Making Chronic Conditions Count: Hypertension Stroke Coronary Heart Disease Diabetes

A systematic approach to estimating and forecasting population prevalence on the island of Ireland

Centre for Health and Diet Research Making Chronic Conditions Count: Hypertension Stroke Coronary Heart Disease Diabetes

A systematic approach to estimating and forecasting population prevalence on the island of Ireland

Authors: Kevin P Balanda, Steve Barron, Lorraine Fahy, Aisling McLaughlin

February 2010

A copy of the full report, the executive summary and the technical supplement can be downloaded from http://www.inispho.org/publications/makingchronicconditionscountexecutivesummary http://www.inispho.org/publications/makingchronicconditionscount http://www.inispho.org/publications/makingchronicconditionscounttechnicalsupplement Making Chronic Conditions Count: Hypertension, Stroke, Coronary Heart Disease, Diabetes. A systematic approach to estimating and forecasting population prevalence on the island of Ireland.

Published by the Institute of Public Health in Ireland.

© The Institute of Public Health in Ireland, 2010.

Prepared by: Kevin P Balanda, Steve Barron, Lorraine Fahy, Aisling McLaughlin (Institute of Public Health in Ireland)

To be cited as: Balanda, K.P., Barron, S., Fahy, L., McLaughlin, A. Making Chronic Conditions Count: Hypertension, Stroke, Coronary Heart Disease, Diabetes. A systematic approach to estimating and forecasting population prevalence on the island of Ireland. Dublin: Institute of Public Health in Ireland, 2010.

The Institute of Public Health in Ireland has produced this document as a resource for public health on the island. It may be freely reproduced with acknowledgement but is not for resale or for use in conjunction with commercial purposes.

ISBN: 978-0-9559598-5-1

Design by Slick Fish Design

For further copies of the full report, executive summary and technical supplement please contact:

Ireland and Northern Ireland’s Population Health Observatory (INIsPHO), The Institute of Public Health in Ireland (IPH).

5th Floor Forestview Bishop’s Square Purdy’s Lane Redmond’s Hill Belfast Dublin 2 BT8 7ZX Ireland Northern Ireland Tel: +353 1 478 6300 Tel: +44 2890 648494 Fax: +353 1 478 6319 Fax: +44 2890 646604

Email: [email protected]

A copy of the full report, the executive summary and the technical supplement can be downloaded from http://www.inispho.org/publications/makingchronicconditionscount http://www.inispho.org/publications/makingchronicconditionscountexecutivesummary http://www.inispho.org/publications/makingchronicconditionscounttechnicalsupplement

2 Making Chronic Conditions Count

Contents

Abbreviations 4

Foreword 5

Executive Summary 6

1. Introduction 15

2. Estimating and Forecasting Prevalence 22

3. Hypertension 27

4. Angina and Heart Attack (CHD) 40

5. Stroke 53

6. Diabetes 66

7. Recommendations 79

References 82

3 Abbreviations

APHO Association of Public Health Observatories

CHD Coronary heart disease (angina or heart attack in the context of this study)

CoE (NI) Centre of Excellence for Public Health Northern Ireland

CSDH Commission on the Social Determinants of Health

CSO Central Statistics Office (Republic of Ireland)

DHSSPS Department of Health, Social Services and Public Safety (Northern Ireland)

Diabetes UK (NI) Diabetes UK (Northern Ireland)

DoHC Department of Health and Children (Republic of Ireland)

FAO Food and Agriculture Organisation of the United Nations

HRB CHDR Health Research Board Centre for Health and Diet Research (Republic of Ireland)

HSE Health Service Executive (Republic of Ireland)

HSfE Health Survey for England

INIsPHO Ireland and Northern Ireland's Population Health Observatory, Institute of Public Health in Ireland

IPH Institute of Public Health in Ireland

(the) Island The island of Ireland

LGD Local Government District (Northern Ireland)

LHO Local Health Office Area (Republic of Ireland)

NISRA Northern Ireland Statistics and Research Agency

OECD Organisation for Economic Cooperation and Development

PHA Public Health Agency (Northern Ireland)

QOF Quality and Outcomes Framework

SLÁN Survey of Lifestyle, Attitudes and Nutrition (Republic of Ireland)

WHO World Health Organization

4 Making Chronic Conditions Count

Foreword

Chronic diseases cause significant morbidity and mortality, and result in poorer quality of life for many people in the Republic of Ireland and Northern Ireland. In both jurisdictions there are also considerable financial costs to health and social care, and to the economy.

Accurate estimates and forecasts of the population prevalence of chronic diseases help us identify need, plan and develop disease prevention and management programmes, and monitor performance.

This important study shows that we can expect a substantial rise in the number of people living with a chronic disease. This is because our population is growing, ageing and lifestyle risk factors such as obesity are becoming more common. The study’s importance is all the greater as most chronic diseases and their complications are preventable.

Previously the Institute of Public Health in Ireland systematically developed estimates and forecasts for diabetes at national and local levels. Those figures have been widely used and made a significant contribution to policy, service planning and public health practice.

This new study extends that systematic approach to hypertension, coronary heart disease (angina and heart attack) and stroke as well as updating earlier diabetes figures. It documents the chronic disease epidemic we are facing over the next 15 years and the challenges posed to our population, our health and social care systems, and our economies.

It describes the unequal way in which the burden of chronic disease is distributed in Northern Ireland and the Republic of Ireland and highlights the pressing need for a greater emphasis on prevention, tackling health inequalities and addressing the social determinants of health. This requires action across government and by many sectors. Considerably greater benefits can be achieved by influencing policies of the non health sector than by health policies alone.

This work is a timely response to a key public health issue. In Northern Ireland it will help inform the current review of the public health strategy, Investing for Health, and in the Republic of Ireland it will make a vital contribution to the intersectoral work that is such an important part of improving the prevention and management of chronic diseases. We commend the Institute and its academic partners and look forward to the next phase of this work which will include other chronic diseases and further improvements in methodology.

Dr Tony Holohan Dr Michael McBride Chief Medical Officer Chief Medical Officer Department of Health and Children Department of Health, Social Republic of Ireland Services and Public Safety Northern Ireland

5 Executive Summary

Executive Summary

This report contains estimates and forecasts of the population prevalence1 of four chronic conditions: hypertension, coronary heart disease (angina and heart attack), stroke and diabetes (Type 1 and Type 2 combined). It shows how their prevalence varies across the island and what change is expected between 2007, 2015 and 2020.

Chronic conditions are responsible for a significant proportion of early deaths. They reduce quality of life in many of the adults living with them, represent substantial financial costs to patients and the health and social care system, and cause a significant loss of productivity to the economy.

Although the population is living longer, chronic conditions have reduced the quality of the extra years that have been gained. There is evidence in the Republic of Ireland, the United Kingdom and Europe, that over recent decades, while life expectancy has increased, healthy life expectancy has not kept up (www.ehemu.eu).

The burden of conditions is expected to rise because our population will grow, it will age and some risk factors such as obesity will become more common. Unless we address this growing burden we may continue to add more years to our lives without adding more life to those years.

Chronic conditions occur more frequently among the poor and vulnerable. A range of interrelated factors including the social determinants of health such as poverty, unemployment and the environment, smoking, alcohol consumption, diet and physical activity are established risk factors for chronic conditions. These risk factors are distributed unevenly across society.

The Study

Estimates and forecasts of the population prevalence of chronic conditions quantify how many people have these conditions; in this report they are described by sex, age, place of residence and characteristics of the area.

To date reliable sub-national estimates and forecasts of the population prevalence of chronic conditions have not been available on the island. This study deals with recent (2007) and future (2015 and 2020) population prevalence of four conditions: hypertension, angina and heart attack (CHD), stroke and diabetes (Type 1 and Type 2 combined)2. The full report contains figures for Local Health Offices (LHOs) in the Republic of Ireland and Local Government Districts (LGDs) in Northern Ireland, broken down by sex, age and local socio-economic circumstances.

1 Population prevalence refers to both diagnosed and undiagnosed cases. 2 Findings are based on models that incorporate the effects of demographic characteristics (sex, age and ethnicity), local socio- economic circumstances and lifestyle factors (obesity and smoking). The diabetes model is based on physical measurements, the hypertension model is based on a combination of self-reported and physical measurements, and the stroke and CHD models are based on self-reported measurements. See Chapter 2 of the full report and its technical supplement for further details.

6 Making Chronic Conditions Count

Key Findings

KEY FINDING 1:

Very large numbers of adults across the island live with hypertension, angina and heart attack (CHD), stroke and diabetes.

The prevalence of each of these conditions: • Increases dramatically with age. • Tends to be higher in the northern and western parts of the island, and lower around Dublin. • Is generally higher amongst males.

These differences reflect variation in demographic characteristics (sex, age and ethnicity), local socio-economic circumstances and lifestyle factors (obesity and smoking) across the island.

Table 1 presents population prevalence rates in 2007. In that year:

• Nearly 1.25 million adults aged 16 years and over (396,000 in Northern Ireland and 852,000 in the Republic of Ireland) have high blood pressure. • Almost 206,000 adults aged 16 years and over (75,000 in Northern Ireland and 131,000 in the Republic of Ireland) have ever had angina or a heart attack. • Nearly 92,000 adults aged 16 years and over (33,000 in Northern Ireland and 59,000 in the Republic of Ireland) have ever suffered a stroke. • Over 210,000 adults aged 20 years and over (67,000 in Northern Ireland and 144,000 in the Republic of Ireland) have diabetes (Type 1 and Type 2 combined).

Table 1: Demographic variation in population prevalence rates in 2007

Males Females Persons 16-44 yrs 45-64 yrs 65-74 yrs 75+ yrs Hypertension Northern Ireland 29.8% 27.6% 28.7% 9.2% 39.6% 65.1% 71.9% Republic of Ireland 26.7% 23.4% 25.1% 8.7% 38.4% 64.0% 70.9%

Angina and heart attack (CHD) Northern Ireland 6.5% 4.5% 5.4% 0.4% 6.1% 16.5% 22.4% Republic of Ireland 4.7% 3.0% 3.8% 0.3% 5.0% 14.1% 19.1%

Stroke Northern Ireland 2.4% 2.4% 2.4% 0.3% 2.0% 6.8% 11.8% Republic of Ireland 1.8% 1.7% 1.7% 0.3% 1.7% 5.9% 10.3%

Diabetes (Type 1 and Type 2 combined) Males Females Persons 20-29 yrs 30-59 yrs 60+ yrs Northern Ireland 4.5% 6.0% 5.3% 0.5% 3.1% 13.4% Republic of Ireland 3.9% 5.1% 4.5% 0.6% 3.0% 13.2%

7 Executive Summary

Except for diabetes, the prevalence estimates for these chronic conditions are more common amongst males3.

The prevalence of each of these conditions increases dramatically with age. For example, in 2007 the percentage of adults in Northern Ireland who have high blood pressure rose from 9.2% amongst 16-44 year olds, to 39.6% amongst 45-64 year olds, to 65.1% amongst 65-74 year olds, and to 71.9% amongst adults aged 75 years and over. The same pattern is observed in the Republic of Ireland and amongst males and females. This is not surprising given that each of the conditions generally reflects influences whose effects accumulate over time and tend to express themselves later in life.

KEY FINDING 2:

Between 2007 and 2020, the burden of chronic conditions is expected to increase dramatically in both Northern Ireland and the Republic of Ireland. By 2020:

• The number of adults with these chronic conditions will increase by around 40% in the Republic of Ireland and by around 30% in Northern Ireland. • Relatively more (compared to 2007) of the burden of these conditions will be borne by adults in the older age groups.

Larger increases are expected in the Republic of Ireland because its population is projected to grow more than Northern Ireland’s population.

Except for diabetes, these forecasts do not incorporate changes in lifestyle factors such as obesity and smoking.

Table 2 illustrates how the number of people living with each of these chronic conditions is expected to increase dramatically between 2007 and 2020 in both Northern Ireland and the Republic of Ireland.

3 This reflects the findings of the underlying population-based reference studies. Other studies have reported different findings about diabetes prevalence amongst males and females. See full report and its technical supplement for further details.

8 Making Chronic Conditions Count

Table 2: Number of cases and prevalence rates in 2007, 2015 and 2020 in Northern Ireland and the Republic of Ireland

2007 2015 2020 n% n% n% Hypertension Northern Ireland 395,529 28.7% 448,011 30.3% 481,867 31.7% Republic of Ireland 851,658 25.1% 1,050,591 26.8% 1,192,415 28.3%

Angina and heart attack (CHD) Northern Ireland 75,158 5.4% 87,848 5.9% 97,255 6.4% Republic of Ireland 130,703 3.8% 166,985 4.3% 195,243 4.6%

Stroke Northern Ireland 32,941 2.4% 38,405 2.6% 42,457 2.8% Republic of Ireland 58,778 1.7% 74,493 1.9% 86,845 2.1%

Diabetes (Type 1 and Type 2 combined) Northern Ireland 67,262 5.3% 82,970 6.0% 94,219 6.6% Republic of Ireland 143,618 4.5% 193,240 5.2% 232,644 5.9%

• In 2007 nearly 852,000 adults in the Republic of Ireland (25.1%) have high blood pressure. By 2020 this is expected to rise to over 1,192,000 (28.3%). This represents a 40% increase in the numbers of people affected - an additional 341,000 adults - in less than 15 years. • In 2007 nearly 396,000 adults in Northern Ireland (28.7%) have high blood pressure. By 2020 this is expected to rise to nearly 482,000 (31.7%). This represents a 22% increase – an additional 86,000 adults – in less than 15 years. • In 2007 nearly 131,000 adults in the Republic of Ireland (3.8%) have ever had a CHD. By 2020 this is expected to rise to over 195,000 (4.6%). This represents a 50% increase – an additional 65,000 adults – in less than 15 years. • In 2007 over 75,000 adults in Northern Ireland (5.4%) have ever had a CHD. By 2020 this is expected to rise to over 97,000 (6.4%). This represents a 30% increase – an additional 22,000 adults – in less than 15 years. • In 2007 almost 59,000 adults in the Republic of Ireland (1.7%) have ever had a stroke. By 2020 this is expected to rise to almost 87,000 (2.1%). This represents a 48% increase – an additional 28,000 adults – in less than 15 years. • In 2007 almost 33,000 adults in Northern Ireland (2.4%) have ever had a stroke. By 2020 this is expected to rise to over 42,000 (2.8%). This represents a 29% increase – an additional 10,000 adults – in less than 15 years. • In 2007 nearly 144,000 adults in the Republic of Ireland (4.5%) have diabetes (Type 1 and Type 2 combined). By 2020 this is expected to rise to over 233,000 (5.9%). This represents a 62% increase – an additional 89,000 adults – in less than 15 years. • In 2007 over 67,000 adults in Northern Ireland (5.3%) have diabetes (Type 1 and Type 2 combined). By 2020 this is expected to rise to over 94,000 (6.6%). This represents a 40% increase – an additional 27,000 adults – in less than 15 years.

9 Executive Summary

For each chronic condition, higher prevalence rates amongst older adults along with an ageing population mean that the percentage of all adults with these conditions who belong to the older age groups will increase. For example, in the republic of Ireland the percentage of all adults who have ever had a stroke who are aged 65 years and over will rise from 62.8% in 2007 to 67.1% in 2020. In Northern Ireland the percentage will rise from 67.2% to 71.2%.

KEY FINDING 3:

Local socio-economic circumstances affect the prevalence of chronic conditions in an area. Adults living in more deprived areas are more likely to be living with a chronic condition.

Generally speaking, this is true across all chronic conditions, amongst males and females, in each age group, and in both the Republic of Ireland and Northern Ireland.

Figures 1 and 2 below illustrate how the prevalence of angina and heart attack (CHD), and diabetes, in an area increases as the local socio-economic circumstances (as measured by an area’s local deprivation score) worsen.

Figure 1: Population prevalence rates of angina and heart attack (CHD) amongst adults; across the deprivation bands4 in the Republic of Ireland within each sex and age group (2007).

35%

30%

25%

20%

15%

10%

5%

0% Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years Band 1 (least deprived) Band 2 Band 3 Band 4 Band 5 (most deprived)

4 LGDs in Northern Ireland and LHOs in the Republic of Ireland were grouped into bands according to their deprivation scores. See the main report’s technical supplement for definition of deprivation bands.

10 Making Chronic Conditions Count

Figure 2: Population prevalence rates of diabetes amongst adults; across the deprivation bands4 in Northern Ireland within each sex and age group (2007). 16%

14%

12%

10%

8%

6%

4%

2%

0% Persons Male Female 20-29 years 30-59 years 60+ years Band 1 (least deprived) Band 2 Band 3 Band 4 (most deprived)

The effect of local socio-economic circumstances is similar amongst males and females, and across all age groups. This is true for each chronic condition.

The contrast between the most deprived areas and the least deprived areas is sometimes quite large. For example, CHD prevalence in the most deprived areas in the Republic of Ireland is almost 2.5 times that in the least deprived areas. Although direct North-South comparisons are not possible because of methodological differences (see the main report’s technical supplement), in Northern Ireland CHD prevalence in the most deprived areas is about 1.5 times that in the least deprived areas.

4 LGDs in Northern Ireland and LHOs in the Republic of Ireland were grouped into bands according to their deprivation scores. See the main report’s technical supplement for definition of deprivation bands.

11 Executive Summary

Prevention, inequalities and the social determinants of health

Like many developed countries, life expectancy in the Republic of Ireland and Northern Ireland is increasing.

Between 1985 and 2000 the Republic of Ireland experienced a 47% reduction in deaths from heart disease (CHD) amongst those aged 25–84 years. A recent application of the IMPACT model to the Republic of Ireland found that 44% of this reduction could be attributed to more effective treatment. Improvements in population-level risk factors such as smoking prevalence, mean cholesterol concentrations and blood pressure levels had a greater effect (Bennett et al, 2006). While modern cardiology treatments had gained many thousands of life-years, twice as many life-years were generated by relatively modest reductions in major population-level risk factors (Kabir et al, 2007).

WHO (World Health Organization) estimates that 80% of heart disease, stroke and Type 2 diabetes, and 40% of cancer could be avoided if major risk factors were eliminated.

The WHO Strategy for Chronic Disease recommends that countries adopt an integrated strategy that incorporates population-level disease prevention programmes as well as targeted disease management programmes that focus on individuals at high risk (WHO, 2008).

Despite this, the Organisation for Economic Cooperation and Development (OECD) estimates that only 3% of total healthcare expenditure goes towards population-based disease prevention programmes. More focus on prevention is clearly needed.

A range of interrelated factors including the social determinants of health such as poverty, education, housing and the physical environment as well as smoking, alcohol consumption, diet and physical activity are established risk factors for chronic conditions.

These risk factors are distributed unevenly across society and efforts to reduce the burden of chronic conditions must address the causes of these uneven distributions.

The variation across a range of factors - age, sex, geography and local socio-economic conditions - observed in this study in the prevalence of chronic conditions means it is essential that chronic disease prevention programmes take these factors into account5. The recent publication Tackling Health Inequalities: an All-Ireland Approach to Social Determinants reviewed the key social determinants in the Republic of Ireland and Northern Ireland and highlighted possible policy responses to reduce health inequalities (Farrell et al, 2008).

5 Similar variations in quality of care, care outcomes and mortality suggest that the same is true for chronic disease management programmes.

12 Making Chronic Conditions Count

Recommendations

A review of key government policies across the island would identify opportunities to incorporate the three Principles of Action identified by the WHO Commission on the Social Determinants of Health. These are: • Improving daily living conditions. • Tackling the inequitable distribution of power, money and resources. • Measuring and understanding the problem and assessing the impact of action.

The following recommendations emphasise the importance of a stronger focus on prevention, tackling inequalities using a social determinants of health and life course perspective, and the crucial importance of building appropriate information systems to support these efforts.

CHRONIC DISEASE PREVENTION

A stronger focus on prevention is urgently needed. Key government policies and supporting policies and strategies need to promote healthier lifestyles and strengthen the early assessment and diagnosis of chronic conditions.

Chronic disease prevention programmes need to take a life course perspective with a strong focus on early childhood, and develop interventions based on the needs of vulnerable and disadvantaged groups.

CHRONIC DISEASE MANAGEMENT

Equity should be incorporated more strongly into the implementation of key government policies and should be extended beyond access and quality of care to reflect the definition used in the WHO Commission on the Social Determinants of Health.

Chronic disease management programmes must be based on need and not ability to pay. An understanding of current and future prevalence and how it varies with factors such as age, sex, geography and local socio-economic circumstances is an essential prerequisite for good planning and monitoring of chronic disease management.

Appropriate models of integrated care that involve a greater role for primary care and community care sectors should be developed.

13 Executive Summary

RESEARCH AND DATA GAPS

Further research into the impact of chronic diseases on the population, the health and social care system, and the economy is required. This research should consider the magnitude of the burden of these conditions (including financial costs); how it is distributed across the population; how that burden might change in the future; and the implications for the health and social care workforce and its training requirements.

Alongside patient registers, a system of standardised population prevalence estimates and forecasts (available at national and sub-national level) should be developed and maintained.

Prevalence estimates and forecasts should be incorporated into routine local data collections such as the core data set for the Republic of Ireland’s Primary Care Teams and the community profiles that will support local government in Northern Ireland.

A comprehensive and standardised system for monitoring risk factors (overweight/obesity, nutrition, physical activity and smoking) at the national and sub-national level should be established and maintained.

Relevant data on social determinants of health should be incorporated into clinical, service and public health information systems - including chronic disease patient registers and local data collections - and used to help plan, deliver and evaluate chronic disease prevention and management programmes.

Performance indicators which can be used to measure differences in disease prevention and management between population subgroups should be developed and used to plan and monitor efforts to reduce health inequalities.

14 1 Introduction

15 Chapter 1 Introduction

CHAPTER 1. INTRODUCTION

Burden of Chronic Conditions

This report contains estimates and forecasts of the prevalence of four chronic conditions: hypertension, coronary heart disease (angina and heart attack), stroke and diabetes. It shows how their prevalence varies across the island of Ireland and what changes are expected between 2007, 2015 and 2020.

Chronic conditions are responsible for a significant proportion of early deaths. WHO estimates that chronic diseases, representing 60% of all deaths, are by far the leading cause of mortality in the world (WHO/FAO, 2003). In more developed parts of the world this percentage is even higher. For example, conditions such as cancer, heart disease, stroke, chronic respiratory diseases and diabetes account for 86% of all deaths in the WHO region for Europe (WHO, 2005)

The burden of these conditions on the island of Ireland is expected to rise because the population will grow, it will age and some risk factors such as obesity will become more common.

Chronic conditions reduce quality of life in many of the adults living with them, represent substantial financial costs to patients themselves and the health and social care system, and cause a significant loss of productivity to the economy.

Poorer quality of life Although the population is living longer, chronic conditions have reduced the quality of the extra years that have been gained. There is evidence in the Republic of Ireland, the United Kingdom and Europe that life expectancy has increased over recent decades while healthy life expectancy has not kept up (www.ehemu.eu). For example; male life expectancy at age 65 years increased in the Republic of Ireland from 13.5 years in 1995 to 16.9 years in 2006. In the same period male healthy life expectancy at age 65 years was unchanged from 9.2 years in 1995 to 9.1 years in 2006. The percentage of the years of life after age 65 that is spent in good health decreased from 68% in 1995 to 54% in 2006. Unless we address the growing burden of chronic conditions we may continue to add more years to our lives without adding more life to those years.

Health and social care costs Patients with chronic conditions are heavy users of health and social services. For example, it is estimated that three quarters of the healthcare expenditure in the Republic of Ireland is allocated to the management of chronic diseases. Approximately 80% of GP consultations and 60% of hospital bed days are related to chronic diseases and their complications. Chronic diseases account for two thirds of emergency medical admissions to hospitals. Healthcare costs and the risk of avoidable inpatient admission increases dramatically with the number of co- morbidities (DoHC, 2008).

