Nutrition 48 (2018) 24–32

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Nutrition
j o u r n a l h o m e p a g e : w w w. n u t r i t i o n j r n l . c o m

Applied Nutritional Investigation

The potential health and economic effects of plant-based food

patterns in Belgium and the United Kingdom
Janne Schepers M.Sc. a,b,*, Lieven Annemans Ph.D. a
a Department of Public Health, Interuniversity Centre for Health Economics Research (I-CHER), Ghent University, Ghent, Belgium
b Department of Pharmaceutical and Pharmacologic Sciences, KU Leuven, Flanders, Belgium

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Policymakers increasingly require scientific evidence on both health and economic conse-
Received 8 August 2017 quences of different nutritional patterns. The aim of this study was to assess health and economic
Received in revised form effects of Mediterranean and soy-containing diets. Selected countries were Belgium and the United
6 November 2017
Kingdom.
Accepted 11 November 2017
Methods: Cost-effectiveness of these plant-based food patterns was assessed in comparison with a “con-
ventional” diet using an age- and sex-dependent prediction model. The model allowed the prediction
Keywords:
of health outcomes and related health care costs for the food patterns over 20 y. A societal perspective
Plant-based
Diet was applied for cost calculation and health outcomes were expressed in quality-adjusted life-years
Soy (QALYs).
Mediterranean Results: For Belgium, a soy-containing diet is estimated to lead to 202 QALYs and 107 QALYs per 1000
Cost-effectiveness women and men, respectively, whereas societal savings of €2 146 000 and €1 653 000 are predicted.
Belgium For the United Kingdom, a gain of 159 QALYs and 100 QALYs per 1000 women and men, respectively, is
UK estimated, as are a prediction of savings of £1 580 000 and £1 606 000. For the Mediterranean diet in
the corresponding estimates for Belgium are 184 QALYs and 148 QALYs per 1000 women and men, re-
spectively, and savings of €1 618 000 and €1 595 000. For the United Kingdom, these are 122 QALYs and
110 QALYs per 1000 women and men, respectively, and savings of £1 155 000 and £1 046 000, respectively.
Conclusion: A wider implementation of plant-based eating would lead to large net economic gains for
society and improved health outcomes for the population.
© 2017 Elsevier Inc. All rights reserved.

Introduction overweight (according to country estimates of the World Health

Nutritional patterns and their relation to general health and
well-being are receiving attention worldwide. Unhealthy food
habits and insufficient physical activity are recognized as leading
risk factors for the development of non-communicable dis-
eases (NCDs) and their associated comorbidities [1,2]. NCDs are
the largest contributors to premature death caused by cardio-
vascular disease (CVD) and cancer in Europe [3,4]. Moreover, these
NCDs are associated with large health care expenditures, loss of
productivity, and other societal costs [5].
The importance of healthy nutrition patterns is an increas-
ing global concern [6]. In Europe, >50% of the population is
This study was funded by the ALPRO Foundation.
* Corresponding author: Tel.: +32 9 332 60 37; fax: +32 9 332 49 94.
E-mail address: Janne.Schepers@Ugent.be, janne.schepers@kuleuven.be
(J. Schepers).
Organization European Region for 2008) [7] and ~23% of women
and 20% of men are obese [8]. Therefore, several nutritional guide-
lines were developed to obtain or maintain a healthy lifestyle.
A consumption of at least five portions (equivalent to 400 g) of
fruit and vegetables is recommended for the adult population on
a daily basis [9,10]. However, only 12% of European adults are able
to achieve this goal [11].
In this study, we chose to focus on the Mediterranean diet and
a soy-containing diet, two examples of healthy, balanced, plant-
based food pattern. A soy-containing diet is rich in soy protein,
which can be consumed as soybeans, tofu, miso, soy drinks, soy
yogurt, and so on. It is known to protect against obesity, coro-
nary heart disease (CHD), stroke, type 2 diabetes mellitus (T2DM),
and breast, colon, stomach, lung, and prostate cancers [12–21].
The Mediterranean diet is defined by a large amount of fruit, veg-
etables, whole grains, nuts, seeds, high amounts of olive oil, a
moderate to high consumption of fish and other seafood, and a
low intake of meat and dairy products [22]. Previous studies have

