Diet and Cancer:

What Don’t We Know and

When Didn’t We Know it?

Dileep G. Bal, M.D., Chief

Cancer Control Branch
Department of Health Services
 WRITTEN DISCLAIMER

This presentation represents the

opinions of
Dileep G. Bal, M.D.
and not the California Department
of Health Services, in any way
whatsoever. The opinions of either
can change without further notice.
Objectives Today
„ Present the
American Cancer
Society Nutrition and
Physical Activity
Guidelines for
Cancer Prevention

„ Discuss the science

base behind the
recommendations

„ Present current
trends and statistics
On any given day
in the United States...
„ 815 billion calories
are consumed (200
billion more than needed)
„ 47 million hot dogs
„ 4 million pounds of bacon
„ 60 million pounds
of red meat
„ 170 million eggs
On any given day
in the United States...
„ 3 million gallons of ice cream

„ 10 million pounds
of candy

„ 16 million gallons
of beer and ale

„ 1.5 million gallons of hard liquor

(enough to make 26 million people
drunk!)
 WEDNESDAY, MAY 22, 1996

Thou Shalt Reduce Salt Intake:

True? False? Choose Your Study
By GINA KOLATA
 All Sites (Invasive) – Incidence Rates
By Year of Diagnosis – All Races, Males and Females
2015 Goals – 25% Reduction from Baseline
550 1999
1992 Baseline
476.1
511.2 ( È 6.9% from Baseline)
500
406.7 If Trend
2000 US Std.
450 Continues
Population
Rate

400
1970 US Std. 2015 Goal
Population 383.4
350

319.5
300
Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard population
SEER Cancer Statistics Review 1973-1999.
250
'73 '76 '79 '82 '85 '88 '91 '94 '97 '00 '03 '06 '09 '12 '15
Year

„ Average Decline 1.0% per Year Between 1992-1999

„ If Trend Continues, 20% Reduction by 2015
„ Recent Trend Appears Level or Decreasing
 All Sites – Mortality Rates
By Year of Death – All Races, Males and Females
2015 Goals – 50% Reduction from Baseline
1991 Baseline
1999 (È 5.9 % from Baseline)
215.4
220 202.8
210
200
190 2000 Std. Population
180
170
160
180.4 If Recent
Rate

1970 Std. Population Trend Continues

150
140
130 2015 Goal
120 107.7
110
100 Incidence and mortality rates are per 100,000 and are age-adjusted to the 2000 U.S. standard population.
90 SEER Cancer Statistics Review 1973 - 1999. 86.7
80
'73 '76 '79 '82 '85 '88 '91 '94 '97 '00 '03 '06 '08 '11 '14
Year

„ Steeper Rate of Decrease, 1.4 % per Year, Beginning 1995 and

Continuing through 1999
„ If trend Continues - 16% Reduction by 2015
„ Trend Continues
Actual Causes of Death
in the United States (1990)
Tobacco
Diet/Activity
Alcohol
Microbial Agents
Toxic Agents
Firearms
Sexual Behavior
Motor Vehicles
0 5 10 15 20
Percent of all causes of death
Data Source: McGinnis & Foege, JAMA, November, 1993
Causes of Cancer
Estimate percentage of total cancer deaths attributable
to established causes of cancer
Tobacco
Adult diet/obesity
Sedentary lifestyle
Occupational factors
Family history of cancer
Viruses/other biologic agents
Perinatal factors/growth
Reproductive factors
Alcohol
Socioeconomic status
Environmental pollution
Ionizing/ultraviolet radiation
Prescription drugs
Medical procedures
Salt/other food additives or
contaminants
0 5 10 15 20 25 30 35
Source: Harvard Report on Cancer Prevention, Cancer Causes and Control, November/December, 1996
 Carcinogenesis
Normal Cell
Tumor
Cell with DNA
abnormality

MUTATION PROMOTION
Inherited PROGRESSION
Spontaneous
Acquired Hormones
Growth factors
 Obesity,Nutrition,and Cancer
Gene-Nutrient
Imbalance

Energy
Expenditure

(Phytochemicals)

