Obesity, physical activity and cancer - global perspectives

Transcription

1 Obesity, physical activity and cancer - global perspectives Philip James London School of Hygiene and Tropical Medicine, International Association for the Study of Obesity

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3 Body mass index and cause specific mortality in 900,000 adults: collaborative analyses of 57 cohorts Total mortality in relation to BMI 32 Yearly deaths per thousand (95% CI) 16 Normal Obese Lancet 2009:373:

4 % 18-29yrs 30-44yrs 45-59yrs 60-69yrs yrs 30-44yrs 45-59yrs 60-69yrs yrs 30-44yrs 45-59yrs 60-69yrs yrs 30-44yrs 45-59yrs 60-69yrs yrs 30-44yrs 45-59yrs 60-69yrs yrs 30-44yrs 45-59yrs 60-69yrs 70+ Rachel Leach, IOTF yrs 30-44yrs 45-59yrs 60-69yrs 70+ Female overweight and obesity by Region % 90 Female Overweight & Obesity by Region Overweight (BMI ) Obesity (BMI >30) Overweight (BMI kg/m2) Obesity (=>30 kg/m2) Africa Northern America Latin America Europe Middle East Asia Oceania Africa N. America L. America Europe M. East Asia Oceana Age (years) AGE

5 Popkin B. Amer.J Clin Nut ,

6 Greece Scotland Israel Czech Czech Republic Cyprus England Austria Finland Slovakia Lithuania Germany Latvia Croatia Hungary Russia Ireland Spain France Belgium Switzerland Switzerland (urban) Sweden Denmark Netherlands Norway Norw ay Obese Overweight Obese Women Men Percent

7 % overweight + obese The natural history of childhood overweight/obesity using IOTF cut-offs in Australia over the last century and regional global increases Global total now: obese 74 mil. +overwt. 287 mil Australia 45 e.g. US 30 Raw data All data e.g. S.Arabia e.g. UK Year % e.g. Japan e.g. India Americas ( ) Eastern Med ( ) Europe ( ) South East Asia ( ) West Pacific ( ) Recent surveys Projected 2006 Projected 2010 Norton K et al, Int J Ped Ob 2006 Wang and Lobstein, IOTF, Int J Ped Ob 2006.

8 Overweight & Obesity in Children around the Globe (Based on IOTF cut off points) % Overweight Obesity North America Latin America Eastern Med Europe West Pacific Region South East Asia Africa Rachel Leach, IOTF, April 28 th 2008

9 Socio-economic differences in overweight and obesity Jebb SA, Rennie KL, Cole TJ. Public Health Nutrition, 2004: 7(3), Prevalence (%) of overweight (hatched bars) and obesity (solid bars) by socio-economic category in young people aged 4-18 years in 1997 (n=1555). Socio-economic category I-III vs. IV and V: obesity, P=0.003; obesity and overweight, P= NM - non-manual. M - manual

10 Relative Risk The importance of modest weight gain in precipitating chronic disease: risks markedly increase within "normal" BMI range Aged at start Type 2 Diabetes Type 2 diabetes Women Asian?Hispanic "Normal" BMIs High Blood Pressure Hypertension Colon Cancer Coronary Heart Disease Coronary Heart Disease 0 < Body Mass Index Adapted: Willett, Dietz & Colditz, NEJM, 1999; 341, & AICR Report: Food Nutrition, Physical Activity and the Prevention of Cancer Nov. 2007

11 Disease Burdens in Europe linked to increasing body weights 3000 MEN Arthritis Breast Ca. WOMEN 2500 Endomet. Ca. Colon Ca. DALYs x Diabetes Stroke HT IHD Euro A Euro B Euro C Euro A Euro B Euro C Sub-region Euro A: EU countries in Croatia, Czech, Norway, Switzerland Euro B: Bulgaria, Poland, Romania, Turkey, Balkans, some Asian republics Euro C: Baltic countries, Hungary, Russia, Ukraine, Belarus, Kazakhstan, Moldavia.