https://doi.org/10.1016/j.nut.2017.11.028
0899-9007/© 2017 Elsevier Inc. All rights reserved.
 J. Schepers, L. Annemans / Nutrition 48 (2018) 24–32
shown that the Mediterranean diet is able to reduce the risk for
developing CHD, stroke, T2DM, and breast cancer [23–28].
The aim of this study was to assess the health and economic
consequences of a soy-containing diet and the Mediterranean diet
from the societal perspective in Belgium and the United Kingdom.
Methods
Decision model
For the purpose of this economic evaluation, a modeling approach was applied,
as is typical for this type of research question [29]. An age- and sex-dependent
epidemiologic prediction model was built to predict health outcomes and related
health care costs associated with a soy-containing diet and the Mediterranean
diet over a 20-y period. A societal perspective was taken for the calculation of
costs. The health outcomes were expressed as quality-adjusted life-years (QALYs),
the most common measure used to value health gains. This measure combines
the effects on life duration and health-related quality of life (QoL) of an individ-
ual. Utilities are used to calculate QALYs by multiplying them with the number
of life-years spent in a particular condition. Utilities are “quality weights” whose
value varies from 0 (equivalent to death) to 1 (equivalent to perfect health) [29,30].
The epidemiologic prediction model was based on an earlier published model
used for the health and economic effects of obesity [31] and further developed
in light of the specific context and characteristics of the present study. The model
consists of 17 health states: healthy, diabetes, CHD, CHD1+, stroke, stroke1+, breast
cancer, breast cancer1+, colon cancer, colon cancer1+, lung cancer, lung cancer1+,
stomach cancer, stomach cancer1+, prostate cancer, prostate cancer1+, death (Fig. 1).
The simulation is conducted for a virtual cohort of 1000 women and 1000
men. All simulated individuals start the model in the healthy state, meaning that
they do not yet have any of the considered diseases. In the course of each year
(the cycle length of the model is 1 y) every individual has a certain risk for de-
veloping one of the included diseases, to stay healthy, or to die due to other reasons
or diseases not included in this Markov model. If an individual moves from the
healthy state to a certain disease state, he or she can never return to the healthy
state. After 1 y (cycle) in a certain disease state, the individual will automatical-
ly move to the follow-up state of this disease or die (except for the individuals
suffering from T2DM).
Individuals suffering from T2DM have a higher risk for developing CHD, stroke,
breast cancer, and colon cancer. Therefore, after 1 y in the T2DM, state individu-
als can move to the CHD 1 state, stroke 1 state, breast cancer 1 state, colon cancer
Fig. 1. Structure of the epidemiologic prediction model. CHD, coronary heart disease.
25
1 state, the dead state, or remain in the diabetes state. When an individual has
reached the dead state, further transitions are no longer possible. The dead state
is a final and absorbent state. The time horizon of the model was set at 20 y.
Disease transition probabilities and mortality probabilities
Age- and sex-dependent transition probabilities for the included diseases were
derived from the incidence numbers for the Belgian and British population for
the included diseases. The age- and sex-dependent incidence rates for breast, colon,
lung, prostate, and stomach cancers were derived from the databases of the Belgian
Cancer registry [32] and Cancer Research UK [33]. British incidence rates for CHD,
stroke, and diabetes were derived from literature [34–36]. However, no stroke-
or diabetes-related incidence rates were available for the Belgian population. There-
fore, incidence rates from the Dutch population were used and were corrected
for the Belgian population by applying a correction factor accounting for the dif-
ference in CHD incidence between the two countries [37,38].
General population mortality transition probabilities were derived from na-
tional databases and were applied for the year 2015 [39,40]. Mortality transition
probabilities for the included diseases were derived from literature or were cal-
culated by multiplying average national mortality probabilities [39,40] with the
mortality risk for the included diseases in the model [32,41,42] (Appendices A,
B, C, D, and E).
Effects of a soy-containing diet and the Mediterranean diet
The effects of a soy-containing diet and the Mediterranean diet were based
on evidence from literature. We used two main criteria for study selection: Rel-
ative risk reductions were preferably selected from studies with high
methodological quality (meta-analysis or large cohort studies) and had to be ad-
justed for important related confounding factors. Not all results were corrected
for the same confounders but most of them were adjusted for age, sex, body mass
index (BMI), education, total energy intake, smoking, alcohol consumption, and
physical activity. Additionally, some adjustments were made for history of hy-
pertension, hypercholesterolemia, and diabetes. A soy-containing diet is associated
with a significant reduction of 2.27 mm Hg systolic blood pressure (BP) and
1.21 mm Hg diastolic BP in normotensive individuals [12] compared with a control
diet without soy. This BP reduction induces a 3.36% decreased risk in men and
women for developing CHD and a 9.075% decrease in stroke for men [43]. Kokubo
et al. showed a significant reduction of 36% in women’s risk for stroke. In the
present study, the highest quintile of soy intake (≥5 times/wk) was compared
with the lowest quintile of soy intake (0–2 times/wk) [13]. For the purpose of
26 J. Schepers, L. Annemans / Nutrition 48 (2018) 24–32

Table 1 Table 2
Relative risk reductions of the included diseases associated with the plant- Costs of included diseases
based food patterns
Disease Medical Lost Total Reference
Health outcome Mediterrannean Soy References cost/y productivity/y cost/y

