Food, nutrition, physical activity, and the prevention of cancer

537 Pages·2007·8.095 MB·English

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a Global Perspective
Please cite the Report as follows:
World Cancer Research Fund / American Institute for Cancer Research.
Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective.
Washington DC: AICR, 2007
First published 2007 by the American Institute for Cancer Research
1759 R St. NW, Washington, DC 20009
© 2007 World Cancer Research Fund International
All rights reserved
Readers may make use of the text and graphic material in this Report
for teaching and personal purposes, provided they give credit to
World Cancer Research Fund and American Institute for Cancer Research.
ISBN: 978-0-9722522-2-5
CIP data in process
Printed in the United States of America by RR Donnelley
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a Global Perspective
A project of
World Cancer Research Fund
International
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I am very grateful to the special group of distinguished scientists who made up the Panel
and Secretariat for this major review of the evidence on food, nutrition, physical activity
and cancer. The vision of WCRF International in convening this Panel and confidence in
letting a strong-willed group of scientists have their way is to be highly commended.
In our view, the evidence reviewed here that led to our recommendations provides a
wonderful opportunity to prevent cancer and improve global health. Individuals and
populations have in their hands the means to lead fuller, healthier lives. Achieving that
will take action, globally, nationally, and locally, by communities, families, and
individuals.
It is worth pausing to put this Report in context. Public perception is often that experts
disagree. Why should the public or policy-makers heed advice if experts differ in their
views? Experts do disagree. That is the nature of science and a source of its strength.
Should we throw up our hands and say one opinion is as good as another? Of course not.
Evidence matters. But not evidence unguided by human thought. Hence the process that
was set up for this review: use a systematic approach to examine all the relevant evidence
using predetermined criteria, and assemble an international group of experts who, having
brought their own knowledge to bear and having debated their disagreements, arrive at
judgements as to what this evidence means. Both parts of the exercise were crucial: the
systematic review and, dare I say it, the wisdom of the experts.
The elegance of the process was one of the many attractions to me of assuming the role
of chair of the Panel. I could pretend that it was the major reason, and in a way it was, but
the first reason was enjoyment. What a pleasure and a privilege to spend three years in
the company of a remarkable group of scientists, including world leaders in research on
the epidemiology of cancer, as well as leaders in nutrition and public health and the
biology of cancer, to use a relatively new methodology (systematic literature reviews),
supported by a vigorous and highly effective Secretariat, on an issue of profound
importance to global public health: the prevention of cancer by means of healthy patterns
of eating and physical activity. It was quite as enjoyable as anticipated.
Given this heady mix, the reasons why I might have wanted to take on the role of Panel
chair were obvious. I did question the wisdom of WCRF International in inviting me to do
it. Much of my research has been on cardiovascular disease, not cancer. What I described
as my ignorance, WCRF International kindly labelled impartiality.
WCRF also appreciated the parallels between dietary causes of cardiovascular disease
and cancer. There is a great deal of concordance. In general, recommendations in this
Report to prevent cancer will also be of great relevance to cardiovascular disease. The only
significant contradiction is with alcohol. From the point of view of cancer prevention, the
best level of alcohol consumption is zero. This is not the case for cardiovascular disease,
where the evidence suggests that one to two drinks a day are protective. The Panel
therefore framed its recommendation to take this into account.
The fact that the conclusions and recommendations in this Report are the unanimous
view of the Panel does not imply that, miraculously, experts have stopped disagreeing. The
Panel debated the fine detail of every aspect of its conclusions and recommendations with
remarkable vigour and astonishing stamina. In my view, this was deliberation at its best. If
conclusions could simply fall out of systematic literature reviews, we would not have
needed experts to deliberate. Human judgement was vital; and if human, it cannot be
infallible. But I venture to suggest this process has led to as good an example of evidence-
based public health recommendations as one can find.
Throughout the Panel’s deliberations, it had in mind the global reach of this Report.
Most of the research on diet and cancer comes from high-income countries. But
iv
noncommunicable diseases, including cancer, are now major public health burdens in
every region of the world. An important part of our deliberations was to ensure the
global applicability of our recommendations.
