Second_Expert_Report - Physical Activity and the Prevention of Cancer a Global Perspective The most definitive review of the science to date and the

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Unformatted text preview: Physical Activity, and the Prevention of Cancer: a Global Perspective The most definitive review of the science to date, and the most authoritative basis for action to prevent cancer worldwide. uR  ecommendations based on expert judgements of systematic reviews of the world literature. uT  he result of a five-year examination by a panel of the world’s leading scientists. u Includes new findings on early life, body fatness, physical activity, and cancer survivors. uR  ecommendations harmonised with prevention of other diseases and promotion of well-being. uA  vital guide for everybody, and the indispensable text for policy-makers and researchers. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective Food, Nutrition, World Cancer Research Fund American Institute for Cancer Research Food, Nutrition, Physical Activity, World Cancer Research Fund SECOND EXPERT REPORT American Institute for Cancer Research World Cancer Research Fund Wereld Kanker Onderzoek Fonds ER HARD FINAL.indd 1 World Cancer Research Fund Hong Kong Fonds Mondial de Recherche contre le Cancer American Institute for Cancer Research World Cancer Research Fund International and the Prevention of Cancer: a Global Perspective 30/10/07 10:07:25 Food, Nutrition, P h y s i c a l A c t i v i t y, a n d t h e P re v e n t i o n o f C a n c e r : a Global Perspective Please cite the Report as follows: World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007 First published 2007 by the American Institute for Cancer Research 1759 R St. NW, Washington, DC 20009 © 2007 World Cancer Research Fund International All rights reserved Readers may make use of the text and graphic material in this Report for teaching and personal purposes, provided they give credit to World Cancer Research Fund and American Institute for Cancer Research. ISBN: 978-0-9722522-2-5 CIP data in process Printed in the United States of America by RR Donnelley Food, Nutrition, P h y s i c a l A c t i v i t y, a n d t h e P re v e n t i o n o f C a n c e r : a Global Perspective A project of World Cancer Research Fund International P re f a c e I am very grateful to the special group of distinguished scientists who made up the Panel and Secretariat for this major review of the evidence on food, nutrition, physical activity and cancer. The vision of WCRF International in convening this Panel and confidence in letting a strong-willed group of scientists have their way is to be highly commended. In our view, the evidence reviewed here that led to our recommendations provides a wonderful opportunity to prevent cancer and improve global health. Individuals and populations have in their hands the means to lead fuller, healthier lives. Achieving that will take action, globally, nationally, and locally, by communities, families, and individuals. It is worth pausing to put this Report in context. Public perception is often that experts disagree. Why should the public or policy-makers heed advice if experts differ in their views? Experts do disagree. That is the nature of science and a source of its strength. Should we throw up our hands and say one opinion is as good as another? Of course not. Evidence matters. But not evidence unguided by human thought. Hence the process that was set up for this review: use a systematic approach to examine all the relevant evidence using predetermined criteria, and assemble an international group of experts who, having brought their own knowledge to bear and having debated their disagreements, arrive at judgements as to what this evidence means. Both parts of the exercise were crucial: the systematic review and, dare I say it, the wisdom of the experts. The elegance of the process was one of the many attractions to me of assuming the role of chair of the Panel. I