The Socio-economic Cost and Review of Food Hypersensitivity on the Island of Ireland
Document Type Theses, Masters
Thesis submitted to the School of Food Science and Environmental Health for the award of MPhil., Technological University Dublin, January 2022.
Supervisor: Dr Ciara Walsh.
Abstract
Surveys collecting data on food hypersensitivity were circulated online (and in person) between November 2019 and October 2020. Participants included (a) adults aged 18 years and over, and (b) parents of children and adolescents under 18 years of age living in the Ireland and Northern Ireland (NI). In total, 3,001 surveys from three food hypersensitive groups were collected: 744 from people with a medically diagnosed food allergy (MDFA), 1,035 with medically diagnosed coeliac disease (MDCD), and 1,222 from those reporting to have food intolerance and or suspected/undiagnosed food allergy (FI). All data was self-reported for adults ≥18 years or parent-reported in the case of a food hypersensitive child/adolescentyears, and an additional 1,113 control surveys were collected from non-food hypersensitive individuals for data comparison purposes. In summary, the total number of surveys collected in this study was 4,114.
Following analysis of the 744 surveys completed by MDFA respondents, peanuts (47%), milk (36%), other nuts (35%), eggs (30%) and fruit (19% including 6% kiwi) were the five most reported trigger foods, noted in Ireland and Northern Ireland. These allergens were also the most associated with previous incidences of anaphylaxis among respondents: peanuts (7%), other nuts (6%), eggs (4%), milk (3%), and fruit (2% including 1% kiwi), highlighting the importance of these allergens among susceptible populations. In addition, MDFA to kiwi (6%) was reported to be higher than that of lupins (2%), sulphur dioxide and sulphites (2%), mustard (2%), celery (2%), and various other non-declarable allergens under each of the different categories investigated (child, adolescent, and adults). Notably, kiwi is currently not included in Appendix 2 to Regulation (EU) No 1169/2011 – ‘Substances or products causing allergies or intolerances’. The findings of this research suggest its inclusion warrants consideration.
Across the Island of Ireland (IoI), a total of 1,222 respondents reported having a food intolerance and or suspected/undiagnosed food allergy (FI), and an additional 1,035 participants reported to have been MDCD. The two most prominent food intolerances reported by the FI cohort were to milk (59%) and cereals containing gluten (45%). These were followed by fruit (20% including 3% kiwi), eggs (10%), peanuts (9%) and other nuts (6%).
The socioeconomic cost of food hypersensitivity was calculated by examining direct and indirect costs associated with each condition (MDFA, MDCD and FI) in Ireland and Northern Ireland. Survey responses relating to an individual’s (for a food hypersensitive adult) or households (for a food hypersensitive child/adolescent) expenditure were reviewed. For the latter, costs were calculated for a family with just one FH child or adolescent in this study, although many families consist of more than one. In more general terms, only surveys where related questions were completed were included for analysis. This gave a final total of 2,066 food hypersensitivity and 735 control surveys for adults. These surveys consisted of 178/111 for adults with MDFA, 609/173 for adults with MDCD, 536/459 for adults with FI, and 531/204 controls in Ireland and NI, respectively. For parent-reported surveys, a total of 635 food hypersensitivity and 295 control surveys were analysed which consisted of 173/147 for children/adolescents with MDFA, 148/60 for children/adolescents with MDCD, and 56/51 for children/adolescents with FI, respectively (130/165 controls, respectively). Notably, no statistically significant difference was found between genders on types of food allergies, regardless of food hypersensitivity, examined in this study.
Direct costs consisting of healthcare related expenses (medical visits, associated travel, hospital stays, medication, etc.) and total food costs per condition, were calculated for food hypersensitive adults and parents of food hypersensitive children/adolescents in Ireland and Northern Ireland. Moreover, indirect costs, based on lost time, missed days, or lost earnings as a result of having a food hypersensitivity, were added to the direct costs to give an overall estimate of the total socioeconomic costs associated with these conditions.