One last point about disagreement among experts: its relevance to the link between
science and policy. A caricature would be to describe science as precise and policy-makers
as indecisive. In a way, the opposite is the case. Science can say: could be, might be,
some of us think this, and some think that. Policy-makers have either to do it or not
do it — more often, not. Our effort here was to increase the precision of scientific
judgements. As the Report makes clear, many of our conclusions are in the ‘could be’
category. None of our recommendations is based on these ‘could be’ conclusions. All are
based on judgements that evidence was definite or probable. Our recommendations, we
trust, will serve as guides to the population, to scientists, and to opinion-formers.
But what should policy-makers do with our judgements? A year after publication of
this Report, we will publish a second report on policy for diet, nutrition, physical activity,
and the prevention of cancer. As an exercise developing out of this one, we decided to
apply, as far as possible, the same principles of synthesis of evidence to policy-making.
We enhanced the scientific panel that was responsible for this Report with experts in
nutrition and food policy. This policy panel will oversee systematic literature reviews on
food policy, deliberate, and make recommendations.
The current Report and next year’s Policy Report have one overriding aim: to reduce
the global burden of cancer by means of healthier living.
Michael Marmot
v
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PPrreeffaaccee iivv CChhaapptteerr 77 CCaanncceerrss 224444
CCoonntteennttss vvii 7.1 Mouth, pharynx and larynx 245
7.2 Nasopharynx 250
AAcckknnoowwlleeddggeemmeennttss vviiiiii 7.3 Oesophagus 253
7.4 Lung 259
SSuummmmaarryy xxiivv 7.5 Stomach 265
7.6 Pancreas 271
IInnttrroodduuccttiioonn xxxxiiii 7.7 Gallbladder 275
7.8 Liver 277
7.9 Colon and rectum 280
■■ PPAARRTT OONNEE BBAACCKKGGRROOUUNNDD 11 7.10 Breast 289
7.11 Ovary 296
CChhaapptteerr 11 IInntteerrnnaattiioonnaall vvaarriiaattiioonnss aanndd ttrreennddss 44 7.12 Endometrium 299
7.13 Cervix 302
1.1 Food systems and diets throughout history 5 7.14 Prostate 305
1.2 Foods and drinks, physical activity, 7.15 Kidney 310
body composition 11 7.16 Bladder 312
1.3 Migrant and other ecological studies 22 7.17 Skin 315
1.4 Conclusions 25 7.18 Other cancers 318
CChhaapptteerr 22 TThhee ccaanncceerr pprroocceessss 3300 CChhaapptteerr 88 DDeetteerrmmiinnaannttss ooff wweeiigghhtt ggaaiinn,,
oovveerrwweeiigghhtt,, oobbeessiittyy 332222
2.1 Basic concepts and principles 31
2.2 Cellular processes 32 CChhaapptteerr 99 CCaanncceerr ssuurrvviivvoorrss 334422
2.3 Carcinogen metabolism 36
2.4 Causes of cancer 37 CChhaapptteerr 1100 FFiinnddiinnggss ooff ootthheerr rreeppoorrttss 334488
2.5 Nutrition and cancer 41
2.6 Conclusions 46 10.1 Method 349
10.2 Interpretation of the data 350
CChhaapptteerr 33 JJuuddggiinngg tthhee eevviiddeennccee 4488 10.3 Nutritional deficiencies 350
10.4 Infectious diseases 351
3.1 Epidemiological evidence 49 10.5 Chronic diseases other than cancer 352
3.2 Experimental evidence 52 10.6 Cancer 355
3.3 Methods of assessment 55 10.7 Conclusions 358
3.4 Causation and risk 57
