesity is projected to increase in 44 countries. If present trends continue, 33 of the 53 countries are projected to have an obesity prevalence of 20% or more. The highest prevalence is projected for Ireland (43%, 95% confidence interval (CI): 28-58%). Lithuania, Finland, and the Netherlands were each estimated to have an absolute increase of 2 percentage points in the prevalence of obesity between 2015 and 2025. Discussion: The quality of BMI data across Europe is highly variable, with fewer than 50% of the 53 countries having measured nationally representative data and often not enough data to interpret projections meaningfully. Nevertheless, the prevalence of obesity in the European Region appears to be increasing in most countries and, with it, the health and economic burden of its associated diseases. This paints a concerning picture of the future burden of obesity-related noncommunicable diseases across the region. Greater and continued effort for the implementation of effective preventive policies and interventions is required from governments.

Background Air pollution damages health by promoting the onset of some non-communicable diseases (NCDs), putting additional strain on the National Health Service (NHS) and social care. This study quantifies the total health and related NHS and social care cost burden due to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) in England. Method and findings Air pollutant concentration surfaces from land use regression models and cost data from hospital admissions data and a literature review were fed into a microsimulation model, that was run from 2015 to 2035. Different scenarios were modelled: (1) baseline ‘no change’ scenario; (2) individuals’ pollutant exposure is reduced to natural (non-anthropogenic) levels to compute the disease cases attributable to PM2.5 and NO2; (3) PM2.5 and NO2 concentrations reduced by 1 μg/m3; and (4) NO2 annual European Union limit values reached (40 μg/m3). For the 18 years after baseline, the total cumulative cost to the NHS and social care is estimated at £5.37 billion for PM2.5 and NO2 combined, rising to £18.57 billion when costs for diseases for which there is less robust evidence are included. These costs are due to the cumulative incidence of air-pollution-related NCDs, such as 348,878 coronary heart disease cases estimated to be attributable to PM2.5 and 573,363 diabetes cases estimated to be attributable to NO2 by 2035. Findings from modelling studies are limited by the conceptual model, assumptions, and the availability and quality of input data. Conclusions Approximately 2.5 million cases of NCDs attributable to air pollution are predicted by 2035 if PM2.5 and NO2 stay at current levels, making air pollution an important public health priority. In future work, the modelling framework should be updated to include multi-pollutant exposure–response functions, as well as to disaggregate results by socioeconomic status., Using microsimulation, Laura Webber and colleagues project the health and social care cost burden of fine particulate matter (PM2.5) and nitrogen dioxide (NO2) in England., Author summary Why was this study done? Air pollution is the leading environmental cause of early death—contributing to the equivalent of 5% of all deaths globally and an estimated 40,000 premature deaths each year in the UK. Air pollution is also responsible for a substantial amount of morbidity, causing short- and long-term health effects, as well as being a significant contributor to health inequalities. Tackling air pollution will improve both the environment and public health. In the new National Institute for Health and Care Excellence/Public Health England air pollution guidance, local authorities are urged to consider a range of effective interventions that promote low or zero emission areas. Knowing the local impact of air pollution on health and related healthcare costs over time is important for future policy and resource planning and to target mitigation measures and public health campaigns. What did the researchers do and find? This study used a dynamic microsimulation model to predict the future health and economic impact of the air pollutants PM2.5 and NO2 to the year 2035. This microsimulation examined data on air pollution exposure by age and sex, making use of disease and population data collected from the literature and from publicly available databases. The microsimulation method is an advanced method for modelling chronic diseases because of its capacity to simulate entire populations at an individual level over a lifetime. Between 2017 and 2025, the total cost to the NHS and social care of air pollution for diseases for which there is more robust evidence for an association is estimated to be £5.56 billion, corresponding to 1.15 million new cases of disease. What do these findings mean? This is the first time to our knowledge that the healthcare costs of air pollution have been estimated in England. The microsimulation tool provides estimates of the prevalence of disease and related NHS and social care costs due to air pollution. These estimates are important and useful statistics that highlight the burden of air pollution to the healthcare system and quantify the health and related NHS and social care cost savings under different scenarios compared to a ‘do nothing’ scenario. The impacts of air pollution and the action required to address them are highly relevant to local government priorities: health, housing, transport, education, local economies, greenspace, and quality of life. Local authorities have long had specific legal air quality powers to tackle air pollution locally where there is evidence from either the local or national assessment regimes that it exceeds legal limits. Alongside these specific obligations, strategic decisions on transport, planning, and public health taken by local governments all contribute to the quality of the air that people breathe in local communities. The UK Government will publish a final clean air strategy by the end of the year. This strategy will set out the range of actions the government will take in the coming years to tackle emissions of 5 key pollutants from a wide range of sources. There will be a need to continually improve our understanding of the important health, environmental, and economic consequences of air pollution in order to deliver an ambitious programme of actions.