could pretend that it was the major reason, and in a way it was, but the first reason was enjoyment. What a pleasure and a privilege to spend three years in the company of a remarkable group of scientists, including world leaders in research on the epidemiology of cancer, as well as leaders in nutrition and public health and the biology of cancer, to use a relatively new methodology (systematic literature reviews), supported by a vigorous and highly effective Secretariat, on an issue of profound importance to global public health: the prevention of cancer by means of healthy patterns of eating and physical activity. It was quite as enjoyable as anticipated. Given this heady mix, the reasons why I might have wanted to take on the role of Panel chair were obvious. I did question the wisdom of WCRF International in inviting me to do it. Much of my research has been on cardiovascular disease, not cancer. What I described as my ignorance, WCRF International kindly labelled impartiality. WCRF also appreciated the parallels between dietary causes of cardiovascular disease and cancer. There is a great deal of concordance. In general, recommendations in this Report to prevent cancer will also be of great relevance to cardiovascular disease. The only significant contradiction is with alcohol. From the point of view of cancer prevention, the best level of alcohol consumption is zero. This is not the case for cardiovascular disease, where the evidence suggests that one to two drinks a day are protective. The Panel therefore framed its recommendation to take this into account. The fact that the conclusions and recommendations in this Report are the unanimous view of the Panel does not imply that, miraculously, experts have stopped disagreeing. The Panel debated the fine detail of every aspect of its conclusions and recommendations with remarkable vigour and astonishing stamina. In my view, this was deliberation at its best. If conclusions could simply fall out of systematic literature reviews, we would not have needed experts to deliberate. Human judgement was vital; and if human, it cannot be infallible. But I venture to suggest this process has led to as good an example of evidencebased public health recommendations as one can find. Throughout the Panel’s deliberations, it had in mind the global reach of this Report. Most of the research on diet and cancer comes from high-income countries. But iv noncommunicable diseases, including cancer, are now major public health burdens in every region of the world. An important part of our deliberations was to ensure the global applicability of our recommendations. One last point about disagreement among experts: its relevance to the link between science and policy. A caricature would be to describe science as precise and policy-makers as indecisive. In a way, the opposite is the case. Science can say: could be, might be, some of us think this, and some think that. Policy-makers have either to do it or not do it — more often, not. Our effort here was to increase the precision of scientific judgements. As the Report makes clear, many of our conclusions are in the ‘could be’ category. None of our recommendations is based on these ‘could be’ conclusions. All are based on judgements that evidence was definite or probable. Our recommendations, we trust, will serve as guides to the population, to scientists, and to opinion-formers. But what should policy-makers do with our judgements? A year after publication of this Report, we will publish a second report on policy for diet, nutrition, physical activity, and the prevention of cancer. As an exercise developing out of this one, we decided to apply, as far as possible, the same principles of synthesis of evidence to policy-making. We enhanced the scientific panel that was responsible for this Report with experts in nutrition and food policy. This policy panel will oversee systematic literature reviews on food policy, deliberate, and make recommendations. The current