Costs to business The rising cost of lost productivity associated with chronic conditions is a growing burden and threatens the sustainability of many businesses, according to a recent report (World Economic

16 Making Chronic Conditions Count

Forum, 2008). Losses in productivity are caused by disability, unplanned absences, reduced workplace effectiveness, increased accidents and negative impacts on the quality of work and customer service. Depression, fatigue and sleeping problems - risks that are often associated with chronic conditions - have the largest impact on productivity. Similar to health and social care costs, co-morbidities multiply the losses in productivity. The report found that productivity losses associated with chronic conditions are as much as 400% more than the costs of treating chronic disease.

The uneven distribution of burden A range of interrelated factors including the social determinants of health, smoking, alcohol consumption, diet and physical activity are established risk factors for chronic conditions. The burden of chronic conditions and these risk factors are distributed unevenly across society. They occur more frequently among the poor and vulnerable. Efforts to reduce the burden of chronic conditions must address the causes of these uneven distributions.

Prevention

WHO estimates that 80% of heart disease, stroke and Type 2 diabetes, and 40% of cancer could be avoided if major risk factors were eliminated.

Much of the recent improvement in chronic disease mortality has been attributed to improvements in the level of major population-level risk factors. For example, between 1985 and 2000 the Republic of Ireland experienced a 47% reduction in deaths from heart disease amongst those aged 25–84 years. A recent application of the IMPACT model to the Republic of Ireland found that 44% of this reduction could be attributed to more effective treatment. Improvement in population-level risk factors such as smoking prevalence, mean cholesterol concentrations and blood pressure levels had a greater effect (Bennett et al, 2006). An associated study found that while modern cardiology treatments had gained many thousands of life-years, twice as many life-years were gained by relatively modest reductions in major population-level risk factors (Kabir et al, 2007). This occurred despite estimates that only 3% of total healthcare expenditure goes towards population-based prevention and public health programmes (OECD). Kabir et al conclude that ’effective policies, such as the promotion of healthy diets, and weight reduction, together with the recent nationwide workplace smoking ban, will be essential to maintain and further enhance health gain’ (Kabir et al, 2007).

Social Determinants of Health

How can further improvements in the level of population-level risk factors be achieved?

The prevalence of most of the major population-level risk factors for chronic conditions is much higher in particularly vulnerable populations. The variation in the prevalence of chronic conditions across a range of factors - age, sex, geography and local socio-economic circumstances - means it is essential that chronic disease prevention programmes take these factors into account6.

6 Similar variations in quality of care, care outcomes and mortality suggest that the same is true for chronic disease management programmes.

17 Chapter 1 Introduction

Social issues also play a key role and influence, to varying degrees, the prevalence of these risks across the whole population. The WHO’s Commission on the Social Determinants of Health emphasises that the social determinants of health - such as poverty, education, housing and the physical environment - must also be taken into account if we hope to promote healthier lifestyles and reduce health inequalities. The effects of these determinants accumulate over time and often persist in later generations. The Commission identified three Principles of Action that should underpin efforts to promote health and equity in health. They are:

• To improve daily living conditions • To tackle the inequitable distribution of power, money and resources • To measure and understand the problem, and assess the impact of action (CSDH, 2008).

The recent publication Tackling Health Inequalities: An All-Ireland Approach to Social Determinants reviewed the key social determinants in the Republic of Ireland and Northern Ireland and highlighted possible policy responses that could reduce health inequalities (Farrell et al, 2008).

Key Government Frameworks for Chronic Disease

This section focuses on the Republic of Ireland’s Policy Framework for the Management of Chronic Diseases (DoHC, 2008) and Northern Ireland’s Service Framework for Cardiovascular Health and Wellbeing (DHSSPS, 2009). In both jurisdictions, the implementation of these policies is supported by a range of further policy and strategy documents addressing specific issues7.

High level of government support In both jurisdictions there is a high level of government support for efforts to prevent and manage the burden of chronic conditions.

In the Republic of Ireland, the Department of Health and Children (DoHC) published Building Healthier Hearts: Introduction to the Report of the Cardiovascular Health Strategy Group in 1999 (DoHC, 1999). In 2008 the DoHC launched Tackling Chronic Disease: Policy Framework for the Management of Chronic Disease (DoHC, 2008). Amongst its key challenges for action, the Health Service Executive’s Corporate Plan 2008-2011 lists the prevention and management of chronic diseases (HSE, 2008)

In June 2009, Northern Ireland’s Department of Health, Social Services and Public Safety (DHSSPS) published Service Framework for Cardiovascular Health and Wellbeing (DHSSPS, 2009). This framework considers hypertension, coronary heart disease, stroke and diabetes. Overarching Standards and Performance Indicators are defined for each condition as well as Health Improvement / Prevention.

7 In the Republic of Ireland these include existing health and primary care strategies and a new cardiovascular strategy including stroke (under consideration). In Northern Ireland, they include the forthcoming Obesity Prevention Framework, the Investing for Health strategy (under review) and a service framework for Older People's Health and Wellbeing (planned).

18 Making Chronic Conditions Count

Broadly similar approaches There also are strong similarities in the approaches to the prevention and management of chronic conditions in the two jurisdictions.

Reflecting the emerging evidence from other countries and developments in best practice that are advocated by the World Health Organization (WHO, 2008), the approach in both jurisdictions focuses on:

• Population directed disease prevention and health promotion • Patient-centred care and self care • Greater patient and public participation in care • Muliti-disciplinary care teams and intersectoral working • Need to address inequalities in outcomes.

Both jurisdictions are exploring models of care delivery such as models of shared care that are integrated across organisational boundaries and include a greater role for the primary care and community care sectors. For example, the Republic of Ireland is rolling out multi- disciplinary Primary Care Teams across the country. In Northern Ireland there have been significant reforms in planning, commissioning and service delivery arrangements including establishment of a Public Health Agency (PHA) and a stronger role for local government.

The whole service spectrum WHO’s Strategy for Chronic Disease recommends that countries adopt an integrated strategy that incorporates population-level disease prevention programmes as well as targeted disease management programmes that focus on individuals at high risk (WHO, 2008).

Key frameworks on the island reflect this recommendation. The Republic of Ireland’s Tackling Chronic Disease: Policy Framework for the Management of Chronic Disease is explicitly framed around ‘Disease Prevention Programmes’ and ‘Disease Management Programmes’. Northern Ireland’s Service Framework for Cardiovascular Health and Wellbeing sees the whole service spectrum as incorporating: Prevention / Promotion / Protection / Lifestyle; Assessment and Diagnosis; Treatment and Care; Ongoing care / Chronic Disease Management; and End-of-life Care / Palliative Care.

The frameworks focus more on the treatment and management end of the spectrum while issues relating to chronic disease prevention tend to be addressed in associated documents such as the Northern Ireland strategy Investing for Health. Issues relating to chronic disease prevention tend to be addressed in associated documents such as (public) health strategies.

Tackling health inequalities Key documents in the Republic of Ireland and Northern Ireland acknowledge that the burden of chronic diseases is unequally distributed across the population and recognise the need to tackle health inequalities. One of the six ‘dimensions of quality’ in Northern Ireland’s Service Framework for Cardiovascular Health and Wellbeing is equity. Equity is also one of the four principles underpinning the Republic of Ireland’s health strategy Quality and Fairness: A Health System for You (DoHC, 2001).

19 Chapter 1 Introduction

The key framework documents on the island tend to interpret equity in terms of access to - and quality of - care. The background to Policy Requirement 9 of the Republic of Ireland’s Tackling Chronic Disease: Policy Framework for the Management of Chronic Disease states that ‘access to differing levels of care should be equitable’. Northern Ireland’s Service Framework for Cardiovascular Health and Wellbeing takes equity to mean ‘health and social care which does not vary in quality because of personal characteristics such as age, gender, ethnicity, race, geographical location or socio-economic status-based and are capable of being measured’. In Northern Ireland’s Service Framework for Cardiovascular Health and Wellbeing the Performance Indicators of Equity measure overall population levels rather than differences between population subgroups.

However, Northern Ireland’s public health strategy Investing for Health (DHSSPS, 2002) sets regional targets of halving the gap in life expectancy between the Northern Ireland life expectancy and the life expectancy of people living in the fifth most deprived electoral wards.

A focus on behaviour change Key government policy documents in the Republic of Ireland and Northern Ireland emphasise the need to promote healthier lifestyles and address population-level risk factors. For example, the Overarching Standards for Health Improvement / Prevention in Northern Ireland’s Service Framework for Cardiovascular Health and Wellbeing are defined for smoking and smoking cessation, physical inactivity, healthy eating support and advice, and hazardous/harmful alcohol consumption. While key government policies have a strong focus on behaviour change, they have less emphasis on the socio-economic factors and other social determinants of health – the ‘causes of the causes’ – that underpin them.

Why Population Prevalence?

Estimates and forecasts of the population prevalence of chronic conditions quantify how many people live with these conditions and describe them in terms of sex, age and characteristics of their place of residence.

In turn, these tell us something about undiagnosed cases (when the estimates and forecasts are coupled to patient registers), and help us plan and design disease prevention and management efforts. They are needed at sub-national level to support planning and delivery of services to meet local needs.

20 Making Chronic Conditions Count

Current Study

Until now, reliable sub-national estimates and forecasts have not been available on the island of Ireland.

The Association of Public Health Observatories (APHO) (www.apho.org.uk) and its partner8 were commissioned by the English Department of Health to develop models to estimate and forecast the population prevalence of a number of chronic conditions. These models incorporate the effects of demographic characteristics (sex, age and ethnicity), local socio- economic circumstances and lifestyle issues (obesity and smoking). Diabetes and hypertension models are, to some degree, based on physical measurements. The other models are based on self-reported health status only9.

In 2006 and 2007, IPH adapted one of these models and published population prevalence estimates and forecasts for diabetes on the island of Ireland (IPH 2006, IPH 2007).

This study extends that work to include hypertension, angina and heart attack (CHD), stroke as well as updates of previous diabetes estimates and forecasts. It was undertaken by Ireland and Northern Ireland’s Population Health Observatory (INIsPHO), in the Institute of Public Health in Ireland (IPH), and our academic partners: the HRB Centre for Health and Diet Research (HRB CHDR) in the Republic of Ireland and the Centre of Excellence for Public Health (CoE (NI) in Northern Ireland.

The report contains estimates for 2007 and forecasts for 2015 and 2020 of the population prevalence for hypertension, angina or heart attack, stroke and diabetes (Type 1 and Type 2 combined) amongst adults. These are broken down by age, sex and area10. An ‘adult’ is someone aged 16 years and over, except for diabetes where an ‘adult’ is someone aged 20 years and over. Figures are presented for each LHO in the Republic of Ireland and each LGD in Northern Ireland.

8 The diabetes model was developed in collaboration with Brent PCT and University of Sheffield, prior to the models for the other conditions. 9 See this report’s technical supplement for more details. 10 Ethnicity is incorporated into the modelling but is not reported here.

21 2 Estimating and Forecasting Prevalence

22 Making Chronic Conditions Count

CHAPTER 2. ESTIMATING AND FORECASTING PREVALENCE

Introduction

Initially, APHO, Brent PCT and University of Sheffield developed a model to estimate and forecast the population prevalence of diabetes. Subsequently, APHO was commissioned by the English Department of Health to develop models to estimate and forecast the population prevalence of a number of other chronic conditions.

INIsPHO has adapted these models to estimate the prevalence of hypertension, angina and heart attack (CHD), stroke and diabetes on the island of Ireland. This chapter summarises how the APHO models were applied; full details of methods can be found in this report’s technical supplement which can be downloaded from www.apho.org.uk.

How the Models Work

Each model involves three simple steps that are described below.

Figure 2.1: How the models work

STEP 1: Reference studies What is the risk ESTIMATING RISK among white women aged 55-64 Adjust for known biases years who live in a (Adjusted) risk estimates for groups of deprived area? people with combinations of risk factors

STEP 2: (Estimated) (Forecasted) How many white ESTIMATING & distribution of risk distribution of risk women aged 55-64 FORECASTING THE factors in current factors in future years live (or are DISTRIBUTION OF RISK population population projected to live) in a deprived area? Apply group-specific risk estimates to group-specific population counts

STEP 3: (Estimated) number of (Forecasted) number How many white OBTAINING ESTIMATED cases & prevalence of cases & prevalence women aged 55-64 & FORECASTED rate in current rate in who live (or are PREVALENCE population future population projected to live) in a deprived area have Adjust for any known biases (or will have) the condition?

23 Chapter 2 Estimating and Forecasting Prevalence

Step 1: Estimating risk Reference studies were used to reliably estimate the risk that a person with a particular combination of risk factors will have the condition. For example, what is the risk among white women aged 55-64 years living in a deprived area? In the case of diabetes, some additional adjustment for known biases in the reference studies was also made.

Step 2: Estimating and forecasting the distribution of risk The next step was to calculate the number of people with these particular combinations of risk factors in the current and future population across the island. For example, how many white women aged 55-64 years live (or are projected to live) in a deprived area in 2007, 2015 and 2020?

Step 3: Obtaining estimated and forecasted prevalence Group-specific risk estimates were then applied to corresponding group-specific population counts to estimate and forecast the number of people with the condition and the population prevalence rate of the condition. For example, how many white women aged 55-64 years living in a deprived area have (or will have) the condition? In the case of diabetes, some additional adjustment for known biases was also made.

24 Making Chronic Conditions Count

Step 1: Estimating Risk

Table 2.1 describes the definition, the reference studies and the risk factors used in the models for each condition.

Table 2.1: Definition, reference studies and risk factors for each condition

Condition Definition Reference studies Risk factors

Hypertension Measured systolic blood Health Survey for England Age, Sex, Ethnicity, Area pressure (SBP) ≥ 140mmHg (2003 and 2004 combined). deprivation. or measured diastolic blood pressure (DBP) ≥ 90mmHg or taking medicine prescribed for high blood pressure*.

Angina or heart attack Answered YES to the Health Survey for England Age, Sex, Ethnicity, Area (CHD) question ‘Ever told by a (2003 and 2004 combined). deprivation, Smoking. doctor that you have angina or have had a heart attack?’

Stroke Answered YES to the Health Survey for England Age, Sex, Area deprivation, question ‘Ever told by a (2003 and 2004 combined). Smoking. doctor that you have had a stroke?’

Diabetes (Type 1 and Type 2 According to WHO diagnostic Coventry Diabetes Study Age, Sex, Ethnicity, Area combined) criteria (1985) based on (Simmons, Williams and deprivation, Obesity. Glucose Tolerance Test. Powell, 1991). London-Brent Study (Chaturvedi, McKeigue and Marmot, 1993). Welsh Study (Harvey, Craney and Kelly, 2002).

*Being hypertensive includes controlled, uncontrolled and untreated hypertension

Hypertension, coronary heart disease and stroke Reference studies for hypertension, CHD and stroke consisted of analyses of the combined data from the Health Survey for England (HSfE) 2003 and 2004. Two models were developed for each condition:

• A ‘complete’ model that included all the HSfE risk factors which were included in the final variable-selection logistic regression model • A ‘local’ model that only included the risk factors from the ‘complete’ model for which population data were available at the relevant local geographical levels.

While each ‘complete’ model performed slightly better than the corresponding ‘local’ model, all three ‘local’ models performed well in predicting disease status.

25 Chapter 2 Estimating and Forecasting Prevalence

APHO used the ‘local’ model to estimate and forecast population prevalence in Local Authorities and Primary Care Trusts in England. INIsPHO also used the ‘local’ model to estimate and forecast population prevalence in LHOs in the Republic of Ireland and LGDs in Northern Ireland.

Diabetes The model for diabetes was based on three reference studies: the Coventry Diabetes Study (Simmons, Williams and Powell, 1991), the London-Brent Study (Chaturvedi, McKeigue and Marmot, 1993) and the Welsh Study (Harvey, Craney and Kelly, 2002).

Step 2: Estimating and Forecasting the Distribution of Risk

The distribution of risk factors in LHOs in the Republic of Ireland and LGDs in Northern Ireland was estimated for the years 2007, 2015 and 2020. If risk factor data were not available at LHO or LGD level then the distribution of risk factor at a larger geographical area was applied to all LHOs or LGDs within that area.

Area-level population estimates and projections for 2007, 2015 and 2020, broken down by age and sex were provided by the Central Statistics Office (CSO) and the Northern Ireland Statistics and Research Agency (NISRA) (personal communication). It was assumed that the ethnic profile, from Census 2001 in Northern Ireland and Census 2006 in the Republic of Ireland applied in 2007, 2015 and 2020.

The New Measures of Deprivation for the Republic of Ireland (Haase and Pratschke, 2008) were used for area-level deprivation scores in the Republic of Ireland. The Northern Ireland Multiple Deprivation Measure 2005 (NISRA, 2005) was used for area-level deprivation scores in Northern Ireland. It was assumed that an area’s deprivation level has not changed (and will not change) since these deprivation scores were calculated.

Smoking data were obtained from Survey of Lifestyle, Attitudes and Nutrition (SLÁN) 2007 (Morgan et al, 2008) in the Republic of Ireland and Continuous Household Survey 2007/2008 (NISRA, 2008) in Northern Ireland. It was assumed that an area’s smoking profile has not changed (and will not change) since these data were collected. Current and future obesity prevalence was modelled using data from HSfE 1991-2006 (Department of Health, 2008)

Step 3: Obtaining Estimated and Forecasted Prevalence

Prevalence estimates for 2007 and prevalence forecasts for 2015 and 2020 were produced for each LHO in the Republic of Ireland and each LGD in Northern Ireland. Figures were broken down by age, sex, ethnicity (where applicable) and local area deprivation bands.

26 3 Hypertension

27 Chapter 3 Hypertension

CHAPTER 3. HYPERTENSION

This chapter relates to adults (aged 16 years and over) who have high blood pressure. Measured blood pressure on a sample (of approximately 55%) of survey respondents and self- reported use of hypertension medication were used to determine blood pressure status11.

Detailed estimates and forecasts of hypertension prevalence, broken down by sex and age within each area, are given at the end of the chapter.

KEY POINTS: HYPERTENSION

In 2007 nearly 852,000 adults in the Republic of Ireland (25.1%) have high blood pressure. By 2020 this is expected to rise to over 1,192,000 (28.3%). This represents a 40% increase – an additional 341,000 adults – in less than 15 years.

In 2007 nearly 396,000 adults in Northern Ireland (28.7%) have high blood pressure. By 2020 this is expected to rise to nearly 482,000 (31.7%). This represents a 22% increase – an additional 86,000 adults – in less than 15 years.

Hypertension is more common amongst males than females.

Hypertension prevalence rates increase with age. Nearly three out of four (71%) adults aged 75 years and over have high blood pressure. In 2020 relatively more of the adults with high blood pressure will belong to the older age groups.

While high hypertension prevalence rates are observed in many parts of the island, prevalence rates are noticeably lowest around Dublin.

Local socio-economic circumstances affect hypertension prevalence. Across all age groups, hypertension tends to be more common in more deprived areas.

Hypertension prevalence is slightly higher in Northern Ireland than in the Republic of Ireland. North-South differences in the current and future hypertension prevalence are chiefly due to differences in current and (projected) future demographic and socio-economic profiles.

11 Adults are defined to be ‘hypertensive’ if their hypertension is ‘controlled’ (SBP <140mmHg and DBP <90mmHg and taking medicine prescribed for high blood pressure), ‘uncontrolled’ (SBP ≥140mmHg and/or DBP ≥90mmHg and taking medicine prescribed for high blood pressure) or ‘untreated’ (SBP ≥140mmHg and/or DBP ≥90mmHg and not taking medicine prescribed for high blood pressure). See this report’s technical supplement for more details.

28 Making Chronic Conditions Count

National Estimates in 2007

In 2007, a quarter (25.1%) of adults in the Republic of Ireland (851,658 people) and 28.7% of adults in Northern Ireland (395,529 people) have high blood pressure.

The estimated hypertension prevalence rate (25.1%) in the Republic of Ireland is lower than estimates from other survey studies. Direct comparisons with these studies, however, are confounded by important differences in methodology.

• The SLÁN 2007 survey (Morgan et al, 2008) uses the same definition of high blood pressure in its physical examination sub-study of adults aged 45 years and over. It reports that that 60% of adults aged 45 years and over have high blood pressure; higher than the estimated 51.8% prevalence rate in our study. • In the CSO’s Quarterly National Household Survey 2007 (CSO, 2008) 10% of adults aged 18 years and over have ever been told by a doctor that they had high blood pressure. This is not comparable to our national prevalence estimate because it includes people who have had high blood pressure at any time in the past, it is not based on physical measurement and it excludes people with undiagnosed high blood pressure12.

The estimated hypertension prevalence rate (28.7%) in Northern Ireland is broadly similar to estimates from other studies:

• It is higher (28.7% compared to 11.7%) than the Quality and Outcomes Framework (QOF) estimate that is based on primary care data (DHSSPS, 2007). However, this is not unexpected because the QOF covers all ages while this report covers adults aged 16 years and over. • The Health and Social Wellbeing Survey 2005-2006 reports that 25% of adults aged 16 years and over have ever been told by a doctor or nurse that they have high blood pressure (DHSSPS, 2007). This estimate is similar to our national prevalence estimate although it is based on somewhat different methodology - the estimate includes people who have had high blood pressure at any time in the past, it is not based on physical measurement and it excludes people with undiagnosed high blood pressure.

Again, direct comparisons are confounded by important differences in methodology.

Hypertension prevalence in England in 2007 is estimated to be 30.0% (HSfE, 2007). The percentages of adults with high blood pressure in the three countries (the Republic of Ireland, Northern Ireland and England) are slightly different. This is chiefly due to differences in their demographic and socio-economic profiles. In particular, both Northern Ireland and England have an older population than the Republic of Ireland.

12 In the SLÁN 2007 survey, approximately 60% of respondents with measured high blood pressure had not been diagnosed (Morgan et al, 2008).

29 Chapter 3 Hypertension

Demographic Variation in 2007

Slightly more males than females have high blood pressure. This is true in both the Republic of Ireland (male 26.7%, female 23.4%) and Northern Ireland (male 29.8%, female 27.6%).

Hypertension is more common in older age groups. Just less than three out of four adults aged 75 years and over in Northern Ireland (71.9%) and the Republic of Ireland (70.9%) have high blood pressure.

Ethnicity does not contribute much to North-South differences because neither jurisdiction has a large ‘non-white’ ethnic population.

Geographic Variation in 2007

Figure 3.1: Percentage of adults who have high blood pressure; across Local Health Offices (LHOs) in the Republic of Ireland and Local Government Districts (LGDs) in Northern Ireland (2007).

30.0 - 31.5

28.5 - 30.0

27.0 - 28.5

25.5 - 27.0

24.0 - 25.5

22.5 - 24.0

21.0 - 22.5

19.5 - 21.0

30 Making Chronic Conditions Count

In addition to the higher hypertension prevalence rate in Northern Ireland, areas with high hypertension prevalence rates occur across the island. Quite noticeably, hypertension prevalence is lowest in parts of Dublin and its surrounds.

Socio-economic Variation in 2007

Local socio-economic circumstances in an area affect hypertension prevalence although, like diabetes, the effect does not seem to be as strong as it is for CHD and stroke.

Figure 3.2: Percentage of adults who have high blood pressure; across deprivation bands13 in the Republic of Ireland within each sex and each age group (2007).

80

70

60

50

% 40

30

20

10

0 Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years Band 1 (least deprived) Band 2 Band 3 Band 4 Band 5 (most deprived)

Figure 3.3: Percentage of adults who have high blood pressure; across deprivation bands13 in Northern Ireland within each sex and each age group (2007).

80

70

60

50

% 40

30

20

10

0 Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years Band 1 (least deprived) Band 2 Band 3 Band 4 (most deprived)

13 See this report’s technical supplement for definitions of the deprivation bands.

31 Chapter 3 Hypertension

The effects of local socio-economic circumstances are observed in both jurisdictions but are more apparent in the Republic of Ireland14. In the Republic of Ireland hypertension prevalence in the most deprived LHOs is 1.3 times what it is in the least deprived LHOs. In Northern Ireland hypertension prevalence in the most deprived LGDs is almost 1.1 times what it is in the least deprived LGDs.

Within each age group and in both jurisdictions, hypertension prevalence rates increase as you move from the least deprived areas to the most deprived areas. Like diabetes, local socio- economic circumstances do not appear to have an effect amongst either males or females in Northern Ireland.