Background & Aims: The burden of liver disease in Europe continues to grow. We aimed to describe the epidemiology of liver diseases and their risk factors in European countries, and identify public health interventions that could impact on these risk factors to reduce the burden of liver disease. Methods: As part of the HEPAHEALTH project, commissioned by EASL, we extracted information on historical and current prevalence and mortality from national and international literature and databases on liver disease in 35 countries in the WHO European region, as well as historical and recent prevalence data on their main determinants; alcohol consumption, obesity and hepatitis B and C virus infections. We extracted information from peer-reviewed and grey literature to identify public health interventions targeting these risk factors. Results: The epidemiology of liver disease is diverse and countries cluster with similar pictures, although the exact composition of diseases and the trends in risk factors which drive them is varied. Prevalence and mortality data indicate that increasing cirrhosis and liver cancer may be linked to dramatic increases in harmful alcohol consumption in Northern European countries, and viral hepatitis epidemics in Eastern and Southern European countries. Countries with historically low levels of liver disease may experience an increase in non-alcoholic fatty liver disease in the future, given the rise of obesity across the majority of European countries. Interventions exist for curbing harmful alcohol use, reducing obesity, preventing or treating viral hepatitis, and screening for liver disease at an early stage. Conclusions: Liver disease in Europe is a serious issue, with increasing cirrhosis and liver cancer. The public health and hepatology communities are uniquely placed to implement measures aimed at reducing their causes: harmful alcohol consumption, child and adult obesity prevalence and chronic infection with hepatitis viruses, which will in turn reduce the burden of liver disease. Lay summary: The European region has seen dramatic increases in liver disease mortality and morbidity in recent decades as a result of changes in the underlying risk factors: excessive alcohol consumption, obesity and viral hepatitis. However, there are highly effective ways to combat these, for example increasing the price of alcohol, making it less readily available, reducing the number of calories, sugar and fat in foods we consume, or screening people earlier to treat them more effectively. The time is now for governments, the health system and individuals to implement the changes required to substantially reduce the burden of liver disease.

BACKGROUND: Evidence exist that primary care referral to an open-group behavioural programme is an effective strategy for management of obesity, but little evidence on optimal intervention duration is available. We aimed to establish whether 52-week referral to an open-group weight-management programme would achieve greater weight loss and improvements in a range of health outcomes and be more cost-effective than the current practice of 12-week referrals. METHODS: In this non-blinded, parallel-group, randomised controlled trial, we recruited participants who were aged 18 years or older and had body-mass index (BMI) of 28 kg/m(2) or higher from 23 primary care practices in England. Participants were randomly assigned (2:5:5) to brief advice and self-help materials, a weight-management programme (Weight Watchers) for 12 weeks, or the same weight-management programme for 52 weeks. We followed-up participants over 2 years. The primary outcome was weight at 1 year of follow-up, analysed with mixed-effects models according to intention-to-treat principles and adjusted for centre and baseline weight. In a hierarchical closed-testing procedure, we compared combined behavioural programme arms with brief intervention, then compared the 12-week programme and 52-week programme. We did a within-trial cost-effectiveness analysis using person-level data and modelled outcomes over a 25-year time horizon using microsimulation. This study is registered with Current Controlled Trials, number ISRCTN82857232. FINDINGS: Between Oct 18, 2012, and Feb 10, 2014, we enrolled 1269 participants. 1267 eligible participants were randomly assigned to the brief intervention (n=211), the 12-week programme (n=528), and the 52-week programme (n=528). Two participants in the 12-week programme had been found to be ineligible shortly after randomisation and were excluded from the analysis. 823 (65%) of 1267 participants completed an assessment at 1 year and 856 (68%) participants at 2 years. All eligible participants were included in the analyses. At 1 year, mean weight changes in the groups were -3·26 kg (brief intervention), -4·75 kg (12-week programme), and -6·76 kg (52-week programme). Participants in the behavioural programme lost more weight than those in the brief intervention (adjusted difference -2·71 kg, 95% CI -3·86 to -1·55; pINTERPRETATION: For adults with overweight or obesity, referral to this open-group behavioural weight-loss programme for at least 12 weeks is more effective than brief advice and self-help materials. A 52-week programme produces greater weight loss and other clinical benefits than a 12-week programme and, although it costs more, modelling suggests that the 52-week programme is cost-effective in the longer term. FUNDING: National Prevention Research Initiative, Weight Watchers International (as part of an UK Medical Research Council Industrial Collaboration Award).