Report and next year’s Policy Report have one overriding aim: to reduce the global burden of cancer by means of healthier living. Michael Marmot v Contents P re f a c e iv Contents vi Acknowledgements viii S u m m a ry xiv I n t ro d u c t i o n xxii ■ PA RT O N E B A C K G R O U N D 1 Chapter 1 4 1.1 1.2 1.3 1.4 Food systems and diets throughout history Foods and drinks, physical activity, body composition Migrant and other ecological studies Conclusions Chapter 2 2.1 2.2 2.3 2.4 2.5 2.6 T h e c a n c e r p ro c e s s 5 11 22 25 30 Basic concepts and principles Cellular processes Carcinogen metabolism Causes of cancer Nutrition and cancer Conclusions 31 32 36 37 41 46 Judging the evidence 48 Chapter 3 3.1 3.2 3.3 3.4 3.5 3.6 I n t e r n a t i o n a l v a r i a t i o n s a n d t re n d s Epidemiological evidence Experimental evidence Methods of assessment Causation and risk Coming to judgement Conclusions 49 52 55 57 58 62 ■ PA RT T W O E V I D E N C E A N D J U D G E M E N T S 63 Chapter 4 66 Foods and drinks 4.1 4.2 Cereals (grains), roots, tubers and plantains Vegetables, fruits, pulses (legumes), nuts, seeds, herbs, spices 4.3 Meat, poultry, fish and eggs 4.4 Milk, dairy products 4.5 Fats and oils 4.6 Sugars and salt 4.7 Water, fruit juices, soft drinks and hot drinks 4.8 Alcoholic drinks 4.9 Food production, processing, preservation and preparation 4.10 Dietary constituents and supplements 4.11 Dietary patterns Chapter 5 Physical activity Chapter 6 G ro w t h , d e v e l o p m e n t , b o d y composition 6.1 6.2 6.3 vi Body fatness Growth and development Lactation 67 75 116 129 135 141 148 157 172 179 190 Chapter 7 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 Cancers Mouth, pharynx and larynx Nasopharynx Oesophagus Lung Stomach Pancreas Gallbladder Liver Colon and rectum Breast Ovary Endometrium Cervix Prostate Kidney Bladder Skin Other cancers Chapter 8 Chapter 9 245 250 253 259 265 271 275 277 280 289 296 299 302 305 310 312 315 318 D e t e rm i n a n t s o f w e i g h t g a i n , o v e rw e i g h t , o b e s i t y 322 C a n c e r s u rv i v o r s 342 C h a p t e r 1 0 F i n d i n g s o f o t h e r re p o r t s 10.1 10.2 10.3 10.4 10.5 10.6 10.7 244 Method Interpretation of the data Nutritional deficiencies Infectious diseases Chronic diseases other than cancer Cancer Conclusions 348 349 350 350 351 352 355 358 C h a p t e r 1 1 R e s e a rc h i s s u e s 360 ■ PA RT T H R E E R E C O M M E N D AT I O N S 365 Chapter 12 Public health goals and p e r s o n a l re c o m m e n d a t i o n s 368 12.1 Principles 12.2 Goals and recommendations 12.3 Patterns of food, nutrition and physical activity 369 373 391 APPENDICES 395 A p p e n d i x A P ro j e c t p ro c e s s 396 A p p e n d i x B T h e f i r s t W C R F / A I C R E x p e rt R e p o rt 398 Appendix C WCRF global network 400 G l o s s a ry 402 R e f e re n c e s 410 Index 506 198 210 211 229 239 CHAPTER BOXES Box 4.6.1 Box 4.6.2 ■ PA RT O N E B A C K G R O U N D Chapter 1 Box Box Box Box 1.1 Box Box Box Box 1.2 Box Box Box Box Box Box Chapter 2 I n t e r n a t i o n a l v a r i a t i o n s a n d t re n d s Egypt South Africa China Measurement of food supply and consumption India Japan UK Measurement of cancer incidence and mortality Poland Spain USA Mexico Australia Brazil 6 8 10 13 14 16 18 18 20 22 24 26 27 28 Sugar, sugars, sugary foods and drinks Salt and salty, salted and salt-preserved foods Box 4.6.3 Chemical sweeteners Box 4.6.4 Refrigeration Box 4.7.1 High temperature, and irritant drinks and foods Box 4.7.2 Contamination of water, and of foods and other drinks Box 4.8.1 Types of alcoholic drink Box 4.9.1 Food systems Box 4.9.2 ‘Organic’ farming Box 4.9.3 Regulation of additives and contaminants Box 4.9.4 Water fluoridation Box 4.10.1 Food fortification Box 4.10.2 Functional foods Box 4.10.3 Levels of supplementation Chapter 5 Box 5.1 Box 5.2 Nutrition over the life course Oncogenes and tumour suppressor genes Mechanisms for DNA repair Body fatness and attained height