Men, Women, Men, Women, Belgium

% % % % Diabetes €3562 €721 €4283 [50]
CHD (1) €8561 €551 €9113 [45]
Diabetes −26 −26 −28 −28 [14,26]
CHD (1+) €3274 €211 €3485 [45]
CHD −42 −26 −4 −4 [12,23,24]
Stroke (1) €25 398 €1636 €27 034 [45]
Stroke −35 −37 −9 −36 [12,13,23,25]
Stroke (1+) €7627 €491 €8118 [45]
Breast cancer <50 y −33 −36 [15,27]
Breast cancer (1) €8203 €5283 €13 486 [47]
Breast cancer ≥50 y −17 −27 [15,28]
Breast cancer (1+) €1189 €766 €1955 [47]
Colon cancer −40 −44 [16,17]
Lung cancer (1) €8547 €5505 €14 052 [48] (adjusted)
Lung cancer −23 −25 [19,20]
Lung cancer (1+) €3095 €1994 €5089 [48] (adjusted)
Stomach cancer −29 −42 [18]
Stomach cancer €25 574 €16 469 €42 043 [49] (adjusted)
Prostate cancer −30 [21]
men (1)
Stomach cancer €2308 €1487 €3795 [49] (adjusted)
men (1+)
Stomach cancer €23 169 €14 921 €38 090 [49] (adjusted)
women (1)
the other conditions, we applied studies comparing the highest and lowest quintiles Stomach cancer €2144 €1381 €3525 [49] (adjusted)
of soy consumption. According to the evidence, the intake of the highest levels women (1+)
of soy intake decreases the risk for developing T2DM by 28% [14], lung cancer Colon cancer (1) €24 430 €15 801 €40 231 [46]
by 23% in men [19] and 25% in women [20], gastric cancer by 29% in men and Colon cancer (1+) €4224 €2732 €6955 [46]
42% in women [18], colon cancer by 40% in men [16] and 44% in women [17], Prostate cancer (1) €4119 €2653 €6772 [48] (adjusted)
prostate cancer by 30% [21], and breast cancer by 36% in premenopausal women Prostate cancer (1+) €2067 €1331 €3399 [48] (adjusted)
and 27% in those who are postmenopausal [15]. United Kingdom
In the Mediterranean diet, the incidence of T2DM is decreased by 26% in both Diabetes £4407 £892 £5299 [51]
men and women [26]. Also, a significant risk reduction was reported for CHD CHD (1) £9476 £610 £10 086 [52]
(−42% for men; −26% for women) [23,24] and stroke (−35% for men; −37% for CHD (1+) £245 £16 £261 [52]
women) [23,24]. Furthermore, the diet pattern is associated with a decreased risk Stroke (1) £3504 £226 £3729 [52]
for breast cancer in which a distinction is made between premenopausal (−33.3%) Stroke (1+) £3549 £229 £3778 [52]
[27] and postmenopausal women (−16.5%) [28] (Table 1). All included studies Breast cancer (1) £9353 £6023 £15 376 [53]
compared the highest adherence to a Mediterranean diet to the lowest adherence. Breast cancer (1+) £1338 £863 £2201 [53]
Lung cancer (1) £9754 £6282 £16 036 [48]
Lung cancer (1+) £3487 £2246 £5733 [48]
Cost data input Stomach cancer £12 583 £8103 £20 686 [49] (adjusted)
men (1)
For the estimation of the disease costs, a societal perspective was taken, in- Stomach cancer £1678 £1080 £2758 [49] (adjusted)
cluding direct and indirect costs. Direct costs are those associated to the disease men (1+)
or its associated comorbidities including all costs related to diagnosis and treat- Stomach cancer £11 413 £7349 £18 762 [49] (adjusted)
ment. Indirect costs are those covering employment-related costs (e.g., women (1)
absenteeism, loss of productivity loss due to sickness) [30,44] and are not only Stomach cancer £1709 £1100 £2809 [49] (adjusted)
restricted to health care [5]. A difference was made in terms of direct costs between women (1+)
the “first year” state and the “follow-up” state [45–53]. All costs were calcu- Colon cancer (1) £14 658 £9438 £24 096 [48]
lated for the year 2015 and validated or adjusted for Belgium and the United Colon cancer (1+) £2179 £1403 £3582 [48]
Kingdom. Costs and savings predicted to occur in the future were discounted at Prostate cancer (1) £4701 £3027 £7728 [48]
3% (Belgium) and 3.5% (United Kingdom), which is in accordance with the re- Prostate cancer (1+) £2329 £1500 £3829 [48]
spective national guidelines for health economic evaluations [54,55] (Table 2).
CHD, coronary heart disease; 1, first year in a certain disease state; 1+, after first
year in a certain disease state..
Health-related quality of life

QoL is characterized by utility values. Utilities are needed to calculate QALYs
and express the QoL level of a certain health state. These utility levels are age
specific and were assigned to the different health states in the model. In this
Markov model, all individuals start in the “healthy” state and associated utility
levels were derived from a national available database for Belgium [56] or lit-
erature for the United Kingdom [57]. Through penalties, derived from literature,
the “utility loss” for each health state was defined [58–62]. Hence, every disease
state was linked to a disease-specific utility value (Table 3). Subsequently, the
corresponding utilities were calculated and applied for each life-year the indi-
vidual suffers from one of the in-model included diseases. A discount rate of 1.5%/y
was used for future QALYs in Belgium, which is in accordance with the Belgian
guidelines for health economic evaluations [54]. For the United Kingdom, a dis-
count rate of 3.5%/y was used for future QALYs [55].
Sensitivity analysis
Parameters used in health economic evaluations often are exposed to un-
certainty. To capture these uncertainties in the present analyses, sensitivity analyses
were performed [63]. By means of a one-way sensitivity analysis, the effect of
each parameter on the outcome was evaluated separately. Cost data were varied
over an interval of ±30%, relative risk reductions were varied over their 95% con-
fidence interval derived from literature. The effect of the uncertainty on each key
input parameter is demonstrated in a tornado diagram.
Results
Soy-containing diet
In Belgium, the estimated prevalence of cancer decreases by
1.57% in women and 1.45% in men who consume a soy-containing
diet compared with a “non-soy” diet. For stroke, the prevalence
numbers decrease by 0.93% and 0.24% in women and men, re-
spectively. The reduction of the estimated prevalence of CHD is
less explicit (−0.01% in women and −0.03% in men). These esti-
mated prevalence reductions are similar in the United Kingdom.
In Belgium, a soy-containing diet is estimated to lead to 202
QALYs and 107 QALYs per 1000 women and men, respectively,
whereas societal savings of €2 146 000 and €1 653 000 are pre-
dicted over 20 y.
For the United Kingdom, a soy-containing diet is estimated
to yield 159 QALYs and 100 QALYs per 1000 women and men,
respectively, whereas societal savings of £1 580 000 and £1
606 000 are predicted over 20 y. Hence, a high soy intake yielded
more QALYs and was less expensive than a low soy intake for both
 J. Schepers, L. Annemans / Nutrition 48 (2018) 24–32 27