12 Weight gain i.e. body fatness (obesity) increases the risk of many cancers Convincing evidence for inducing cancers in: oesophagus (adenocarcinoma) pancreas colorectum breast (postmenopausal) endometrium kidney Probable effects: gallbladder cancer Abdominal fatness probable effects: endometrium, pancreas, breast (postmenopausal) and colorectum AICR/WCRF Report, 2007

13 Causes of deaths after bariatric surgery : obesity related cancer is preventable within 7 years Surgical Group (N= *) Control Group (N= *) CVD Coronary Heart Failure Stroke Other CVD Cancer Suicide/poisoning* 12 3 * Significant adverse event *Deaths per 10,000 patient years Adams et al. NEJM, 2007.

14 From Policy and Action for Cancer Prevention, WCRF/AICR, 2009 Data sources: World Health Organization (2008) Parkin DM, et al (1988, 1993, 1999) Pisani et al (1993, 1999) IARC (2002)

15 Cancer Incidence Changes in Cancer Incidence Colon Breast ' ' ' ' ' * Per 100,000, world population standard

16 Lifecycle: the proposed causal links Inadequate food, health & care Elderly Malnourished Reduced capacity to care for baby Inadequate foetal nutrition Woman Malnourished Pregnancy Low Weight Gain Higher mortality rate Baby Low Birth Weight Impaired mental development Inadequate growth Adolescent Stunted Child Stunted Epigenetic susceptibility to chronic diseases if diet becomes inappropriate Untimely Weaning / inadequate Frequent infections Inadequate food, health & care Inadequate food, health & care Reduced mental capacity Higher maternal mortality Inadequate food, health & care Reduced mental capacity Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.

17 The impact of inappropriate Western diets on most of the world's susceptible populations: health systems already overwhelmed Diabetes, strokes, heart disease, cancers arthritis Inadequate health care system Reduced fertility; CVD, HT Cancers Elderly Early onset Type 2 Diabetes Reduced capacity to care for baby Disordered foetal nutrition Woman o/w or obese Pregnancy Glucose intolerance/ diabetes Fat Baby High Birth Weight Rapid Abdominal obesity Inadequate obstetric care Normal/high growth weight gain Adolescent O/W-obese Reduced job opportunities Child overweight Untimely Early Weaning / inadequate Poor school conditions Frequent fast foods Inadequate physical activity Reduced play and social isolation Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.

18 BMI and colorectal cancer: cohort studies and risk gradient

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20 Recreational Activity and Colon Cancer: Cohort Studies High BMI Low BMI

21 BMI and Post-menopausal Breast Cancer: Cohort Studies

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23 WCRF/AICR: BMI and Oesophageal adenocarcinoma

24 WHO : Risk Factors for DALYs. Dec 2009 DALYs (Millions) %Total *

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26 WCRF/IARC: The Impact of Diet on the Cancer Process

27 WCRF/IARC: The Impact of Diet on the Cancer Process

28 Estimates of Cancer Preventability ( %) by appropriate food, nutrition, physical activity and body fatness* Cancer USA UK Brazil China Oesophagus Pancreas Colorectum 45(15 ) 43(12) 37(15) 17(7) Breast 38(17*) 42(16) 28(14) 20(12) Endometrium, WCRF/AICR. Policy and Action for Cancer Prevention..Food, Nutrition, and Physical Activity: a Global Perspective 2009

29 Economic development and falling food needs US Intakes Kcals 3000? Japan UK Intakes Increasing obesity Car Use Mechanical aids TV Computers Economic development and ageing Energy needs

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31 A quarter-pound cheeseburger, large fries and a 16 oz. soda provide: 1,166 calories 51 g fat 95 mg cholesterol 1,450 mg sodium Obesity is a commercial success. Promotional budgets and advertising markets for energy-dense nutrient-poor (junk) food and drinks hugely outweigh those for healthy food. Similarly, the budgets for inactive transport and entertainment (video games, internet, TV) morbidly outweigh those for active transport and active entertainment Australian Prev.HlthTaskforce,Oct,2008