Energy restriction 34 35 37 39 46 Box 6.2.1 Box 6.2.2 Chapter 7 Chapter 3 Box 3.1 Box 3.2 Box 3.3 Box 3.4 Box 3.5 Box 3.6 Box 3.7 Box 3.8 Box 4.1.1 Box 4.1.2 Box 4.1.3 Box 4.1.4 Box 4.2.1 Box 4.2.2 Box 4.2.3 Box 4.2.4 Box 4.3.1 Box 4.3.2 Box 4.3.3 Box 4.3.4 Box 4.3.5 Box 4.4.1 Box 4.5.1 150 150 159 173 174 175 176 182 182 183 Physical activity Energy cost and intensity of activity Sedentary ways of life 200 201 G ro w t h , d e v e l o p m e n t , b o d y c o m p o s i t i o n Sexual maturity Age at menarche and risk of breast cancer 232 232 Cancers Judging the evidence Issues concerning interpretation of the evidence Dose-response Forest plots Systematic literature reviews Experimental findings Effect modification Energy adjustment Criteria for grading evidence 50 52 53 54 55 56 57 60 ■ PA RT T W O E V I D E N C E A N D J U D G E M E N T S Chapter 4 143 143 144 T h e c a n c e r p ro c e s s Chapter 6 Box 2.1 Box 2.2 Box 2.3 Box 2.4 Box 2.5 142 Foods and drinks Wholegrain and refined cereals and their products Foods containing dietary fibre Glycaemic index and load Aflatoxins Micronutrients and other bioactive compounds and cancer risk Phytochemicals Preparation of vegetables and nutrient bioavailability Foods containing dietary fibre Processed meat Nitrates, nitrites and N-nitroso compounds Foods containing iron Heterocyclic amines and polycyclic aromatic hydrocarbons Cantonese-style salted fish Foods containing calcium Hydrogenation and trans-fatty acids Box 7.1.1 Box 7.2.1 Box 7.5.1 Box 7.8.1 Box 7.13.1 Chapter 8 Box 8.1 Box 8.2 Box 8.3 Box 8.4 Chapter 9 Box 9.1 69 69 69 70 78 79 79 80 117 118 118 119 120 131 137 Box 9.2 Cancer incidence and survival Epstein-Barr virus Helicobacter pylori Hepatitis viruses Human papilloma viruses 246 251 266 278 303 D e t e rm i n a n t s o f w e i g h t g a i n , o v e rw e i g h t , o b e s i t y Energy density Fast food Body fatness in childhood Television viewing 324 325 326 331 C a n c e r s u rv i v o r s Conventional and unconventional therapies Use of supplements by cancer survivors Chapter 10 F i n d i n g s o f o t h e r re p o r t s Chapter 11 R e s e a rc h i s s u e s 345 346 ■ PA RT T H R E E R E C O M M E N D AT I O N S Chapter 12 Box 12.1 Box 12.2 Box 12.3 Box 12.4 Box 12.5 Public health goals and personal re c o m m e n d a t i o n s Quantification Making gradual changes Height, weight and ranges of BMI When supplements are advisable Regional and special circumstances 371 372 375 387 392 vii F O O D , N U T R I T I O N , P H Y S I C A L A C T I V I T Y, A N D T H E P R E V E N T I O N O F C A N C E R : A G L O B A L P E R S P E C T I V E Acknowledgements Panel Sir Michael Marmot MB BS MPH PhD FRCP FFPH Chair University College London UK Tola Atinmo PhD University of Ibadan, Nigeria Tim Byers MD MPH University of Colorado Health Sciences Center Denver, CO, USA Junshi Chen MD Chinese Centre for Disease Control and Prevention Beijing, People’s Republic of China Tomio Hirohata MD DrScHyg PhD Kyushu University Fukuoka City, Japan Alan Jackson CBE MD FRCP FRCPCH FRCPath University of Southampton UK W Philip T James CBE MD DSc FRSE FRCP International Obesity Task Force London, UK Laurence N Kolonel MD PhD University of Hawai’i Honolulu, HI, USA Jim Mann DM PhD FFPH FRACP University of Otago Dunedin, New Zealand Hilary J Powers PhD RNutr University of Sheffield, UK World Health Organization (WHO) Geneva, Switzerland Denise Coitinho PhD Ruth Bonita MD Chizuru Nishida PhD MA Pirjo Pietinen DSc K Srinath Reddy MD DM MSc Institute of Medical Sciences New Delhi, India Panel observers Additional members for policy panel Elio Riboli MD ScM MPH Was at: International Agency for Research on Cancer (IARC), Lyon, France Now at: Imperial College London, UK Food and Agriculture Organization of the United Nations (FAO) Rome, Italy Guy Nantel PhD Prakash Shetty MD PhD Barry Popkin PhD MSc BSc Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA Juan A Rivera PhD Instituto Nacional de Salud Publica