Table 3
Age- and sex-specific disease-related utilities (range between youngest and oldest age categories)

Health state Base case Reference

Women Men

Belgium United Kingdom Belgium United Kingdom

Healthy 0.87–0.65 0.94–0.75 0.92–0.74 0.94–0.75 [56,57]

Diabetes 0.66–0.44 0.73–0.54 0.71–0.53 0.73–0.54 [58]
CHD 0.59–0.37 0.66–0.47 0.64–0.46 0.66–0.47 [58]
Stroke 0.53–0.31 0.60–0.41 0.58–0.40 0.60–0.41 [58]
Colon cancer 0.68–0.46 0.74–0.56 0.72–0.54 0.74–0.56 [59]
Lung cancer 0.62–0.39 0.68–0.49 0.66–0.48 0.68–0.49 [60]
Stomach cancer 0.58–0.36 0.65–0.46 0.63–0.45 0.65–0.46 [61]
Breast cancer 0.64–0.42 0.70–0.52 [60]
Prostate cancer 0.76–0.57 0.77–0.59 [62]

CHD, coronary heart disease.

Table 4 Belgium and the United Kingdom (women). The cost of CHD,
Results expressed per 1000 individuals stomach cancer, and lung cancer only had a limited effect on the
Intervention Country Sex Delta cost Delta QALYs societal savings of a soy-containing diet in both countries. The
Mediterranean Belgium Men −€1 595 000 148 results in men and for the Mediterranean diet are similar (not
Women −€1 618 000 184 shown).
UK Men −£1 046 000 110
Women −£1 155 000 122
Soy Belgium Men −€1 653 000 107 Discussion
Women −€2 146 000 202
UK Men −£1 606 000 100 The aim of the present study was to estimate the health and
Women −£1 580 000 159
economic effects of two plant-based food patterns, a soy-
QALY, quality adjusted life-year. containing diet and the Mediterranean diet. By means of a health
economic model, estimates about the societal savings and health
benefits of the two diets were provided. For both food patterns,
men and women. Therefore, a soy-containing diet is dominant we applied clinical inputs comparing the highest and lowest levels
(Table 4). of adherence. The lowest level, for both food patterns, corre-
sponded to no or almost no adherence. The highest levels of
Mediterranean diet consumption associated with soy, varies from almost every day
to more times a day. Highest adherence to the Mediterranean diet
In Belgium, the estimated prevalence of T2DM decreases by corresponded to 6 to 8 points on the Mediterranean Diet Score.
1.04% in women and 1.34% in men when consuming a Mediter- Highest adherence of both food patterns were associated with
ranean diet compared with a Western diet. For stroke, the substantial health benefits societal savings. The soy-containing
prevalence numbers decrease by 0.56% and 0.71% in women and food pattern demonstrated the most favorable results from the
men, respectively, and for CHD the numbers decrease by 0.31% two evaluated plant-based food patterns (Fig. 2A, B).
in women and 0.83% in men. The results remain robust when changing the key input pa-
In the United Kingdom, the estimated prevalence of T2DM de- rameters over their uncertainty range. Despite the relevance, to
creases by 1.36% in women and 1.62% in men. For stroke, the the best of our knowledge the economic effects of these two plant-
prevalence numbers decrease by 1.13% and 0.88% in women and based food patterns have not been studied before, nor in Belgium
men, respectively, and for CHD by 0.07% in women and 0.32% in nor in the United Kingdom. The findings of an Italian systemat-
men. ic review, examining the cost and the cost-effectiveness of the
In Belgium, a Mediterranean diet is estimated to yield 184 Mediterranean diet, also concluded that a Mediterranean diet
QALYs and 148 QALYs per 1000 women and men, respectively, could lead to a net increase of health benefits and a decrease of
compared with a Western diet. Corresponding societal savings total lifetime costs. Given that the results of the current analy-
of €1 618 000 and €1 595 000 are predicted over 20 y. sis are based on another methodology and another target
In the United Kingdom, a Mediterranean diet is estimated to population, we should sound a note of caution with regard to
lead to 122 QALYs and 110 QALYs per 1000 women and men. Cor- compare these findings [64].
responding societal savings of £1 155 000 and £1 046 000 are The differences between the results for Belgium and the United
estimated over 20 y. Likewise, the Mediterranean diet is domi- Kingdom can be explained in part by the differences in costs and
nant in men as well as in women compared with a conventional incidences between the two countries. Interestingly, the inci-
diet (Table 4). dence rates for CHD and stroke were significantly lower in the
United Kingdom than in Belgium (Appendix A). The possible cause
One-way sensitivity analysis of the discrepancy could be a consequence of the intensive health
promotion campaigns to prevent cardiovascular disease (CVD) in
The goal of a one-way sensitivity analysis is to estimate the the United Kingdom [36]. The difference in incidence rates could
effect of the uncertainty on the outcomes. The results are illus- be tangible evidence that health promotion interventions are ef-
trated in Tornado diagrams (Fig. 2A, B). Varying the relative risk fective and useful.
of diabetes and stroke over their 95% confidence interval has the An increasing prevalence of obesity has been reported over
highest effect on estimated savings of a soy-containing diet in the past few decades. Due to the fact that obesity is caused by
28 J. Schepers, L. Annemans / Nutrition 48 (2018) 24–32