IntroductionTaxing tobacco is one of the most effective ways to reduce smoking prevalence, mitigate its devastating consequential health harms and progress towards a tobacco-free society. This study modelled the health and economic impacts of increasing the existing cigarette tobacco duty escalator (TDE) in the UK from the current 2% above consumer price inflation to 5%.MethodsA two-stage modelling process was used. First, a non-linear multivariate regression model was fitted to cross-sectional smoking data, creating longitudinal projections from 2015 to 2035. Second, these projections were used to predict the future incidence, prevalence and cost of 17 smoking-related diseases using a Monte Carlo microsimulation approach. A sustained increase in the duty escalator was evaluated against a baseline of continuing historical smoking trends and the existing duty escalator.ResultsA sustained increase in the TDE is projected to reduce adult smoking prevalence to 6% in 2035, from 10% in a baseline scenario. After increasing the TDE, only 65% of female and 60% of male would-be smokers would actually be smoking in 2035. The intervention is projected to avoid around 75 200 new cases of smoking-related diseases between 2015 and 2035. In 2035 alone, £49 m in National Health Service and social care costs and £192 m in societal premature mortality and morbidity costs are projected to be avoided.ConclusionIncreasing the UK TDE to 5% above inflation could effectively reduce smoking prevalence, prevent diseases and avoid healthcare costs. It would deliver substantial progress towards a tobacco-free society and should be implemented by the UK Government with urgency.

Aim: After dramatic rises in paediatric obesity, the critical period for obesity onset may now be pre-adolescence. Methods: We monitored adiposity over 4 years in 400 children aged 7-9 years recruited from schools in London. Weight, height, waist circumference (WC) and fat mass were measured annually. Weight status was defined using International Obesity Task Force (IOTF) criteria, and standardised scores and percentiles used British 1990 reference data. Results: BMI, WC and fat mass index all tracked strongly over time (average correlation for BMI = 0.95). Emergence of obesity was relatively uncommon: only 2% of the total sample increased from overweight to obese over the 4-year period, and this was nearly matched by the 1.3% that reduced from obese to overweight. However, more children (6%) moved from healthy weight to overweight than the reverse direction (2%). There were greater absolute gains in adiposity in children with higher baseline weight status, but this was disguised in analyses using standardised scores. Obesity was not an emergent trait in middle childhood, but rates were already high and, in absolute terms, adiposity increased more in overweight and obese than healthy weight children. Conclusion: These results highlight the need for active management of obesity in middle childhood.

IntroductionSmoking is still the most preventable cause of cancer, and a leading cause of premature mortality and health inequalities in the UK. This study modelled the health and economic impacts of achieving a ‘tobacco-free’ ambition (TFA) where, by 2035, less than 5% of the population smoke tobacco across all socioeconomic groups.MethodsA non-linear multivariate regression model was fitted to cross-sectional smoking data to create projections to 2035. These projections were used to predict the future incidence and costs of 17 smoking-related diseases using a microsimulation approach. The health and economic impacts of achieving a TFA were evaluated against a predicted baseline scenario, where current smoking trends continue.ResultsIf trends continue, the prevalence of smoking in the UK was projected to be 10% by 2035—well above a TFA. If this ambition were achieved by 2035, it could mean 97 300 +/- 5 300 new cases of smoking-related diseases are avoided by 2035 (tobacco-related cancers: 35 900+/- 4 100; chronic obstructive pulmonary disease: 29 000 +/- 2 700; stroke: 24 900 +/- 2 700; coronary heart disease: 7600 +/- 2 700), including around 12 350 diseases avoided in 2035 alone. The consequence of this health improvement is predicted to avoid £67 +/- 8 million in direct National Health Service and social care costs, and £548 million in non-health costs, in 2035 alone.ConclusionThese findings strengthen the case to set bold targets on long-term declines in smoking prevalence to achieve a tobacco ‘endgame’. Results demonstrate the health and economic benefits that meeting a TFA can achieve over just 20 years. Effective ambitions and policy interventions are needed to reduce the disease and economic burden of smoking.

This study explored associations between child eating behaviors and maternal feeding practices, specifically testing the hypotheses that maternal "restriction" is associated with having a child with stronger food approach tendencies (eg, overresponsiveness to food), and maternal pressure to eat is associated with having a child with food avoidant tendencies (eg, satiety responsiveness). Five-hundred thirty-one families with 7- to 9-year-old children from schools in London, UK, were invited to take part in the Physical Exercise and Appetite in Children Study (PEACHES). Results are from baseline data of this longitudinal study. Of those invited, 405 gave consent for their child to participate (51.6% male; 48% female). Just over half of the mothers (n=213, 53%) completed the Child Eating Behavior Questionnaire and the Child Feeding Questionnaire for the index child (mean age: 8.3±0.62 years) during the 2006-2007 school year. Children were weighed and measured at school by trained researchers. As predicted, maternal restriction was associated with child food responsiveness (P0.001), and maternal pressure to eat was associated with child satiety responsiveness (P0.001), slowness (P=0.03), and fussiness (P=0.01). Child enjoyment of food was associated with lower maternal pressure to eat (P=0.01). All effects were independent of the child's body mass index standard deviation score and sociodemographic factors. Practitioners may find it useful to take an interactional perspective, acknowledging that children both influence and are influenced by their parents' feeding practices. This will allow the development of targeted interventions and better parental guidance on managing obesogenic eating behaviors in young children.

