Table 2 Top five risk factors for CVD health loss ordered by decreasing size of health gain (through all diseases) and cost-savings from studied interventions in the NZ context
Risk factor (top 5 from Table 1) | Highest impact health gain from an intervention | Highest impact cost-saving* from an intervention | Details of the relevant NZ health economic publications (with all specific health gain and cost values given being for lifetime impacts at an annual discount rate of 3% and a threshold for defining "cost-effective" used**) |
|---|---|---|---|
Dietary risk factors | 894,000 HALYs gained (a combined fruit and vegetable (F&V) subsidy plus a sugar tax) [19] | US$ 11.0 billion saved (US$ 2018) (as per the intervention in the column to the left) | Cost-saving: (i) Various combinations of food taxes and subsidies [19]. The highest impact intervention was a combined fruit and vegetable (F&V) subsidy plus a sugar tax. Behind this in impact were a sugar tax, then a salt tax with F&V subsidy, then a saturated fat tax with F&V subsidy, then a salt tax, and then a saturated fat tax. Higher per capita health gains for Māori vs non-Māori were identified |
(ii) Adoption of climate-friendly eating patterns [20] (the model included multiple CVD risk factors list in Table 1 including: red meat, sugar-sweetened beverages (SSBs), and sodium as well as low intake of fruit, vegetables, and polyunsaturated fat). But the economic analysis did not include the intervention costs associated with achieving these dietary pattern changes and it was assumed that the whole population shifted eating patterns | |||
(iii) A cap on the size of single servings for SSBs [21] | |||
Cost-effective: A multicomponent through-school physical activity and nutrition program (“Project Energize”) [22] | |||
Comment: There is some overlap with this dietary risk factor grouping in this table and interventions to reduce BP, lower LDL cholesterol and to lower BMI (as detailed elsewhere in this table). Some of the cost-saving interventions capture non-CVD health benefits (e.g., preventing diet-related cancers, diabetes etc.) | |||
High systolic blood pressure (BP) | 453,000 HALYs gained (salt tax) [19] | US$ 5.90 billion saved (US$ 2018) (salt tax) [19] | Cost-saving: (i) Three publications each involving multiple different dietary salt reduction interventions (including salt substitution, salt tax, UK style interventions etc.) [23,24,25]; (ii) salt tax [19] |
Cost-effective: (i) A “soft regulation” national policy for dietary sodium reduction that combines targeted industry agreements, government monitoring, and public education (international study with NZ data) [26] | |||
(ii) Double therapy (an antihypertensive and a statin) and antihypertensive alone by clinician-assessed absolute risk level (cost-effective for nearly all risk levels in the middle-aged male age-group studied) [27] | |||
Comment: There is some overlap with these BP interventions with those in the dietary risk factor grouping (elsewhere in this table) given that some of the latter will lower sodium intake and increase potassium intake | |||
High LDL cholesterol | 436,000 HALYs gained (saturated fat tax) [19] | US$ 5.87 billion saved (US$ 2018) (saturated fat tax) [19] | Cost-saving: Saturated fat tax [19] |
Cost-effective: Double therapy (a statin and antihypertensive) and statin alone by clinician-assessed absolute risk level (at least in middle-aged males) [27] | |||
Comment: There is some overlap with this risk factor grouping and the dietary interventions detailed elsewhere in this table (many of which would reduce dietary intakes of saturated fat and increase intakes of polyunsaturated fat) | |||
Tobacco use | 282,000 QALYs gained (from a sinking lid on supply) [28] | NZ$ 5.43 billion saved (NZ$ 2011) (~ US$ 4.07 in US$ 2018) (from a sinking lid on supply) [28] | |
(ii) Reduced retail access [31] | |||
(iii) Five endgame interventions (including impact on access and supply etc.) [28]. Higher per capita health gains for Māori vs non-Māori were identified | |||
(iv) Pharmacy-only sales and pharmacist counseling [32] | |||
(v) Promotion of the Quitline for smoking cessation [33] | |||
(vi) Promoting smartphone apps for smoking cessation [34] | |||
(vii) Two studies [35, 36] on permitting ready access to e-cigarettes (albeit this has now largely occurred in NZ) | |||
Not cost-effective: Exercise counseling intervention to enhance smoking cessation [37] | |||
Comment: All the cost-saving studies detailed above capture CVD-related health benefits but also the benefits of preventing 14 other tobacco-related diseases. In one tobacco tax intervention study that identified how the QALYs gained were distributed, 16.6% were from CVD prevention and the majority were from chronic respiratory disease prevention (Table S6 in Blakely et al. [29]) | |||
High body-mass index (BMI) | 250 QALYs gained (from the weight-loss counseling intervention applied to 21.6% of the eligible population [38]). A total was not calculated for any scaled up form of “Project Energize” | No cost-saving intervention identified | Cost-saving: Nil |
Cost-effective: A multicomponent through-school physical activity and nutrition program (“Project Energize”) [22]. But this was not cost-effective in some sensitivity analyses, e.g., 5% decay per annum in BMI change after the first 5 years | |||
Not cost-effective: (i) Weight-loss dietary counseling by nurses in primary care [38]; (ii) Mass media promotion of smartphone apps for weight loss [39] | |||
Comment: There is considerable overlap with this BMI risk factor grouping and the dietary intervention grouping (as detailed elsewhere in this table). We did not include four health economic studies of physical activity interventions [40,41,42,43], given that the evidence of the association between physical activity and BMI is not particularly strong |