Obesity, physical activity and

cancer - global perspectives

Philip James
London School of Hygiene and Tropical Medicine,
International Association for the Study of Obesity
Body – mass index and cause – specific mortality in 900,000
adults: collaborative analyses of 57 cohorts
Total mortality in relation to BMI

“Normal” Obese
32

Yearly
deaths
per
thousand
(95% CI)
16

Lancet
8 2009:373:
20 25 30 35 40 1083-1096
 Female overweight and obesity by Region
Female Overweight & Obesity by Region Overweight (BMI 25-29.9 kg/m2)
% Overweight (BMI 25-29.9) Obesity (=>30 kg/m2)
Obesity (BMI >30)
90

80

70

60

50
%

40

30

20

10

0
18-29yrs
30-44yrs
45-59yrs
60-69yrs

18-29yrs
30-44yrs
45-59yrs
60-69yrs

18-29yrs
30-44yrs
45-59yrs
60-69yrs

18-29yrs
30-44yrs
45-59yrs
60-69yrs

18-29yrs
30-44yrs
45-59yrs
60-69yrs

18-29yrs
30-44yrs
45-59yrs
60-69yrs

18-29yrs
30-44yrs
45-59yrs
60-69yrs
70+

70+

70+

70+

70+

70+

70+
Africa Northern America Latin America Europe Middle East Asia Oceania
Africa N. America L. America Europe
Age (years) M. East Asia Oceana
AGE

Rachel Leach, IOTF 2008

Popkin B. Amer.J Clin Nut 2006. 84, 289-298
 Obese Overweight Obese
Greece
Greece
Scotland
Scotland
Israel
Israel
CzechCzechRepublic
Republic
Cyprus
Cyprus
England
England
Austria
Austria
Finland
Finland
Slovakia
Slovakia
Lithuania
Lithuania
Germany
Germany
Latvia
Latvia
Croatia
Croatia
Hungary
Hungary
Russia
Russia
Ireland
Ireland
Spain
Spain
France
France
Belgium
Belgium
Switzerland (urban)
Sw itzerland (urban)
Sweden
Sw eden
Denmark
Denmark
Netherlands
Netherlands
Women Men
Norway
Norw ay

80 60 40 20 0 20 40 60 80
Percent
 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.
50

40 Australia 45 e.g. US
40
% overweight + obese

Raw data
35
30 e.g. S.Arabia e.g. UK
All data 30

% 25
20
20
e.g. Japan
15 Americas (1988-2002)
10 Eastern Med (1992-2001)
10
e.g. India Europe (1992-2003)
5 South East Asia (1997-2002)
West Pacific (1993-2000)
0 0
1900 1920 1940 1960 1980 2000
Year Recent surveys Projected 2006 Projected 2010

Norton K et al, Int J Ped Ob 2006 Wang and Lobstein, IOTF, Int J Ped Ob 2006.
 Overweight & Obesity in Children around the Globe
(Based on IOTF cut off points)

40
35
30
25
% 20
15
10
5
0
North Latin Eastern Med Europe West South East Africa
America America Pacific Asia
Overweight
Obesity
Region

Rachel Leach, IOTF, April 28th 2008

 Socio-economic differences in overweight and obesity

Jebb SA, Rennie KL, Cole TJ. Public Health Nutrition, 2004: 7(3), 461-465.

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=0.004. NM - non-manual. M - manual
The importance of modest weight gain in precipitating chronic
disease: risks markedly increase within "normal" BMI range

Aged 30-55 at start Type

Type 2 Diabetes
2 diabetes

6
Women
5
High Blood
Relative Risk

Asian Hypertension
Pressure
4
?Hispanic
3 Colon
Cancer
2
Coronary Heart Disease
Coronary Heart
1 Disease
"Normal" BMIs

0
<21 22 23 24 25 26 27 28 29 30
Body Mass Index

Adapted: Willett, Dietz & Colditz, NEJM, 1999; 341, 426-434 & AICR Report:
Food Nutrition, Physical Activity and the Prevention of Cancer Nov. 2007
 Disease Burdens in Europe linked to increasing body weights

3000
MEN Arthritis WOMEN
Breast Ca.

2500 Endomet. Ca.

Colon Ca.

Diabetes
2000
Stroke
DALYs HT

x 103 1500 IHD

1000

500

0
Euro A Euro B Euro C Euro A Euro B Euro C

Sub-region

Euro A: EU countries in 2003 + Croatia, Czech, Norway, Switzerland

Euro B: Bulgaria, Poland, Romania, Turkey, Balkans, some Asian republics
Euro C: Baltic countries, Hungary, Russia, Ukraine, Belarus, Kazakhstan, Moldavia.
 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
 Causes of deaths after bariatric surgery : obesity
related cancer is preventable within 7 years

Surgical Group Control Group

(N=7925 213*) (N=7925 321*)
CVD 9.7 18.5
Coronary 2.6 5.9
Heart Failure 0.4 1.1
Stroke 1.1 2.0
Other CVD 5.5 9.6
Cancer 5.5 13.3
Suicide/poisoning* 12 3
* Significant adverse event
*Deaths per 10,000 patient years Adams et al. NEJM, 2007.
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)
 Changes in Cancer Incidence

30
Cancer Incidence

25

Colon
20
Breast

15

10

0
1960 1965 1970 - 1973 - 1979 - 1983 - 1988 - 1995 1997
'71 '77 '82 '87 '92

* Per 100,000, world

population standard
 Lifecycle: the proposed Epigenetic
Higher
causal links mortality susceptibility to
rate Impaired mental chronic diseases
development if diet becomes
Reduced inappropriate
Elderly capacity to Baby Inadequate
Malnourished care for baby Low Birth Weaning / inadequate
growth Untimely
Weight
Frequent
infections