3.5 Coming to judgement 58 CChhaapptteerr 1111 RReesseeaarrcchh iissssuueess 336600
3.6 Conclusions 62
■■ PPAARRTT TTHHRREEEE RREECCOOMMMMEENNDDAATTIIOONNSS 336655
■■ PPAARRTT TTWWOO EEVVIIDDEENNCCEE AANNDD JJUUDDGGEEMMEENNTTSS 6633
CChhaapptteerr 1122 PPuubblliicc hheeaalltthh ggooaallss aanndd
CChhaapptteerr 44 FFooooddss aanndd ddrriinnkkss 6666 ppeerrssoonnaall rreeccoommmmeennddaattiioonnss 336688
4.1 Cereals (grains), roots, tubers and plantains 67 12.1 Principles 369
4.2 Vegetables, fruits, pulses (legumes), nuts, 12.2 Goals and recommendations 373
seeds, herbs, spices 75 12.3 Patterns of food, nutrition and
4.3 Meat, poultry, fish and eggs 116 physical activity 391
4.4 Milk, dairy products 129
4.5 Fats and oils 135
4.6 Sugars and salt 141 AAPPPPEENNDDIICCEESS 339955
4.7 Water, fruit juices, soft drinks and hot drinks 148
4.8 Alcoholic drinks 157 AAppppeennddiixx AA PPrroojjeecctt pprroocceessss 339966
4.9 Food production, processing, preservation
and preparation 172 AAppppeennddiixx BB TThhee ffiirrsstt WWCCRRFF//AAIICCRR EExxppeerrtt RReeppoorrtt 339988
4.10 Dietary constituents and supplements 179
4.11 Dietary patterns 190 AAppppeennddiixx CC WWCCRRFF gglloobbaall nneettwwoorrkk 440000
GGlloossssaarryy 440022
CChhaapptteerr 55 PPhhyyssiiccaall aaccttiivviittyy 119988
RReeffeerreenncceess 441100
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ccoommppoossiittiioonn 221100 IInnddeexx 550066
6.1 Body fatness 211
6.2 Growth and development 229
6.3 Lactation 239
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CCHHAAPPTTEERR BBOOXXEESS Box 4.6.1 Sugar, sugars, sugary foods and drinks 142
Box 4.6.2 Salt and salty, salted and salt-preserved
■■ PPAARRTT OONNEE BBAACCKKGGRROOUUNNDD foods 143
Box 4.6.3 Chemical sweeteners 143
CChhaapptteerr 11 IInntteerrnnaattiioonnaall vvaarriiaattiioonnss aanndd ttrreennddss Box 4.6.4 Refrigeration 144
Box 4.7.1 High temperature, and irritant drinks
Box Egypt 6 and foods 150
Box South Africa 8 Box 4.7.2 Contamination of water, and of foods
Box China 10 and other drinks 150
Box 1.1 Measurement of food supply Box 4.8.1 Types of alcoholic drink 159
and consumption 13 Box 4.9.1 Food systems 173
Box India 14 Box 4.9.2 ‘Organic’ farming 174
Box Japan 16 Box 4.9.3 Regulation of additives and
Box UK 18 contaminants 175
Box 1.2 Measurement of cancer incidence Box 4.9.4 Water fluoridation 176
and mortality 18 Box 4.10.1 Food fortification 182
Box Poland 20 Box 4.10.2 Functional foods 182
Box Spain 22 Box 4.10.3 Levels of supplementation 183
Box USA 24
Box Mexico 26 CChhaapptteerr 55 PPhhyyssiiccaall aaccttiivviittyy
Box Australia 27
Box Brazil 28 Box 5.1 Energy cost and intensity of activity 200
Box 5.2 Sedentary ways of life 201
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CChhaapptteerr 66 GGrroowwtthh,, ddeevveellooppmmeenntt,, bbooddyy ccoommppoossiittiioonn
Box 2.1 Nutrition over the life course 34
Box 2.2 Oncogenes and tumour suppressor genes 35 Box 6.2.1 Sexual maturity 232
Box 2.3 Mechanisms for DNA repair 37 Box 6.2.2 Age at menarche and risk of
Box 2.4 Body fatness and attained height 39 breast cancer 232
Box 2.5 Energy restriction 46
CChhaapptteerr 77 CCaanncceerrss
CChhaapptteerr 33 JJuuddggiinngg tthhee eevviiddeennccee
Box 7.1.1 Cancer incidence and survival 246