Additional direct costs per annum associated with having a MDFA (calculated from the survey data), were found to range from €1,115 (children/adolescents) to €1,325 (adults) in Ireland, and €982 (adults) to €1,404 (children/adolescents) in Northern Ireland. Similarly, additional direct costs per annum associated with MDCD were found to range from €444 for adults (or €501 prior to claiming a tax rebate for gluten free food) to €903 for children/adolescents (or €993 prior to claiming a tax rebate for gluten free food) in Ireland, and from €856 for adults to €1,871 for children/adolescents in NI. Lastly, additional direct costs per annum associated with FI were found to range from €-128 (children/adolescents) to €350 (adult) in Ireland, and from €337 (children/adolescents) to €438 (adult) in NI. Notably, direct costs were higher for all food hypersensitive individuals in Ireland and NI compared to their controls, with the exception of the child and adolescent FI cohort in Ireland. However, the sample number was small for this FI group (n=56) due to challenges in findings parents of FI children and adolescents to complete this survey, potentially impacting this figure. In more general terms, higher direct costs as a result of additional healthcare and food related expenses were noted for eleven (€337 - €1,871 p.a.) out of the twelve food hypersensitive groups investigated across the IoI.
Indirect costs calculated in this study were smaller than direct costs and were found to range from €96 to €730 for each of the ten cohorts who reported them; with the exceptions being MDCD adult Ireland, and FI parental NI. The main driver for indirect costs was found to be ‘missed days of work/school/college’, which tended to be higher in responses from NI (€142 to €486), than the Ireland (€0 to €302).
Notably, the additional total cost (direct & indirect) associated with having a MDFA ranged from €1,439 (children/adolescents) to €1,602 p.a. (adult) in Ireland, and €1,461 p.a. (adult) to €1,643p.a. (children/adolescents) in Northern Ireland. In addition, the final figures calculated for all MDFA cohorts were found to be statistically significantly higher (p-value
In summary, health care related expenses were the main driver of costs associated with food hypersensitivity in both Ireland and Northern Ireland. Total food costs, lost earnings, and ‘missed days’ were independently statistically significant expenses (p-value
Intangible costs are defined as a loss of value or utility i.e., lost days, lost earnings, etc. These costs can be difficult to measure in monetary terms, but health status values using the EQ-5D (a set of standardised health-related quality of life questions) were examined. Notably this study found that children under 18 years of age and adults with MDFA, MDCD or FI had a statistically significantly lower quality of life compared to controls (p-value
In total, 76 priority setting semi-structured interviews were conducted with 8 cohorts: MDFA and MDCD adults and parents in both Ireland and Northern Ireland. The surveys returned a wide selection of challenges. Interestingly, all MDFA and MDCD cohorts prioritised ‘Public and Food Industry awareness and understanding of their/their child’s condition’ as their number one challenge; with the exception of Northern Irish parents of children/adolescents with MDFA in who ranked ‘Awareness and training in an educational setting’ first and the former option third. All 8 cohorts recorded ‘Accessing medical teams e.g., consultant’s specialist nurses etc. to treat your (or your child’s) condition’ as the second most important priority. Notably, the provision of ‘Adrenaline auto-injector in public places similar to AED’ (mirroring approaches currently in place in countries like Canada) was the third highest priority for MDFA adults and parents. Similarly, challenges with regard to ‘Awareness and training in an educational setting’ was the third highest priority of MDCD adults and parents, and the fourth highest for their MDFA counterparts. Other important issues ranked, included cost and availability of medication, access to counselling and dietetic services, and consideration to the recognition of food allergy and coeliac disease as a disability (similar to measures in place for severe food hypersensitivity in the US). An array of different strategies, ideas and suggestions were proposed by participants to assist in combating these challenges.
Lastly, this study reviewed food hypersensitivity anonymised data from previously published surveys and datasets for the IoI, including the collation of prevalence rates reported for Ireland, the UK, Europe and elsewhere in the wider literature. In addition, anonymised food hypersensitivity information was sought (2,513 institutions were contacted) and collected from public and private organisations in Ireland and Northern Ireland. More specifically this study reports percentages of food hypersensitivity, food allergy and coeliac disease among 9,517 children in early years services, 3,233 school children (primary and secondary) and 2,139 residences of nursing homes on the IoI. Higher levels of all food hypersensitivity were reported in children in early years services than in schools and nursing homes, with the exception of CD. The reported percentage of CD was 1.5% in nursing homes (from a study cohort of 2,139 residents) for Ireland and NI combined, compared to 0.3-0.7% in the younger cohorts in this study. It is hoped that the findings of this study will assist risk assessors, researchers, regulators, policy makers and other stakeholders, in devising measures to improve the lives of food hypersensitive consumers on the IoI.
Document Type
Master thesis