Nutrition and Physical Activity Cancer Prevention Guidelines and Cancer Prevention Ana Maria Lopez, MD, MPH, FACP Professor of Medicine and Pathology University of Arizona Cancer Center Medical Director, Arizona Telemedicine Program
Objectives 1. Outline the known lifestyle risk factors for Cancer 2. Define the ACS Cancer Prevention Guidelines 3. Discuss the benefits of the ACS Cancer Prevention Guidelines on Cancer Incidence
Background
Wellness Guidelines: Lifestyle Modification Nutrition and physical activity guidelines for cancer prevention and chronic disease risk reduction generally overlap Both focus on: Good nutrition: eating right Greater physical activity Moderate alcohol consumption Healthy body weight
Nutrition/Physical Activity and Heart Disease
Nurses Health Study 80,000 women for 20 years Those with the healthiest lifestyle had an 82% reduced risk of CHD. Healthy lifestyle included: no smoking physical activity: at least 30 minutes of walking daily not overweight: BMI of < 25 alcohol intake: ½ glass a day nutrition: high in marine omega-3 fatty acids and cereal fiber low in trans fat and glycemic load high in ratio of polyunsaturated to saturated fat Independent of family history, age, hypertension, or lipid status!
Cancer Prevention Smoking cessation Most important behavioral change to reduce cancer risk
Recent Literature Cancer Prevention Study II and the European Prospective Investigation of Cancer (EPIC) study confirmed: behaviors consistent with Nutrition and Physical Activity Cancer Prevention Guidelines were associated with lower cancer incidence and mortality The Iowa Women's Health Study reported that non-adherence to cancer prevention guidelines was associated with a 35% greater cancer risk
What next? Healthy lifestyle behaviors are recommended to reduce cancer risk and overall mortality. Adherence to cancer-preventive health behaviors reduces subsequent cancer risk Adherence to cancer-preventive health behaviors and subsequent cancer risk has not been evaluated in a diverse sample of postmenopausal women.
Nutrition and Physical Activity Cancer Prevention Guidelines, Cancer Risk, and Mortality in the Women's Health Initiative Cynthia A. Thomson, Marjorie L. McCullough, Betsy C. Wertheim,Rowan T. Chlebowski, Maria Elena Martinez, Marcia L. Stefanick,Thomas E. Rohan, JoAnn E. Manson, Hilary A. Tindle, Judith Ockene,Mara Z. Vitolins, Jean Wactawski-Wende, Gloria E. Sarto, Dorothy S. Lane, and Marian L. Neuhouser Cancer Prevention Research7(1); 42 53. 2014 AACR.
Study Schema Build upon available evidence--apply the American Cancer Society (ACS) guidelines on nutrition and physical activity for cancer prevention as a framework to evaluate associations with cancer outcomes Focus on the Women's Health Initiative Observational Study (WHI-OS): postmenopausal women Opportunity to evaluate these associations in an older age group, within diverse racial/ethnic strata, and by smoking status.
Hypothesis Behaviors most consistent with the nutrition and physical activity guidelines would be associated with lower: cancer risk all-cause and cancer-specific mortality.
Study Outline Population: Postmenopausal women enrolled in the Women's Health Initiative Observational Study (N=93,676) Definition of adherence to cancer-preventive health behaviors: American Cancer Society (ACS) Nutrition and Physical Activity Cancer Prevention Guidelines ACS guidelines ACS score (0 8 points) determined from a combined measure of diet, physical activity, body mass index (current and at age 18 years), and alcohol consumption. Outcome measures: risk of incident cancer, cancer-specific mortality, and allcause mortality
WHI-OS Prospective study of health outcomes among 93,676 postmenopausal women (1993 to 1998) 40 U.S. clinical centers Ages 50 to 79 years at enrollment Questionnaires to characterize : physical activity, food frequency questionnaire, medical history, and quality of life, and provided self-determined race/ethnicity information. Weight and height were measured at clinic visits by trained staff, and body mass index (BMI) was computed. Self-reported height and weight at age 18 years was used to estimate change in BMI during adulthood. The Institutional Review Boards at each institution approved the study and all participants provided written informed consent.