Fig. 2. Tornado diagrams of soy-containing diets in Belgian (A) and British (B) women. Ca, cancer; CHD, coronary heart disease; RR, relative risk.

the consumption of unhealthy foods and a lack of physical ac-
tivity and that it can be reduced by lifestyle changes such as the
consumption of more fruit, vegetables, whole grains, and nuts
[6], it is relevant to mention obesity in light of the two diets. Ev-
idence from literature suggests a health-enhanced effect of the
two diets on obesity [65,66], which in turn is associated with a
higher risk for developing NCDs such as CVDs and certain cancers.
People who are overweight or those suffering from obesity also
experience higher health care expenditures. They have a greater
need to make use of more health care services, which implies
higher direct health care–related costs [67,68]. Additionally, high
additional loss of productivity was reported in the overweight
and obese population [69,70]. It is clear that unhealthy nutri-
tion patterns are a major risk factor for the growing burden related
to chronic diseases and their comorbidities and as such affect
society as a whole [8].
The societal effects can be predicted from the results pre-
sented in this study. If 10% of the total population commit to a
high adherence of the Mediterranean diet, societal cost savings
of €1.30 billion in Belgium and even £5.21 billion in the United
Kingdom are estimated over 20 y. If 10% of the total population
commit to consuming a high soy-containing diet, the correspond-
ing estimated savings would be €1.53 billion and £7.54 billion for
Belgium and the United Kingdom, respectively.
 J. Schepers, L. Annemans / Nutrition 48 (2018) 24–32
The present study had some limitations, with the first being
that the included studies regarding a soy-containing diet were
mostly from Asia. The consumption of soy is remarkably higher
in Asian countries than in Western countries. The intake of soy
products is an important part of the food habits in Asia, and as
a result most research about soy has been done in those coun-
tries. The results of the current cost-effectiveness analysis thus
needed to be interpreted with caution due to the lower con-
sumption of soy in Belgium and the United Kingdom.
Consequently, further investigation is needed in more Western
countries to describe the effects of soy on a Western popula-
tion. On the other hand, our estimates should be interpreted to
undertand what could be achievable if more people would adhere
to soy as described in the studies we applied. These levels were
moreover still quite reasonable. In Mueller et al.’s study, high ad-
herence was associated with an intake of soy of at least twice
per week [14]. Kokubo, for example, showed high adherence was
linked to an intake of at least five times per week [13].
The past decade has seen increased soy consumption in Europe.
Today, the total European soy production corresponds to 2.3
million tons. Also, since 2014, a growing interest in soy-based
products is noticed all over Europe, which indicates that the taste
perception by European citizens is no longer a barrier [71]. Cur-
rently, 70% of the worldwide soy production is used to feed
animals that are raised for consumption. A shift to more plant-
or soy-based food patterns may shift the worldwide production
toward more human consumption of soy [72].
A second concern related to the Mediterranean diet is that
Mediterranean foods may not be readily available in Nordic coun-
tries. However, healthy alternatives to the Mediterranean diet,
such as the Low Land diet and the New Nordic diet, also include
large amounts of plant-based foods and are also dense in mi-
cronutrients [73,74]. Van Dooren et al. calculated the health score
of the Mediterranean diet, the Nordic diet, and the Low Lands
diet. The same nutritional characteristics, as well as the same re-
lationship between the risk for chronic diseases were found
between the three dietary patterns [74].
A further limitation of the present study was the two diet types
are associated with more health conditions than the conditions
included in this model. Only the health conditions with the stron-
gest evidence associated with these two plant-based food patterns
were included. As reported previously, these diet patterns have
29
the potential to reduce the risk for overweight/ obesity, which
is not explicitly incorporated in the model. Furthermore, the virtual
cohort of this model was assumed to be “healthy,” not suffering
from any disease, which can underestimate the potential health
benefits associated with the investigated food patterns.
Another limitation was that all input data were based on ev-
idence from literature, collected from different studies. Therefore,
there was no unambiguous “intervention” defined to promote a
soy-containing or Mediterranean diet. Moreover, the net savings
could be overestimated because there was no intervention cost
assigned to the two food patterns. In light of the implementa-
tion of these food patterns as a health promotion intervention
in the future, costs associated with the development and
promotion/distribution of the intervention should be taken into
account.
A final limitation was that epidemiologic prediction models
are based on assumptions. For instance, we assume that, over 20
y, the levels of adherence to either type of diet by an individual
remain equal. Other assumptions were made in terms of missing
data. There were no Belgian incidence rates available for stroke
and T2DM; hence, we used data based on information from The
Netherlands [37,38].
The strength of the present study lies in the fact that the
current epidemiologic prediction model was age and sex spe-
cific. For both sexes, the disease transition and mortality
probabilities were specified in 12 different age categories.
Conclusion
The result of the present analysis suggests that both a soy-
containing diet and the Mediterranean diet could contribute to
health promotion because they are predicted to lead to substan-
tial health benefits and societal savings. However, these results
must be interpreted with caution because no intervention costs
were taken into account and, regarding a soy-containing diet, the
effect on health outcomes was mostly based on Asian studies.
Therefore, further studies are required to establish more evi-
dence on the current topic. The present study has the potential
to contribute to health promotion. The findings of the cost-
effectiveness analyses could facilitate the decision-making process
of policymakers in terms of health care budget allocation.
30 J. Schepers, L. Annemans / Nutrition 48 (2018) 24–32

