Annie Anderson Bowel Cancer UK

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					Lifestyle and colorectal cancer

      Professor Annie S. Anderson
      Centre for Public Health Nutrition Research
      Centre for Research into Cancer Prevention and Screening
      Ninewells Medical School,
      University of Dundee
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

                    Decreases Risk                   Increases Risk

                    Physical activity                Red meat
                    Foods containing dietary fibre   Processed meat
Convincing                                           Alcoholic drinks (men)

                                                     Body fatness
                                                     Abdominal fatness
Probable            Garlic                           Alcoholic drinks
                    Milk                             (women)
Preventability estimates (PAF%) for cancers
of the colon and rectum (UK) (WCRF, 2009)
              and Parkin (2011)
   Exposure                 WCRF           Parkin
                            PAF% (range)   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
   Body Fatness             7 (0-17)       13
   Total estimate           43 (0 -73)     48
 % of incident CRC cases in the UK in 2010
due to 14 lifestyle factors (Parkin et al, 2011)

   Exposure                 % cancers attributable to
   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
      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                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
5% increased risk per inch
of waist circumference
Possible mechanisms
– impacts on insulin
– oestrogens
– stimulates inflammatory
             Weight perceptions
                 (Yaemsiri et al, 2011)
National Health and Nutrition Examination Survey

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
 •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
 Meeting current
 32% aged 55 to 64
 19% aged 65 to 74
  8% aged 75 +

                                         Cancer reduction

and obesity
               Energy Balance
Food             Kcal      Sitting                     Walking Running
                 value per (light                      (3mph)            (6mph or 10
                 portion   office                                        min/mile)
Muesli bar       127       1hr                         34 mins 12 mins
(35g)                      25mins

Big MAC          481                 5hrs              2hrs 10 46 mins
(200g)                               20mins            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
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
 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 Finland-

Population strategy
High risk strategy
Strategy of early diagnosis
and management
83,767 Nurses, 701 cases of colon cancer
High body weight                   Magnitude of risk reduction
                                   through endoscopic
Low physical activity              screening was less than
Ate red and processed meat daily   the risk reduction for
                                   lifestyle and diet change
Low folate intake                  alone
never been screened
had x4 higher risk
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
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
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
Prevention is everyones business

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