Study Population Exclusions: Cancer history: personal history of cancer (n = 12,075), cancer history unknown (n = 752), developed a cancer diagnosis within 2 yrs of study enrollment (n = 2,246) BMI: underweight (BMI < 18.5 kg/m2) at baseline (n = 1107), unknown BMI at baseline (n = 1,105) or at age 18 years (n= 2,703); unreliable BMI data (change in height or weight between age 18 years and baseline >4 SDs beyond the mean; n = 4,948) Dietary data: unavailable (n = 96); unreliable (<600 or >5,000 kcal/d, n = 3,571) Missing data: ETOH (n = 685), physical activity (n = 1,051), follow-up health status (n = 473), or any other covariates (n = 6,786) Died (n = 710) within 2 years of study entry Analytical cohort comprised 65,838 women.
Outcome Assessment Women completed a health status questionnaire annually. Medical records were reviewed/verifed re: self-reported study outcomes: cancer and death If lost to follow-up, vital status determined through linkage with the National Death Index Underlying causes of death were coded according to the International Classification of Diseases: Cancer includes all cancers other than non-melanoma skin cancer Cancer mortality defined as death from any cancer other than non-melanoma skin cancer Outcomes for specific cancers included breast, colorectal, endometrial, ovarian, and lung cancer; Cancer sites were selected on the basis of sufficiency in case numbers and/or evidence of an association with modifiable lifestyle behaviors included in the ACS guidelines for diet and physical activity and cancer prevention All other types of cancer (except non-melanoma skin cancer) were combined into an other cancer group.
ACS Prevention Guidelines Score Four behavior-associated components: body weight, physical activity, diet, and alcohol consumption (McCullough, et al) Score derived from the individual components of the 2006 and more-recent 2012 ACS Guidelines on nutrition and physical activity for cancer prevention: Data collected at baseline and food and beverage line items on the food frequency questionnaire. Least consistent with the recommendations: score of 0 Mid-level concordance: score of 1 Meet criteria: score of 2. Score range: 0 to maximum score of 8. Tobacco not included in the ACS diet and physical activity guidelines score; was considered in a stratified analysis, given its association with select cancers.
Be physically active Adults: Get at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity activity each week (or a combination of these), preferably spread throughout the week. Children and teens: Get at least 1 hour of moderate or vigorous intensity activity each day, with vigorous activity on at least 3 days each week. Limit sedentary behavior such as sitting, lying down, watching TV, and other forms of screen-based entertainment. Doing some physical activity above usual activities, no matter what one s level of activity, can have many health benefits. http://www.cancer.org/acs/groups/cid/documents/webcontent/002577-pdf.pdf
http://www.hsph.harvard.edu/obesity-preventionsource/moderate-and-vigorous-physical-activity/ Measuring Physical Activity Exercise experts measure activity in metabolic equivalents, or METs. One MET = energy it takes to sit quietly For the average adult: one calorie per kg or every 2.2 pounds of body weight per hour e.g. someone who weighs 160 pounds would burn approximately 70 calories an hour while sitting or sleeping. Moderate-intensity activities: get you moving fast enough or strenuously enough to burn off three to six times as much energy per minute as you do when you are sitting quietly = 3 to 6 METs. Increases heart rate, can still carry on conversation Vigorous-intensity activities burn more than 6 METs Increases heart rate, causes rapid breathing Limitation: does not consider level of fitness walking at 3 to 4 miles-per-hour=4 METs, moderate-intensity activity regardless of who is doing the activity
Light <3.0 METs Walking slowly Sitting at computer Standing-light work ie washing dishes Fishng Playing most instruments Moderate 3-6 METs Brisk walk, 4 mph Heavy housework: washing windows, mopping Carrying moderate loads (<50 lbs) Mowing lawn Dancing Cycling, 10-12 mph Recreational badminton Tennis, doubles Vigorous +6 METs Hiking Jogging, 6 mph Shoveling Carrying heavy loads (>50 lbs) Bicycling, 14-16 mph Basketball game Soccer game Aerobics Tennis, singles Swimming http://www.who.int/dietphysicalactivity/physical_activity_intensity/en/ http://www.hsph.harvard.edu/obesity-prevention-source/moderate-andvigorous-physical-activity/
Eat a healthy diet, with an emphasis on plant foods Choose foods and drinks in amounts that help you get to and maintain a healthy weight. Limit how much processed meat and red meat you eat. Eat at least 2½ cups of vegetables and fruits each day. Choose whole grains instead of refined grain products.