Energy
Intake Physical Activity
Fruits
Vegetables
(Carcinogen) Whole Grains
Soy Protein
High Fat/Calories
High ω -6 fats Genetic
Growth Factors Susceptibility
(Common Polymorphisms)
Purpose of the Nutrition
and Physical Activity Guidelines
„ To review current scientific
data on diet and cancers
„ To translate this into clear,
defensible recommendations
for the general public
„ To promote changes in
environments that support
healthful eating and physical
activity habits
„ To reduce cancer risk
 Which year? (1)

“In England, four and a half times

as many people die now from
cancer as half a century ago.
Probably no single factor is more
important in determining the
outbreak of cancer in the
predisposed than high feeding.
Many indications point to the
gluttonous consumption of meat
as likely to be especially harmful.
 Which year? (2)

Statistics show that the

consumption of meat has reached
the amazing total of 131 pounds
per head per year, which is more
than double what it was half a
century ago. No doubt other
factors co-operate, among these I
should be inclined to name
deficient exercise and deficiency
in fresh vegetable food.”
 December, 1898!
W. Roger Williams in The
Lancet

So, what didn’t we know and

when didn’t we know it?
Society Recommendations
Individual Choices
Eat a variety of foods, with an
emphasis on plant sources.

Adopt a physically active lifestyle.

Maintain a healthful weight

throughout life.

If you drink alcoholic beverages,

limit consumption.
Society Recommendations
Community Action
„ Public, private,
and community
organizations
should work
to create social
and physical
environments
that support the adoption and maintenance
of healthful nutrition and physical activity
behaviors
Society Recommendations
Community Action
„ Increase access
to healthful
foods in
schools,
worksites, and
communities.

„ Provide safe, enjoyable, and accessible

environments for physical activity in schools,
and for transportation and recreation in
communities.
Society Recommendations
Individual Choices
Eat a variety of healthful foods,
with an emphasis on plant
sources.
ƒ Eat 5 or more servings of a
variety of vegetables and fruit
each day.
ƒ Choose whole grains in
preference to processed
(refined) grains and sugars.
ƒ Limit consumption of red
meats, especially those high
in fat and processed.
ƒ Choose foods that help
maintain a healthful weight.
Eat five or more
servings of a variety
of vegetables and
fruits each day
ƒ Include vegetables or fruits in
every meal and for snacks.
ƒ Limit french fries, snack chips,
and other fried vegetable
products.
ƒ Choose 100% juice if you drink
fruit or vegetable juices.
Why Fruits and Vegetables?
Fruits and Vegetables and the
Prevention of Cancer
Decreases Risk Decreases Risk Decreases
Convincing Probable Risk Possible
„ Mouth and „ Larynx „ Liver*
pharynx „ Pancreas „ Ovary
„ Oesophagus „ Breast „ Endometrium
„ Lung „ Bladder „ Cervix
„ Stomach „ Prostate*
„ Colon, „ Thyroid
rectum* „ Kidney*
*Vegetables only
Food, Nutrition and the Prevention of Cancer: A Global Perspective American Institute for
Cancer Research, 1997
Origins of the 5 a Day Campaign

„ 1986 National Cancer Institute

grant to the California Department
of Health Services
„ Original plan called for addressing
fat, fruits and vegetables, and fiber
„ Plan revised to focus on promoting
5 daily servings of fruits and
vegetables because
– strong science
– win-win-win
– feasibility
California 5 a Day Campaign

„ 1988: California 5 a Day

Campaign developed
„ 1988-1991: Campaign
promotions conducted
„ 1991: 5 A Day goes national
California 5 a Day
Campaign Spinoffs

„ Children’s 5 a Day--Power Play!

Campaign (1993)
„ Latino 5 a Day Campaign (1994)
„ Network 5 a Day Campaign for
low-income families (1998)
„ Women’s 5 a Day Campaign
(1999)
 Relative Risk
What it means
„ RR = Relative Risk = Risk Ratio
„ Risk among exposed/Risk among non-exposed
„ Null association, RR = 1.00
„ RR of 1.5 means exposed group has 50%
greater risk of disease than non-exposed;
„ RR of 0.60 means 40% lower risk
Vegetables and Colorectal Cancer
Prospective Cohort Studies

Thun, 1992- Men

Thun, 1992- Women

Steinmetz, 1994

Pietinen, 1999

Voorrips, 2000- Men

Voorrips, 2000-Women

Michels, 2000

Terry, 2001

0 .2 0.5 1 1.5 2
Relative Risk
Lung cancer incidence associated with
beta-carotene treatment versus placebo