How Hypertension Prevalence Will Change Between 2007 and 2020

The percentage of adults with high blood pressure is expected to increase over time:

• In Northern Ireland it is expected to increase from 28.7% in 2007 to 30.3% in 2015 to 31.7% in 2020. • In the Republic of Ireland it is expected to increase from 25.1% in 2007 to 26.8% in 2015 to 28.3% in 2020.

With an increasing and ageing population, far more adults will have high blood pressure in 2020 than in 2007. The number of adults in Northern Ireland with high blood pressure is expected to rise from 395,529 in 2007 to 481,867 in 2020; an increase of 86,338 adults (or 21.8%). The number of adults in the Republic of Ireland with high blood pressure is expected to rise from 851,658 in 2007 to 1,192,415 in 2020; an increase of 340,757 adults (or 40.0%). A proportionally larger increase is expected in the Republic of Ireland because its population is projected to increase more than Northern Ireland’s.

14 Direct North-South comparison is confounded by the fact there are five deprivation bands in the Republic of Ireland but only four deprivation bands in Northern Ireland. See this report’s technical supplement for details.

32 Making Chronic Conditions Count

Figure 3.4: Expected changes in the percentage of adults in the Republic of Ireland, Northern Ireland and England who have high blood pressure; within each sex group and age group (2007, 2015, 2020).

80

70

60

50

% 40

30

20

10

0 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years

Republic of Ireland Northern Ireland England

Amongst males and females, and in each age group, similar changes in hypertension prevalence rates are expected in each country (the Republic of Ireland, Northern Ireland and England).

An ageing population profile and higher hypertension prevalence rates in older age groups mean that a growing percentage of adults with high blood pressure will belong to the older age groups. Between 2007 and 2020, the percentage of adults with high blood pressure who are aged 65 years and over will rise in the Republic of Ireland from 37.0% to 41.6%. In Northern Ireland the percentage will rise from 42.0% to 46.7%.

33 ber Prevalence ssure (2007). ssure Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Num Table 3.1: Demographic and geographic variation in the percentage of adults in the Republic of Ireland who have high blood pre of adults in the Republic Ireland 3.1: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 11,499Donegal 13,552Dublin North 26.6% 14,113Dublin North Central 27.9% 9,961 Dublin North West 29.5%Dublin South City 11,635 13,121 23.4% 11,910Dublin South East 20,988 18,297 24.5%Dublin South West 17,427 21,460 25.9% 25.2%Dublin West 24.1% 12,165 32.0% 25,187Dun Laoghaire South Dublin 23.4% 12,724 26,024 10,715 25.0%Galway 18,903 15,792 15,813 13,416 21.5% 26.2% 15,472Kerry 16,738 23.7% 27.7% 3,827 24.1% 20.7% Wicklow Kildare / West 27.5% 10,961 27.0% 27.2% 4,929 20.1% 12,691 25,844Laois / Offaly 30.1% 11,018 4,916 8.2% 39,891 34,089 14,689 19.1%Limerick 14,148 18,288 32,898 9.1% 14,850 24.4% 24.4% 22.5% Longford / Westmeath 9.5% 22.4% 9,485 29.7% 23,127 24,990 23.6% 25.5%Louth 11,993 22.7% 21.7% 10,767 10,953 27.1% 21,733 5,609Mayo 11,069 12,634 15,279 8,584 30,503 6,428 20.3% 36.2% 27.1% 27,564 14,770Meath 27.7% 20.3% 31,588 8,918 23.2% 39.2% 8.5%North Cork 40.5% 28.2% 10.3% 21,515 27.8% 25.3% 16,854 5,592 7.9% 4,276 10,736 18.6% 26.3% 23,458North Lee - Cork 28.6% 8.8% 4,280 4,927 / 9,459 11,073North Tipperary 12,802 5,043 23.1% 14,713 6,387 61.2% 33,058 17,579 27.9% 24.1% 7.4% 4,279 22.3%East Limerick 5,258 64.8% 13,115 7.6% 24.5%Roscommon 23.8% 65.7% 46,505 39.2% 14,953 15,642 22,729 20.7% 43.2% 9.0% 36.1% 17,648 6,411 3,872 Cavan West / 9,318 7.8% Leitrim / Sligo 15,068 9,538 9.2% 38.5% 23,706 4,378 28,081 8,656South Lee - Cork 25.1% 24.5% 5,474 11,130 25.8% 31.7% 8,105 4,995 6,767 68.2% 13,750 8,361 26.6% 11,285 9.3%South Tipperary 35.4% 23.4% 13,717 10,093 71.4% 29.0% 5,795 26.3% 25.8% 31,808 65.0% 9,603 36.1% 72.2% 14,019Waterford 4,901 68.1% 30.3% 61.3% 15,361 8.0% 40.2% 12,399 10,329 4,077 7,471 Cork West 35.7% 64.9% 25.6% 8,504 39.7% 4,604 17,070 5,708 26.2% 4,386 28.7% 15,247 8.7%Wexford 9,850 5,303 23.0% 9.4% 15,463 5,999 6,181 19.5% 5,366 61.5% 10,562 30.9% 39.4% 6,312Wicklow 10,775 26.6% 6,515 8,732 5,071 29,661 24.1% 61.5% 9.0% 6,074 9.1% 71.9% 19,560 33,009 26.9% 29.4%Republic of Ireland 74.2% 65.9% 68.4% 27,467 9,782 35.3% 18,042 61.5% 3,768 6,573 29.5% 64.8% 22.7% 25.0% 71.9% 4,140 13,431 16,161 10,239 30.2% 12,139 13,369 20,980 8.8% 24.8% 4,410 39.1% 21.5% 6,771 5,293 451,019 40.3% 4,368 69.1% 65.9% 28.6% 27.8% 18,825 9,257 9,682 21.6% 5,688 28.2% 6,098 4,671 69.1% 25.7% 39.3% 13,787 28.6% 39.1% 7,195 9,068 6,469 72.5% 61.3% 31.7% 4,313 14,044 26.7% 3,207 24.2% 26.5% 21.7% 33,231 68.8% 71.5% 12,012 2,950 28,616 4,621 9.5% 3,437 5,439 64.7% 39.5% 9.0% 400,639 8.1% 65.8% 6,040 29.8% 19,820 4,197 72.8% 20,457 3,436 9.2% 25.0% 22.8% 27.5% 64.8% 12,607 64.8% 6,517 9.1% 23.4% 14,526 8,274 68.4% 29.0% 12,350 2,203 28.0% 25,442 23.3% 3,732 6,656 7.8% 7,679 5,503 851,658 64.8% 40.5% 71.4% 4,242 4,795 12,811 9,007 39.5% 72.7% 35.5% 3,426 4,050 9.4% 26.6% 7.6% 8,131 39.4% 25.1% 71.6% 9.6% 71.2% 6,229 30.4% 5,429 6,297 39.4% 4,751 4,849 9.2% 171,455 8.0% 5,821 13,899 3,646 36.1% 12,385 65.7% 71.5% 64.9% 1,943 4,279 61.2% 9.0% 8,534 8.7% 9,249 39.4% 64.8% 35.5% 3,844 40.4% 6,154 64.7% 9.5% 4,991 364,792 3,897 10,837 2,990 6,932 61.2% 39.4% 35.8% 3,511 6,088 72.4% 71.6% 68.4% 5,368 4,257 38.4% 64.7% 39.4% 61.5% 4,075 71.6% 3,987 65.7% 3,415 71.4% 168,229 39.7% 5,339 64.8% 61.3% 68.2% 3,030 5,743 4,640 64.0% 2,819 64.8% 71.4% 68.8% 3,784 72.3% 3,172 147,182 64.7% 71.3% 68.6% 4,418 70.9% 71.5% 2,681 71.4%

34 ber Prevalence sure (2015). sure Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Num Table 3.2: Demographic and geographic variation in the percentage of adults in the Republic of Ireland who have high blood pres of adults in the Republic Ireland 3.2: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 13,948Donegal 16,711Dublin North 28.0% 17,081Dublin North Central 29.7% 11,983 Dublin North West 31.0%Dublin South City 14,157 25.5% 16,382 14,259Dublin South East 26,242 22,159 26.6%Dublin South West 21,594 25,930 27.4% 27.2%Dublin West 25.6% 15,055 33.6% 30,868Dun Laoghaire South Dublin 26.8% 25.0% 15,490 31,340 13,424Galway 23,014 18,918 19,648 16,950 23.2% 28.2% 18,750Kerry 20,596 4,243 25.3% 29.3% 25.8% 21.9% Wicklow Kildare / West 29.1% 13,282 29.0% 29.1% 5,487 21.4% 15,683 31,872Laois / Offaly 32.5% 13,412 5,480 8.5% 49,256 41,077 17,829 20.4%Limerick 17,280 24,673 40,344 9.5% 17,910 26.0% 26.2% 23.8% Longford / Westmeath 10,930 9.7% 23.7% 31.4% 28,337 30,300 25.0% 26.8%Louth 14,441 24.8% 23.2% 13,033 13,105 29.1% 26,836 6,557Mayo 36.3% 12,979 10,310 15,942 19,260 37,477 7,153 34,230 21.8% 28.6% 19,933 10,537Meath 29.1% 21.5% 38,506 24.8% 39.2% 9.1%North Cork 5,894 40.5% 8.5% 30.0% 10.6% 25,967 29.5% 26.9% 20,374 6,535 27.9% 12,846 20.5% 28,716North Lee - Cork 9.4% 30.8% 5,073 6,633 11,322 61.2% / 13,558North Tipperary 15,692 6,913 21,046 24.0% 17,255 7,521 44,606 29.4% 25.5% 5,135 7.9% 23.7%East Limerick 15,686 5,766 64.8% 8.2% 26.7% 39.4%Roscommon 26.0% 65.7% 56,267 17,989 4,863 19,089 27,286 36.2% 22.7% 43.2% 9.6% 11,150 21,385 8.4% 7,630 Cavan West / 11,697 Leitrim / Sligo 20,467 38.7% 9.6% 10,362 29,500 5,643 34,953 7,162 67.9% 10,957South Lee - Cork 26.2% 13,531 26.9% 27.3% 33.3% 9,821 5,968 9,277 16,450 13,505 28.8% 35.5% 9.9% 31.3%South Tipperary 7,585 25.5% 16,182 12,232 71.0% 28.4% 64.9% 11,283 36.2% 27.9% 61.3% 38,363 71.8% 16,904Waterford 31.9% 5,470 68.0% 18,448 8.4% 40.4% 5,339 10,249 16,792 35.9% 12,354 64.9% 9,132 Cork West 27.1% 39.7% 5,257 5,739 20,775 6,527 9.2% 11,802 28.2% 29.5% 6,831 18,837Wexford 6,943 24.9% 9.7% 20,301 7,852 61.4% 28.6% 7,392 21.5% 8,258 10,512 13,099 32.4% 39.5%Wicklow 14,765 8,806 6,536 61.5% 71.5% 35,993 28.4% 26.3% 9.6% 23,247 6,688 68.0% 9.7% 39,833 31.2%Republic of Ireland 73.9% 11,476 21,946 65.9% 37,259 35.3% 61.5% 24.9% 71.5% 5,313 4,935 7,925 31.4% 64.7% 27.4% 16,587 19,463 25,333 12,629 31.4% 14,967 5,662 16,298 39.4% 9.2% 26.8% 30.0% 23.6% 40.3% 8,398 68.7% 8,720 22,744 5,653 11,296 65.8% 560,456 29.4% 13,197 7,332 23.5% 68.7% 30.1% 30.2% 7,752 12,074 5,521 27.8% 39.4% 15,883 39.3% 7,867 3,513 7,864 72.1% 5,910 61.2% 34.1% 26.0% 28.7% 17,057 23.9% 68.4% 28.5% 40,238 71.0% 14,646 3,797 3,827 64.7% 10.0% 35,135 6,373 7,500 39.6% 9.5% 65.8% 490,135 9.6% 24,396 8.6% 27,962 3,787 7,301 30.9% 5,765 72.5% 27.2% 24.9% 14,998 29.5% 9.3% 64.7% 64.8% 9,663 8,982 17,135 25.1% 68.0% 31.0% 30.1% 16,213 25.6% 2,610 4,430 9,057 8.2% 31,233 7,240 1,050,591 71.0% 6,143 10,562 40.9% 64.8% 5,241 5,959 15,699 72.4% 39.6% 3,817 4,916 35.5% 9.8% 28.6% 39.5% 9,368 8.1% 26.8% 10.0% 8,294 71.3% 39.4% 70.8% 32.6% 6,810 8,505 9.6% 7,827 197,116 8.5% 5,397 4,927 6,922 16,390 36.2% 14,816 65.7% 5,867 71.2% 64.8% 2,143 61.2% 10,211 12,137 64.8% 9.1% 9.4% 5,298 39.8% 35.6% 40.5% 64.7% 7,180 9.9% 437,937 6,326 39.4% 35.7% 5,354 12,965 61.2% 4,450 3,981 9,357 8,198 72.0% 5,079 71.2% 68.0% 6,333 5,487 71.2% 38.5% 6,566 64.7% 39.5% 61.4% 65.7% 4,291 71.1% 230,219 64.8% 61.3% 39.8% 67.8% 7,188 3,543 7,250 5,977 63.9% 3,813 64.8% 4,880 4,343 70.9% 68.4% 72.0% 185,318 71.0% 64.7% 68.2% 5,683 70.5% 71.2% 3,411 71.0%

35 ber Prevalence sure (2020). sure Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Num Table 3.3: Demographic and geographic variation in the percentage of adults in the Republic of Ireland who have high blood pres of adults in the Republic Ireland 3.3: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 15,600Donegal 18,796Dublin North 29.2% 19,031Dublin North Central 31.3% 13,353 Dublin North West 32.6%Dublin South City 15,948 27.2% 18,881 15,924Dublin South East 30,305 24,711 28.6%Dublin South West 24,711 28,952 29.1% 28.8%Dublin West 26.8% 17,249 35.2% 34,744Dun Laoghaire South Dublin 28.3% 26.4% 17,636 34,955 15,515Galway 26,175 21,109 22,635 19,777 24.6% 30.0% 21,246Kerry 23,161 4,385 26.4% 30.9% 27.2% 22.7% Wicklow Kildare / West 30.8% 15,068 30.4% 30.3% 5,604 22.3% 17,970 36,517Laois / Offaly 34.3% 15,268 5,608 8.8% 56,480 45,820 20,250 21.3%Limerick 19,744 29,169 45,957 9.8% 20,120 27.3% 27.6% 24.8% 10.0% Longford / Westmeath 11,787 24.7% 33.0% 32,317 33,751 25.9% 27.6%Louth 15,974 26.5% 24.4% 14,766 14,540 30.8% 30,783 7,026 14,175Mayo 36.4% 11,281 18,051 21,784 42,885 7,339 22.9% 30.1% 39,521 23,786 11,313Meath 30.6% 22.4% 43,281 26.0% 39.4% 9.3% 40.5%North Cork 6,915 8.8% 31.9% 10.9% 29,275 31.5% 28.1% 22,709 6,970 14,303 22.3% 28.9% 32,736North Lee - Cork 9.6% 32.6% 5,479 7,715 12,951 61.2% 8,084 / 15,358North Tipperary 17,755 24,050 25.4% 18,847 8,123 52,955 30.7% 27.2% 8.2% 5,658 24.8%East Limerick 17,956 5,871 64.8% 8.4% 65.7% 29.1% 39.4%Roscommon 28.4% 63,026 20,022 5,866 21,453 30,276 36.2% 24.4% 43.3% 9.8% 12,768 23,742 8,277 Cavan West / 8.7% 13,115 Leitrim / Sligo 24,284 38.7% 9.9% 11,839 33,409 6,884 39,539 8,405 67.7% 12,860South Lee - Cork 27.7% 15,142 28.8% 10,268 7,088 10,847 28.9% 34.8% 18,795 10.2% 30.5% 35.5% 15,437 33.1%South Tipperary 8,902 27.3% 17,820 13,677 70.9% 30.6% 64.9% 11,819 36.2% 71.6% 30.0% 61.3% 42,730 68.1% 19,154Waterford 33.5% 5,595 8.6% 20,595 40.4% 14,148 6,266 10,280 11,506 20,099 64.9% Cork West 35.9% 28.3% 39.9% 5,316 6,736 23,162 6,591 9.5% 13,204 29.8% 30.9% 8,135 10.0% 21,201Wexford 24,188 8,290 26.6% 8,787 9,215 61.4% 30.4% 23.4% 33.9% 39.5% 10,289 11,719 14,817 9,691Wicklow 17,647 7,787 61.5% 10.0% 10.1% 71.3% 40,607 30.0% 28.0% 25,468 6,859 67.8% 73.6% 12,534 44,337 32.8%Republic of Ireland 35.3% 24,621 65.9% 44,382 5,792 8,986 64.7% 26.7% 71.3% 6,314 61.5% 33.0% 29.1% 14,121 18,674 21,807 28,346 16,732 32.8% 6,729 18,364 39.4% 9.5% 10,807 28.6% 40.4% 31.8% 25.4% 9,502 68.5% 65.8% 30.7% 25,396 636,473 6,752 12,770 15,888 9,301 25.1% 68.5% 8,735 31.6% 31.8% 39.6% 14,378 5,868 39.4% 29.8% 61.2% 17,128 7,955 6,913 3,564 8,220 71.9% 19,266 35.9% 27.5% 30.7% 25.8% 30.0% 70.8% 4,520 44,969 68.2% 16,520 3,928 64.8% 7,693 10.3% 39,565 9,053 65.8% 39.7% 9.7% 555,942 7,692 32.3% 9.9% 27,587 8.7% 72.2% 33,535 3,901 8,225 29.2% 26.5% 64.7% 16,424 64.7% 11,361 31.4% 9.6% 10,535 67.8% 26.6% 18,867 2,775 5,235 32.6% 31.9% 19,316 27.5% 9,971 8.4% 35,194 7,335 70.8% 1,192,415 6,291 11,535 64.8% 40.8% 6,279 7,163 72.1% 10.2% 17,726 39.7% 3,914 5,158 35.5% 10,103 30.5% 39.7% 28.3% 8.3% 71.1% 10.3% 70.6% 9,878 39.4% 8,208 34.3% 9,935 7,583 206,008 9.9% 9,700 8.6% 5,513 5,757 36.3% 18,037 16,449 65.7% 71.1% 6,859 64.8% 2,203 61.2% 11,335 14,453 39.7% 64.8% 9.4% 6,215 9.7% 35.8% 40.7% 64.7% 8,437 10.2% 490,724 7,579 4,741 61.2% 39.7% 35.7% 7,146 14,396 10,929 5,330 9,535 71.8% 6,025 71.0% 6,974 64.7% 67.8% 38.5% 6,383 71.0% 8,137 61.4% 39.7% 5,178 65.7% 70.8% 271,980 39.9% 64.7% 61.3% 67.7% 4,167 8,360 8,667 7,290 63.9% 4,456 70.8% 68.2% 64.8% 5,956 5,786 71.8% 223,704 64.7% 70.8% 68.0% 70.3% 6,925 4,094 71.0% 70.8%

36 ce Number Prevalence ce Number 007). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Local Government District Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalen Table 3.4: Demographic and geographic variation in the percentage of adults in Northern Ireland who have high blood pressure (2 of adults in Northern who have high blood pressure 3.4: Demographic and geographic variation in the percentage Ireland Table Antrim Ards Armagh Ballymena 5,690Ballymoney 8,809Banbridge 6,428 28.5%Belfast 7,437 29.3%Carrickfergus 5,238 30.2% 3,420Castlereagh 31.1% 4,770 8,779 25.7%Coleraine 6,161 29.9% 30,747 7,455Cookstown 27.5% 26.7% 4,304 10,928 26.9% 3,279Craigavon 30.9% 7,287 29.4% 17,588Derry 4,537 28.3% 27.1% 12,589 27.7% 6,858 33,808Down 14,892 29.5% 3,874 28.4% 24.8% 4,300 2,083Dungannon 28.5% 6,699 31.6% 9,916 29.3% 30.2% 7,889Fermanagh 2,419 28.7% 9,307 26.0% 2,032 11,940 9.3%Larne 64,554 28.8% 6,973 29.4% 28.3% 2,265 7,861 3,596Limavady 8.2% 25.7% 5,813 8,604 29.9% 8.8% 4,703 30.1% 1,124 29.7%Lisburn 9,630 15,176 7,333 9.3% 26.2% 29.5% 1,593 7,634Magherafelt 27.8% 11,271 27.1% 11,148 13,831 5,339 27.3% 39.7% 9.3% 28.8% 3,937Moyle 30.4% 7,472 7,470 6,042 3,838 26.4% 8.2% 1,302 5,386 36.6%Newry and Mourne 9.6% 30.6% 19,546 2,332 39.6% 12,339 2,071 2,743 32.2% 6,742 27.5%Newtownabbey 27.4% 23,210 28.2% 39.9% 4,597 25.7% 3,932 8.1% 3,864 1,977 24,446 28.3% 64.9%North Down 2,785 29.7% 28.0% 8.3% 3,821 15,333 39.5% 1,392 2,123 10,258 28.1% 11,199 3,404Omagh 3,309 61.3% 27.5% 35.8% 3,556 3,544 42.4% 9.1% 64.9% 12,244 14,075Strabane 29.6% 1,810 1,474 28.5% 5,774 64.9% 4,743 25.6% 32.9% 9.2% 26.8% 29.0% 9,577 4,107Northern Ireland 14,002 3,603 2,021 9,129 26.6% 71.5% 35.8% 9.5% 5,611 29.2% 2,433 64.9% 7,758 2,568 10.1% 35.4% 2,080 2,045 7,147 9,556 5,734 25.1% 68.5% 3,142 30.8% 3,180 68.3% 61.4% 24,583 29.7% 1,961 71.7% 2,225 8,123 39.6% 4,782 30.8% 9.1% 198,803 1,358 3,505 10,185 30.0% 25.9% 71.7% 26.9% 8.9% 29.2% 8,704 9,761 40.4% 14,958 28.1% 61.3% 9,797 1,830 3,313 1,112 9.1% 71.5% 40.3% 31.8% 61.4% 19,814 29.8% 6,449 42.4% 4,168 1,451 75.0% 28.7% 5,244 26.4% 1,530 4,591 68.4% 4,181 29.3% 64.9% 1,785 196,727 4,222 4,329 9.3% 5,966 27.4% 4,645 31.4% 19,339 39.5% 3,827 26.2% 9.6% 1,703 65.8% 18,926 39.3% 68.6% 9.0% 27.6% 65.9% 28.5% 2,930 68.5% 3,708 3,326 39.6% 68.2% 10,977 3,274 29.7% 594 9.0% 3,113 2,364 29.5% 395,529 1,407 10,492 71.7% 9,111 3,657 2,983 64.9% 9.2% 27.7% 39.9% 2,973 3,637 72.4% 64.9% 2,388 9.4% 28.7% 40.5% 3,605 39.2% 72.5% 30.1% 64.8% 74.7% 2,013 1,808 8,369 9.1% 66,402 3,042 1,412 8.1% 2,164 1,746 39.2% 5,273 1,712 64.9% 71.7% 2,902 9.3% 40.2% 7,897 71.7% 65.8% 9.2% 64.9% 1,794 7,830 41.0% 10.4% 71.5% 163,047 1,512 4,198 4,721 39.4% 64.9% 1,172 36.7% 4,637 971 3,781 71.6% 65.8% 39.6% 72.4% 40.1% 4,339 71.7% 1,602 4,109 65.8% 43.3% 85,879 64.9% 2,235 3,538 71.4% 61.3% 1,993 65.1% 857 72.6% 65.8% 4,130 4,599 68.2% 72.5% 80,202 71.7% 2,008 68.8% 71.9% 1,625 72.5% 74.3%