BACKGROUND: The relative reinforcing value (RRV) of food, defined as how hard an individual is prepared to work to gain access to food rather than a nonfood alternative, has been shown to be higher in obese adults and children than in their normal-weight counterparts. However, these cross-sectional studies are unable to determine whether a high RRV of food is predictive of adiposity change or whether it is a consequence of being obese. OBJECTIVE: The objective was to examine the association between the RRV of food and 1-y weight gain in children aged 7-10 y. DESIGN: An observational longitudinal study design was used. The RRV of food was determined by using a questionnaire method at baseline when the children (n = 316) were aged 7-9 y. Adiposity [body mass index (BMI), BMI SD score, fat mass index, waist circumference, and waist circumference SD score] was assessed at baseline and after 1 y. RESULTS: Regression analyses indicated that the RRV of food was not associated with any measure of adiposity at baseline or at the 1-y follow-up (all P > 0.58). Changes in BMI (B = 0.06, P < 0.001), BMI SD score (B = 0.03, P = 0.001), and fat mass index (B = 0.09, P = 0.001) after 1 y were significantly predicted by the RRV of food at baseline. CONCLUSIONS: The RRV of food predicted the change in adiposity over a relatively short-term period of 1 y and thus may be associated with the development of obesity. The lack of association in cross-sectional analyses indicates that this behavior is a risk factor for weight gain, although weight differences may not emerge until later childhood.

BACKGROUND: Although obesity causes many adverse health consequences, modest weight loss reduces the incidence. There are effective interventions that help people to lose weight but weight regain is common and long term maintenance remains a critical challenge. As a high proportion of the population of most high and middle income countries are overweight, there are many people who would benefit from weight loss and its maintenance. Therefore, we need to find effective low cost scalable interventions to help people achieve this. One such intervention that has shown promise is regular self-weighing, to check progress against a target, however there is no trial that has tested this using a randomised controlled design (RCT). The aim of this RCT is to evaluate the effectiveness and cost effectiveness of a brief behavioural intervention delivered by non-specialist staff to promote regular self-weighing to prevent weight regain after intentional weight loss.METHODS: A randomised trial of 560 adults who have lost ≥ 5 % of their initial body weight through a 12 week weight loss programme. The comparator group receive a weight maintenance leaflet, a diagram representing healthy diet composition, and a list of websites for weight control. The intervention group receive the same plus minimally trained telephonists will ask participants to set a weight target and encourage them to weigh themselves daily, and provide support materials such as a weight record card. The primary outcome is the difference between groups in weight change from baseline to 12 months.DISCUSSION: If effective, this study will provide public health agencies with a simple, low cost maintenance intervention that could be implemented immediately.TRIAL REGISTRATION: ISRCTN52341938 Date Registered: 31/03/2014.

Objective Non-communicable diseases (NCDs) are the biggest cause of death in Europe putting an unsustainable burden on already struggling health systems. Increases in obesity are a major cause of NCDs. This paper projects the future burden of coronary heart disease (CHD), stroke, type 2 diabetes and seven cancers by 2030 in 53 WHO European Region countries based on current and past body mass index (BMI) trends. It also tests the impact of obesity interventions on the future disease burden. Setting and participants Secondary data analysis of country-specific epidemiological data using a microsimulation modelling process. Interventions The effect of three hypothetical scenarios on the future burden of disease in 2030 was tested: baseline scenario, BMI trends go unchecked; intervention 1, population BMI decreases by 1%; intervention 2, BMI decreases by 5%. Primary and secondary outcome measures Quantifying the future burden of major NCDs and the impact of interventions on this future disease burden. Results By 2030 in the whole of the European region, the prevalence of diabetes, CHD and stroke and cancers was projected to reach an average of 3990, 4672 and 2046 cases/100 000, respectively. The highest prevalence of diabetes was predicted in Slovakia (10 870), CHD and stroke—in Greece (11 292) and cancers—in Finland (5615 cases/100 000). A 5% fall in population BMI was projected to significantly reduce cumulative incidence of diseases. The largest reduction in diabetes and CHD and stroke was observed in Slovakia (3054 and 3369 cases/100 000, respectively), and in cancers was predicted in Germany (331/100 000). Conclusions Modelling future disease trends is a useful tool for policymakers so that they can allocate resources effectively and implement policies to prevent NCDs. Future research will allow real policy interventions to be tested; however, better surveillance data on NCDs and their risk factors are essential for research and policy.