Inadequate Inadequate food,

foetal health & care
Inadequate nutrition
food, health
& care Child
Stunted
Woman Reduced
Malnourished mental
Pregnancy capacity
Low Weight
Gain Adolescent Inadequate food,
Stunted health & care

Higher Reduced
maternal Inadequate food, mental
Adapted from James et al. SCN
mortality health & care Millennium Rep. Food &
capacity Nutrition Bulletin, 2000, 21, 3S.
 The impact of inappropriate Western diets on most of the world's
susceptible populations: health systems already overwhelmed

Diabetes,
strokes, Reduced
heart capacity to Fat Baby
Elderly care for baby High Birth
Normal/high
disease, growth Early Weaning
Untimely / inadequate
cancers Weight
arthritis Frequent
fast foods
Rapid weight gain
Disordered Inadequate
foetal physical activity
Inadequate nutrition
Abdominal
health care
obesity
system Child
overweight
Woman Reduced
o/w or obese Pregnancy play and
Glucose social
intolerance/ isolation
diabetes Adolescent
O/W-obese Poor school
Reduced conditions
fertility;
CVD, HT Early onset Reduced job
Type 2 Inadequate Adapted from James et al. SCN
Cancers opportunities
Diabetes obstetric care Millennium Rep. Food &
Nutrition Bulletin, 2000, 21, 3S.
BMI and colorectal cancer: cohort studies and risk gradient
Recreational Activity and Colon Cancer: Cohort Studies

High BMI
Low BMI
BMI and Post-menopausal Breast Cancer: Cohort Studies
WCRF/AICR: BMI and Oesophageal adenocarcinoma
 WHO : Risk Factors for DALYs. Dec 2009
DALYs (Millions) %Total

*
WCRF/IARC: The Impact of Diet on the Cancer Process
WCRF/IARC: The Impact of Diet on the Cancer Process
 Estimates of Cancer Preventability ( %)
by appropriate food , nutrition, physical
activity† and body fatness*
Cancer USA UK Brazil China
Oesophagus
69 75 60 44
Pancreas
39 41 34 14
Colorectum
45(15†) 43(12) 37(15) 17(7)
Breast
38(17*) 42(16) 28(14) 20(12)

Endometrium,
70 56 52 34
WCRF/AICR. Policy and Action for Cancer Prevention.
.Food, Nutrition, and Physical Activity: a Global Perspective 2009
 Economic development and falling food needs
US Intakes

Kcals
3000 ? Japan
UK Intakes Increasing
obesity

2000 Energy needs

Car Use
Mechanical aids
1000

TV
Computers
Economic development and ageing
 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
The keys to success in the food business and
in obesity and chronic disease prevention

• Marketing

• Price

• Availability
 Who controls the food chain ?
Global Feed Companies
Family and other
Global Food small food

Companies
companies P
F
Supermarkets: U
a
r
the "food consuming B
industry"
m L
e Local markets,
roadside stalls and I
farm shops
r
s
Small
food
C
outlets

Corinna Hawkes, 2006

 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.
Marketing : celebrities and sports

David Beckham
= soft drinks

Gary Lineker
= potato crisps
 The current obesity dilemma
UK Government report Oct. 2007
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
Complementary Individual responsibility
e.g. Any focus on Health Education
approaches to selectively helps upper socio-economic
obesity & groups. But need understandable food
chronic disease labelling; Drs have major role in
identifying susceptible adults to avoid
prevention diabetes

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
Adapted from Puska P, 2001
Obesity: time watching TV overwhelms leisure activity in Australia

28
Increasing TV time Leisure time
27
27 sport & activity

26
Average 26
TV
Mean BMI

BMI for
each 25
25 time
group 24
24 <1 hr/day
23
23 1-2.5 hrs/day
2.5-4 hrs/day
22
22 >4 hrs/day
21
21
*High
High *Mod
Moderate #Low
Low Inactive
Inactive
Total daily
Physical physical
Activity Level activity

Adapted from Salmon, Bauman et al IJO 2000; 24:600-606

 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
Societal policies/ processes constraining personal choice
& impacting the population prevalence of Cancer
INTERNATIONAL NATIONAL/ COMMUNITY WORK/SCHOOL/ INDIVIDUAL POPULATION
FACTORS REGIONAL LOCALITY HOME

Public Leisure
Transport
Transport Activity/
Facilities

Globalization
Energy
Urbanization Public Expenditure
of Safety Labour
markets
%
Health Health Infections
Care With
Development
Worksite
Cancer
Social security Food &
Sanitation Activity Food
intake :
Media Media & Nutrient
programs Culture Manufactured/ Family & density
& advertising Imported Home
Food
Education

School
Food & Agriculture/ Food &
Nutrition Gardens/ Activity
Local markets

National
perspective

Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipatis V. IOTF website 1999: http://www.iotf.org
Evaluation: Options for Action
• Level of confidence in evidence
• Potential impact on cancer/public health
Healthy Weight, Healthy Lives. Two Years on.
UK March 10th 2010
 The interest and influences of different stakeholders
Health
professionals
10 Advocacy
Parents orgs. Ministry of
Children Teachers
Scientists Health
5
Church Ministry of
Food Education
Parliament
inspectors Treasury
Farmers
Ministry of
0 Trade
Retailers President
Ministries of
INTEREST

Transport Media
& Agriculture
-5
Advertising
industry
Food/drink
industry
-10
0 5 10
INFLUENCE
Lobstein T : Analyses based on The Food Commission's experience and
new EU policy work.
Impact of Concerted Action

• Everyone has a role

• Action to be coherent
• Leadership from
- Government
- Health professionals