If you drink alcohol, limit your intake Drink no more than 1 drink per day for women or 2 per day for men.
Associations between ACS cancer prevention guidelines score and (A) any incident cancer, (B) all-cause mortality, and (C) cancer-specific mortality. Thomson C A et al. Cancer Prev Res 2014;7:42-53 2014 by American Association for Cancer Research
Results: Summary Mean follow-up of 12.6 years 8,632 incident cancers 2,356 cancer deaths Highest ACS guidelines scores compared with the lowest: 17% lower risk of any cancer [HR, 0.83; 95% confidence interval (CI), 0.75 0.92] 22% lower risk of breast cancer (HR, 0.78; 95% CI, 0.67 0.92) 52% lower risk of colorectal cancer (HR, 0.48; 95% CI, 0.32 0.73) 27% lower risk of all-cause mortality 20% lower risk of cancer-specific mortality (HR, 0.80; 95% CI, 0.71 0.90) Ethnicity: association of lower cancer incidence and mortality- -generally strongest among Asian, black, and Latina populations weakest among non-latina whites
Summary Behaviors concordant with Nutrition and Physical Activity Cancer Prevention Guidelines were associated with lower risk of total, breast, and colorectal cancers and lower cancer-specific mortality in postmenopausal women.
Conclusions Healthy lifestyle behaviors recommended for nutrition and physical activity behavior may be associated with lower risk of cancer and death in postmenopausal women. The lower cancer incidence and all-cause mortality risk in Latinas and African American postmenopausal women, in relation to nutrition and physical activity behaviors, warrant further study.
Question 1 Your new patient is Mrs. Jones, a 45 year old woman, who was recently discharged from the hospital with an acute MI. Mrs. Jones has a BMI of 35, cholesterol of 330, and fasting blood sugar of 180. She is also a smoker who recently cut back from 2ppd to 1ppd during her recent hospital stay. She walks for half an hour with her husband after dinner and runs after her twin 18 month old grand babies all day. As you review her risk factors, you prioritize which of the following as having the most impact on her health: a- Weight loss to a BMI of 20 b- Smoking cessation c- Decrease carbohydrate intake d- Increase dietary fiber
Question 2 The ACS Prevention Guideline Score include: a- Body weight, Activity, and Smoking b- Body weight, Activity, and Fiber Intake c- Body weight, Activity, and Diet d- Body weight, Activity, and Sleep quality
Question 3 The ACS guidelines score was directly related to decreased cancer incidence of: a- Breast cancer, Cervical cancer b- Breast cancer, Colon cancer c- Breast cancer, Lung cancer d- Breast cancer, Leukemia
References McCullough ML, Patel AV, Kushi LH, Patel R, Willett WC, Doyle C, et al. Following cancer prevention guidelines reduces risk of cancer, cardiovascular disease, and all-cause mortality. Cancer Epidemiol Biomarkers Prev 2011;20:1089 97 Romaguera D, Vergnaud AC, Peeters PH, van Gils CH, Chan DS, Ferrari P, et al. Is concordance with World Cancer Research Fund/American Institute for Cancer Research guidelines for cancer prevention related to subsequent risk of cancer? Results from the EPIC study. Am J Clin Nutr 2012;96:150 63 Cerhan JR, Potter JD, Gilmore JM, Janney CA, Kushi LH, Lazovich D, et al. Adherence to the AICR cancer prevention recommendations and subsequent morbidity and mortality in the Iowa Women's Health Study cohort. Cancer Epidemiol Biomarkers Prev 2004;13:1114 20.
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http://sheetalsheth.com/latest/desert-dreams/ Thank you! alopez@uacc.arizona.ed u