37 ce Number Prevalence ce Number 015). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 3.5: Demographic and geographic variation in the percentage of adults in Northern Ireland who have high blood pressure (2 of adults in Northern who have high blood pressure 3.5: Demographic and geographic variation in the percentage Ireland Table AntrimArdsArmaghBallymenaBallymoneyBanbridge 6,716Belfast 10,285Carrickfergus 7,540 29.6% 8,451Castlereagh 32.0% 4,218Coleraine 6,264 31.3% 32.8% 5,883 10,337Cookstown 32.0% 26.5% 7,193Craigavon 5,253 31,480 8,596 28.4% 29.8%Derry 3,944 12,980 7,667 28.3% 31.5% 32.0% 31.8%Down 20,621 5,598 29.7% 28.0% 7,542Dungannon 14,733 30.7% 33,365 17,048 4,620 5,124 30.8% 26.8%Fermanagh 11,745 8,162 2,183 29.7% 34.8% 8,316Larne 30.1% 32.1% 28.8% 30.3% 11,480 2,268Limavady 30.8% 30.3% 2,167 7,569 8.9% 13,843 30.6% 64,845 2,158 10,377Lisburn 27.6% 4,180 8.0% 7,337 9,179 11,273 1,168Magherafelt 32.9% 15,984 8.8% 32.6% 30.9% 5,207 8,541 30.4% 9.0% 27.5% 1,630Moyle 27.6% 8,115 27.8% 31.5% 15,111 10,672 13,217 9.3% 30.6%Newry & Mourne 5,891 1,133 32.2% 38.7% 8,799 4,414 6,654 8.0% 4,497Newtownabbey 23,017 6,365 8,767 36.0% 33.8% 29.1% 1,699 9.7% 3,300North Down 3,115 14,360 7,789 39.4% 7.8% 28.9% 5,503 35.0% 39.1% 25.6% 30.9% 29.0% 4,819 29.2%Omagh 5,840 27,060 1,644 12,356 24,984 7.7% 64.9% 39.2% 29.7% 3,576 31.5%Strabane 1,509 4,354 28.7% 13,702 4,208 4,132 3,844 17,946 3,995 61.3% 10,278 35.9% 2,376 30.8%Northern Ireland 8.8% 30.0% 42.6% 16,330 14,394 1,958 6,355 64.8% 2,476 31.8% 64.9% 4,826 9.3% 26.6% 36.0% 29.2% 30.3% 2,700 9.2% 32.2% 4,507 34.1% 9,988 11,304 4,398 13,896 5,909 28.6% 64.9% 31.0% 71.3% 35.6% 3,099 26.7% 2,660 8,621 2,528 226,368 2,543 8,492 10,804 61.3% 3,530 4,104 10.1% 68.1% 26.9% 2,248 9,336 68.3% 31.8% 6,841 28,754 2,322 39.7% 71.3% 3,741 5,456 1,736 10,328 61.3% 71.5% 33.4% 31.5% 9.1% 30.1% 31.4% 8.9% 11,850 23,661 10,780 40.6% 31.2% 2,330 15,292 30.8% 39.9% 30.0% 71.1% 3,838 61.5% 9.3% 34.7% 27.8% 221,642 21,082 1,384 2,361 68.4% 32.0% 942 2,007 5,516 74.6% 28.5% 42.3% 4,623 7,411 5,235 6,185 4,060 64.8% 29.3% 6,709 1,850 5,002 4,189 68.0% 31.9% 20,768 65.8% 9.8% 4,034 5,951 8.8% 39.1% 32.6% 65.9% 28.2% 448,0111 39.3% 8.7% 68.4% 30.8% 3,719 39.7% 9.2% 2,608 31.9% 68.2% 2,922 13,026 9.1% 3,603 1,753 4,247 30.3% 3,559 590 4,602 11,874 71.3% 10,458 3,827 8.7% 2,170 4,324 72.0% 64.9% 65,430 29.5% 64.8% 72.2% 40.3% 4,752 9,954 39.4% 9.2% 38.9% 32.8% 64.8% 39.1% 8.0% 8,369 74.2% 2,108 9.1% 1,947 2,604 2,257 40.1% 3,744 6,820 1,574 1,888 3,472 2,203 181,044 71.3% 39.2% 7,710 65.8% 71.4% 9.3% 64.8% 5,079 64.8% 10.2% 40.7% 71.1% 64.9% 5,105 39.5% 36.3% 65.8% 5,537 1,558 1,863 4,285 6,000 1,118 104,990 64.9% 1,951 5,610 72.3% 71.1% 71.5% 40.6% 4,595 65.8% 42.7% 65.0% 71.3% 61.4% 5,000 72.2% 2,876 2,461 96,547 1,027 71.6% 5,278 65.8% 68.2% 71.6% 71.9% 68.3% 2,505 2,138 72.2% 74.2% Local Government District Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalen

38 ce Number Prevalence ce Number 020) Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 3.6: Demographic and geographic variation in the percentage of adults in Northern Ireland who have high blood pressure (2 of adults in Northern who have high blood pressure 3.6: Demographic and geographic variation in the percentage Ireland Table Local Government DistrictAntrim NumberArds PrevalenceArmagh Number Ballymena Prevalence 7,351Ballymoney Number 11,104Banbridge 8,196 30.2% Prevalence Belfast 9,058 33.6% Number Carrickfergus 7,015 32.2% 4,726 Prevalence Castlereagh 11,389 34.0% 6,583 Number 27.3%Coleraine 7,917 33.5% 31,835 31.6% Prevalence 9,321Cookstown 29.6% 5,806 14,366 29.5% 4,402Craigavon Number 22,493 32.8% 7,768 32.9% Prevalen Derry 6,347 34.4% 28.7% 16,114 31.0% 7,835 33,410 32.6%Down 18,379 31.9% 5,093 28.3% 5,675 2,324Dungannon 30.8% 12,952 9,128 36.6% 31.3% 2,220 33.5% 8,540Fermanagh 31.5% 12,929 31.0% 2,248 14,944 8.9%Larne 31.2% 65,245 32.3% 7,923 8.1% 32.6% 2,175 9,959 29.0% 4,592Limavady 11,480 8,477 34.4% 12,444 8.9% 5,627 32.0% 1,168 35.6%Lisburn 16,308 9,315 8,559 9.1% 28.8% 32.9% 1,682 32.6%Magherafelt 28.3% 14,590 28.6% 10,508 15,759 6,265 39.2% 9.2% 32.3% 4,631Moyle 33.6% 9,687 36.7% 9,685 6,975 4,896 8.1% 1,060 31.6% 25,395 7,131 10.0%Newry and Mourne 36.1% 3,212 39.7% 15,447 1,592 3,744 36.9% 8,569 30.8%Newtownabbey 6,091 30.2% 29,534 32.9% 39.6% 6,142 26.3% 7.8% 29.9% 5,334 25,030 1,479 64.8%North Down 3,836 32.9% 31.4% 7.8% 4,463 19,646 39.9% 61.3% 1,590 2,524 13,726 32.9% 15,608 4,391Omagh 4,461 4,165 30.2% 36.4% 4,679 43.5% 8.9% 64.8% 15,839 17,883Strabane 33.6% 3,203 2,074 31.8% 6,396 64.9% 4,442 10,565 32.1% 35.6% 9.6% 27.4% 30.8% 5,623 13,792 5,331Northern Ireland 3,012 9.5% 10,429 37.0% 30.3% 71.2% 5,944 32.5% 3,765 64.9% 9,094 2,622 67.7% 12,549 10.4% 37.1% 3,020 33.3% 2,418 9,357 68.2% 7,529 28.2% 61.3% 3,805 4,837 10,204 33.1% 2,830 31,286 71.1% 2,343 40.3% 5,850 35.2% 9.2% 28.0% 242,740 11,432 2,142 3,805 12,669 32.7% 71.4% 11,472 32.5% 9.5% 15,915 32.2% 11,422 41.0% 61.2% 40.6% 2,901 31.5% 3,959 9.5% 70.9% 36.6% 26,275 33.6% 61.4% 893 32.6% 74.4% 7,841 43.1% 29.2% 4,942 1,292 33.9% 6,846 68.2% 2,149 6,324 5,521 4,166 2,911 64.8% 239,127 21,997 5,415 29.4% 7,145 6,674 1,852 8.9% 21,851 34.1% 40.0% 4,515 29.9% 9.9% 65.8% 65.8% 67.7% 39.4% 9.0% 30.8% 32.7% 4,396 33.5% 4,376 68.4% 39.8% 68.2% 14,375 33.5% 4,715 9.3% 3,680 592 3,884 3,226 481,867 2,141 5,506 12,550 11,265 71.1% 2,444 9.4% 4,360 64.8% 2,098 31.1% 5,750 71.9% 4,854 40.6% 64.8% 72.1% 9.4% 31.7% 40.6% 39.9% 34.6% 10,791 8.7% 64.8% 74.1% 2,184 8.2% 66,025 4,468 2,303 39.5% 2,210 3,039 1,911 7,262 1,470 40.7% 8,541 71.2% 4,035 9.6% 64.8% 7,673 71.1% 65.8% 9.3% 2,486 64.8% 10.1% 41.1% 70.9% 5,726 40.0% 190,890 5,843 64.8% 36.9% 2,217 1,970 1,245 7,307 4,620 65.8% 5,268 70.9% 40.1% 72.2% 5,701 41.0% 2,280 71.3% 65.7% 43.0% 111,791 64.9% 5,362 61.4% 71.3% 3,336 1,195 2,608 64.9% 72.0% 5,743 65.8% 6,380 71.7% 68.1% 113,161 71.4% 68.1% 3,012 71.3% 2,566 72.1% 74.1%

39 4 Angina and Heart Attack (CHD)

40 Making Chronic Conditions Count

CHAPTER 4. ANGINA AND HEART ATTACK (CHD)

This chapter relates to adults (aged 16 years and over) who have ever been told by a doctor that they have angina or have had a heart attack. We refer to this as coronary heart disease (CHD)15.

Detailed estimates and forecasts of CHD prevalence, broken down by sex and age within each area, are given at the end of the chapter.

KEY POINTS: ANGINA AND HEART ATTACK (CHD)

In 2007, nearly 131,000 adults in the Republic of Ireland (3.8%) have ever had a CHD. By 2020 this is expected to rise to over 195,000 (4.6%). This represents a 50% increase – an additional 65,000 adults – in less than 15 years.

In 2007, over 75,000 adults in Northern Ireland (5.4%) have ever had a CHD. By 2020 this is expected to rise to over 97,000 (6.4%). This represents a 30% increase – an additional 22,000 adults – in less than 15 years.

CHD is more common amongst males than females. The CHD prevalence rate amongst males is nearly 50% higher than amongst females.

CHD prevalence increases with age. About one in five adults aged 75 years and over have ever had a CHD. In 2020 relatively more of the adults living with CHD will belong in the older age groups.

CHD tends to be most common in northern parts of the island and least common around Dublin.

Local socio-economic circumstances affect CHD prevalence. Amongst males and females, and across all age groups, CHD tends to be more common in more deprived areas.

CHD prevalence is higher in Northern Ireland than in the Republic of Ireland. North-South differences in the current and future CHD prevalence are chiefly due to differences in current and (projected) future demographic and socio-economic profiles and smoking rates.

National Estimates in 2007

In 2007, 3.8% of adults in the Republic of Ireland (130,703 people) and 5.4% of adults in Northern Ireland (75,158 people) have ever had a CHD.

The estimated CHD prevalence rate (3.8%) in the Republic of Ireland is higher than estimates from other survey studies. Direct comparisons with these studies, however, are confounded by important differences in methodology.

15 ‘Heart murmur’, ‘abnormal heart rhythm’ and ‘any other heart trouble’ are also recognised as coronary heart diseases. However, they are not within the definition of CHD used here.

41 Chapter 4 Angina and Heart Attack (CHD)

• In the SLÁN 2007 survey (Morgan et al, 2008) 2% of adults aged 18 years and over report having had a doctor-diagnosis of angina in the previous 12 months. Less than 1% report having had a doctor diagnosis of a heart attack in the previous 12 months. • In the CSO’s Quarterly National Household Survey 2007 (CSO, 2008) 2% of adults aged 18 years and over report ever having had a doctor-diagnosis of angina. One per cent report ever having had a doctor-diagnosis of heart attack.

The estimated CHD prevalence rate (5.4%) in Northern Ireland is also higher than estimates from other studies:

• It is higher (5.4% compared to 4.2%) than the Quality and Outcomes Framework (QOF) estimate that is based on primary care data (DHSSPS, 2007). However, this is not unexpected because the QOF covers all ages while this report covers adults aged 16 years and over. • The Health and Social Wellbeing Survey 2005-2006 found that 6% of adults aged 16 years and over have ever been told by a doctor that they have had angina and 3% have ever been told by a doctor that they have had a heart attack (DHSSPS, 2007).

Again, direct comparisons are confounded by important differences in methodology.

CHD prevalence in England in 2007 is estimated to be 5.6% (APHO, 2008). The percentage of people who are living with a CHD is lower in the Republic of Ireland than it is in either Northern Ireland or England. This is chiefly due to differences in these countries’ demographic and socio-economic profiles, and smoking rates. In particular, both Northern Ireland and England have an older population than the Republic of Ireland.

Demographic Variation in 2007

More males than females have ever had a CHD. This is true in both the Republic of Ireland (male 4.7%, female 3.0%) and Northern Ireland (male 6.5%, female 4.5%).

These CHDs are more common in older age groups. Approximately one in five adults aged 75 years and over in Northern Ireland (22.4%) and the Republic of Ireland (19.1%) have ever had angina or a heart attack.

Ethnicity does not contribute much to North-South differences because neither jurisdiction has a large ‘non-white’ ethnic population.

42 Making Chronic Conditions Count

Geographical Variation in 2007

Figure 4.1: Percentage of adults who have ever had angina or a heart attack; across Local Health Offices (LHOs) in the Republic of Ireland and Local Government Districts (LGDs) in Northern Ireland (2007).

7.2 - 8.0

6.4 - 7.2

5.6 - 6.4

4.8 - 5.6

4.0 - 4.8

3.2 - 4.0

2.4 - 3.2

1.6 - 2.4

In addition to the higher CHD prevalence rate in Northern Ireland, nearly all of the areas with higher CHD prevalence rates are in northern parts of the island. The exceptions are Mayo LHO and West Cork LHO. CHD prevalence rates tend to be lowest in parts of Dublin and its surrounds.

43 Chapter 4 Angina and Heart Attack (CHD)

Socio-economic Variation in 2007

Local socio-economic circumstances in an area affect CHD prevalence.

Figure 4.2: Percentage of adults who have ever had angina or a heart attack; across the deprivation bands16 in the Republic of Ireland within each sex and each age group (2007). 35

30

25

20 % 15

10

5

0 Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years Band 1 (least deprived) Band 2 Band 3 Band 4 Band 5 (most deprived)

Figure 4.3: Percentage of adults who have ever had angina or a heart attack; across the deprivation bands16 in Northern Ireland within each sex and each age group (2007).

35

30

25

20 % 15

10

5

0 Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years Band 1 (least deprived) Band 2 Band 3 Band 4 (most deprived)

16 See this report’s technical supplement for definitions of the deprivation bands.

44 Making Chronic Conditions Count

Within each age group, and amongst males and females, CHD prevalence rates increase as you move from the least deprived areas to the most deprived areas. These effects are observed in both the Republic of Ireland and Northern Ireland17. In the Republic of Ireland CHD prevalence in the most deprived LHOs is almost 2.5 times what it is in the least deprived LHOs. In Northern Ireland CHD prevalence in the most deprived LGDs is 1.5 times what it is in the least deprived LGDs. The effect of local socio-economic circumstances on CHD prevalence rates appears to be the same amongst males and females, and does not seem to depend on age.

How CHD Prevalence Will Change Between 2007 and 2020

The percentage of adults who have ever had angina or a heart attack is expected to increase over time:

• In Northern Ireland, it is expected to increase from 5.4% in 2007 to 5.9% in 2015 to 6.4% in 2020. • In the Republic of Ireland, it is expected to increase from 3.8% in 2007 to 4.3% in 2015 to 4.6% in 2020.

With a growing and ageing population, far more adults will be living with a CHD in 2020 than in 2007. The number of adults in Northern Ireland living with a CHD is expected to rise from 75,158 in 2007 to 97,255 in 2020; an increase of 22,097 adults (29.4%). The number of adults in the Republic of Ireland living with a CHD is expected to rise from 130,703 in 2007 to 195,243 in 2020; an increase of 64,540 adults (or 49.4%). A proportionally larger increase is expected in the Republic of Ireland because its population is projected to increase more than Northern Ireland’s.

Figure 4.4: Expected changes in the percentage of adults in the Republic of Ireland, Northern Ireland and England who have ever had angina or a heart attack; within each sex group and age group (2007, 2015, 2020).

25

20

15

% 10

5

0 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years

Republic of Ireland Northern Ireland England

17 Direct North-South comparison is confounded by the fact there are five deprivation bands in the Republic of Ireland but only four deprivation bands in Northern Ireland. See this report’s technical supplement for details

45 Chapter 4 Angina and Heart Attack (CHD)

Amongst males and females, and in each age group, similar changes in CHD prevalence rates are expected in each country (the Republic of Ireland, Northern Ireland and England).

Like stroke, differences between CHD prevalence rates in the three countries appear to be greater in the older age groups.

An ageing population profile and higher CHD prevalence rates in older age groups mean that a growing percentage of adults living with CHD will belong to the older age groups. Between 2007 and 2020, the percentage of adults living with CHD who are aged 65 years and over will rise in the Republic of Ireland from 58.7% to 62.8%. In Northern Ireland the percentage will rise from 62.2% to 66.0%.

46 ber Prevalence rt attack or angina (2007). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 4.1: Demographic and geographic variation in the percentage of adults in the Republic of Ireland who have ever had a hea of adults in the Republic Ireland 4.1: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 2,020Donegal 2,336Dublin North 4.7% 2,878Dublin North Central 4.8% Dublin North West 1,247 6.0%Dublin South City 1,468 2,219Dublin South East 2.9% 1,789 3,411 4,887Dublin South West 2,597Dublin West 3.1% 4.3% 3,268 3.9% 1,586 3.9%Dun Laoghaire South Dublin 8.5% 1,545 3.5%Galway 3,803 1,671 2,983 2,071 3.8% 4,667 2,252Kerry 3,049 3,131 2.8% 1,855 3.5% Wicklow Kildare / West 4.0% 3.1% 5.1% 156 4.2% 2,093 5.0%Laois / Offaly 2.5% 1,111 5.4% 5.5% 2.4% 1,168Limerick 3,890 2,725 186 2,087 1,525 0.3%Longford / Westmeath 5,662 1.9% 8,019 1,939 217 4.0% 4,452 2.4%Louth 2,275 4,287 3.7% 0.3% 3.4% 3.4% 2.8%Mayo 2,697 1,203 1,449 3.2% 3.5% 0.4% 7.0% 2,180 2,617 2,713Meath 2.9% 5.2% 4.6% 1,684 183 1,375 5,070North Cork 3,596 2.7% 4,988 2.4% 4.6% 1,636 331 383 2,907 4.9% 4.8%North Lee – Cork 2.9% 1,562 2,697 305 2.1% 0.3% / North Tipperary 4.2% 4.9% 3.4% 3,542 4.5% 186 0.3% 0.6% 1,407 904East Limerick 6.0% 1,598 4.8% 3.5% 2.9% 0.3% 148 4,409Roscommon 1,181 1,066 254 3,364 3.4% 153 12.9% 0.2% 2,879 1,265 2,212 201 Cavan Sligo / Leitrim West 3.1% 2,932 1,897 3.0% 1,689 2,332 3,838 6,983 0.3% 1,603 14.0%South Lee – Cork 2.8% 2,055 4.9% 0.4% 16.5% 0.3% 6.8% 267South Tipperary 3,587 1,005 0.4% 4,215 4.3% 3.1% 4.5% 943 8.6% 1,760 5.1% 3.6% 4.4% 3.8%Waterford 4.7% 893 1,177 1,149 318 17.7% 5.6% 2,019 2,168 1,409 Cork West 1,153 1,549 0.4% 1,889 1,741 4,803 1,748 4.0% 2,233 3.9% 1,112 1,452 2,397 4.5% 3.6% 19.2% 217 3,065 344Wexford 1,223 13.6% 0.3% 22.4% 1,291 3.7% 4.4%Wicklow 1,776 12.8% 22.5% 1,912 5.8% 5.9% 2.8% 1,470 4.0% 3.7% 174 3.5% 5.1% 2.3% 216 1,094 13.7%Republic of Ireland 3.4% 0.4% 0.3% 704 5.9% 1,377 3.5% 1,904 5,532 750 1,467 4,768 4.1% 1,078 1,378 5.3% 2,350 2,471 1,407 879 2,801 5.6% 0.3% 3,784 221 0.3% 2.8% 10.6% 1,661 1,321 18.7% 1,964 1,429 1,290 2,446 3,346 10.5% 16.1% 17.6% 78,943 29.7% 4.4% 5.6% 10.5% 1,176 14.0% 1,200 3.6% 3.8% 18.7% 4.9% 4.3% 0.3% 2,854 1,286 928 3.0% 1,515 2.2% 3.8% 6.0% 5.9% 4.9% 863 4.6% 1,110 1,331 4.7% 2.6% 210 3.4% 1,212 921 1,631 2,288 16.2% 1,530 267 1,741 3.7% 4,058 121 258 4.9% 14.4% 5,028 4.9% 1,073 1,977 22.1% 12.8% 51,761 807 14.4% 14.7% 19.1% 131 2,951 3,112 0.4% 3.2% 0.3% 4.8% 1,004 0.3% 1,176 2.8% 0.3% 16.4% 132 14.1% 5.0% 877 4.8% 3.0% 3.9% 1,076 0.3% 3.4% 1,870 4.4% 3,881 14.1% 21.6% 14.0% 1,838 1,399 130,703 0.3% 86 1,527 236 1,119 2,216 17.5% 968 249 2,097 1,141 161 132 4.1% 13.9% 6.0% 21.8% 19.1% 1,124 1,308 5.0% 0.4% 1,024 3.8% 0.3% 4.4% 0.4% 5.0% 5.0% 19.0% 19.4% 5.0% 0.3% 1,570 0.4% 1,344 183 1,443 6,703 1,410 4.5% 1,827 997 733 785 16.6% 78 19.0% 13.8% 1,157 933 1,076 0.3% 0.3% 12.9% 3.6% 14.0% 809 6.0% 5.0% 0.4% 14.1% 1,882 1,318 47,317 4.5% 1,372 5.0% 12.9% 1,194 1,001 1,526 22.1% 653 18.9% 927 1,141 685 831 17.6% 5.0% 10.6% 884 5.0% 16.5% 18.9% 14.1% 890 19.2% 36,945 12.8% 14.0% 1,150 5.1% 1,219 17.8% 1,427 14.1% 815 14.0% 14.6% 22.2% 1,021 615 802 19.2% 39,737 19.2% 17.4% 14.1% 1,176 19.1% 19.0% 719 19.2% Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Num