The first objective is to project obesity trends to 2030 based on the current data from Poland. The second objective is to test the effect of a 1% or 5% decrease in population BMI upon future incidence and prevalence of related non-communicable diseases. A two-stage modelling design projecting overweight and obesity trends and related diseases in a microsimulation model was developed. Epidemiological data for entry into a microsimulation model were gathered from Poland. This study used population level data from Poland creating a virtual population within a microsimulation model. Obesity and overweight in Poland was found to increase to very high levels in men while trends remained unchanged in women. In a country that currently has about 38 million inhabitants, it is anticipated that by 2030, there might be more than 9 million new cancer cases; 10 million CHD and stroke cases, and 7 million new cases of type 2 diabetes. These findings have policy implications highlighting the need for action to curb trends and to reduce increases in the rates of diet-related non-communicable disease.

Background: The majority of chronic disease is caused by risk factors which are mostly preventable. Effective interventions to reduce these risks are known and proven to be applicable to a variety of settings. Chronic disease is generally developed long before the fatal outcome, meaning that a lot of people spend a number of years in poor health. Effective prevention measures can prolong lives of individuals and significantly improve their quality of life. However, the methods to measure cost-effectiveness are a subject to much debate. The Economics of Chronic Diseases project aims to establish the best possible methods of measuring cost-effectiveness as well as develop micro-simulation models apt at projecting future burden of chronic diseases, their costs and potential savings after implementation of cost-effective interventions. Method: This research project will involve eight European countries: Bulgaria, Finland, Greece, Lithuania, The Netherlands, Poland, Portugal and the United Kingdom (UK). A literature review will be conducted to identify scientific articles which critically review the methods of cost-effectiveness. Contact will be made health economists to inform and enrich this review. This evidence will be used as a springboard for discussion at a meeting with key European stakeholders and experts with the aim of reaching a consensus on recommendations for cost-effectiveness methodology. Epidemiological data for coronary heart disease, chronic kidney disease, type 2 diabetes and chronic obstructive pulmonary disease will be collected along with data on time trends in three major risk factors related to these diseases, specifically tobacco consumption, blood pressure and body mass index. Economic and epidemiological micro-simulation models will be developed to asses the future distributions of risks, disease outcomes, healthcare costs and the cost-effectiveness of interventions to reduce the burden of chronic diseases in Europe. Discussion: This work will help to establish the best methods of measuring cost-effectiveness of health interventions as well as test a variety of scenarios to reduce the risk factors associated with selected chronic diseases. The modelling projections could be used to inform decisions and policies that will implement the best course of action to curb the rising incidence of chronic diseases. The EConDA project is supported by the European Commission Health Programme and the Executive Agency for Health and Consumers, grant agreement n0 20121213.www.econdaproject.eu

BackgroundGiven the scale of the current obesity epidemic and associated health consequences there has been increasing concern about the economic burden placed on society in terms of direct healthcare costs and indirect societal costs. In the Republic of Ireland these costs were estimated at €1.13 billion for 2009. The total direct healthcare costs for six major obesity related conditions (coronary heart disease & stroke, cancer, hypertension, type 2 diabetes and knee osteoarthritis) in the same year were estimated at €2.55 billion. The aim of this research is to project disease burden and direct healthcare costs for these conditions in Ireland to 2030 using the established model developed by the Health Forum (UK) for the Foresight: Tackling Obesities project.MethodologyRoutine data sources were used to derive incidence, prevalence, mortality and survival for six conditions as inputs for the model. The model utilises a two stage modelling process to predict future BMI rates, disease prevalence and costs. Stage 1 employs a non-linear multivariate regression model to project BMI trends; stage 2 employs a microsimulation approach to produce longitudinal projections and test the impact of interventions upon future incidence of obesity-related disease.ResultsOverweight and obesity are projected to reach levels of 89% and 85% in males and females respectively by 2030. This will result in an increase in the obesity related prevalence of CHD & stroke by 97%, cancers by 61% and type 2 diabetes by 21%. The direct healthcare costs associated with these increases will amount to €5.4 billion by 2030. A 5% reduction in population BMI levels by 2030 is projected to result in €495 million less being spent in obesity-related direct healthcare costs over twenty years.DiscussionThese findings have significant implications for policy, highlighting the need for effective strategies to prevent this avoidable health and economic burden.