32 The keys to success in the food business and in obesity and chronic disease prevention Marketing Price Availability

33 Who controls the food chain? Global Feed Companies F a r m e r s Global Food Companies Supermarkets: the "food consuming industry" Local markets, roadside stalls and farm shops Family and other small food companies Small food outlets P U B L I C Corinna Hawkes, 2006

34 Manipulating children's behaviour: evidence from the UK government's systematic analysis Food industry promotions: Can confuse nutritional knowledge, e.g. whether fruit is in product Change food preferences Change purchasing behaviour Influence choice and consumption by brand Alter balance of food categories eaten Hastings Report, UK Food Standards Agency, 25th September, 2003.

35 Marketing : celebrities and sports David Beckham = soft drinks Gary Lineker = potato crisps

36 The current obesity dilemma UK Government report Oct Obesity is a normal "passive" biological response to our changed physical and food environment Some children/adults are more susceptible for genetic, social and economic reasons Overwhelming environmental impact reflects outcome of normal industrial development Obesity reflects failure of the free market

37 Complementary approaches to obesity & chronic disease prevention Individual responsibility e.g. Any focus on Health Education selectively helps upper socio-economic groups. But need understandable food labelling; Drs have major role in identifying susceptible adults to avoid diabetes Adapted from Puska P, 2001 Changes to the "toxic" environment Progressively adapt all towns/cities to favour pedestrian/cycling as norm with car restrictions Nutritional standards for food in all government facilities/schools; eliminate trans fats; catering on Finnish scale: fruit + veg. within meal costs Limit/abolish all marketing to children Selectively increase costs of high fat/sugary products; soft drinks Social/employment/medical policies for breast feeding as the norm/new nursery standards

38 Mean BMI Obesity: time watching TV overwhelms leisure activity in Australia Increasing TV time Leisure time sport & activity Average BMI for each group *High *Mod #Low Inactive High Moderate Low Inactive Total daily physical activity Physical Activity Level TV time <1 hr/day hrs/day hrs/day >4 hrs/day Adapted from Salmon, Bauman et al IJO 2000; 24:

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40 Fundamental changes in physical activity: inevitable and optional changes Inevitable: Rural to urban transition Labour changes; Mechanisation/computerisation of standard work; also home duties e.g. cooking, washing, cleaning Optional: Urban building policies: high intensity or US style sprawl? Road and community design Office & supermarket location policies Car policies versus preference for cyclists/pedestrians Policies on free spaces for children's play; lighting for safety e.g. for older people Park/leisure/sports facilities/school PA lessons Ease of transport of perishable foods into towns/cities

41 Societal policies/ processes constraining personal choice & impacting the population prevalence of Cancer INTERNATIONAL FACTORS NATIONAL/ REGIONAL COMMUNITY LOCALITY WORK/SCHOOL/ HOME INDIVIDUAL POPULATION Transport Public Transport Leisure Activity/ Facilities Globalization of markets Development Media programs & advertising Urbanization Health Social security Media & Culture Education Public Safety Health Care Sanitation Manufactured/ Imported Food Labour Infections Worksite Food & Activity Family & Home Energy Expenditure Food intake : Nutrient density % With Cancer Food & Nutrition Agriculture/ Gardens/ Local markets School Food & Activity National perspective Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipatis V. IOTF website 1999:

42 Evaluation: Options for Action Level of confidence in evidence Potential impact on cancer/public health

43 Healthy Weight, Healthy Lives. Two Years on. UK March 10 th 2010

44 INTEREST The interest and influences of different stakeholders Lobstein T : Analyses based on The Food Commission's experience and new EU policy work. Health professionals Advocacy Parents orgs. Children Teachers Scientists INFLUENCE Church Food inspectors Farmers Retailers Ministry of Health Ministry of Education Ministries of Transport & Agriculture Advertising industry Ministry of Trade Parliament Media Food/drink industry Treasury President

45 Impact of Concerted Action Everyone has a role Action to be coherent Leadership from - Government - Health professionals