47 ber Prevalence t attack or angina (2015). 3.8% 197 0.3% 1,384 3.7% 1,422 10.6% 1,606 15.0% Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 4.2: Demographic and geographic variation in the percentage of adults in the Republic of Ireland who have ever had a hear of adults in the Republic Ireland 4.2: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 2,578Donegal 3,033Dublin North 5.2% 3,635Dublin North Central 5.4% Dublin North West 1,529 6.6%Dublin South City 1,818 2,932Dublin South East 3.3% 2,157 4,451 6,169Dublin South West 3,401Dublin West 3.4% 4.9% 4,106 4.1% 2,069 4.3%Dun Laoghaire South Dublin 9.4% 2,028 3.9% 4,851 2,059 2,730 3,889 4.2% 5,792 2,771 3,783 3.2% 2,280 3.9% 4.4% 3.4% 4.7% 5.7% 179 2,716 5.4% 2.6% 1,365 5.8% 2.6% 1,436 4,991 216 1,878 2,566 0.4% 7,222 2.1% 9,951 248 4.5% 5,681 2.6% 4.1% 0.4% 2.9% 3.6% 3,434 1,391 1,779 3.5% 0.4% 7.6% 3,464 3.3% 238 1,646 4,608 6,455 2.9% 2.6% 4.6% 1,913 436 437 3.2% 398 0.3% 4.6% 4.9% 4,495 1,246 234 0.4% 0.6% 6.0% 0.4% 189 1,418 1,436 12.9% 332 3.7% 0.3% 1,740 2,655 3,429 0.3% 1,923 14.0% 4.9% 0.4% 1,290 16.5% 350 1,132 4.6% 8.6% 1,072 4.7% 18.0% 1,552 1,515 2,422 1,892 0.5% 2,300 3,070 3.6% 19.5% 1,614 13.7% 3.7% 22.8% 12.9% 22.5% 5.9% 1,763 930 13.8% 989 1,819 1,935 1,831 3,016 10.7% 5.6% 1,746 19.1% 10.6% 16.2% 17.9% 30.1% 1,225 19.1% 1,138 1,214 1,766 16.3% 14.7% 14.7% 22.5% 1,157 22.1% GalwayKerry 3,980 Wicklow Kildare / West Laois / Offaly 6.3%Limerick 3,941 Longford / Westmeath 2,369Louth 2,865 5,403 4.0%Mayo 3.8% 2,876 3,451Meath 5.8% 5.1% 2,323North Cork 6,349 3,710 5.4% 5.3%North Lee – Cork 1,886 3,247 2.4% / North Tipperary 5.1% 1,742East Limerick 1,984 5.4% 3.7% 3.0% 6,264Roscommon 4,245 3,722 235 Cavan Sligo / Leitrim West 3.4% 2,333 3.3% 2,203 3,394 4,752 8,650South Lee – Cork 3.2% 2,605 7.4%South Tipperary 4,618 0.4% 5,435 5.0% 3.5% 2,250 5.9% 4.2% 4.8% 4.0%Waterford 414 6.1% 2,603 1,781 Cork West 2,308 6,043 2,067 4.4% 4.3% 1,358 2,007 3,112 5.0% 248 3,975 430Wexford 1,555 0.4% 4.5%Wicklow 2,598 2,491 6.3% 3.1% 4.4% 210 3.8% 5.1% 2.6% 260 1,344Republic of Ireland 3.9% 0.4% 0.3% 6.6% 3.7% 2,490 6,848 1,054 6,030 4.8% 6.0% 3,054 1,915 3,561 0.4% 5,400 252 0.4% 3.2% 2,032 2,437 1,672 1,692 2,932 102,976 4,160 4.3% 6.0% 3.9% 1,630 14.1% 1,488 4.1% 5.5% 4.9% 0.3% 3,594 1,600 3.4% 1,885 2.5% 4.2% 6.9% 5.9% 5.0% 5.0% 5.2% 1,837 2,835 3.0% 263 3.8% 2,132 1,899 312 2,014 4.1% 5,143 141 336 5.0% 6,412 5.0% 1,475 2,626 64,009 12.9% 987 150 19.5% 4,228 5.1% 3,980 0.5% 3.5% 0.4% 1,386 0.4% 1,625 3.2% 0.4% 16.4% 151 14.1% 5.0% 5.4% 3.3% 4.2% 1,522 0.4% 3.9% 2,244 4.9% 107 4,953 14.1% 14.0% 2,173 166,985 1,929 1,145 0.3% 1,997 271 1,357 2,662 18.0% 290 2,679 1,334 210 0.4% 153 4.5% 13.9% 6.1% 22.2% 19.6% 1,421 1,665 4.3% 5.0% 1,184 0.3% 5.0% 4.4% 0.5% 5.6% 19.3% 5.0% 19.8% 0.4% 2,085 0.4% 8,192 1,828 213 1,849 880 1,068 1,651 1,666 4.6% 2,187 1,283 16.5% 91 19.3% 13.9% 1,512 1,288 0.4% 0.4% 14.0% 12.9% 5.1% 1,115 3.6% 14.2% 6.0% 0.4% 2,256 56,869 1,717 4.5% 1,643 12.9% 5.0% 1,207 1,416 1,623 867 2,056 22.6% 1,393 19.3% 19.3% 1,376 18.0% 810 1,191 5.0% 10.7% 14.1% 5.0% 1,143 16.5% 19.5% 12.8% 50,746 14.1% 18.1% 1,550 5.1% 1,584 1,880 981 14.1% 1,131 14.0% 1,347 14.9% 22.6% 837 19.6% 51,177 17.8% 19.6% 14.2% 1,547 19.5% 19.4% 941 19.6% Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Num

48 ber Prevalence t attack or angina (2020). 4.0% 224 0.3% 1,578 3.7% 1,670 10.6% 1,943 15.2% Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 4.3: Demographic and geographic variation in the percentage of adults in the Republic of Ireland who have ever had a hear of adults in the Republic Ireland 4.3: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 2,995Donegal 3,567Dublin North 5.6% 4,223Dublin North Central 5.9% Dublin North West 1,737 7.2%Dublin South City 2,092 3,502Dublin South East 3.5% 2,448 5,275 7,150Dublin South West 4,042Dublin West 3.8% 5.3% 4,732 4.5% 2,450 10.2% 4.7%Dun Laoghaire South Dublin 2,411 4.3% 5,659 2,367 3,256 4,612 4.6% 6,671 4,289 3,179 3.5% 2,617 4.2% 4.9% 3.5% 5.0% 6.2% 192 6.3% 3,214 5.9% 2.8% 1,567 2.8% 1,650 5,870 231 11,439 2,159 2,943 0.4% 8,454 2.2% 266 4.9% 6,659 2.7% 4.4% 0.4% 3.0% 8.2% 3.8% 4,017 1,501 2,039 3.7% 0.5% 4,061 3.5% 273 1,836 5,415 7,555 471 3.1% 2.9% 4.6% 2,092 505 3.4% 456 0.4% 5.0% 5.0% 0.7% 5,253 1,466 258 0.4% 6.0% 0.4% 211 1,618 1,673 13.0% 3,750 382 4.0% 0.3% 2,029 3,027 0.3% 2,196 14.0% 4.9% 0.5% 1,574 16.5% 8.6% 404 1,293 4.6% 1,222 4.7% 18.2% 1,918 1,780 3,581 2,761 2,284 0.5% 2,702 3.6% 19.7% 1,895 13.7% 3.7% 22.5% 23.1% 12.9% 5.9% 2,014 1,092 13.8% 1,162 2,199 3,638 2,273 10.7% 2,220 5.6% 10.6% 2,112 19.3% 30.5% 16.2% 18.2% 1,373 1,439 19.3% 1,466 14.9% 2,140 16.3% 14.9% 22.8% 1,397 22.3% GalwayKerry 4,667 Wicklow Kildare / West Laois / Offaly 6.9%Limerick 4,906 Longford / Westmeath 2,704Louth 3,307 6,259 4.5%Mayo 4.1% 3,411 4,095Meath 6.3% 5.6% 2,845North Cork 7,371 4,310 6.0% 5.9%North Lee – Cork 2,138 3,714 2.7% / North Tipperary 5.5% 2,014East Limerick 2,293 5.8% 4.1% 3.2% 7,751Roscommon 4,926 4,332 252 Cavan Sligo / Leitrim West 3.8% 2,653 3.7% 2,582 4,241 5,445 9,973South Lee – Cork 3.6% 3,032 8.0%South Tipperary 5,425 0.4% 6,389 5.6% 3.8% 2,619 6.5% 4.8% 5.2% 4.4%Waterford 451 6.7% 2,981 2,072 Cork West 2,628 6,963 2,284 5.0% 4.9% 1,551 2,463 3,625 5.4% 267 4,665 484Wexford 1,765 0.4% 4.8%Wicklow 3,253 2,940 6.8% 3.4% 4.9% 227 4.1% 5.1% 2.9% 281 1,527Republic of Ireland 4.4% 0.5% 0.4% 7.2% 4.0% 2,964 7,906 1,208 6,959 5.4% 6.5% 3,591 2,240 4,132 0.4% 6,704 269 0.4% 3.5% 2,317 2,802 1,829 1,991 3,201 121,520 4,797 4.3% 6.4% 4.1% 2,006 14.1% 1,715 4.5% 6.1% 5.3% 0.4% 4,146 1,794 3.8% 2,113 2.7% 4.6% 7.5% 5.9% 5.0% 5.4% 5.7% 2,276 3,280 3.3% 298 4.1% 2,594 2,186 334 2,172 4.5% 5,942 152 366 5.0% 7,467 5.0% 1,720 1,127 3,120 73,723 12.9% 161 19.8% 5,259 5.5% 4,655 0.5% 3.9% 0.4% 1,679 0.4% 1,967 3.5% 0.4% 16.4% 161 14.1% 5.0% 5.9% 4.5% 3.5% 2,060 0.4% 4.3% 2,449 5.4% 122 5,777 14.1% 14.1% 2,401 195,243 2,268 1,265 0.3% 2,377 282 3,118 1,630 3,168 18.1% 311 1,459 229 0.4% 164 5.0% 14.0% 6.1% 22.4% 19.8% 1,725 2,028 4.6% 5.1% 1,277 0.3% 5.0% 6.0% 4.4% 0.5% 19.5% 5.0% 20.0% 0.4% 2,477 0.4% 9,011 2,138 228 2,254 960 1,249 2,045 1,840 4.6% 2,440 98 1,496 16.5% 19.5% 13.9% 1,799 1,438 0.4% 0.4% 14.1% 12.9% 5.0% 1,312 3.6% 14.1% 6.0% 0.5% 2,682 63,677 2,086 4.4% 1,833 12.9% 5.0% 1,030 1,467 1,916 1,898 2,394 22.8% 1,681 19.6% 895 19.5% 1,704 18.2% 14.1% 1,387 5.0% 10.7% 5.1% 1,396 16.5% 19.8% 12.8% 59,946 14.1% 5.1% 18.2% 1,168 1,805 1,922 2,321 14.1% 19.8% 1,528 14.0% 1,666 980 15.1% 22.9% 62,610 17.9% 19.8% 14.2% 1,911 19.7% 19.6% 1,145 19.8% Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Num

49 ce Number Prevalence ce Number k or angina (2007). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Local Government District Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalen Table 4.4: Demographic and geographic variation in the percentage of adults in Northern who have ever had a heart attac 4.4: Demographic and geographic variation in the percentage Ireland Table AntrimArdsArmaghBallymenaBallymoneyBanbridge 1,048Belfast 1,759Carrickfergus 1,241 5.2% 1,495Castlereagh 663 5.9%Coleraine 5.8% 699 6.2%Cookstown 896 1,206Craigavon 5.8% 8,766 850 842 1,054 3.4%Derry 5.0% 1,500 3.8%Down 456 3.7% 1,746 4.2% 8.8% 5.5% 1,387Dungannon 611 2,966 6.1%Fermanagh 3.9% 829 2,092 7,433 2,548 4.3% 588 2,133Larne 6.4% 3.3% 1,115 4.8% 1,119Limavady 6.4% 4.7% 6.1% 5.2% 3.6% 87 3,131 6.3%Lisburn 1,507 4.0% 989 108 1,074 16,198 1,510 4.8%Magherafelt 568 1,430 83 96 0.4% 1,436 1,532 7.8% 2,615Moyle 4.2% 4.2% 0.4% 5.1% 7.5% 5.7%Newry & Mourne 47 4.1% 0.4% 4.5% 0.4% 4.3% 5.9% 2,286 2,376 637 5.0%Newtownabbey 784 784 71 1,043 1,033 647 738 1,396North Down 0.4% 3,665 2,342 5.3% 719 59 942 820 846 5.3%Omagh 5.4% 6.4% 0.4% 95 5.8% 3.8% 5.0% 3.5% 0.6% 2,173 5.1%Strabane 5.3% 5,417 368 5.6% 0.4% 3.9% 5.3% 5.1% 1,911 5.4%Northern Ireland 517 496 0.4% 83 2,543 535 1,812 511 854 512 5,021 6.1% 1,665 63 6.5% 169 2,378 5.3% 1,868 14.4% 622 475 6.2% 755 553 0.4% 13.3% 7.7% 4.1% 4.7% 4.0% 4.3% 1,498 753 4.7% 8.7% 3.6% 43,462 0.4% 0.5% 295 1,213 4.9% 14.5% 326 14.4% 6.1% 1,370 3.4% 1,319 1,336 4.8% 504 1,295 105 336 4.1% 754 4,619 4.6% 961 81 432 4,007 14.4% 6.5% 1,262 0.6% 1,393 6.2% 489 4.0% 19.9% 1,399 91 668 5.2% 22.5% 18.3% 877 8.9% 3,671 424 4.9% 4.9% 0.4% 13.1% 5.3% 0.3% 747 31,696 4.6% 2,093 4.2% 19.7% 6.3% 3,281 19.8% 825 6.3% 378 0.4% 4.2% 13.3% 5,911 5.1% 913 48 13.1% 831 69 869 4.5% 733 492 173 611 1,078 19.9% 3,261 8.7% 5.0% 4.1% 29.6% 394 808 68 6.0% 75,158 173 0.4% 14.4% 473 18.4% 6.3% 1,021 0.5% 16.8% 5.3% 0.4% 5.1% 1,564 5.2% 2,038 17.0% 125 18.2% 18.3% 0.4% 2,248 0.4% 5.4% 5.4% 451 29 806 23.0% 485 730 1,155 1,395 104 526 5.1% 0.4% 450 3,173 7.4% 1,295 19.7% 22.9% 671 480 14.5% 0.5% 5.4% 14.4% 1,465 6.3% 5.2% 0.4% 23.1% 1,058 94 0.4% 14.6% 111 6.2% 30.1% 5.2% 1,166 399 839 279 368 1,069 594 25,273 5.3% 0.4% 1,087 0.7% 14.4% 19.8% 807 14.3% 400 17.2% 19.7% 6.6% 5.0% 17.0% 959 6.1% 19.9% 731 14.5% 794 1,272 421 21,759 373 251 14.3% 888 1,116 19.7% 6.2% 19.9% 9.1% 23.1% 452 16.5% 17.0% 13.3% 22.9% 1,139 20.1% 575 673 24,954 19.8% 1,200 272 16.9% 22.4% 23.0% 18.0% 23.0% 638 669 23.0% 30.6%

50 ce Number Prevalence ce Number k or angina (2015). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 4.5: Demographic and geographic variation in the percentage of adults in Northern who have ever had a heart attac 4.5: Demographic and geographic variation in the percentage Ireland Table Local Government DistrictAntrim NumberArds PrevalenceArmagh Number Ballymena Prevalence Ballymoney NumberBanbridge 1,316 Prevalence Belfast Number 2,224Carrickfergus 1,547 5.8% 1,786 Prevalence Castlereagh Number 867 6.9%Coleraine 6.4% 853 1,152 6.9% Prevalence Cookstown 1,445Craigavon 6.6% Number 1,008 1,122 9,238 1,244 3.6% Prevalen 5.6%Derry 1,643 4.2% 4.0%Down 554 6.8% 2,169 4.6% 9.3% 768 1,673Dungannon 3,669 6.6% 1,043 2,555Fermanagh 4.2% 7,335 3,030 714 4.7% 2,623 3.7%Larne 7.7% 1,192 5.5% 5.2% 6.8% 1,422Limavady 6.6% 4.0% 5.7% 1,920 84 1,107 3,925 6.8%Lisburn 4.4% 1,359 16,573 97 1,870 5.4% 671Magherafelt 1,836 84 86 0.3% 1,777 1,808 4.6% 4.8% 9.2% 2,835Moyle 5.1% 0.3% 7.9% 4.4% 6.4% 0.3%Newry & Mourne 5.4% 48 0.4% 2,780 4.5% 6.7% 2,752 687 5.4% 68Newtownabbey 951 996 1,227 1,714 1,090 610 865North Down 0.4% 796 4,431 48 2,930 1,094 1,034 6.2% 6.1% 882 0.3%Omagh 5.1% 7.5% 68 6.8% 4.1% 5.6% 3.5% 0.6% 2,739 4.8%Strabane 0.3% 4.2% 5.6% 6,677 439 6.4% 5.3% 5.4% 65 2,184 5.2%Northern Ireland 696 587 0.3% 642 3,097 601 1,272 2,224 641 5,151 6.7% 68 2,871 2,000 7.6% 174 801 5.2% 2,205 583 659 0.3% 14.5% 6.9% 914 13.3% 8.4% 4.5% 5.2% 4.8% 4.7% 4.3% 1,789 845 8.8% 0.4% 4.0% 5.4% 14.5% 51,958 0.4% 272 1,536 3.6% 436 14.4% 7.0% 1,559 4.8% 1,552 802 1,627 1,210 702 1,636 371 4.3% 583 4,634 102 98 4.7% 4,930 555 14.5% 7.2% 1,434 0.6% 1,693 1,558 95 6.9% 18.7% 4.5% 874 20.2% 1,149 552 10.4% 6.0% 13.3% 22.8% 4,528 5.4% 5.1% 5.8% 0.3% 0.3% 794 35,890 5.1% 20.1% 20.0% 2,424 4.6% 6.4% 0.4% 4.6% 6.1% 13.4% 3,743 992 1,083 498 6,178 5.4% 861 37 13.0% 958 626 66 4.7% 733 988 155 1,340 20.4% 3,763 518 8.6% 5.7% 4.5% 6.7% 30.2% 914 74 14.5% 652 18.4% 87,848 178 0.3% 6.8% 1,128 0.5% 16.9% 0.3% 5.2% 5.2% 17.0% 5.8% 2,009 18.8% 2,528 2,710 0.4% 99 5.4% 18.4% 1,053 0.4% 5.9% 478 27 23.0% 562 1,483 1,575 652 958 5.7% 8.5% 20.2% 90 573 0.3% 864 2,990 576 1,546 23.3% 14.5% 0.4% 14.6% 5.3% 1,971 23.6% 6.3% 5.2% 0.3% 100 14.6% 1,117 95 0.4% 5.2% 6.2% 30.8% 1,523 1,054 505 300 507 737 1,042 0.6% 27,921 0.4% 5.2% 1,316 999 491 20.1% 14.5% 14.5% 20.2% 17.1% 6.5% 20.4% 4.9% 1,137 17.1% 6.1% 886 14.5% 875 1,677 533 26,436 14.4% 501 1,204 291 1,489 20.0% 8.8% 6.4% 552 20.4% 23.2% 16.4% 13.2% 17.1% 23.4% 1,390 20.2% 833 745 30,501 19.9% 1,426 340 23.1% 17.0% 22.6% 18.5% 23.8% 891 812 30.9% 23.4%

51 ce Number Prevalence ce Number k or angina (2020) Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Local Government District Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalen Table 4.6: Demographic and geographic variation in the percentage of adults in Northern who have ever had a heart attac 4.6: Demographic and geographic variation in the percentage Ireland Table AntrimArdsArmaghBallymenaBallymoneyBanbridge 1,507Belfast 2,542Carrickfergus 1,758 6.2% 1,984Castlereagh 1,012 7.7%Coleraine 6.9% 975 1,353 7.4%Cookstown 7.2% 1,627Craigavon 1,127 1,328 9,627 1,375 3.8% 6.1%Derry 1,743 4.5% 629 4.2%Down 7.9% 2,482 4.9% 9.9% 887 1,846Dungannon 4,169 7.2% 4.4% 1,197 2,884Fermanagh 7,409 3,359 809 5.0% 2,992 4.0%Larne 8.6% 1,247 6.0% 1,641 5.5% 7.4%Limavady 6.9% 4.4% 6.1% 2,240 90 1,187 4,477 7.2%Lisburn 4.8% 5.8% 1,591 17,036 96 2,131 750Magherafelt 2,137 87 89 0.3% 2,018 2,019 10.3% 5.0% 5.3% 2,990Moyle 5.3% 0.3% 8.4% 48 4.7% 7.0% 0.3%Newry & Mourne 6.1% 3,125 0.4% 3,032 4.6% 7.3% 1,062 755 5.9% 1,151 71Newtownabbey 1,380 1,947 1,171 0.4% 636 973North Down 6.8% 855 5,011 45 3,330 1,220 1,192 6.9% 938 8.5% 0.3% 7.7%Omagh 5.3% 62 4.4% 6.1% 3.6% 0.6% 3,152 5.0% 508Strabane 7,602 0.3% 4.5% 5.9% 7.1% 5.4% 5.9% 58 2,354 5.3% 651Northern Ireland 723 654 739 0.3% 724 3,511 1,320 2,564 5,259 7.1% 75 8.5% 3,237 5.4% 2,248 195 863 2,426 648 740 0.3% 14.6% 4.9% 7.4% 971 5.3% 13.3% 9.2% 5.7% 4.9% 4.5% 2,010 891 9.1% 0.5% 4.3% 5.9% 14.6% 280 58,032 463 0.4% 1,768 3.9% 14.4% 7.7% 1,713 1,684 5.1% 1,890 821 1,838 1,582 913 105 406 4.5% 655 4,620 123 5.2% 14.5% 5,578 0.7% 608 1,080 7.8% 1,599 1,932 1,689 99 7.6% 19.1% 4.9% 20.3% 6.6% 1,362 624 6.6% 11.5% 13.3% 22.9% 5,163 5.6% 5.5% 0.4% 0.4% 20.4% 818 39,223 5.6% 2,668 20.1% 1,123 5.0% 6.5% 622 0.4% 4.9% 6.4% 13.5% 4,038 1,195 35 1,059 6,522 62 5.8% 1,070 894 13.2% 789 5.1% 20.6% 846 166 1,421 4,115 4.9% 9.1% 555 6.1% 7.2% 30.5% 974 74 0.4% 14.6% 820 18.6% 7.3% 0.5% 97,255 201 5.5% 1,219 16.9% 2,254 0.4% 5.3% 2,891 17.0% 6.3% 19.1% 3,033 0.4% 89 5.4% 18.5% 1,259 1,062 0.4% 514 6.4% 28 612 23.0% 1,796 1,713 724 6.2% 9.3% 20.4% 89 709 0.3% 14.6% 990 3,100 649 1,714 23.5% 0.4% 5.7% 6.4% 14.5% 2,400 23.8% 5.4% 102 0.3% 14.7% 1,165 92 1,274 0.4% 30.9% 5.3% 6.5% 519 304 578 1,629 0.4% 871 20.3% 1,053 29,964 0.6% 1,174 5.4% 1,490 14.6% 562 17.2% 14.5% 20.4% 6.5% 20.6% 934 5.1% 1,169 17.1% 6.3% 14.6% 974 2,069 645 638 327 28,215 14.4% 1,222 6.6% 1,757 20.2% 20.6% 9.1% 23.4% 647 17.3% 16.4% 13.2% 23.6% 1,615 871 20.2% 891 35,975 20.1% 1,751 400 17.2% 23.3% 22.7% 18.7% 24.0% 984 1,076 23.6% 31.0%

52 5 Stroke

53 Chapter 5 Stroke

CHAPTER 5. STROKE

This chapter relates to adults (aged 16 years and over) who have ever been told by a doctor that they have had a stroke.

Detailed estimates and forecasts of stroke prevalence, broken down by age and sex within each area, are given at the end of the chapter.

KEY POINTS: STROKE

In 2007, almost 59,000 adults in the Republic of Ireland (1.7%) have ever had a stroke. By 2020 this is expected to rise to almost 87,000 (2.1%). This represents a 48% increase – an additional 28,000 adults – in less than 15 years.

In 2007, almost 33,000 adults in Northern Ireland (2.4%) have ever had a stroke. By 2020 this is expected to rise to over 42,000 (2.8%). This represents a 29% increase – an additional 10,000 adults – in less than 15 years.

Stroke prevalence is similar amongst males and females.

Stroke prevalence increases with age. More than one in ten adults aged 75 years and over have ever had a stroke. In 2020 relatively more of the adults living with a stroke will belong in the older age groups.

Strokes tend to be most common in northern parts of the island and least common around Dublin.

Local socio-economic circumstances affect stroke prevalence. Amongst males and females, and across all age groups, strokes tend to be more common in more deprived areas.

The stroke prevalence rate is higher in Northern Ireland than in the Republic of Ireland. North- South differences in the current and future stroke prevalence are chiefly due to differences in current and (projected) future demographic and socio-economic profiles and smoking rates.

National Estimates in 2007

In 2007, 1.7% of adults in the Republic of Ireland (58,778 people) and 2.4% of adults in Northern Ireland (32,941 people) have ever had a stroke.