RR
2

1.5

0.5

0
Current Never Former Current Former Current
smoker smoker smoker smoker smoker smoker

ATBC Physicians’ Health CARET

Percent of adults eating 5 or more fruits
and vegetables per day, 1998

26.6 to 31.9
United States Median: 23.9 23.9 to 26.5
20.7 to 23.8
Source: BRFSS, NCCDPHP, CDC, 2000 9.1 to 20.6
Choose whole grains in preference
to processed (refined) grains and
sugars.
ƒ Include grain products such
as breads, cereals rice,
pasta, or beans in every
meal.
ƒ Eat other foods from plant
sources several times each
day.
ƒ Limit consumption of refined
carbohydrates, including
pastries, sweetened cereals,
soft drinks, and sugars.
Whole grains & cancer
Prospective cohort studies

Thun, 1992-men*

Thun, 1992-women*

Jacobs, 1999-women

Jacobs, 2001

0 0.5 1 1.5 2
Relative Risk
*colon cancer mortality; others = all cancers
Limit consumption of red meats,
especially those high in fat and
processed
ƒ Choose fish, poultry, or beans as an
alternative to beef, pork, and lamb
ƒ When you eat meat, select lean cuts and
smaller portions
ƒ Prepare meat by baking, broiling, poaching,
rather than by frying or charbroiling
 Red meat (1 portion)
and colorectal cancer

Source: Sandhu MS et al. CEBP 2001;10:439

- 446
Processed meat (1 portion)
and colorectal cancer

Source: Sandhu MS et al. CEBP 2001;10:439

- 446
Current research about meat

ƒ Heterocyclic amines
ƒ Cooking methods
ƒ Food safety
What about fat?

ƒ Total fat?
ƒ Type of fat?
ƒ Calories from fat?
ƒ Some other factor in the
fat in foods?
 Prevalence of Overweight among
U.S. Adults, BRFSS, 1985

Source: Mokdad, et al. <10% 10-15% >15%

 Prevalence of Overweight among
U.S. Adults, BRFSS, 1997

Source: Mokdad, et al. <10% 10-15% >15%

Choose foods that help maintain a
healthful weight
„ When you eat away from
home, choose foods low in
fat, calories and sugar, and
avoid large portion sizes.
„ Eat smaller portions of high
calorie foods.
„ Substitute vegetables, fruits,
and other low- calorie foods
for calorie
- dense foods such
as French fries,
cheeseburgers, pizza, ice
cream, doughnuts and other
sweets.
Nutrition & cancer
research in early
stages

• active controversy of
whether benefit is due to
individual nutrients, whole
foods or overall dietary
pattern
• most evidence shows that
people who have healthy
diets have lower risk of
many cancers
“It is often necessary to
make a decision on the
basis of information
sufficient for action but
insufficient to entirely
satisfy the intellect.”
-Emmanuel Kant
Asymmetric Information

Exploring how people can

make better decisions
despite incomplete
information
The late William Vickery (Columbia
University) and James Mirrlees
(Cambridge University) shared 1996
Nobel Prize in Economics
Society Recommendations
Individual Choices
1. Adopt a physically active
lifestyle.
Adults
ƒ Engage in at least
moderate activity for 30
minutes or more on 5 or
more days of the week

ƒ 45 minutes or more of
moderate to vigorous even
more helpful for breast and
colon cancer
Society Recommendations
Individual Choices
2. Adopt a physically active
lifestyle.
Children & Adolescents
ƒ Engage in at least
60 minutes per day of
moderate - to
- vigorous
physical activity
at least 5 days per week.
Physical activity and cancer
Summary of evidence
Cancer Studies Temporality Strength
Colon 39/46 Throughout Convincing
Breast 24/36 Early & adult Convincing
Prostate 15/26 Early life? Probable
Lung 6/8 Unknown Possible
Endometrial 8/11 Unknown Possible
Testicular 3/8 Unknown Insufficient
Ovarian 2/5 Unknown Insufficient

Source: Friedenreich. CEBP 2001;10:287- 301

Physical activity and
colorectal cancer

Source: Friedenreich. CEBP 2001;10:287- 301

Physical activity and
breast cancer

Source: Friedenreich. CEBP 2001;10:287- 301

Participation in physical activity, adults, 1998
(% regular and sustained physical activity)