Appendix A. Disease-related transition probabilities (%)

Age, y Diabetes CHD Stroke Colon cancer

Women Men Women Men Women Men Women Men

B UK B UK B UK B UK B UK B UK B UK B UK

20–24 0.036 0.115 0.047 0.036 0.002 0.000 0.003 0.000 0.004 0.003 0.005 0.000 0.003 0.002 0.002 0.002
25–29 0.050 0.115 0.066 0.036 0.005 0.001 0.008 0.002 0.007 0.003 0.009 0.000 0.001 0.003 0.002 0.003
30–34 0.074 0.191 0.098 0.136 0.012 0.002 0.019 0.012 0.013 0.003 0.016 0.000 0.003 0.006 0.003 0.006
35–39 0.113 0.191 0.150 0.136 0.024 0.004 0.040 0.014 0.022 0.026 0.028 0.035 0.006 0.007 0.003 0.008
40–44 0.173 0.300 0.229 0.402 0.046 0.005 0.076 0.015 0.037 0.026 0.047 0.035 0.009 0.012 0.010 0.013
45–49 0.258 0.300 0.341 0.402 0.083 0.026 0.135 0.056 0.060 0.060 0.077 0.076 0.016 0.021 0.017 0.024
50–54 0.367 0.543 0.486 0.786 0.137 0.026 0.221 0.056 0.095 0.060 0.123 0.076 0.027 0.037 0.036 0.050
55–59 0.494 0.543 0.653 0.786 0.212 0.066 0.334 0.153 0.148 0.140 0.190 0.214 0.054 0.062 0.073 0.088
60–64 0.619 0.848 0.818 1.187 0.301 0.066 0.462 0.153 0.225 0.140 0.288 0.214 0.092 0.096 0.140 0.162
65–69 0.720 0.848 0.951 1.187 0.396 0.129 0.588 0.225 0.332 0.464 0.423 0.678 0.140 0.131 0.268 0.223
70–74 0.775 1.032 1.025 1.268 0.484 0.129 0.696 0.225 0.479 0.464 0.606 0.678 0.201 0.194 0.378 0.326
75–79 0.777 1.032 1.027 1.268 0.548 0.146 0.774 0.305 0.675 1.109 0.848 1.085 0.215 0.250 0.290 0.400

Age, y Lung cancer Stomach cancer Breast Ccancer Prostate cancer

Women Men Women Men Women Men

B UK B UK B UK B UK B UK B UK

20–24 0.000 0.000 0.001 0.000 0.000 0.000 0.000 0.000 0.002 0.002 0.000 0.000
25–29 0.000 0.001 0.001 0.001 0.000 0.000 0.000 0.000 0.013 0.001 0.000 0.000
30–34 0.002 0.001 0.003 0.001 0.002 0.001 0.002 0.001 0.035 0.033 0.000 0.000
35–39 0.003 0.002 0.006 0.003 0.001 0.001 0.001 0.001 0.090 0.075 0.001 0.000
40–44 0.012 0.005 0.009 0.007 0.003 0.002 0.003 0.003 0.158 0.144 0.005 0.003
45–49 0.021 0.015 0.024 0.016 0.006 0.003 0.006 0.005 0.247 0.261 0.017 0.017
50–54 0.051 0.035 0.068 0.036 0.015 0.004 0.015 0.009 0.293 0.330 0.079 0.063
55–59 0.090 0.073 0.154 0.084 0.021 0.006 0.021 0.014 0.322 0.325 0.198 0.177
60–64 0.135 0.124 0.263 0.150 0.034 0.009 0.034 0.023 0.400 0.418 0.362 0.343
65–69 0.160 0.189 0.374 0.242 0.048 0.013 0.048 0.036 0.427 0.476 0.604 0.577
70–74 0.155 0.256 0.474 0.377 0.057 0.025 0.057 0.064 0.442 0.409 0.707 0.712
75–79 0.133 0.298 0.537 0.465 0.079 0.039 0.079 0.090 0.429 0.468 0.769 0.815

B, Belgium; CHD, coronary heart disease; UK, United Kingdom.