The estimated stroke prevalence rate (1.7%) in the Republic of Ireland is higher than estimates from other survey studies. Direct comparisons with these studies, however, are confounded by important differences in methodology.

54 Making Chronic Conditions Count

• In the SLÁN 2007 survey (Morgan et al, 2008) less than 1% of adults aged 18 years and over report having had a doctor-diagnosis of stroke in the previous 12 months. • In the CSO’s Quarterly National Household Survey 2007 (CSO, 2008) 1% of adults aged 18 years and over report ever having had a doctor-diagnosis of stroke.

The estimated stroke prevalence rate (2.4%) in Northern Ireland is higher than estimates from other studies:

• It is higher (2.4% compared to 1.6%) than the Quality and Outcomes Framework (QOF) estimate that is based on primary care data (DHSSPS, 2007). However, this is not unexpected because the QOF covers all ages while this report covers adults aged 16 years and over. • The Health and Social Wellbeing Survey 2005-2006 found that 2% of adults aged 16 years and over have ever been told by a doctor that they have had a stroke (DHSSPS, 2007).

Again, direct comparisons are confounded by important differences in methodology.

The stroke prevalence rate in England in 2006 is estimated to be 2.3% (HSfE, 2006). The percentage of adults who are living with a stroke is lower in the Republic of Ireland than it is in either Northern Ireland or England. This is chiefly due to differences in the three countries’ demographic and socio-economic profiles, and smoking rates. In particular, both Northern Ireland and England have an older population than the Republic of Ireland.

Demographic Variation in 2007

Similar percentages of males and females have ever had a stroke. This is true in both the Republic of Ireland (male 1.8%, female 1.7%) and Northern Ireland (male 2.4%, female 2.4%).

Strokes are more common in older age groups. One in ten adults aged 75 years and over in Northern Ireland (11.8%) and the Republic of Ireland (10.3%) have ever had a stroke.

55 Chapter 5 Stroke

Geographic Variation in 2007

Figure 5.1: Percentage of adults who have ever had a stroke; across Local Health Offices (LHOs) in the Republic of Ireland and Local Government Districts (LGDs) in Northern Ireland (2007).

3.0 - 3.3

2.7 - 3.0

2.4 - 2.7

2.1 - 2.4

1.8 - 2.1

1.5 - 1.8

1.2 - 1.5

0.9 - 1.2

In addition to the higher stroke prevalence rate in Northern Ireland, many of the areas with higher stroke prevalence rates are in northern parts of the island. The exceptions are Mayo LHO and West Cork LHO. Stroke prevalence tends to be lower in parts of Dublin and its surrounds.

56 Making Chronic Conditions Count

Socio-economic Variation in 2007

Local socio-economic circumstances in an area affect stroke prevalence.

Figure 5.2: Percentage of adults who have ever had a stroke; across the deprivation bands18 in the Republic of Ireland within each sex and each age group (2007). 18

16

14

12

10 % 8

6

4

2

0 Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years Band 1 (least deprived) Band 2 Band 3 Band 4 Band 5 (most deprived)

Figure 5.3: Percentage of adults who have ever had a stroke; across the deprivation bands18 in Northern Ireland within each sex and each age group (2007).

18

16

14

12

10 % 8

6

4

2

0 Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years Band 1 (least deprived) Band 2 Band 3 Band 4 (most deprived)

18 See this report’s technical supplement for definitions of the deprivation bands.

57 Chapter 5 Stroke

Within each age group, and amongst males and females (at least in the Republic of Ireland), stroke prevalence rates increase as you move from the least deprived areas to the most deprived areas19. In the Republic of Ireland stroke prevalence in the most deprived LHOs is 2.2 times what it is in the least deprived LHOs. In Northern Ireland stroke prevalence in the most deprived LGDs is 1.4 times what it is in the least deprived LGDs. The effect of local socio- economic circumstances on stroke prevalence rates appears to be the same amongst males and females, and does not seem to depend on age.

How Stroke Prevalence Will Change Between 2007 and 2020

The percentage of adults who have ever had a stroke is expected to increase over time:

• In Northern Ireland, it is expected to increase from 2.4% in 2007 to 2.6% in 2015 to 2.8% in 2020. • In the Republic of Ireland, it is expected to increase from 1.7% in 2007 to 1.9% in 2015 to 2.1% in 2020.

With a growing and ageing population, more adults will be living with a stroke in 2020 than in 2007. The number of adults in Northern Ireland living with a stroke is expected to rise from 32,941 in 2007 to 42,457 in 2020; an increase of 9,516 adults (or 28.9%). The number of adults in the Republic of Ireland living with a stroke is expected to rise from 58,778 in 2007 to 86,845 in 2020; an increase of 28,067 adults (or 47.8%). A proportionally larger increase is expected in the Republic of Ireland because its population is projected to increase more than Northern Ireland’s.

Figure 5.4: Expected changes in the percentage of adults in the Republic of Ireland, Northern Ireland and England who have ever had a stroke; within each sex group and age group (2007, 2015, 2020). 14

12

10

8 % 6

4

2

0 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 Persons Male Female 16-44 years 45-64 years 65-74 years 75+ years

Republic of Ireland Northern Ireland England

19 Direct North-South comparison is confounded by the fact there are five deprivation bands in the Republic of Ireland but only four deprivation bands in Northern Ireland. See this report’s technical supplement for details.

58 Making Chronic Conditions Count

Amongst males and females, and in each age group, similar changes in stroke prevalence rates are expected in each country (the Republic of Ireland, Northern Ireland and England).

Like CHD, differences between stroke prevalence rates in the three countries appear to be greater in the older age groups.

An ageing population profile and higher stroke prevalence rates in older age groups mean that a growing percentage of adults living with a stroke will belong to the older age groups. Between 2007 and 2020, the percentage of adults living with stroke who are aged 65 years and over will rise in the Republic of Ireland from 62.8% to 67.1%. In Northern Ireland the percentage will rise from 67.2% to 71.2%.

59 ber Prevalence oke (2007). 736 1.7% 128 0.2% 428 1.4% 486 4.7% 694 8.4% Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 5.1: Demographic and geographic variation in the percentage of adults in the Republic of Ireland who have ever had a str of adults in the Republic Ireland 5.1: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClareDonegalDublin North 866 1,020Dublin North Central Dublin North West 1.8% 2.1%Dublin South CityDublin South East 857 1,372 819 1,769 803Dublin South West 946 1,004Dublin West 1.6% 1.7% 1.6%Dun Laoghaire South Dublin 3.1% 2.1% 1.9% 635 1.3% 612 1,057 1,685 815 1,363 962 1,644 1,965 1.1% 753 1,071 1.4% 1.8% 1.5% 1.8% 1.8% 2.9% 1.7% 754 2.1% 1.8% 1.4% 696 717 1,096 2,736 1,819 3,413 157 921 1,556 169 1.4% 2,075 1.2% 1.5% 1.8% 1.5% 1.7% 3.0% 0.3% 1.7% 0.3% 1.8% 1,331 780 1.4% 1,329 2,153 317 180 1, 291 463 1.5% 138 1.2% 287 513 1.4% 1.8% 0.3% 0.3% 0.5% 1,534 0.3% 0.3% 1.7% 166 1.9% 128 224 826 404 1.5% 924 0.2% 441 438 499 554 0.2% 0.3% 1.7% 225 1.7% 2.7% 5.8% 6.5% 349 1.7% 1.6% 330 651 0.3% 793 487 904 404 1.3% 625 517 785 1.4% 1.9% 5.8% 5.8% 10.2% 9.1% 479 11.3% 5.8% 5.8% 315 338 592 1,295 1.8% 799 748 4.8% 575 717 4.7% 6.5% 15.5% 10.2% 10.1% 10.1% 373 10.2% 500 533 686 6.5% 8.3% 11.4% 8.3% 458 11.3% GalwayKerry 1,118 Wicklow Kildare / West Laois / Offaly 2.0%Limerick 1,088 Longford / Westmeath 1,074Louth 801 1,598 1.4%Mayo 2.0%Meath 807 976 1.8% 1.7% 1,025North Cork 2,192 1,070North Lee - Cork 1,516 1.8% 1.8% 824 1.3% / North Tipperary 2.0%East Limerick 1.8% 1.6% 789 1.8% 893 2,113Roscommon 1,183 166 Cavan 1,056Sligo / Leitrim West 1,053 3,113 934 623 1.7% 1,624 1.7%South Lee - Cork 1.3% 758 2.4%South Tipperary 0.3% 1.7% 1.6% 1.7% 1,596 706Waterford 1,870 1.5% 1.9% 1.8% 293 1,142 Cork West 2.1% 2,123 1,047 523 580 1,076 304Wexford 1.8% 1.8% 1.7% 933 169 885 620 0.3% 2.3%Wicklow 702 1.6% 720 1.7% 709 2.2%Republic of Ireland 1.7% 0.3% 2.1% 147 1.4% 0.3% 182 1.3% 1.9% 663 2,325 703 1.6% 2,103 2.0% 192 2.0% 869 490 1,025 581 1,000 0.3% 1,819 1,243 0.3% 1.7% 474 821 29,568 453 2.4% 1,478 1.6% 1.6% 709 0.3% 2.1% 1.8% 668 2.0% 5.8% 1.3% 1,369 1.4% 1.9% 2.2% 1.6% 433 511 1.8% 161 1.9% 2.0% 1.6% 498 227 1,013 1.9% 2,102 582 852 1,933 1.8% 29,211 234 101 865 447 813 1.7% 0.3% 1.6% 425 1,411 5.8% 0.3% 109 2.1% 1,376 2.0% 1.8% 10.1% 1.7% 1.3% 1.7% 0.3% 124 0.3% 2.1% 5.8% 415 6.5% 488 1.6% 0.3% 587 614 1.9% 1,720 619 58,778 191 69 195 580 0.3% 562 323 1,175 5.8% 922 5.8% 10.1% 147 1.9% 577 380 109 1.8% 1.7% 1.7% 0.3% 0.3% 5.8% 0.2% 10.1% 374 2.2% 1.6% 11.2% 1.7% 0.3% 601 689 5,744 617 0.3% 1.7% 155 559 579 245 515 768 10.1% 1.7% 10.2% 447 325 61 6.5% 0.3% 425 0.3% 5.8% 384 10.1% 361 1.9% 1.7% 1.3% 5.8% 5.8% 363 0.3% 16,096 1.6% 5.8% 961 461 1.7% 704 603 268 530 5.8% 1.7% 11.3% 576 495 227 10.1% 374 605 366 1.7% 6.5% 5.8% 4.7% 15,513 10.1% 10.1% 508 5.8% 1.7% 10.2% 5.8% 477 5.9% 10.1% 728 431 693 252 465 11.3% 5.8% 10.2% 21,426 541 8.3% 10.1% 5.8% 10.3% 10.2% 627 381 10.2% 10.1% Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Num

60 ber Prevalence oke (2015). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 5.2: Demographic and geographic variation in the percentage of adults in the Republic of Ireland who have ever had a str of adults in the Republic Ireland 5.2: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 1,029Donegal 1,127Dublin North 2.1% 1,292Dublin North Central 2.0% Dublin North West 917 2.3%Dublin South City 1,008 1,131Dublin South East 1,130 1,791 2.0% 2,242Dublin South West 1,309Dublin West 1.9% 1.9% 2.2% 1,945 1.8%Dun Laoghaire South Dublin 3.4% 828 1.5%Galway 2,136 806 1,178 1,380 1,080 2,422 1,669Kerry 1,465 2.0% 1,968 1.3% 1,307 Wicklow Kildare / West 2.0% 1.9% 1.6% 2.0% 1.9% 2.3%Laois / Offaly 1.6% 3.0% 152 2.3% 976 1.5% 848Limerick 2,309 1,566 174 877 1,340 1,131 Longford / Westmeath 3,460 4,210 1,304 188 0.3% 1.6% 2,616 1.3%Louth 1,010 2,010 1.9% 0.3% 1.6% 1.6% 1.9% 1.8%Mayo 1.7% 2.1% 0.3% 3.2% 1,061 1,283 1,676 506Meath 951 1.5% 2.0% 1.9% 1,394 210 1,683 2,720North Cork 2,210 553 2,769 381 323 1,371 2.0% 601 2.0%North Lee - Cork 1.6% 1.3% 1,803 340 1.7% 985 1.4% 0.3% / North Tipperary 1.6% 2.0% 1.8% 2.2% 1.7% 0.3% 0.5%East Limerick 1,096 2.0% 1,926 966 1.9% 1.7% 0.3% 194 557 2.0% 2,961Roscommon 152 265 1,494 484 154 182 Cavan 1,365Sligo / Leitrim West 595 1,083 1,285 1.8% 1,355 989 1.9% 1.6% 3,813 815 0.2% 684 5.8% 1,995South Lee - Cork 663 1.5% 0.2% 0.3% 963 0.3% 2.6%South Tipperary 1.7% 0.3% 5.8% 2,378 1.9% 1.8% 2,027 2.7% 1.7% 1.8% 1.7% 268 6.5% 2.2%Waterford 905 2.0% 418 354 1.6% 730 1,355 Cork West 2.3% 395 2,655 779 1,269 640 661 1,240 1.9% 512 1,206 1,042 685 2.0% 1,211 814 0.3% 1,400 359Wexford 10.2% 753 2.0% 189 948 0.3% 1.3% 679 2.4%Wicklow 1,026 1.7% 5.8% 860 10.2% 9.1% 1.9% 1.4% 927 2.3% 1.9% 1.5% 207 5.8% 1.4% 167Republic of Ireland 1.7% 0.3% 1.5% 11.4% 2.3% 2.1% 572 0.3% 808 5.8% 2,849 414 921 1.9% 2,634 2.1% 1,131 2,561 210 1,564 0.3% 443 2.2% 777 581 1,048 1,214 0.3% 976 638 1,265 788 1,567 625 982 1.9% 1.8% 38,634 4.8% 531 2.5% 15.6% 1,823 1.6% 1.8% 10.3% 972 935 10.2% 2.0% 0.3% 4.7% 1.6% 6.5% 2.2% 1.5% 824 4.7% 2.2% 632 5.8% 2.1% 536 1,713 2.5% 1.7% 490 2.0% 10.2% 191 1.9% 2.2% 1,050 1.8% 650 823 249 1,243 2,425 284 2.1% 2,666 672 693 899 1.7% 1,114 35,859 110 1,081 906 2.0% 1.7% 6.5% 544 0.3% 8.4% 583 1,998 1.9% 5.8% 0.3% 121 11.5% 0.3% 2.3% 10.2% 1,750 1.5% 8.4% 2.2% 1.7% 8.5% 1.8% 5.8% 0.3% 673 135 573 2.3% 2,182 6.5% 597 1.8% 0.3% 702 724 2.2% 212 863 74,493 213 82 737 800 5.8% 1,391 0.3% 5.8% 1,169 11.4% 381 2.0% 10.2% 178 1.9% 692 446 0.2% 121 1.9% 10.2% 1.7% 0.3% 0.3% 5.8% 1.6% 2.4% 866 1.7% 432 11.3% 751 172 0.3% 6,606 820 0.3% 1.7% 757 608 10.3% 692 739 293 10.2% 973 68 440 1.7% 0.3% 6.5% 0.3% 557 5.8% 527 10.2% 432 5.8% 1.3% 1.9% 1.7% 0.3% 5.8% 500 19,339 551 1,136 1.6% 5.8% 1.7% 717 904 812 357 802 5.8% 11.4% 268 635 1.7% 1.7% 10.2% 618 10.2% 4.7% 730 492 6.5% 5.8% 10.2% 21,284 1.7% 645 643 5.8% 10.2% 5.8% 5.9% 887 948 10.2% 511 342 5.8% 646 11.4% 10.2% 8.4% 27,264 705 5.8% 10.1% 10.4% 816 10.3% 10.2% 491 10.2% Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Num

61 ber Prevalence oke (2020). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 5.3: Demographic and geographic variation in the percentage of adults in the Republic of Ireland who have ever had a str of adults in the Republic Ireland 5.3: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 1,201Donegal 1329Dublin North 2.3% 1,507Dublin North Central Dublin North West 2.2% 1,041 2.6%Dublin South City 1,348Dublin South East 1,154 2.1% 1,277 2,119 2,613Dublin South West 1,548Dublin West 2.1% 2.1% 2,242 2.3% 1.9%Dun Laoghaire South Dublin 3.7% 979 1.7%Galway 960 2,484 1,350 1,635 1,292 2.2% 2,784 1,908Kerry 1,724 2,224 1.4% 1,492 WicklowKildare / West 2.0% 1.7% 2.1% 2.2% 157 2.0% 1,149 2.5%Laois / Offaly 1.7% 3.2% 2.6% 1.6% 969Limerick 2,698 1,004 1,946 177 1,532 1,298 0.3%Longford / Westmeath 4,028 4,837 1,485 192 1.7% 3,040 1.4%Louth 1,168 2,329 1.6% 2.0% 0.3% 2.0% 1.8% 1.8%Mayo 1,085 1.8% 2.3% 0.3% 3.5% 545 1,258 1,521 1,948Meath 1.6% 2.2% 2.1% 1,964 226 1,698 3,167North Cork 2,590 1.6% 3,208 616 417 332 1,599 2.2% 1.7% 657 2.2%North Lee - Cork 1.4% 1,111 2,053 366 1.7% 0.3% / 1.6%North Tipperary 2.1% 1.9% 2,234 2.4% 0.3% 1.7% 0.5% 1,109East Limerick 1,256 2.2% 654 2.1% 1.9% 1.8% 0.3% 207Roscommon 164 3,644 287 1,741 551 1.7% 170 1,127 186 Cavan 1,588Sligo / Leitrim West 2.1% 1,183 1,459 2.0% 692 1,691 5.8% 2,279 4,382 957 0.2% 799South Lee - Cork 0.3% 756 1,126 1.7% 0.3% 0.3% 2.8% 291South Tipperary 1.7% 2,366 0.3% 2,777 2.1% 5.8% 2.0% 1.7% 2.7% 1,058 1.9% 2.2% 1.9% 6.5% 2.4%Waterford 885 477 1.6% 2.5% 370 450 1,548 Cork West 0.4% 1,224 3,058 887 1,437 2.2% 751 772 1,448 2.1% 584 1,474 756 10.2% 2.2% 1,414 193 1,648 378 999Wexford 1,135 856 1.3% 0.3% 797 2.5% 973Wicklow 1,287 1.4% 1,098 5.8% 1.9% 5.8% 9.1% 2.1% 168 10.3% 2.5% 1.9% 653 1.7% 208 11.5% 1.4%Republic of Ireland 1.7% 0.3% 0.3% 1.7% 917 2.6% 2.3% 1,095 5.8% 3,289 486 2.2% 2.1% 3,026 521 2.4% 1,333 1,260 0.3% 3,166 1,170 215 1,873 0.3% 912 665 1.8% 1,377 749 2.1% 1,449 1,074 921 1,813 581 739 45,678 4.8% 2,099 2.7% 10.3% 1,194 1,122 10.3% 1.6% 15.7% 4.8% 1.9% 2.3% 946 0.3% 1.8% 6.5% 2.3% 1.6% 1,975 4.7% 600 2.4% 575 708 5.8% 2.3% 1.7% 10.3% 2.8% 1.9% 1,019 2.2% 2.4% 1.9% 204 1,204 778 252 2.3% 1,437 2,791 297 829 1,081 3,097 6.5% 724 2.1% 1,286 1,087 1.7% 1.7% 1,346 41,168 112 5.8% 681 621 2,480 0.4% 124 8.4% 2.1% 11.5% 2,044 0.3% 8.4% 0.3% 2.4% 10.2% 1.6% 8.5% 2.5% 5.8% 139 1.7% 692 2.0% 0.3% 813 715 6.5% 2.5% 2.0% 1,159 0.3% 2,537 768 2.4% 799 215 11.4% 86,845 218 0.3% 88 876 1,645 5.8% 939 5.8% 10.2% 1,359 420 187 2.2% 825 487 124 10.3% 1.9% 0.2% 2.1% 1.7% 0.4% 0.3% 5.8% 1.6% 466 1,048 2.6% 11.4% 906 0.3% 1.7% 175 0.3% 1.7% 6,907 976 10.3% 885 10.2% 670 1,180 771 915 320 1.7% 70 515 0.3% 662 6.5% 0.3% 615 10.2% 481 5.8% 5.8% 1.3% 1.9% 1.7% 587 0.3% 5.8% 21,655 1.6% 614 5.8% 1,342 1.7% 1,090 1,077 839 5.8% 945 424 11.4% 296 766 1.7% 10.2% 766 1.7% 10.2% 873 573 4.7% 6.5% 5.8% 10.2% 25,148 783 5.8% 1.7% 10.3% 748 5.8% 1,067 10.2% 1,164 5.9% 605 400 5.8% 866 11.5% 8.4% 10.3% 866 33,135 10.2% 5.8% 1,000 10.3% 10.4% 10.3% 593 10.3% Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Num

62 ce Number Prevalence ce Number 07). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 5.4: Demographic and geographic variation in the percentage of adults in Northern Ireland who have ever had a stroke (20 of adults in Northern who have ever had a stroke 5.4: Demographic and geographic variation in the percentage Ireland Table Local Government DistrictAntrim NumberArds PrevalenceArmagh Number Ballymena Prevalence Ballymoney NumberBanbridge Prevalence 376Belfast Number Carrickfergus 678 446 Prevalence 1.9%Castlereagh 541 Number 241Coleraine 2.3% 2.1% Prevalence Cookstown 376 353 2.3%Craigavon 2.1% Number 3,211 704 329 Prevalen 463 1.8%Derry 2.0% 572 600Down 248 2.2% 3.2% 2.2% 2.0%Dungannon 752 2.3% 363 501 2.4%Fermanagh 2.1% 290 1,382 3,933 349 909 1,113Larne 1.9% 741 2.0% 2.3% 670Limavady 3.4% 2.1% 2.2% 489 2.1% 1,116 2.1% 2.3%Lisburn 2.2% 716 68 537 2.4% 392 7,144Magherafelt 544 2.1% 292 90 677 2.8% 522Moyle 67 74 0.3% 787 2.0% 2.3% 1,269 3.3% 1.9%Newry & Mourne 2.1% 2.0% 0.3% 37 1,179 2.1% 2.2%Newtownabbey 0.3% 280 0.3% 1,037 2.2% 272 209 2.4% 59 525North Down 405 560 581 0.3% 2.8% 372 841 310Omagh 1,528 49 515 2.3% 2.3% 2.0% 237 270 0.3% 1.8% 0.5% 1.9% 78 753Strabane 2.1% 2.1% 2,295 121 2.0% 1.8% 1.9% 0.3% 2.1%Northern Ireland 2.2% 170 693 287 263 65 1.8% 1.8% 1,600 213 0.3% 186 1,104 2.1% 798 2.8% 49 1,036 1.7% 380 901 726 301 126 2.6% 2.2% 172 2.2% 2.0% 0.3% 256 311 5.9% 2.8% 2.1% 1.7% 15,827 1.9% 772 277 224 0.3% 422 5.9% 2.0% 2.1% 1.8% 135 2.4% 0.3% 172 568 480 745 1.7% 6.0% 535 5.9% 1,900 249 2.1% 195 262 2.4% 0.5% 83 1.7% 68 1,743 5.9% 2.2% 153 611 823 73 2.5% 540 2.2% 396 2.3% 3.2% 189 9.3% 2.0% 10.3% 17,114 1,525 1.8% 349 5.9% 458 0.3% 0.3% 338 2.0% 668 10.3% 427 2.5% 2.0% 0.3% 1.8% 1,438 196 10.3% 342 5.9% 10.3% 2.0% 2.4% 471 3,118 37 52 2.1% 303 5.9% 276 285 137 10.3% 202 2.8% 1,549 2.1% 15.6% 155 2.2% 32,941 2.6% 267 55 3.1% 426 0.3% 0.3% 5.9% 267 10.3% 132 0.3% 1.7% 576 2.4% 637 1.7% 6.7% 850 2.4% 10.3% 0.3% 6.7% 98 1.8% 21 950 0.3% 148 152 10.3% 421 9.4% 299 2,508 461 217 2.1% 88 0.3% 224 276 0.3% 159 3.1% 10.3% 580 1.8% 406 2.0% 5.9% 0.3% 5.9% 11.5% 0.3% 1.7% 766 11.5% 72 6.0% 350 1.7% 81 165 86 144 1.9% 15.7% 8,284 437 480 0.3% 311 382 164 1.7% 0.5% 421 5.9% 6.7% 2.0% 426 10.3% 10.3% 2.0% 5.9% 10.4% 1.8% 230 5.9% 396 250 6.7% 218 9,001 98 187 665 396 2.0% 5.9% 10.3% 11.6% 233 2.9% 6.8% 6.7% 561 10.3% 5.9% 10.4% 227 11.5% 594 13,148 274 136 10.3% 11.8% 6.7% 683 9.4% 11.5% 10.2% 320 346 11.5% 15.8%