Background Information on the efficacy and costs associated with targeting obesity can inform implementation of cost-effective policies. Within the Economics of Chronic Diseases (EConDA) project, we aimed to quantify the health and economic impact of two approaches to reduce chronic disease in eight European countries through to 2050: a multicomponent lifestyle intervention (MCLI) and a sugar-sweetened beverage tax. Methods Body-mass index (BMI), disease epidemiology, and cost data for the diseases modelled (type 2 diabetes, coronary heart disease, stroke, and hypertension) were obtained from the literature for Bulgaria, Finland, Greece, Lithuania, the Netherlands, Poland, Portugal, and the UK. When country-specific data were not available, other countries were used as a proxy after adjustment for between-country differences. Mean change in BMI after annual MCLI to reduce energy intake and improve physical activity through behaviour change was obtained from the literature and was estimated after a 20% excise tax on sugar-sweetened beverages. A microsimulation model created country-representative synthetic populations. We determined simulated health outcomes in a baseline scenario using projections of BMI trends for each country up to 2050 and in two scenarios applying the interventions' respective BMI reduction to the BMI trends in the population. Simulated individuals developed diseases on the basis of their BMI and outputs provided the incidence and costs associated with the different scenarios. Findings The prevalence of obesity and incidence of BMI-related disease was forecast to increase in all countries to 2050. MCLI had the largest effect on type 2 diabetes, ranging from 147 cases per 100 000 avoided (SD 17) in Bulgaria to 1003 (21) in Portugal by 2050. The highest costs avoided were for stroke (up to €1·15 million, SD €0·008 million) in Portugal. Although tax on sugar-sweetened beverages also had the largest effect on diabetes (from 5 per 100 000 cases avoided [SD 8] in the Netherlands to 87 [13] in the UK), the costs avoided were lower than for MCLI. Interpretation These results highlight the variation in impact depending on the type of intervention aimed at the prevention of chronic diseases. An integrated approach to reducing obesity is required, so that a battery of approaches, varying in uptake and targeted population group, could be useful to obtain a greater effect on BMI reduction. Funding European Commission Health Programme and the Executive Agency for Health and Consumers (project number 2012 12 13).

Background Obesity in the European region has more than tripled since 1980, making it one of the 21st century's main public health challenges. To monitor the prevention and control of major non-communicable diseases (NCDs) WHO and its member states designed an NCD global monitoring framework in which countries agreed to halt obesity levels by 2025. To monitor the feasibility of achieving this goal, we aimed to project the future trends of obesity (body-mass index [BMI] ≥30 kg/m 2 ) to 2025 for each of the 53 WHO European Region Member States. Methods We extrapolated past BMI trends using a non-linear, multivariate, categorical regression model to estimate country-specific projected prevalence of obesity in adults by 2025. We fitted the model to both measured and self-reported data from cross-sectional country-specific BMI data from nationally representative surveys collected between 1990 and 2015. BMI data were obtained from the WHO BMI database, country statistical databases, health reports, and information collected via personal communication. Findings By 2025, obesity is predicted to increase in 44 countries. If present trends continue, 33 of the 53 countries will have an obesity prevalence of 20% or more. The highest projected obesity prevalence is predicted for Ireland (43%, 95% CI 28–58). The smallest absolute increase in the projected obesity prevalence from 2015 to 2025 was in Finland (20% by 2025, 95% CI 11–29), Lithuania (24%, 10–38), and the Netherlands (14%, 10–18), each of them with an estimated absolute increase in obesity prevalence of 2% by 2025. Interpretation Despite efforts from governments, the prevalence of obesity in the European region continues to increase, and with it the health and economic burden of its associated diseases. This paints a concerning picture of the future burden of obesity-related NCDs across the region. Greater and continued effort for the implementation of effective preventive policies and interventions is required from governments if they are to halt obesity prevalence in 10 years'. The data presented by this study could be used to assess or set country-specific obesity reduction targets, as well as provide leverage for investment in obesity prevention and monitoring programmes. Funding WHO Regional Office for Europe.

Non-communicable diseases (NCDs) such as cardiovascular disease and stroke are a major public health concern across Latin America. A key modifiable risk factor for NCDs is overweight and obesity highlighting the need for policy to reduce prevalence rates and ameliorate rising levels of NCDs. A cross-sectional regression analysis was used to project BMI and related disease trends to 2050. We tested the extent to which interventions that decrease body mass index (BMI) have an effect upon the number of incidence cases avoided for each disease. Without intervention obesity trends will continue to rise across much of Latin America. Effective interventions are necessary if rates of obesity and related diseases are to be reduced.