24.1 to 30.3
20.4 to 24.0
United States Median: 20.4 18.6 to 20.3
13.0 to 18.5
Source: BRFSS, NCCDPHP, CDC, 2000
Adopt a physically active lifestyle

Emphasis on children
and adolescents
critically important.
Increasing trends
in overweight and
obesity raise
concerns about future
cancer rates
Potential mechanisms for physical
activity and cancer
„ May prevent overweight
and obesity to protect
against cancer
Colon, rectal, prostate,
endometrial, breast
(among postmenopausal
women), and kidney
„ May act through hormones
-Prostate and breast cancers
„ Energy metabolism
Strongest association with
breast and colon cancers
„ Colon
Stimulates movement through the bowel,
reducing the length of time bowel lining
is exposed to mutagens

„ Breast cancer
– Helps control weight
– Decreases circulating hormones
Society Recommendations
Individual Choices
3. Maintain a healthful
weight throughout life.
ƒ Balance caloric intake
with physical activity

ƒ Lose weight if
currently overweight
or obese
 The Spread of the Obesity Epidemic
1991 1993

State
Prevalence

<10%
10
- 15%
>15%

1995 1998

*Obesity is defined as a BMI of 30 or greater.

**States are white in years 1991 and 1993 because information on weight and height was not collected.
*** The Healthy People 2010 Goal is to reduce the proportion of adults who are obese to less than 15% .
Source: Behavioral Risk Factor Surveillance System, CD-ROM 1984-1995, 1998, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 2000.
 Body mass index and mortality
in women
2.4
2.2
2.0
Cardiovascular
Relative Risk

1.8 Cancer
1.6 All other causes
1.4
1.2
1.0
0.8
0.6
20 0.4

22 1.9

23 3.4

25 4.9

26 6.4

28 7.9

30 9.9

32 1.9

35 4.9

9
18 8.5

9.
-2

-2

-2

-2

-2

-2

-2

-3

-3

-3
<1
.5

.5

.0

.5

.0

.5

.0

.0

.0

.0
Body- Mass Index
Source: Calle EE, et al. NEJM. 1999;341:1097-1105.
How obesity may
cause cancer
„ Estrogen production
„ Insulin resistance
„ Mechanical
„ Other
Society Recommendations
Individual Choices
4. If you drink
alcoholic
beverages,
limit
consumption.
If you drink alcoholic
beverages, limit consumption.
„ Drink is 12 oz of
regular beer, 5 oz of
wine, 1.5 oz liquor

„ Moderate defined as
no more than 2 drinks
per day for men and
1 drink for women
Alcohol and Cancer Risk
Increases risk of:
„ Mouth and esophageal cancers
„ Pharynx and larynx cancers
„ Liver cancer
„ Breast cancer in women

Combined use of alcohol and

tobacco greatly increases risk
compared to drinking or smoking
alone
 Effect of alcohol consumption and cigarette
smoking on oropharyngeal cancer incidence
40 120
Men Women
35
100
30
80
25

OR
OR

20 60

15
40
10
20
5

0 0
<1 1-4 5-14 15-29 30+ <1 1-4 5-14 15-29 30+
Drinks per week Drinks per week
Nonsmoker Short duration or former 1-19 cpd for 20+ years
20-39 cpd for 20+ years 40 cpd for 20+ yrs

Source: Blot WJ et al. Cancer Research 1988;48

- 3282
- 7
CPS-II Men - Risk of alcohol related
diseases increases with drinks per day
RR
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
None <1 1 2 3 4-5 6+
Drinks per day
Source: Thun MJ et al. NEJM 1997;337:1705
- 1714
CPS-II Women - Risk of alcohol related
diseases increases with drinks per day

RR
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
None <1 1 2 3 4-5 6+
Drinks per day
Source: Thun MJ et al. NEJM 1997;337:1705
- 1714
Alcohol & Breast Cancer Risk
„ Risk increases with an
intake beginning at just a
few drinks per week

„ Mechanism unknown
– changes in hormones?
– carcinogenic effect on breast
tissue?
– lowers serum folate

