Lifestyle and colorectal cancer
Prevention
Professor Annie S. Anderson
Centre for Public Health Nutrition Research
Centre for Research into Cancer Prevention and Screening
Ninewells Medical School,
University of Dundee
email: a.s.anderson@dundee.ac.uk
http://www.dietandcancerreport.org
Cancers of 17 sites – 80% of incidence and deaths worldwide
Food, Nutrition, Physical activity and cancers of the
Colon and the Rectum – modifiable risk factors
RECOMMENDATIONS
Convincing
Decreases Risk
Increases Risk
Physical activity
Foods containing dietary fibre
Red meat
Processed meat
Alcoholic drinks (men)
Body fatness
Abdominal fatness
RECOMMENDATIONS
Probable
Garlic
Milk
Calcium
Alcoholic drinks
(women)
Preventability estimates (PAF%) for cancers
of the colon and rectum (UK) (WCRF, 2009)
and Parkin (2011)
Exposure
WCRF
PAF% (range)
Parkin
PAF% (range)
Foods containing Fibre
12 (5-18)
12
Red meat
5 (0-21)
21 (combined)
Processed meat
10 (0-23)
Alcoholic drinks
7 (0-18)
12
Physical Activity
12 (4-20)
3
7 (0-17)
13
43 (0 -73)
48
Body Fatness
Total estimate
% of incident CRC cases in the UK in 2010
due to 14 lifestyle factors (Parkin et al, 2011)
Exposure
% cancers attributable to
exposure
Meat
21.1
Overweight and obesity
13.0
Fibre
12.2
Alcoholic drinks
11.6
Tobacco
8.1
Physical exercise
3.3
Infections
2.2
Radiation- ionising
1.6
All of the above
54.4
CONVINCING
CONVINCING
Meat consumption and the risk of incident distal
colon and rectal adenoma (Ferrucci et al, 2012)
Prostate, Lung, Colorectal and Ovarian screening trial
(17,072), 1008 with distal colorectal adenomas
Rectal adenomas
Meat
OR (CI)
Grilled meat
1.56 (1.04-2.36)
Well or very well done meat
1.59 (1.05-2.43)
2,amino-1-methyly-6-phenyl-imadzo4
(PhIP)
1.75 (1.17-2.43)
benzoapyrene
1.53(1.06-2.20)
Total mutagenic activity
1.57 (1.03-2.40)
Total iron was inversely associated (0.69, 0.56-0.86) with any distal colorectal adenoma
Sansom et al (2012) High Iron plus defective APC gene
Scientific Advisory Committee on Nutrition
(2009) Iron and Health report
58% of men currently have
intakes of total red meat
exceeding 70g/day
Body fatness
Abdominal fatness
Greater for colon cancer
15% increased risk per
5kg/m2
5% increased risk per inch
of waist circumference
Possible mechanisms
include
– impacts on insulin
– oestrogens
– stimulates inflammatory
response
http://www.scotland.gov.uk/Resource/Doc/331913/0107995.pdf
Weight perceptions
(Yaemsiri et al, 2011)
National Health and Nutrition Examination Survey
(NHANES)
16,720 adults 2003-2008
23% of OW women and 48% of OW men perceived
themselves as ‘right weight’
74% of OW and 29% of obese adults had never received a
diagnosis of OW/obese
Weight control was linked with HCP diagnosis of OW/obese
Weight control was associated with overweight perception
Foods and drinks that promote
weight gain
Sugary Drinks- definitions
Principally drinks with “added
sugar”
•Colas, squashes, sodas
•Fruit juices (limited)
2007 to the future…
•Milk Shakes (2160 kcals)
•Fruit Smoothies no sugar added… (120 to 190kcals)
•With “Health added” e.g. Orange Juice Drink with 'Five
Added Nutrients'
Energy Density-definitions
High Energy Dense
>225 to 275 kcals +/100g
High Energy Dense
>225 to 275 kcals+/100g
High Energy Dense
>225 to 275 kcals+/100g
Fast foods- definitions
Fast Foods
Readily available convenience foods
- Energy dense
- Consumed frequently
- Large portions
1420 Kcal
Plant foods
Five a day… minimum (7000)
Fibre from unprocessed cereals /whole
grains and/or pulses with every meal
Limit refined starchy foods (white
flour, pastry, biscuits, baked goods)
Total DF was inversely associated with
CRC (HR per 10g/day increase in fibre
0.87, (0.79-0.96)).
Fibre from cereals and fibre from fruit and
veg were similar with colon cancer.
In rectal cancer, the inverse association
was only evident for cereal from fibre
Current fibre intakes
Dietary Reference Value (UK) 18g/day
National Diet and Nutrition Survey (2012)
Adult intake 13.3-13.8g/day
Alcohol Intake
Plausible mechanisms include..