Background: Parental control has been hypothesized to causeweight gain in children by weakening self-regulatory processes.However, most studies that link control with weight have beencross-sectional, and therefore causation is uncertain. It remains pos-sible that parental control is a response to child overweight ratherthan a cause.Objective: We investigated the direction of the association betweenparental feeding practices and children’s adiposity in a longitudinalstudy.Design: Three subscales of the Child Feeding Questionnaire (CFQ)that measure “pressure,” “restriction,” and “monitoring” were com-pleted by 213 mothers of 7–9-y-old children as part of the PhysicalExercise and Appetite in CHildren Study (PEACHES) and repeatedby 113 mothers 3 y later. Baseline and follow-up anthropometricmeasurements [body mass index (BMI); fat mass index (FMI), andwaist circumference (WC)] were made by researchers when thechildren were aged 7–9 y and 10–11 y.Results: Regression analyses showed no association between any ofthe CFQ scales at baseline and change in child adiposity. In contrast,higher child BMI at baseline predicted a smaller decrease in follow-up CFQ “monitoring” ( P = 0.003) and a larger decrease in “pressureto eat” ( P = 0.04) after baseline scores were controlled for. Similarresults were observed for FMI and WC, although they did not reachsignificance for WC. There were no significant longitudinal associa-tions between child adiposity and the CFQ “restriction” subscale.Conclusion: Theresultsweremoreconsistentwitha“child-responsive”model whereby a mother’s choice of feeding practice is influencedby her child’s weight status rather than her feeding practices influ-encing the child’sweight gain. Am J Clin Nutr doi: 10.3945/ajcn.2010.30112.INTRODUCTIONAs a potentially modifiable risk factor for childhood obesity,parental feeding practices have attracted considerable interest.Parental control has been hypothesized to increase the risk ofchildhood weight gain by weakening the child’s ability to self-regulateenergyintake(1).However,researchfindingsaremixed,and the causal direction of the relation is poorly understood.Cross-sectionalstudiesinNorthAmericanchildrenhavereporteda positive association between restriction of food intake andadiposity (2–4), but more heterogeneous and ethnically diversesamples have generated null or negative findings (5, 6). Pres-suringachildtoeathas,somewhatparadoxically,beenassociatedwith lower adiposity (5, 7–9). This could indicate that pressureis protective against weight gain or, more likely, that pressure isthe mother’s response to her child’s low weight.Longitudinal designs exploring associations between childadiposity and maternal feeding practices potentially offer someinsight into causality. Birch et al (10) measured maternal re-striction and child eating in the absence of hunger (EAH) ina sample of girls at ages 5, 7, and 9 y. Among girls who wereoverweightatage5y,thosewhohadbeenmorerestrictedshowedhigher EAH at age 9, but there was no association between re-striction and EAH in normal-weight girls. A similar associationhas been observed in daughters of overweight compared withnormal-weight mothers (11, 12). This could indicate that theeffects of restriction andEAH are different in normal-weight andat-risk groups or, alternatively, that mothers are responding totheir child’s overweight (13). However, these findings have notbeen replicated in larger, more diverse samples using continuousmeasures of adiposity to assess weight change across differentage ranges. In these studies, parental control has either beenassociated with lower weight gain (13–15) or shows no associ-ation with child weight gain (13, 16–18). For example, ina sample of parents of 204 5–6-y-old and 188 10–12-y-oldchildren, Campbell et al (13) explored longitudinal relationsbetween restriction and change in child body mass index(BMI) SD scores (SDS) 3 y later, with adjustment for baselineBMI. They found that restriction predicted lower BMI SDSchange in 5–6-y-olds, but there was no significant association in10–12-y-olds. Similarly, pressure to eat and monitoring havebeen associated with lower weight gain (12, 15). In a sample ofparent-child dyads, pressure at age 5 y was associated with lowerweight gain2 y later in childrenof overweight but notof normal-weight mothers, whereas monitoring was associated with lowerweight gain only in children of normal-weight mothers (12).The aim of the present study was to build on the current lit-eraturebyexaminingbidirectionallongitudinalrelationsbetweenarangeofparentalfeedingpracticesandchildadiposity.Weuseda validated measure of parental feeding and multiple indexes of

Background: A large proportion of UK children do not reach the recommended levels of physical activity (PA) required for optimum health. Few studies have investigated the psychosocial correlates of objectively measured PA in preadolescents. This study examined child attitudes and parental behaviours as correlates of children’s activity. Methods: In total, 278 children (138 boys and 140 girls) aged 7–9 years were recruited as part of the Physical Exercise and Appetite in Children Study (PEACHES). Activity was objectively measured using the Actigraph GT1M accelerometer; the variables were total PA (mean accelerometer counts min−1) and moderate and vigorous PA (MVPA) >2000 counts min−1. Child-focussed variables were self-efficacy (Physical Activity Self-Efficacy scale), physical performance self-concept (Self-Perception Profile for Children), positive and negative outcome expectancies and liking for PA. Parental variables were PA and support for child activity. Results: Significant sex-by-psychosocial outcome interactions were observed for total PA and MVPA, so data from boys and girls were analysed separately. No psychosocial or parental outcomes were correlated with activity in girls. Significant correlates of activity in boys (self-efficacy, self-concept and parental support) were entered in to a hierarchical regression using both total PA and MVPA and, controlling for BMI SD, SES and ethnicity. PA self-efficacy and self-concept were significantly independently associated with total PA, explaining around 12% of the variance. Self-efficacy was significantly associated with time spent in MVPA, also explaining around 12% of the variance in this behaviour. Parental support was not significant in the regression model. Conclusion: PA self-efficacy and self-concept are significant correlates of objectively measured PA in UK boys.