63 ce Number Prevalence ce Number 15). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Local Government District Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalen Table 5.5: Demographic and geographic variation in the percentage of adults in Northern Ireland who have ever had a stroke (20 of adults in Northern who have ever had a stroke 5.5: Demographic and geographic variation in the percentage Ireland Table AntrimArdsArmaghBallymenaBallymoneyBanbridge 481BelfastCarrickfergus 868 563 2.1%Castlereagh 656 318Coleraine 2.7% 2.3%Cookstown 465 451 2.5%Craigavon 2.4% 3,405 844 439 550 2.0%Derry 2.2% 680 653Down 300 2.4% 3.4% 2.7% 2.2%Dungannon 947 2.5% 455 611 2.6%Fermanagh 2.3% 366 1,711 3,855 1,113 420 1,336Larne 2.0% 922 2.2% 2.8% 712Limavady 3.5% 2.4% 2.6% 617 2.2% 2.4% 1,412 2.5%Lisburn 2.4% 906 71 601 2.6% 502 7,260Magherafelt 678 2.3% 345 85 860 71 3.3% 649Moyle 70 0.3% 933 2.2% 2.6% 1,365 3.5% 1.9%Newry & Mourne 2.3% 2.3% 0.3% 38 1,410 0.3% 2.5% 2.4%Newtownabbey 344 0.3% 1,212 2.3% 345 228 2.6% 61 500North Down 474 663 711 1,061 0.3% 3.1% 392 377Omagh 262 1,855 43 594 2.7% 2.7% 2.4% 293 0.3% 1.7% 0.5% 1.9% 64 958Strabane 2.2% 2.3% 2,822 2.3% 145 1.7% 2.0% 0.3% 2.3%Northern Ireland 2.3% 205 1.8% 799 324 328 54 1.7% 1,643 286 0.3% 232 1,341 2.3% 976 1,085 3.2% 53 1,244 1.7% 564 870 358 137 2.9% 2.5% 329 210 2.5% 2.4% 0.3% 378 5.9% 2.8% 2.3% 19,057 2.2% 1.7% 1.9% 923 309 213 0.3% 535 5.9% 2.4% 2.0% 179 2.8% 0.3% 6.0% 189 668 589 848 1.7% 674 5.9% 1,894 263 2,146 2.2% 2.6% 261 361 0.5% 82 1.7% 86 5.9% 2.4% 172 735 920 76 2.6% 670 2.5% 451 2.6% 3.7% 245 9.3% 2.4% 19,348 451 10.4% 2.2% 1,881 1.8% 5.9% 595 0.3% 0.3% 360 776 10.4% 510 10.4% 2.7% 2.0% 0.3% 2.0% 1,646 255 394 5.9% 2.6% 10.4% 1.9% 562 3,224 31 49 2.3% 133 353 5.9% 352 326 10.4% 242 2.8% 1,790 2.3% 38,405 15.7% 203 2.5% 2.8% 302 60 3.5% 529 0.3% 0.3% 0.3% 6.0% 361 10.3% 144 1,045 1.7% 633 2.7% 817 1.7% 6.7% 2.6% 10.4% 0.3% 1,151 6.7% 85 1.8% 21 0.3% 157 176 521 10.3% 542 2.4% 9.4% 2,456 390 268 80 3.6% 0.3% 283 354 0.3% 190 10.4% 737 1.7% 483 2.0% 1.7% 0.3% 5.9% 6.0% 1,016 11.6% 75 0.3% 11.6% 6.0% 75 372 1.7% 207 93 15.9% 199 1.9% 624 9,165 0.3% 543 380 374 0.5% 202 1.7% 511 6.0% 6.7% 5.9% 2.0% 516 10.4% 10.4% 2.0% 273 10.5% 1.8% 5.9% 280 468 10,911 6.7% 114 273 250 868 2.0% 539 5.9% 10.4% 2.8% 6.8% 11.6% 10.3% 284 6.7% 738 293 5.9% 10.4% 15,873 338 11.6% 722 167 11.8% 6.7% 10.3% 797 9.4% 11.7% 10.3% 403 458 11.6% 15.9%

64 ce Number Prevalence ce Number 20). Males (16+ years) Females (16+ years) Persons (16+ years) 16-44 years 45-64 years 65-74 years 75+ years Table 5.6: Demographic and geographic variation in the percentage of adults in Northern Ireland who have ever had a stroke (20 of adults in Northern who have ever had a stroke 5.6: Demographic and geographic variation in the percentage Ireland Table Local Government DistrictAntrim NumberArds PrevalenceArmagh Number Ballymena Prevalence Ballymoney NumberBanbridge Prevalence 556Belfast Number 1,004Carrickfergus 647 Prevalence 2.3%Castlereagh 731 Number 371 3.0%Coleraine 2.5% Prevalence Cookstown 534 531 2.7%Craigavon 2.6% Number 951 3,558 522 Prevalen 614 2.1%Derry 2.4% 753 690 2.6%Down 340 3.7% 3.1% 2.3% 1,090Dungannon 2.7% 524 680 1,955 2.8%Fermanagh 2.4% 422 3,863 1,261 474 2.2% 1,056 1,485Larne 2.3% 3.2% 2.8% 740Limavady 3.6% 2.6% 711 2.4% 2.6% 1,611 2.5% 2.7%Lisburn 1,055 76 644 2.8% 587 7,421Magherafelt 83 776 2.5% 387 1,039 996 74 3.7% 0.3% 741Moyle 2.4% 71 2.9% 1,430 3.6% 2.0%Newry & Mourne 0.3% 2.4% 2.6% 2.4% 38 1,593 0.3% 2.8% 2.7%Newtownabbey 386 0.3% 1,324 250 401 63 2.8% 492North Down 532 744 2,095 809 418 1,212 0.3% 3.4% 434Omagh 281 40 660 3.1% 0.3% 3.0% 2.7% 1.7% 309 1,104 0.5% 2.0% 59Strabane 2.4% 2.5% 2.5% 3,204 2.6% 1.8% 167 2.1% 0.3% 2.4%Northern Ireland 231 1.8% 867 350 296 379 48 260 1.8% 2.5% 1,118 1,666 0.3% 1,520 1,215 3.6% 149 588 56 1,401 1.8% 970 401 3.3% 2.6% 353 231 2.7% 6.0% 2.7% 0.3% 1,032 1.8% 401 2.0% 2.9% 2.5% 21,372 2.3% 319 0.3% 209 5.9% 0.3% 619 2.5% 2.1% 190 3.1% 6.0% 207 2.3% 735 666 913 1.8% 780 5.9% 1,883 292 268 468 2,427 2.9% 97 0.5% 85 1.8% 500 1,001 5.9% 2.6% 187 866 834 77 2,136 2.8% 10.4% 2.7% 2.8% 4.2% 276 9.3% 2.7% 21,086 552 5.9% 2.4% 1.8% 0.3% 703 0.3% 10.4% 368 845 3.0% 2.0% 577 10.4% 2.0% 0.3% 2.1% 2.4% 1,780 316 438 6.0% 2.7% 10.4% 621 3,379 30 45 137 365 440 5.9% 279 1,971 350 10.5% 2.9% 559 2.5% 42,457 15.8% 218 2.7% 156 3.0% 322 60 3.7% 10.4% 0.3% 0.3% 0.3% 6.0% 449 3.0% 1.7% 1,196 6.7% 1.8% 683 916 6.7% 2.8% 0.3% 10.4% 0.3% 1,287 79 1.8% 21 167 191 562 10.3% 643 297 2.6% 9.4% 2,469 433 77 887 4.0% 0.3% 347 531 405 0.3% 213 10.4% 1.8% 2.0% 1.8% 6.0% 11.6% 0.3% 5.9% 0.3% 1,233 11.7% 78 6.0% 2.0% 70 385 1.7% 212 95 15.9% 226 665 9,767 0.3% 446 376 652 0.5% 583 229 1.8% 598 6.0% 6.7% 5.9% 10.4% 2.0% 10.4% 2.1% 1.8% 290 10.5% 6.7% 6.0% 305 482 11,613 1,063 127 327 317 547 2.0% 10.4% 5.9% 10.5% 866 2.8% 6.7% 11.6% 333 6.7% 5.9% 11.6% 341 10.4% 18,609 360 834 195 11.7% 6.7% 971 10.4% 9.4% 11.7% 10.4% 487 552 11.6% 15.9%

65 6 Diabetes

66 Making Chronic Conditions Count

CHAPTER 6. DIABETES

This chapter relates to adults (aged 20 years and over) with diabetes (Type 1 and Type 2 combined).

Detailed estimates and forecasts of diabetes prevalence, broken down by sex and age within each area, are given at the end of the chapter.

KEY POINTS: DIABETES (TYPE 1 AND TYPE 2 COMBINED)

In 2007, nearly 144,000 adults in the Republic of Ireland (4.5%) have diabetes. By 2020 this is expected to rise to over 233,000 (5.9%). This represents a 62% increase – an additional 89,000 adults – in less than 15 years.

In 2007, over 67,000 adults in Northern Ireland (5.3%) have diabetes. By 2020 this is expected to rise to over 94,000 (6.6%). This represents a 40% increase – an additional 27,000 adults – in less than 15 years.

Diabetes is more common amongst females than males. This reflects the findings of the underlying population-based reference studies.

Diabetes prevalence increases with age. About one in eight people aged 60 years and over have diabetes. In 2020 relatively more of the adults with diabetes will belong in the older age groups.

High diabetes prevalence rates occur across the island. Quite noticeably, prevalence rates are, once again, lowest around Dublin.

Local socio-economic circumstances affect diabetes prevalence. Amongst males and females, and across all age groups, diabetes tends to be more common in more deprived areas.

Diabetes prevalence is higher in Northern Ireland than in the Republic of Ireland. North-South differences in the current and future diabetes prevalence are chiefly due to differences in current and projected future demographic and socio-economic profiles and obesity rates.

National Estimates in 2007

In 2007, 4.5% of adults in the Republic of Ireland (143,618 people) and 5.3% of adults in Northern Ireland (67,262 people) have diabetes (Type 1 and Type 2 combined)20. The comparison of the estimated diabetes prevalence rate (4.5%) in the Republic of Ireland with estimates from other survey studies is mixed:

• In the SLÁN 2007 survey (Morgan et al, 2008) 3% of adults aged 18 years and over report having had a doctor-diagnosis of diabetes in the previous 12 months.

20 In an earlier report, IPH estimated that the diabetes prevalence (Type 1 and Type 2 combined) in 2005 was 5.4% in Northern Ireland and 4.7% in the Republic of Ireland (IPH, 2006).

67 Chapter 6 Diabetes

• In the CSO’s Quarterly National Household Survey 2007 (CSO, 2008) 2% of adults aged 18 years and over report ever having had a doctor-diagnosis of diabetes. • The International Diabetes Federation estimate that 5.7% of adults aged 20-79 years will have diabetes in 2010 (International Diabetes Federation, 2009).

Direct comparisons with these studies, however, are confounded by important differences in methodology.

The estimated diabetes prevalence rate (5.3%) in Northern Ireland is higher than estimates from other studies:

• It is higher (5.3% compared to 3.5%) than the Quality and Outcomes Framework (QOF) estimate that is based on primary care data (DHSSPS, 2007). However, this is not unexpected because QOF data for diabetes covers persons aged 17 years and over while this report covers adults aged 20 years and over. • The Health and Social Wellbeing Survey 2005-2006 found that 4% of adults aged 16 years and over have ever been told by a doctor that they have diabetes (DHSSPS, 2007).

Again, direct comparisons are confounded by important differences in methodology.

The diabetes prevalence rate amongst adults aged 16 years and over in England in 2006 is estimated to be 4.9% (HSfE, 2006). The percentage of adults with diabetes is lower in the Republic of Ireland than it is in either Northern Ireland or England. This is chiefly due to differences in these countries’ demographic and socio-economic profiles, and obesity rates. In particular, both Northern Ireland and England have an older population than the Republic of Ireland.

Demographic Variation in 2007

The study found that more females than males have diabetes. This is true in both the Republic of Ireland (male 3.9%, female 5.1%) and Northern Ireland (male 4.5%, female 6.0%) in terms of numbers and prevalence rates. This reflects the findings of the underlying population-based reference studies (Simmons et al, 1991; Chaturvidi et al, 1993; Harvey et al, 2002). Caution is required when interpreting this finding; some studies have found higher prevalence amongst males. A recent study summarising data from 191 WHO member states found that while more females than males have diabetes, prevalence rates are higher amongst males aged less than 60 years but are higher amongst women in older age groups (Wild et al, 2004)21.

Diabetes is more common in older age groups. Over one out of every eight adults aged 60 years and over in Northern Ireland (13.4%) and the Republic of Ireland (13.2%) have diabetes.

Ethnicity does not contribute greatly to North-South differences because neither jurisdiction has a large ‘non-white’ ethnic population.

21 Wild et al suggested that this might be the combined effect of: • Greater numbers of older women than older men in most countries • Prevalence rates that are higher amongst males aged under 60 years but higher amongst women in older ages • Prevalence rates that increase with age.

68 Making Chronic Conditions Count

Geographic Variation in 2007

Figure 6.1: Percentage of adults who have diabetes; across Local Health Offices (LHOs) in the Republic of Ireland and Local Government Districts (LGDs) in Northern Ireland (2007).

6.0 - 6.4

5.6 - 6.0

5.2 - 5.6

4.8 - 5.2

4.4 - 4.8

4.0 - 4.4

3.6 - 4.0

3.2 - 3.6

In addition to the higher diabetes prevalence rate in Northern Ireland, many of the areas with higher diabetes prevalence rates are in northern, north-western and south-western parts of the island. Diabetes prevalence rates are lowest in parts of Dublin and its surrounds.

69 Chapter 6 Diabetes

Socio-economic Variation in 2007

Local socio-economic circumstances in an area affect diabetes prevalence although, like hypertension, the effect does not seem to be as strong as it is for CHD and stroke.

Figure 6.2: Percentage of adults who have diabetes; across deprivation bands22 in the Republic of Ireland within each sex and each age group (2007). 16

14

12

10

% 8

6

4

2

0 Persons Male Female 20-29 years 30-59 years 60+ years Band 1 (least deprived) Band 2 Band 3 Band 4 Band 5 (most deprived)

Figure 6.3: Percentage of adults who have diabetes; across deprivation bands22 in Northern Ireland within each sex and each age group (2007).

16

14

12

10

% 8

6

4

2

0 Persons Male Female 20-29 years 30-59 years 60+ years

Band 1 (least deprived) Band 2 Band 3 Band 4 (most deprived)

22 See this report’s technical supplement for definitions of the deprivation bands.

70 Making Chronic Conditions Count

The effects of local socio-economic circumstances are observed in both jurisdictions but are more apparent in the Republic of Ireland23. In the Republic of Ireland diabetes prevalence in the most deprived LHOs is 1.4 times what it is in the least deprived LHOs. In Northern Ireland diabetes prevalence in the most deprived LGDs is almost 1.1 times what it is in the least deprived LGDs.

Within each age group, diabetes prevalence rates increase as you move from the least deprived areas to the most deprived areas. Like hypertension, local socio-economic circumstances do not appear to have an effect amongst either males or females in Northern Ireland.

How Diabetes Prevalence Will Change Between 2007 and 2020

The percentage of adults with diabetes is expected to increase over time:

• In Northern Ireland, it is expected to increase from 5.3% in 2007 to 6.0% in 2015 to 6.6% in 2020. • In the Republic of Ireland, it is expected to increase from 4.5% in 2007 to 5.2% in 2015 to 5.9% in 2020.

With a growing and ageing population, far more adults will have diabetes in 2020 than in 2007. The number of adults in Northern Ireland with diabetes is expected to rise from 67,262 in 2007 to 94,219 in 2020; an increase of an additional 26,957 adults (or 40.1%). The number of adults in the Republic of Ireland with diabetes is expected to rise from 143,618 in 2007 to 232,644 in 2020; an increase of 89,026 adults (or 62.0%). A proportionally larger increase is expected in the Republic of Ireland because its population is projected to increase more than Northern Ireland’s.

23 Direct North-South comparison is confounded by the fact there are five deprivation bands in the Republic of Ireland but only four deprivation bands in Northern Ireland. See this report’s technical supplement for details.

71 Chapter 6 Diabetes

Figure 6.4: Expected changes in the percentage of adults in the Republic of Ireland, Northern Ireland and England with diabetes; within each sex group and age group (2007, 2015, 2020). 18

16

14

12

10 % 8

6

4

2

0 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 2007 2015 2020 Persons Male Female 20-29 years 30-59 years 60+ years

Republic of Ireland Northern Ireland England

Amongst males and females, and in each age group, similar changes in diabetes prevalence rates are expected in each country (the Republic of Ireland, Northern Ireland and England).

An ageing population profile along with higher diabetes prevalence rates amongst older age groups, mean that a growing percentage of adults with diabetes will belong to the older age groups. Between 2007 and 2020, the percentage of people living with diabetes who are aged 60 years and over will rise in the Republic of Ireland from 60.8% to 64.8%. In Northern Ireland the percentage will rise from 66.3% to 70.6%.

72 ype 2 diabetes (2007). Males (20+ years) Females (20+ years) Persons (20+ years) 20-29 years 30-59 years 60+ years Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Table 6.1: Demographic and geographic variation in the percentage of adults in the Republic of Ireland living with Type 1 and T living with Type of adults in the Republic Ireland 6.1: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 1,700DonegalDublin North 4.2%Dublin North Central 1,881 Dublin North West 2,017 2,114Dublin South City 4.2%Dublin South East 4.5%Dublin South West 5.3% 1,762Dublin West 2,390 2,980 2,610Dun Laoghaire South Dublin 2,537 2,201 3.6% 3,814Galway 1,585 3.7% 5.0% 5.4%Kerry 2,415 1,332 3.1% 6.0% Wicklow Kildare / West 1,764 2,157 2,672 3.0% 4.8%Laois / Offaly 4,270 3,878 4.6% 3,311 3.2%Limerick 4,555 3,066 3.9% 4.0% 1,576 Longford / Westmeath 5.3% 2,235 85 4.6% 3,127Louth 1,680 6.2% 2,409 4.8% 2,031 4.2% 5.2%Mayo 3.3% 2,687 3,008 4,435 3,357Meath 4.1% 0.6% 6,857 4.2% 5,921 3.2% 6.1% 108 4.4%North Cork 5,266 1,768 2,156 103 2,075 5.2% 5.2%North Lee - Cork 3.9% 3,819 4.5% 1,403 / East Limerick 2,240 5,542North Tipperary 2,872 3,362 4.1% 0.6% 5.6% 2,310 4.2% 4.2%Roscommon 4,450 3.7% 0.6% 4.2% 5,165 4,291 Cavan Sligo / Leitrim West 177 1,477 3.5% 5.4% 3.0% 3.9% 222 4.1% 121 5.4% 1,558South Lee - Cork 3.8% 2,296 2,675 249 3,651 1,582South Tipperary 4.6% 2,271 4.6% 5.0% 2,326 0.6% 4.1% 1,333 207 2,054 2,326 1,590 3,920Waterford 5,281 3,028 0.6% 113 0.6% 3.1% 131 5.5% 5.4% Cork West 0.6% 3.3% 110 5.0% 3.7% 174 7,648 3.8% 2,172Wexford 4.3% 1,365 1,866 12.9% 3.4% 4.7% 0.6% 1,085 4.8% 2,605 2,612 5.3%Wicklow 1,540 0.6% 3.5% 2,002 4,064 0.5% 4,831 2,268 2,869 2,030Republic of Ireland 153 2,978 0.5% 0.6% 4.5% 3,005 4.4% 1,762 1,516 2,488 5.2% 2,056 2.9% 4.8% 1,420 13.5% 3.9% 5,338 105 199 1,864 2.8% 3.4% 3.5% 1,129 14.3% 4.9% 4.8% 2.7% 0.6% 1,455 6.5% 1,937 2,782 243 4.8% 1,864 2,893 4.6% 3,343 5.9% 4.2% 6.0% 1,389 2.7% 4,023 2,007 0.6% 3,797 0.5% 3.3% 976 4.7% 3,164 61,987 2.5% 102 2,987 125 5,249 1,589 2.8% 4.2% 5,331 5.7% 3.2% 14.0% 0.6% 3,095 1,934 4,542 3,647 2,192 6.4% 4.6% 12.5% 14.8% 4.8% 3,565 1,437 4.9% 2,380 150 2,102 3.9% 4.5% 13.5% 0.6% 0.6% 2,886 3,054 2.8% 4,954 5.7% 2,454 2,742 5.9% 12.7% 4.3% 2,474 5.1% 3.8% 5.3% 3,546 13.7% 90 81,631 11.3% 1,264 3.1% 5,432 0.6% 2.7% 1,462 1,780 11.5% 14.1% 1,909 5.5% 3,450 92 5.1% 167 2.9% 151 5.6% 69 2,377 0.5% 74 2,703 5.1% 6.5% 4.3% 1,877 4.0% 3.1% 13.5% 3.1% 4,318 4,663 112 0.6% 0.6% 143,618 5.3% 0.6% 14.2% 0.6% 12.0% 1,192 44 0.6% 2,240 99 3.1% 2,500 189 2,927 13.2% 0.6% 1,714 4.9% 2,017 1,921 72 4.5% 1,060 1,233 0.6% 3.0% 3,312 13.7% 5.7% 0.6% 13.8% 0.5% 109 1,750 4,186 3.4% 2.9% 0.6% 2,061 2.7% 13.3% 3.1% 3.3% 794 1,385 35 1,971 3,443 3,147 0.6% 3.2% 0.6% 2,469 12.9% 1,966 1,194 2,340 3.3% 2.9% 0.6% 2.7% 14.2% 13.0% 3,093 52,054 1,506 12.3% 13.7% 13.6% 3.2% 1,636 2,062 3,273 715 13.9% 3.0% 3.1% 2,185 13.7% 12.6% 11.9% 87,378 3.3% 2,703 13.7% 1,489 13.2% 13.4% 13.5%