Induce folate deficiency in the colon/rectum
Action of intestinal bacteria to oxidise alcohol
and produce acetaldehyde
Consumption of >30g/day of ethanol from
alcohol drinks as a cause of colorectal cancer is
convincing in men and probable in women
Alcohol consumption and the
risk of colon cancer by family
history of colorectal cancer
(Cho et al, 2012)
Nurses Health study + HP follow up), 26 year follow up
Higher alcohol associated with increased risk (significant at
> 30g/day)
If - Family History 1.23 (0.96-1.57)NS
If + Family History 2.02 (1.30-3.13)
Drinker with FH RR 2.80(2.00-3.91) compared to
non drinker, non FH
Smoking and colorectal cancer
Incidence of colorectal cancer
Hannan et al (2009)
Current smokers (HR 1.27 (95% CI 1.06 – 1.52)
Former smokers (HR 1.23 (95% CI 1.11 – 1.36)
Compared to lifelong non-smokers
Tsoi et al (2009) (Meta-analysis of PCS)
Current smokers (RR 1.20 (95% CI 1.10 – 1.30)
Compared to never smokers
HIGHER in Men, rectal cancers and dose -related
Physical Activity
SCOTLAND
Meeting current
guidelines
32% aged 55 to 64
19% aged 65 to 74
8% aged 75 +
Cancer reduction
Overweight
and obesity
reduction
Energy Balance
Food
Muesli bar
(35g)
Big MAC
(200g)
Kcal
Sitting
value per (light
portion
office
work)
127
1hr
25mins
Walking Running
481
2hrs 10 46 mins
mins
5hrs
20mins
(3mph)
(6mph or 10
min/mile)
34 mins 12 mins
Adapted from "Energy Expenditure of Walking and Running," Medicine & Science in
Sport & Exercise, Cameron et al, Dec. 2004. (based on 10st adult) (UPDATED)
Reducing the global cancer burden
Screening and treatment……
availability of clinical interventions
access to and use of existing technologies
Primary Prevention
Lifestyle interventions
Environmental interventions
The Scottish Cancer Taskforce – Where Does
Cancer Prevention Fit?
Health Promoting Health Service
‘Every healthcare contact is a health improvement opportunity’
Opportunities for Advocacy in
CRC setting
In CRC Screening
– Invitation
– Negative results
– Positive results (adenoma)
In utilising lifestyle risk scores
In Family History considerations
CRC screening
Why explore the screening
setting?
Screening “awakens curiosity” about disease
and causes (Bankhead et al, 2003)
Existing healthcare setting and structure
Serious setting….
Most do not have cancer
? “teachable moment……” (health scare)
Re-enforcement of public health efforts
Participants would welcome???
Endorsement by cancer experts (as opposed to
prevention messages from corn flakes packets,
newspapers etc)
Lifestyle information with screening invitation
Negative screening tests
Larsen et al (2007)
“health certificate effect” .. Screening
associated with fewer changes (in weight,
smoking, diet) than non screened at 3 year
follow up
Communication opportunity………..
Formative research
Moderator So if someone said you’ve had your polyps removed.
Now let’s look at your diet and your physical activity. How
would you react to that?
Participant If they said now that is caused by diet. Let’s look at your
diet. Fine I would go along with that. But nobody at any time has
said that was caused by your diet.
Stead M, Caswell S, Craigie AM, Eadie D, Anderson AS and the BEWEL
team Understanding the potential and challenges of adenoma treatment as
a prevention opportunity: insights from the BeWEL study. Preventive
Medicine (in press) doi:10.1016/j.ypmed.2011.10.017.
Formative research
Patients need to
Be ware of the risk factors for adenoma
Be able to relate these to personal
behaviours
To have a shared and accepted
understanding of lifestyle and CRC
Stead M, Caswell S, Craigie AM, Eadie D, Anderson AS and the BEWEL team Understanding the potential and
challenges of adenoma treatment as a prevention opportunity: insights from the BeWEL study. Preventive
Medicine ( 2012) 54:97-103
Dowswell G, Ryan A, Taylor A, Daley A, Freemantle N, Brookes N, et al. Designing an intervention to help people with
colorectal adenomas reduce their intake of red and processed meat and increase their levels of physical activity: a
qualitative study. BMC Cancer 2012;12:255
Utilising lifestyle risk score
Prevention of Type 2 Diabetes in FinlandFIN-D2D
Population strategy
High risk strategy
Strategy of early diagnosis
and management
381
83,767 Nurses, 701 cases of colon cancer
Smoking
High body weight
Low physical activity
Ate red and processed meat daily
Low folate intake
never been screened
had x4 higher risk
Magnitude of risk reduction
through endoscopic
screening was less than
the risk reduction for
lifestyle and diet change
alone
Family history considerations
FH of CRC :clinicians preventive
recommendations and patient behaviour
(Zlot et al, 2012)
FH associated with higher risk of
discussing CRC screening
Respondents having CRC screening
within recommended time period
FH associated with reported lifestyle
changes
NOTE Sisters Study (44,364 women) study of sisters of
women with breast cancer, majority of women no more
likely than women in the general population to engage in
healthy lifestyle behaviours
Conclusions
There is a lot of evidence on lifestyle and
prevention of CRC
Much of the lifestyle change needed would
also reduce risk of CVD and diabetes
Translating evidence into action is a
challenge
Prevention is everyones business