Objective To determine whether controlling parental feeding practices are associated with children’s adiposity and test the hypothesis that any associations are mediated by maternal perception of their child’s weight. Method Children aged 7-9 yrs (n=405) were weighed and measured at school as part of the Physical Exercise and Appetite in CHildren Study (PEACHES). Adiposity was indexed with BMI SD-scores. The Child Feeding Questionnaire (CFQ) was completed by 53% of mothers of participating children (n=213). Mothers reported whether they thought their child was overweight, normal weight or underweight, and rated their concern about future overweight on a 5-point scale. Results Higher child adiposity was associated with lower ‘pressure to eat’ and higher ‘restriction’ scores. Restriction increased linearly with maternal concern about overweight, and maternal concern about overweight fully mediated the association between child adiposity and restriction. Use of pressure increased as mothers perceived their child to be thinner, but perceived weight did not mediate the association between child weight status and maternal pressure to eat. Monitoring was not associated with child adiposity, maternal perception of weight or concern about overweight. Conclusion Restriction appears to be a consequence of mothers’ concern about their child becoming overweight rather than a cause of children’s weight gain. Pressure may be a more complex response that is influenced by the desire to encourage consumption of healthy foods as well as ensure adequate energy intake and appropriate weight gain.

INTRODUCTION: Higher and lower-middle income countries are increasingly affected by obesity. Obesity-related diseases are placing a substantial health and economic burden on Brazil. Our aim is to measure the future consequences of these trends on the associated disease burden and health care costs. METHOD: A previously developed micro-simulation model is used to project the extent of obesity, obesity-related diseases and associated healthcare costs to 2050. In total, thirteen diseases were considered: coronary heart disease, stroke, hypertension, diabetes, osteoarthritis, and eight cancers. We simulated three hypothetical intervention scenarios: no intervention, 1% and 5% reduction in body mass index (BMI). RESULTS: In 2010, nearly 57% of the Brazilian male population was overweight or obese (BMI ≥25 kg/m(2)), but the model projects rates as high as 95% by 2050. A slightly less pessimistic picture is predicted for females, increasing from 43% in 2010 to 52% in 2050. Coronary heart disease, stroke, hypertension, cancers, osteoarthritis and diabetes prevalence cases are projected to at least double by 2050, reaching nearly 34,000 cases of hypertension by 2050 (per 100,000). 1% and 5% reduction in mean BMI will save over 800 prevalence cases and nearly 3,000 cases of hypertension by 2050 respectively (per 100,000). The health care costs will double from 2010 ($5.8 billion) in 2050 alone ($10.1 billion). Over 40 years costs will reach $330 billion. However, with effective interventions the costs can be reduced to $302 billion by 1% and to $273 billion by 5% reduction in mean BMI across the population. CONCLUSION: Obesity rates are rapidly increasing creating a high burden of disease and associated costs. However, an effective intervention to decrease obesity by just 1% will substantially reduce obesity burden and will have a significant effect on health care expenditure.

Background: Studies relating physical activity (PA) to weight gain in children have produced mixed results, although there is some evidence for stronger associations with more intense physical activities. The present study tested the hypothesis that weight gain over one year in 8-10 year olds would be more strongly predicted by moderate and vigorous physical activity (MVPA) than total physical activity (total PA) or sedentary behaviour.Methodology: Participants were 280 children taking part in the Physical Exercise and Appetite in Children Study (PEACHES). Weight status was assessed using body mass index (BMI), fat mass index (FMI), and waist circumference (WC) in school Year 4 (baseline; age 8.7 yrs) and Year 5 (follow-up; age 9.7 yrs). Physical activity was measured at baseline using the Actigraph GT1M accelerometer to assess total PA (mean accelerometers counts per minute), MVPA; >= 4000 counts per minute) and sedentary time (

The following academics collaborated with the authors to finalise this article are and acknowledged as co-signatories on its content. The authors are extremely grateful for their input. University of Cambridge: Ali Abbas, Marko Tanio; University of Edinburgh: Dr Susannah McLean; UK Health Forum: Martin Brown, Tim Marsh, Marco Mesa-Frias, Lise Retat; Imperial College London: Anthony Laverty; The London School of Hygiene and Tropical Medicine: Zaid Chalabi; University College London: Luz Sanchez Romero; University of Oxford: Anja Mizdrak, Mike Rayner, Marco Springmann; University of Sheffield: Alan Brennan, James Chilcott, John Holmes, Petra Meier, John Mooney; University of Southampton: Grant Aitken. ADMB and OTM are funded by the Wellcome Trust. PS is funded by the British Heart Foundation. JW is funded by an MRC Population Health Scientist Fellowship.