73 ype 2 diabetes (2015). Males (20+ years) Females (20+ years) Persons (20+ years) 20-29 years 30-59 years 60+ years Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Table 6.2: Demographic and geographic variation in the percentage of adults in the Republic of Ireland living with Type 1 and T living with Type of adults in the Republic Ireland 6.2: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 2,309DonegalDublin North 4.9%Dublin North Central 2,599 Dublin North West 2,736 2,729Dublin South City 4.9%Dublin South East 5.3%Dublin South West 6.1% 2,475Dublin West 3,116 4,171 3,553Dun Laoghaire South Dublin 3,243 3,066 4.4% 5,038Galway 2,200 4.3% 5.8% 6.2%Kerry 3,348 1,865 3.7% 6.7% Wicklow Kildare / West 2,486 3,019 3,463 3.6% 5.5%Laois / Offaly 5,715 5,035 5.6% 4,247 3.8%Limerick 5,979 3,956 4.5% 4.7% 2,191 Longford / Westmeath 6.0% 2,879 79 5.1% 4,040Louth 2,267 7.0% 3,681 5.6% 2,636 4.8% 6.0%Mayo 3.9% 3,498 3,894 5,938 4,541Meath 4.7% 0.6% 9,206 4.9% 7,800 4.0% 6.9% 100 4.9%North Cork 7,022 2,503 3,047 105 2,679 5.7% 5.8%North Lee - Cork 4.6% 5,078 5.2% 1,715 / East Limerick 2,868 7,388North Tipperary 4,157 4,501 4.7% 0.6% 6.4% 3,134 5.0% 5.0%Roscommon 5,984 4.3% 0.6% 4.7% 6,912 5,481 Cavan Sligo / Leitrim West 157 2,004 4.1% 6.1% 3.2% 4.6% 197 4.9% 124 6.3% 1,984South Lee - Cork 4.4% 3,001 3,499 221 4,871 1,976South Tipperary 5.2% 3,091 5.3% 5.4% 3,180 0.6% 4.8% 1,841 184 3,157 3,244 2,162 5,135Waterford 7,839 3,913 0.6% 0.6% 3.3% 98 116 6.3% 6.2% Cork West 0.6% 3.5% 10,022 5.7% 4.3% 155 97 4.6% 3,007Wexford 5.2% 1,800 2,409 13.9% 4.2% 5.4% 0.6% 1,477 5.5% 3,631 3,441 6.3%Wicklow 2,386 4.3% 2,501 5,504 0.6% 0.6% 6,546 3,096 3,897 2,680Republic of Ireland 136 3,807 0.6% 5.0% 5.3% 0.6% 3,861 2,272 2,105 3,619 6.1% 2,631 3.0% 5.5% 1,872 14.5% 4.7% 7,047 108 184 2.9% 3.6% 4.2% 2,353 1,485 15.3% 5.6% 5.6% 2.7% 0.6% 7.0% 238 2,543 3,637 1,910 5.5% 2,578 3,981 5.4% 4,413 6.7% 4.9% 6.7% 1,774 2.7% 1,359 5,568 2,936 0.6% 5,175 0.6% 5.5% 4,057 86,511 3.5% 2.6% 4,120 112 92 6,898 2,097 0.6% 5.0% 7,041 6.6% 3.3% 15.0% 2.9% 4,114 2,530 6,777 4,792 3,022 6.9% 5.4% 5.9% 13.4% 15.9% 5.6% 1,794 3,364 139 4,937 2,900 4.7% 5.3% 14.5% 0.6% 0.6% 4,214 3,978 2.9% 6,643 3,485 6.4% 3,205 6.8% 13.6% 5.0% 3,251 5.9% 4.6% 6.1% 1,635 5,322 106,729 83 14.7% 12.1% 3.3% 7,153 0.6% 2.9% 2,332 1,916 15.1% 2,638 12.3% 6.3% 3.0% 4,635 90 5.9% 145 141 6.2% 7.3% 60 5.8% 3,234 0.6% 75 4,291 5.2% 2,295 4.8% 14.6% 3.3% 3.3% 6,299 5,783 104 193,240 0.6% 0.6% 6.1% 2,994 0.6% 15.2% 0.6% 12.9% 1,458 43 0.6% 92 3.3% 163 4,102 3,496 14.1% 0.6% 2,174 5.7% 2,541 5.2% 2,717 66 1,338 6.6% 1,540 0.6% 3.2% 4,613 0.6% 14.8% 14.7% 0.6% 3,841 102 2,228 3.5% 3.1% 0.6% 2,872 2.9% 14.3% 3.3% 1,008 3.5% 31 1,960 2,479 4,633 0.6% 4,355 0.6% 3.4% 3,919 13.9% 2,715 1,521 3,177 3.4% 0.6% 3.1% 2.9% 67,361 15.1% 14.0% 4,311 1,917 13.3% 14.7% 14.6% 3.5% 2,200 3,270 4,512 903 15.0% 3.1% 3.3% 3,047 14.6% 13.6% 12.8% 122,038 3.5% 3,764 14.7% 14.2% 2,061 14.4% 14.5%

74 ype 2 diabetes (2020). Males (20+ years) Females (20+ years) Persons (20+ years) 20-29 years 30-59 years 60+ years Local Health Office Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Table 6.3: Demographic and geographic variation in the percentage of adults in the Republic of Ireland living with Type 1 and T living with Type of adults in the Republic Ireland 6.3: Demographic and geographic variation in the percentage Table Carlow / Kilkenny Cavan / MonaghanClare 2,754DonegalDublin North 5.5%Dublin North Central 3,132 Dublin North West 3,273 3,200Dublin South City 5.6%Dublin South East 6.0%Dublin South West 6.9% 3,072Dublin West 3,694 5,133 4,251Dun Laoghaire South Dublin 3,819 3,775 5.0% 5,954Galway 2,706 4.8% 6.5% 7.1%Kerry 4,042 2,300 4.3% 7.4% Wicklow Kildare / West 3,090 3,725 4,151 4.1% 6.2%Laois / Offaly 6,825 5,987 6.3% 4,993 4.2%Limerick 7,093 4,712 5.0% 5.3% 2,692 Longford / Westmeath 6.6% 3,433 75 5.5% 4,770Louth 2,688 7.8% 4,652 6.3% 3,147 5.2% 6.7%Mayo 4.3% 4,189 4,637 7,223 5,442Meath 5.1% 11,120 0.6% 5.5% 9,244 4.6% 7.7% 5.4%North Cork 88 8,486 3,050 3,716 3,185 6.2% 95 6.3%North Lee - Cork 5.2% 6,139 5.8% 1,913 / East Limerick 3,360 8,812North Tipperary 5.2% 5,206 5,448 7.1% 3,738 5.8% 0.6% 5.7%Roscommon 7,278 4.7% 5.1% 8,363 0.6% 6,489 Cavan Sligo / Leitrim West 162 2,395 4.6% 203 6.8% 3.4% 5.2% 5.4% 112 7.0%South Lee - Cork 4.8% 3,581 2,257 4,169 227 5,876 2,235South Tipperary 5.7% 3,732 5.8% 6.0% 3,794 0.6% 5.3% 2,220 189 4,009 3,966 2,590 6,048Waterford 0.6% 9,858 4,598 0.6% 90 119 7.3% 7.1% 3.6% Cork West 0.6% 11,931 100 6.4% 4.7% 159 3.7% 5.2% 3,623Wexford 5.9% 2,153 2,832 14.7% 4.8% 6.1% 0.6% 1,786 4,114 6.1% 7.1%Wicklow 3,050 4.9% 2,830 4,481 6,632 0.6% 0.6% 7,885 3,702 3,198 4,762Republic of Ireland 139 4,532 0.6% 0.6% 5.6% 6.0% 4,527 2,687 2,548 4,557 6.9% 3,098 3.2% 6.2% 2,234 5.4% 8,336 3.1% 172 15.4% 97 3.9% 4.8% 2,674 1,767 6.5% 6.4% 16.2% 3.0% 0.6% 2,286 7.7% 213 3,034 4,309 6.2% 3,108 4,908 6.1% 5,227 7.5% 5.7% 7.5% 2,116 6,803 3.0% 1,649 3,712 6,302 0.6% 105,353 0.6% 6.2% 4,771 3.8% 2.8% 5,062 73 89 8,263 2,507 3.1% 0.6% 5.6% 8,322 7.4% 3.6% 15.7% 4,906 3,008 8,567 5,689 3,716 14.2% 7.6% 6.1% 6.6% 16.8% 6.4% 5.3% 4,076 131 6,048 3,561 2,025 5.9% 15.3% 0.6% 4,892 0.6% 5,170 3.2% 7,932 4,003 7.1% 3,802 7.7% 14.3% 5.7% 3,902 127,291 6.7% 5.2% 6.8% 1,937 6,762 79 15.5% 12.7% 8,473 0.6% 3.1% 3.5% 13.0% 2,201 15.9% 3,229 2,678 7.2% 3.2% 5,556 81 6.7% 133 6.5% 131 6.9% 8.1% 55 0.5% 68 5,610 3,926 5.9% 2,561 5.4% 15.3% 3.6% 3.6% 7,715 6,909 232,644 0.6% 0.6% 91 6.9% 3,586 0.6% 0.6% 13.6% 1,627 38 16.1% 0.6% 86 3.5% 149 4,357 5,118 14.8% 2,502 6.4% 5.9% 2,879 0.6% 3,291 58 1,520 7.3% 1,743 0.6% 3.4% 5,644 0.6% 15.5% 0.6% 15.6% 3,626 3.7% 89 2,536 3.3% 0.6% 3,521 3.2% 15.2% 3.6% 1,160 3.7% 28 2,384 2,809 0.6% 5,681 5,310 0.6% 5,144 14.7% 3.7% 3,332 1,733 3,878 3.6% 0.6% 3.5% 3.1% 78,244 15.9% 14.7% 5,305 14.0% 2,181 15.4% 15.4% 3.7% 2,703 1,027 4,292 5,515 3.4% 15.9% 3,764 3.5% 15.4% 14.4% 13.5% 150,774 3.8% 4,639 15.6% 2,530 15.0% 15.2% 15.3%

75 iabetes (2007). Males (20+ years) Females (20+ years) Persons (20+ years) 20-29 years 30-59 years 60+ years Table 6.4: Demographic and geographic variation in the percentage of adults in Northern Ireland living with Type 1 and Type 2 d 1 and Type of adults in Northern living with Type 6.4: Demographic and geographic variation in the percentage Ireland Table AntrimArdsArmaghBallymenaBallymoneyBanbridgeBelfastCarrickfergusCastlereagh 769Coleraine 1,279 898Cookstown 999 4.1%Craigavon 478 4.6%Derry 4.6% 678 4.5%Down 1,024 4.5% 4,146 605Dungannon 1,794 1,019 4.1% 1,256Fermanagh 1,453 5.4%Larne 4.6% 4.3% 672 949 6.0%Limavady 4.4% 541 5.9% 929 6.1%Lisburn 1,349 1,792 6,995Magherafelt 4.7% 865 6.1% 3,072 1,593 4.4% 2,154Moyle 1,598 2,452 5.4% 4.4%Newry and Mourne 1,066 806 4.8% 6.6% 1,150 1,386 5.6% 1,040Newtownabbey 6.1% 5.3% 4.4% 742 1,607 5.3%North Down 1,945 5.3% 11,141 4.3% 4.2% 40Omagh 1,470 4.7% 6.4% 553 5.3% 519 2,612Strabane 49 2,258 5.8% 5.9% 1,631 42 4.8%Northern Ireland 608 1,493 43 1,122 1,451 5.7% 0.5% 2,335 1,402 4.9% 4.1% 5.0% 21 5.3% 0.5% 5.8% 1,283 1,271 3,294 4.3% 0.5% 4.0% 311 33 4.5% 5.9% 0.5% 5.8% 252 6.3% 625 5.6% 1,248 26 770 0.5% 663 3,856 37 4.4% 2,344 967 5.1% 5.3% 5.1% 2,560 1,929 27,391 0.5% 2,008 691 807 0.6% 733 2,442 788 4.3% 2.9% 36 6.4% 0.5% 5.5% 682 363 0.5% 1,868 5.1% 5.5% 3.0% 31 4.5% 71 5.9% 438 5.1% 3.1% 5.3% 3,147 5.0% 548 3.0% 4.4% 1,127 5.5% 1,906 1,323 0.5% 1,182 4.9% 476 5.9% 2,056 3,975 3.0% 39,871 89 785 0.5% 3,459 1,421 0.5% 1,415 6.9% 1,677 3.2% 51 47 2.8% 12.8% 1,069 6.0% 44 5.6% 4.8% 698 3,139 12.3% 911 2.9% 767 6.0% 0.6% 4.9% 2.9% 13.4% 1,074 7,742 12.6% 420 5.2% 1,027 749 4.6% 0.5% 0.5% 5.8% 3,154 0.5% 67,262 20 6.5% 3.1% 27 13.4% 968 5.2% 1,790 1,386 82 14.6% 12.5% 3.1% 3.1% 79 1,857 35 6.1% 838 632 5.2% 1,601 1,593 784 0.5% 12.1% 12.2% 0.5% 5.3% 53 3.2% 2,150 0.5% 831 0.6% 0.5% 11 5.1% 3.1% 3.0% 12.9% 49 1,337 3.2% 5.7% 2,382 412 13.5% 423 0.5% 1,338 13.9% 1,169 1,671 1,250 0.6% 484 42 0.5% 1,614 0.5% 14.4% 30 3.2% 3.0% 2.9% 972 13.1% 3.2% 13.8% 0.5% 13.6% 2.9% 21,324 225 922 0.6% 2,555 891 731 2.9% 2,211 896 3.1% 3.4% 642 2.9% 12.6% 13.1% 13.6% 2,114 514 14.2% 44,601 12.9% 513 2,183 3.1% 12.5% 3.3% 13.4% 1,173 14.2% 11.7% 1,048 13.8% 14.9% Local Government District Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence

76 iabetes (2015). Males (20+ years) Females (20+ years) Persons (20+ years) 20-29 years 30-59 years 60+ years Local Government District Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Table 6.5: Demographic and geographic variation in the percentage of adults in Northern Ireland living with Type 1 and Type 2 d 1 and Type of adults in Northern living with Type 6.5: Demographic and geographic variation in the percentage Ireland Table AntrimArdsArmaghBallymenaBallymoneyBanbridgeBelfastCarrickfergus 1,004CastlereaghColeraine 1,674 1,174 1,261Cookstown 4.7%Craigavon 659 5.6% 5.2%Derry 5.2% 922 1,336Down 5.3% 4,665 832Dungannon 2,274 1,583 1,170 4.8% 1,813Fermanagh 6.1%Larne 5.1% 5.4% 1,174 870 6.9%Limavady 5.0% 6.7% 712 1,234 7.0% 2,341Lisburn 1,763 5.9% 7,285 1,102Magherafelt 7.0% 3,948 2,757 1,788 5.0% 3,074 6.3%Moyle 2,100 4.9% 1,108 5.4%Newry and Mourne 1,394 1,631 7.1% 6.5% 1,529 1,363Newtownabbey 7.0% 6.3% 2,156 6.0% 5.4% 932 6.1%North Down 2,422 4.4% 11,950 5.2% 49 1,934 7.6%Omagh 5.5% 695 6.2% 694 2,958Strabane 49 2,865 52 6.5% 5.5% 6.3% 2,107 46 1,414Northern Ireland 809 1,879 0.6% 1,926 2,805 6.2% 6.0% 1,730 5.9% 5.1% 23 6.0% 0.6% 6.8% 1,645 0.6% 1,514 4,186 5.0% 37 0.6% 6.1% 4.5% 396 5.1% 6.6% 241 745 6.8% 7.0% 26 1,525 912 0.6% 880 4,965 1,111 43 5.2% 2,974 5.8% 2,521 0.5% 6.1% 819 5.6% 1,021 3,273 34,720 2,539 859 0.6% 1,052 3,093 3.2% 33 0.6% 5.2% 7.3% 6.9% 882 3.3% 472 0.5% 2,238 6.1% 6.3% 34 5.2% 3.4% 6.0% 5.2% 87 698 6.4% 518 3.3% 5.9% 3,439 5.1% 1,547 0.5% 6.3% 2,254 1,607 1,573 583 6.1% 2,788 7.0% 5,080 3.5% 48,251 1,886 89 853 1,831 0.6% 4,465 2,169 0.6% 63 7.6% 3.2% 14.1% 1,364 3.5% 55 7.0% 45 752 13.3% 1,151 3.4% 6.6% 6.0% 1,035 3,752 14.5% 6.8% 0.6% 5.7% 13.8% 3.4% 1,421 1,329 5.3% 8,271 0.6% 510 5.8% 6.6% 914 0.6% 3,779 1,324 0.6% 7.7% 3.6% 14.5% 82,970 21 25 6.1% 2,062 1,661 13.6% 90 15.7% 3.3% 2,416 41 3.4% 94 841 6.9% 991 13.1% 2,020 6.1% 2,033 934 0.6% 13.2% 0.5% 6.0% 58 3.7% 2,770 0.6% 1,101 0.6% 0.6% 5.8% 3.2% 14.0% 14 3.4% 47 1,437 6.9% 3.5% 3,215 464 14.7% 508 0.5% 15.1% 1,574 1,618 1,449 618 48 2,227 0.6% 0.5% 2,114 0.6% 30 15.6% 1,069 3.7% 3.5% 3.3% 14.9% 14.1% 3.5% 0.6% 3.3% 14.6% 24,939 253 0.6% 976 1,122 1,041 3,417 3.4% 2,922 1,172 768 3.4% 3.8% 14.2% 14.8% 3.1% 2,625 13.7% 613 15.3% 14.0% 56,595 3.5% 647 2,756 13.6% 3.9% 14.5% 1,601 15.3% 12.7% 1,390 14.9% 16.3%

77 iabetes (2020). Males (20+ years) Females (20+ years) Persons (20+ years) 20-29 years 30-59 years 60+ years Local Government District Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence Table 6.6: Demographic and geographic variation in the percentage of adults in Northern Ireland living with Type 1 and Type 2 d 1 and Type of adults in Northern living with Type 6.6: Demographic and geographic variation in the percentage Ireland Table AntrimArdsArmaghBallymenaBallymoneyBanbridgeBelfastCarrickfergus 1,157CastlereaghColeraine 1,934 1,361 1,428Cookstown 5.1%Craigavon 787 6.2% 5.7% 1,101Derry 5.7% 1,554Down 5.9% 5,020 977Dungannon 2,651 5.3% 1,824 1,270 2,063Fermanagh 6.5%Larne 5.6% 6.2% 1,020 1,306 7.7% 1,470Limavady 5.5% 7.2% 840 7.7% 2,710Lisburn 2,059 6.5% 7,615 1,275 7.6%Magherafelt 4,585 3,185 7.0% 1,910 5.5% 3,491Moyle 2,435 5.3% 1,347 5.8%Newry and Mourne 1,619 1,806 1,797 7.7% 7.3% 1,583 2,571Newtownabbey 7.7% 7.0% 1,074 6.5% 6.0% 6.7%North Down 2,809 4.8% 12,635 5.7% 51 2,251 8.5%Omagh 6.8% 6.1% 780 810 3,180 7.1% 6.1%Strabane 48 3,308 50 6.8% 2,425 44 1,656Northern Ireland 959 2,170 0.6% 2,276 3,103 6.7% 6.8% 1,996 6.5% 23 5.8% 1,914 6.6% 0.6% 37 7.6% 0.6% 1,657 4,868 5.5% 0.6% 6.5% 5.0% 443 5.5% 7.3% 217 821 7.6% 7.7% 25 1,020 0.6% 1,031 1,689 5,743 1,164 6.3% 42 0.6% 5.6% 3,420 3,003 6.6% 883 6.1% 1,179 3,789 39,673 2,938 922 0.6% 1,245 3,579 3.3% 30 8.1% 0.6% 5.7% 7.8% 1,005 523 3.5% 0.5% 2,480 32 6.8% 6.9% 764 5.7% 3.5% 6.6% 5.6% 86 7.0% 578 3.4% 6.5% 3,447 5.6% 1,839 1,800 0.5% 1,841 6.7% 6.9% 2,522 600 3,373 3.7% 7.7% 5,845 0.6% 54,546 2,252 80 811 2,138 3.4% 5,214 2,525 0.6% 59 8.2% 14.9% 1,582 3.6% 52 1,314 7.8% 7.3% 41 6.8% 1,260 730 14.2% 3.6% 4,137 15.3% 1,770 7.4% 0.6% 6.2% 14.6% 3.5% 557 1,020 1,477 5.8% 8,971 0.6% 6.2% 7.3% 0.6% 4,211 8.4% 15.2% 1,626 0.6% 20 3.8% 23 94,219 14.3% 6.7% 2,327 1,765 86 3.4% 16.3% 3.4% 2,827 38 7.4% 90 1,064 991 2,319 13.7% 2,342 6.8% 1,007 0.6% 0.5% 13.7% 6.6% 1,325 58 3.8% 3,304 0.6% 0.6% 0.6% 12 6.4% 3.5% 3.2% 14.7% 7.6% 3.6% 43 1,359 460 551 15.9% 3,898 15.4% 0.5% 1,649 2,673 1,953 1,608 0.6% 696 45 2,531 28 0.5% 0.6% 16.4% 3.8% 3.7% 1,057 3.3% 14.9% 15.6% 3.5% 0.6% 15.3% 3.4% 264 26,306 0.6% 1,320 1,267 978 4,110 3.6% 3,516 1,405 3.8% 823 14.9% 3.5% 15.6% 657 3.2% 3,022 14.4% 16.1% 14.7% 66,554 744 3.5% 3,190 14.3% 4.1% 15.2% 1,959 16.0% 13.5% 1,634 15.6% 17.2%

78 7 Recommendations

79 Chapter 7 Recommendations

CHAPTER 7. RECOMMENDATIONS

The Republic of Ireland’s Policy Framework for the Management of Chronic Diseases and Northern Ireland’s Service Framework for Cardiovascular Health and Wellbeing, highlight the importance of primary prevention and the need to reduce health inequalities. In both jurisdictions, the implementation of these policies is supported by a range of further policy and strategy documents addressing specific issues.

A review of key government policies across the island would identify opportunities to incorporate the three Principles of Action identified by the WHO Commission on the Social Determinants of Health. These are: • Improving daily living conditions. • Tackling the inequitable distribution of power, money and resources. • Measuring and understanding the problem and assessing the impact of action.

The following recommendations emphasise the importance of a stronger focus on prevention, tackling inequalities using a social determinants of health and life course perspective, and the crucial importance of building appropriate information systems to support these efforts.

Chronic Disease Prevention A stronger focus on prevention is urgently needed. Key government policies and supporting policies and strategies need to promote healthier lifestyles and strengthen the early assessment and diagnosis of chronic conditions.

Chronic disease prevention programmes need to take a life course perspective with a strong focus on early childhood, and develop interventions based on the needs of vulnerable and disadvantaged groups.

Lifestyle behavioural interventions need to address the needs of vulnerable and disadvantaged groups.

• Coordination with social inclusion and regional regeneration/development initiatives is crucial. • An understanding of the variation of chronic disease prevalence with factors such as age, sex, geography and local socio-economic circumstances will support local health needs assessments and service planning.

Chronic Disease Management Equity should be incorporated more strongly in the implementation of key government policies and should be extended beyond access and quality of care to reflect the definition used in the WHO Commission on the Social Determinants of Health.

Chronic disease management programmes must be based on need and not ability to pay. An understanding of current and future prevalence and how it varies with factors such as age, sex, geography and local socio-economic circumstances is an essential prerequisite for good planning and monitoring of chronic disease management.

Appropriate models of integrated care that involve a greater role for primary care and community care sectors should be developed.

80 Making Chronic Conditions Count

Research and Data Gaps Further research into the impact of chronic diseases on the population, the health and social care system, and the economy is required. This research should consider the magnitude of the burden of these conditions (including financial costs); how it is distributed across the population; how that burden might change in the future; and the implications for the health and social care workforce and its training requirements.

Alongside patient registers, a system of standardised population prevalence estimates and forecasts (available at national and sub-national level) should be developed and maintained.

Prevalence estimates and forecasts should be incorporated into routine local data collections such as the core data set for the Republic of Ireland’s Primary Care Teams and the community profiles that will support local government in Northern Ireland.

A comprehensive and standardised system for monitoring risk factors (overweight/obesity, nutrition, physical activity and smoking) at the national and sub-national level should be established and maintained.

Relevant data on social determinants of health should be incorporated into clinical, service and public health information systems - including chronic disease patient registers and local data collections - and used to help plan, deliver and evaluate chronic disease prevention and management programmes.

Performance indicators which can be used to measure differences in disease prevention and management between population subgroups should be developed and used to plan and monitor efforts to reduce health inequalities.

Government commitments to develop chronic disease patient registers across the island are applauded24.

In the first instance, the development of an all-Ireland system of standardised population prevalence estimates and forecasts could be based on further development of the APHO models (greater use of Irish data and research) and exploration of other statistical and probabilistic methods. Definitions and methods should match, as far as possible, those used in clinical information systems.

Current data on lifestyle factors such as obesity and smoking are not available at LHO and LGD level and do not allow trends to be forecast. Filling this small-area data gap would allow the prevalence models to more reliably account for current and future levels of these lifestyle factors.

24 DoHC’s Tackling Chronic Disease: A Policy Framework for the Management of Chronic Diseases supports the development of patient registration systems for the major chronic conditions, starting with diabetes and cardiovascular disease.

81 References

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86 The Institute of Public Health in Ireland (IPH)

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