Appendix B. Age-dependent mortality probabilities (%) for women in Belgium

Women 20–24 y 25–29 y 30–34 y 35–39 y 40–44 y 45–49 y 50–54 y 55–59 y 60–64 y 65–69 y 70–74 y 75–79 y

Death probability diabetes 0.036 0.045 0.063 0.086 0.141 0.262 0.406 0.661 0.926 1.317 2.086 3.674
Death probability CHD (1) 7.300 7.300 7.300 7.300 7.300 7.300 7.300 17.900 17.900 17.900 17.900 39.100
Death probability CHD (1+) 6.014 6.014 6.014 6.014 6.014 6.014 6.014 14.784 14.784 14.784 14.784 32.214
Death probability stroke (1) 25.000 25.000 25.000 25.000 25.000 25.000 18.000 18.000 23.000 23.000 41.000 41.000
Death probability stroke (1+) 0.052 0.064 0.089 0.121 0.200 0.372 0.575 0.937 1.314 1.868 2.959 5.211
Death probability colon cancer (1) 5.667 5.667 5.667 5.667 5.667 5.667 7.153 7.153 7.153 8.914 8.914 8.914
Death probability colon cancer (1+) 5.667 5.667 5.667 5.667 5.667 5.667 7.153 7.153 7.153 8.914 8.914 8.914
Death probability lung cancer (1) 42.700 42.700 42.700 42.700 42.700 42.700 46.750 46.750 46.750 57.300 57.300 57.300
Death probability lung cancer (1+) 21.400 21.400 21.400 21.400 21.400 21.400 26.127 26.27 26.127 30.860 30.860 30.860
Death probability stomach cancer (1) 28.100 28.100 28.100 28.100 28.100 28.100 28.100 28.100 37.300 37.300 37.300 57.300
Death probability stomach cancer (1+) 13.581 13.581 13.581 13.581 13.581 13.581 13.581 13.581 16.620 16.620 16.620 23.500
Death probability breast cancer (1) 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.700 1.700 1.700 1.700 7.200
Death probability breast cancer (1+) 1.718 1.718 1.718 1.718 1.718 1.718 1.718 1.933 1.933 1.933 1.933 4.557
Overall mortality 0.025 0.028 0.039 0.044 0.071 0.125 0.190 0.300 0.419 0.591 0.969 1.781

CHD, coronary heart disease; 1, first year in a certain disease state; 1+, after first year in a certain disease state.

Appendix C. Age-dependent mortality probabilities (%) for women in the United Kingdom

Women 20–24 y 25–29 y 30–34 y 35–39 y 40–44 y 45–49 y 50–54 y 55–59 y 60–64 y 65–69 y 70–74 y 75–79 y

Death probability diabetes 0.030 0.041 0.063 0.098 0.152 0.230 0.361 0.563 0.885 1.368 2.334 4.055
Death probability CHD (1) 7.300 7.300 7.300 7.300 7.300 7.300 7.300 17.900 17.900 17.900 17.900 39.100
Death probability CHD (1+) 6.014 6.014 6.014 6.014 6.014 6.014 6.014 14.784 14.784 14.784 14.784 32.214
Death probability stroke (1) 25.000 25.000 25.000 25.000 25.000 25.000 18.000 18.000 23.000 23.000 41.000 41.000
Death probability stroke (1+) 0.043 0.058 0.090 0.139 0.215 0.326 0.512 0.798 1.255 1.940 3.310 5.751
Death probability colon cancer (1) 5.667 5.667 5.667 5.667 5.667 5.667 7.153 7.153 7.153 8.914 8.914 8.914
Death probability colon cancer (1+) 5.667 5.667 5.667 5.667 5.667 5.667 7.153 7.153 7.153 8.914 8.914 8.914
Death probability lung cancer (1) 42.700 42.700 42.700 42.700 42.700 42.700 46.750 46.750 46.750 57.300 57.300 57.300
Death probability lung cancer (1+) 21.400 21.400 21.400 21.400 21.400 21.400 26.127 26.27 26.127 30.860 30.860 30.860
Death probability stomach cancer (1) 28.100 28.100 28.100 28.100 28.100 28.100 28.100 28.100 37.300 37.300 37.300 57.300
Death probability stomach cancer (1+) 13.581 13.581 13.581 13.581 13.581 13.581 13.581 13.581 16.620 16.620 16.620 23.500
Death probability breast cancer (1) 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.700 1.700 1.700 1.700 7.200
Death probability breast cancer (1+) 1.718 1.718 1.718 1.718 1.718 1.718 1.718 1.933 1.933 1.933 1.933 4.557
 J. Schepers, L. Annemans / Nutrition 48 (2018) 24–32 31

Overall mortality 0.021 0.026 0.038 0.056 0.079 0.110 0.168 0.253 0.405 0.645 1.130 2.017

CHD, coronary heart disease; 1, first year in a certain disease state; 1+, after first year in a certain disease state.