„ Cutting back is a good way

for women who drink
regularly to reduce risk
“ I thought a glass
of wine was good
for me!”
„ Moderate intake of alcohol
appears to decrease risk of heart
disease
– Other approaches to reduce
heart disease risk
„ Not recommended that non-
drinkers begin drinking
„ Consider risk of both heart
disease and cancer to make an
informed decision
At this point in time…

Based on what we
know right now…
To Reduce Your Risk
of Colorectal Cancer
„ Increase intensity and duration of
physical activity
„ Eat more vegetables, fruits and whole
grains
„ Limit intake of red meats

„ Avoid obesity

„ Avoid tobacco use and excessive

alcohol consumption
To Reduce Your Risk
of Breast Cancer
„ Engage in vigorous physical activity at
least 4 hours a week
„ Minimize lifetime weight gain through
– Limiting calories
– Regular physical activity

„ Limit intake of alcoholic beverages

„ Eat a variety of vegetables and fruits

To Reduce Your Risk
of Prostate Cancer
„ Limit intake of foods from animal
products, especially red meats and high
fat dairy products
„ Eat a variety of vegetables and fruits
daily (lycopene hypothesis)
„ Limited evidence on the benefits of
– Vitamin E
– Selenium
To Reduce Your Risk
of Lung Cancer
„ Avoid tobacco use or exposure

„ Eat at least 5 servings of vegetables

and fruits each day
What nutrients or There is no
combination of nutrients controversy
has an effect?
on whether
nutrition
When during the life cycle
and physical
is there an effect?
(or the greatest effect?) activity have
an impact
How much/how little has on cancer
an effect? risk
 Creating Change

How can we get people to eat

healthy and be more active?
A complex issue that requires a
multi channel solution

From: Healthy People 2010, Understanding and Improving Health, Volume 1

Social Ecological Model
Social Structure,
Policy

Community

Institutional/Organizatio
nal

Interpersonal & Social

Networks
Individua
l
 II. III.
I.
Methods Controlled
Basic Hypothesis
Development
Development Intervention
Intervention Trials to test
Biomedical for Cancer
Tools Intervention
Control
Research Strategies
Identified for
Hypothesis
Hypothesis

Testing

IV.
Defined
Population
Studies

Statewide
V. VI.
Prevention
Demonstration Intervention VII.
Institutionalization,
&
& Technology for
Implementation Lifestyle Risk Technology Health
of Benefits Factors Transfer, Program
in Large common to Diffusion Services
Populations other Chronic
Diseases
Programs
 The Theory Is Strong
California Nutrition Network of Healthy Families
Social-Ecological Model for Intervention and
Evaluation

Spheres of Influence

Interpersonal Institutional/
Community Social Structure,
Individual Lifestyle Organizational Policy, Systems
Influences
Research is wasted unless
it is translated into action
and applied on main street
across the land,
by involving the key public
and private sector players.
How can we create change?
„Target Systems
• Schools
• Worksites
• Communities

„Multi-level integrated
interventions
„Environment and
Policy
„Partnerships
„Comprehensive
coordinated
communications efforts
 Nutrition vs. Tobacco

„ Can get to relatively low risk in about

5 years vs. 15-20 years for tobacco
„ Less than 17% of Californians
smoke; everybody eats
„ Each responsible for 1/3 of cancers
„ Tobacco is an addictive substance
 Social Transformation Requires:

· A crisis · Science base

· “Spark plugs”, champions · Advocacy
· An economic imperative, and solutions
· Coalition development
· Government involvement at multiple levels
· Mass communications, including media advocacy
· Environmental and policy change—more than education
· A plan, so pieces work synergistically, at multiple levels,
in multiple sectors
Source: Tufts, National Partnership for Healthy Eating and Active Living, 2000
But Is There the Technical and Political Will?
New Directions for Research---
Beyond the Basics and Across Disciplines
· Who wins, loses with healthy eating and exercise?
· What are the incentives/disincentives of different
marketplace sectors?
· Where we don’t know, what do different consumer
segments want/need?
· What interventions do key intermediaries want to offer?
· For policy change, what does the public want?
What do policy makers think?
· What are the most rational funding sources?
· Who are the coalition members, and how much muscle
will they flex?
· Do “town and gown” have the will to make change?
Will researchers join forces with public health and the
advocates?