Cuernavaca, Mexico International Food Policy Research Institute (IFPRI) Washington DC, USA Lawrence Haddad PhD Marie Ruel PhD Arthur Schatzkin MD DrPH National Cancer Institute Rockville, MD, USA International Union of Nutritional Sciences (IUNS) Mark Wahlqvist MD AO Jacob C Seidell PhD Free University Amsterdam The Netherlands Mechanisms Working Group John Milner PhD David E G Shuker PhD FRSC The Open University Milton Keynes, UK Methodology Task Force Jos Kleijnen MD PhD Gillian Reeves PhD Ricardo Uauy MD PhD Instituto de Nutricion y Tecnologia de los Alimentos Santiago, Chile Union Internationale Contre le Cancer (UICC) Geneva, Switzerland Annie Anderson PhD Curtis Mettlin PhD Harald zur Hausen MD DSc Shiriki Kumanyika PhD MPH University of Pennsylvania Philadelphia, PA, USA Walter C Willett MD DrPH Harvard School of Public Health Boston, MA, USA Claus Leitzmann PhD Justus Liebig University Giessen, Germany Steven H Zeisel MD PhD University of North Carolina Chapel Hill, NC, USA viii Robert Beaglehole ONZM FRSNZ DSc Chair 2003 Was at: World Health Organization (WHO) Geneva, Switzerland Now at: University of Auckland, New Zealand United Nations Children’s Fund (UNICEF) New York, NY, USA Ian Darnton-Hill MD MPH Rainer Gross Dr Agr Jane Wardle PhD MPhil University College London, UK Nick Cavill MPH British Heart Foundation Health Promotion Research Group University of Oxford, UK A C K N O W L E D G E M E N T S Systematic Literature Review Centres University of Bristol, UK Rajendra Persad ChM FEBU FRCS United Bristol Healthcare Trust & Bristol Urological Institute, UK Carlos A Gonzalez PhD MPH MD Catalan Institute of Oncology Barcelona, Spain Vittorio Krogh MD MSc Istituto Nazionale Tumori Milan, Italy George Davey Smith FMedSci FRCP DSc University of Bristol , UK Massimo Pignatelli MD PhD FRCPath University of Bristol, UK Jonathan Sterne PhD MSc MA University of Bristol, UK Jelena Savovic PhD University of Bristol, UK Sylvie Menard ScD Istituto Nazionale Tumori Milan, Italy Steve Thomas MB BS PhD FRCS University of Bristol, UK Eugenio Mugno ScD Istituto Nazionale Tumori Milan, Italy Tim Whittlestone MA MD FRCS United Bristol Healthcare Trust, UK Valeria Pala ScD Istituto Nazionale Tumori Milan, Italy Chris Bain MB BS MS MPH University of Queensland Brisbane, Australia Nahida Banu MB BS University of Bristol, UK Trudy Bekkering PhD University of Bristol, UK Luisa Zuccolo MSc University of Bristol, UK Sabina Sieri ScD Istituto Nazionale Tumori Milan, Italy Rebecca Beynon MA BSc University of Bristol, UK Margaret Burke MSc University of Bristol, UK David de Berker MB BS MRCP United Bristol Healthcare Trust, UK Anna A Davies MSc BSc University of Bristol, UK Roger Harbord MSc University of Bristol, UK Ross Harris MSc University of Bristol, UK Lee Hooper PhD SRD University of East Anglia Norwich, UK Anne-Marie Mayer PhD MSc University of Bristol, UK Andy Ness PhD FFPHM MRCP University of Bristol, UK Istituto Nazionale Tu m o r i M i l a n , I t a l y Franco Berrino MD Istituto Nazionale Tumori Milan, Italy Patrizia Pasanisi MD MSc Istituto Nazionale Tumori Milan, Italy Claudia Agnoli ScD Istituto Nazionale Tumori Milan, Italy Silvana Canevari ScD Istituto Nazionale Tumori Milan, Italy Giovanni Casazza ScD Istituto Nazionale Tumori Milan, Italy Elisabetta Fusconi ScD Istituto Nazionale Tumori Milan, Italy Johns Hopkins U n i v e r s i t y, B a l t i m o re , MD, USA Anthony J Alberg PhD MPH University of South Carolina Columbia, SC, USA Kristina Boyd MS Johns Hopkins University Baltimore, MD, USA Laura Caulfield PhD Johns Hopkins University Baltimore, MD, USA Eliseo Guallar MD DrPH Johns Hopkins University Baltimore, MD, USA James Herman MD Johns Hopkins University Baltimore, MD, USA Karen Robinson MSc Johns Hopkins University Baltimore, MD, USA Xuguang (Grant) Tao MD PhD Johns Hopkins University Baltimore, MD, USA University of Leeds, UK David Forman PhD FFPH University of Leeds, UK Victoria J Burl...
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