Appendix D. Age-dependent mortality probabilities (%) for men in Belgium

Men 20–24 y 25–29 y 30–34 y 35–39 y 40–44 y 45–49 y 50–54 y 55–59 y 60–64 y 65–69 y 70–74 y 75–79 y

Death probability diabetes 0.091 0.088 0.117 0.158 0.224 0.360 0.584 1.041 1.637 2.454 3.759 6.205
Death probability CHD (1) 5.500 5.500 5.500 5.500 5.500 5.500 5.500 15.300 15.300 15.300 15.300 37.400
Death probability CHD (1+) 3.601 3.601 3.601 3.601 3.601 3.601 3.601 10.017 10.017 10.017 10.017 24.486
Death probability stroke (1) 13.000 13.000 13.000 13.000 13.000 13.000 36.000 36.000 24.000 24.000 46.000 46.000
Death probability stroke (1+) 0.127 0.123 0.162 0.219 0.311 0.500 0.811 1.446 2.274 3.409 5.220 8.618
Death probability colon cancer (1) 6.620 6.620 6.620 6.620 6.620 6.620 7.615 7.615 7.615 9.772 9.772 9.772
Death probability colon cancer (1+) 6.620 6.620 6.620 6.620 6.620 6.620 7.615 7.615 7.615 9.772 9.772 9.772
Death probability lung cancer (1) 48.100 48.100 48.100 48.100 48.100 48.100 49.550 49.550 49.550 62.700 62.700 62.700
Death probability lung cancer (1+) 26.127 26.127 26.127 26.127 26.127 26.127 29.033 29.033 29.033 34.344 34.344 34.344
Death probability stomach cancer (1) 33.250 33.250 33.250 33.250 33.250 33.250 33.250 33.250 40.000 40.000 40.000 58.650
Death probability stomach cancer (1+) 15.848 15.848 15.848 15.848 15.848 15.848 15.848 15.848 18.708 18.708 18.708 24.581
Death probability prostate cancer (1) 0.600 0.600 0.600 0.600 0.600 0.600 0.600 0.600 0.100 0.100 0.100 3.400
Death probability prostate cancer (1+) 0.731 0.731 0.731 0.731 0.731 0.731 0.731 0.731 0.792 0.792 0.792 2.304
Overall mortality 0.061 0.061 0.076 0.097 0.138 0.200 0.305 0.479 0.727 1.048 1.583 2.788

CHD, coronary heart disease; 1, first year in a certain disease state; 1+, after first year in a certain disease state.

Appendix E. Age-dependent mortality probabilities (%) for men in the United Kingdom

Men 20–24 y 25–29 y 30–34 y 35–39 y 40–44 y 45–49 y 50–54 y 55–59 y 60–64 y 65–69 y 70–74 y 75–79 y

Death probability diabetes 0.072 0.091 0.120 0.175 0.275 0.371 0.546 0.868 1.399 2.130 3.591 5.993
Death probability CHD (1) 5.500 5.500 5.500 5.500 5.500 5.500 5.500 15.300 15.300 15.300 15.300 37.400
Death probability CHD (1+) 3.601 3.601 3.601 3.601 3.601 3.601 3.601 10.017 10.017 10.017 10.017 24.486
Death probability stroke (1) 13.000 13.000 13.000 13.000 13.000 13.000 36.000 36.000 24.000 24.000 46.000 46.000
Death probability stroke (1+) 0.100 0.126 0.167 0.243 0.357 0.516 0.758 1.206 1.943 2.958 4.987 8.323
Death probability colon cancer (1) 6.620 6.620 6.620 6.620 6.620 6.620 7.615 7.615 7.615 9.772 9.772 9.772
Death probability colon cancer (1+) 6.620 6.620 6.620 6.620 6.620 6.620 7.615 7.615 7.615 9.772 9.772 9.772
Death probability lung cancer (1) 48.100 48.100 48.100 48.100 48.100 48.100 49.550 49.550 49.550 62.700 62.700 62.700
Death probability lung cancer (1+) 26.127 26.127 26.127 26.127 26.127 26.127 29.033 29.033 29.033 34.344 34.344 34.344
Death probability stomach cancer (1) 33.250 33.250 33.250 33.250 33.250 33.250 33.250 33.250 40.000 40.000 40.000 58.650
Death probability stomach cancer (1+) 15.848 15.848 15.848 15.848 15.848 15.848 15.848 15.848 18.708 18.708 18.708 24.581
Death probability prostate cancer (1) 0.600 0.600 0.600 0.600 0.600 0.600 0.600 0.600 0.100 0.100 0.100 3.400
Death probability prostate cancer (1+) 0.731 0.731 0.731 0.731 0.731 0.731 0.731 0.731 0.792 0.792 0.792 2.304
Overall mortality 0.050 0.062 0.081 0.117 0.168 0.234 0.329 0.429 0.762 1.144 1.922 3.285

CHD, coronary heart disease; 1, first year in a certain disease state; 1+, after first year in a certain disease state.

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