Box 3.1 Issues concerning interpretation of Box 7.2.1 Epstein-Barr virus 251
the evidence 50 Box 7.5.1 Helicobacter pylori 266
Box 3.2 Dose-response 52 Box 7.8.1 Hepatitis viruses 278
Box 3.3 Forest plots 53 Box 7.13.1 Human papilloma viruses 303
Box 3.4 Systematic literature reviews 54
Box 3.5 Experimental findings 55 CChhaapptteerr 88 DDeetteerrmmiinnaannttss ooff wweeiigghhtt ggaaiinn,,
Box 3.6 Effect modification 56 oovveerrwweeiigghhtt,, oobbeessiittyy
Box 3.7 Energy adjustment 57
Box 3.8 Criteria for grading evidence 60 Box 8.1 Energy density 324
Box 8.2 Fast food 325
Box 8.3 Body fatness in childhood 326
■■ PPAARRTT TTWWOO EEVVIIDDEENNCCEE AANNDD JJUUDDGGEEMMEENNTTSS Box 8.4 Television viewing 331
CChhaapptteerr 44 FFooooddss aanndd ddrriinnkkss CChhaapptteerr 99 CCaanncceerr ssuurrvviivvoorrss
Box 4.1.1 Wholegrain and refined cereals and Box 9.1 Conventional and unconventional
their products 69 therapies 345
Box 4.1.2 Foods containing dietary fibre 69 Box 9.2 Use of supplements by cancer survivors 346
Box 4.1.3 Glycaemic index and load 69
Box 4.1.4 Aflatoxins 70 CChhaapptteerr 1100 FFiinnddiinnggss ooff ootthheerr rreeppoorrttss
Box 4.2.1 Micronutrients and other bioactive
compounds and cancer risk 78 CChhaapptteerr 1111 RReesseeaarrcchh iissssuueess
Box 4.2.2 Phytochemicals 79
Box 4.2.3 Preparation of vegetables and nutrient
bioavailability 79 ■■ PPAARRTT TTHHRREEEE RREECCOOMMMMEENNDDAATTIIOONNSS
Box 4.2.4 Foods containing dietary fibre 80
Box 4.3.1 Processed meat 117 CChhaapptteerr 1122 PPuubblliicc hheeaalltthh ggooaallss aanndd ppeerrssoonnaall
Box 4.3.2 Nitrates, nitrites and N-nitroso rreeccoommmmeennddaattiioonnss
compounds 118
Box 4.3.3 Foods containing iron 118 Box 12.1 Quantification 371
Box 4.3.4 Heterocyclic amines and polycyclic Box 12.2 Making gradual changes 372
aromatic hydrocarbons 119 Box 12.3 Height, weight and ranges of BMI 375
Box 4.3.5 Cantonese-style salted fish 120 Box 12.4 When supplements are advisable 387
Box 4.4.1 Foods containing calcium 131 Box 12.5 Regional and special circumstances 392
Box 4.5.1 Hydrogenation and trans-fatty acids 137
vii
FOOD, NUTRITION, PHYSICAL ACTIVITY, AND THE PREVENTION OF CANCER: A GLOBAL PERSPECTIVE
AAcckknnoowwlleeddggeemmeennttss
Panel Jim MannDM PhD FFPH Robert BeagleholeONZM World Health Organization
FRACP FRSNZ DSc (WHO)
Sir Michael Marmot University of Otago Chair 2003 Geneva, Switzerland
MB BS MPH PhD FRCP FFPH Dunedin, New Zealand Was at: World Health Denise Coitinho PhD
Chair Organization (WHO) Ruth Bonita MD
University College London Hilary J PowersPhD RNutr Geneva, Switzerland Chizuru Nishida PhD MA
UK University of Sheffield, UK Now at: University of Pirjo Pietinen DSc
Auckland, New Zealand
Tola AtinmoPhD K Srinath ReddyMD DM MSc
University of Ibadan, Nigeria Institute of Medical Sciences Additional
New Delhi, India Panel observers members for policy
Tim ByersMD MPH panel
University of Colorado Health Elio RiboliMD ScM MPH Food and Agriculture
Sciences Center Was at: International Agency Organization of the United Barry PopkinPhD MSc BSc
Denver, CO, USA for Research on Cancer Nations (FAO) Carolina Population Center,
(IARC), Lyon, France Rome, Italy University of North Carolina,
Junshi ChenMD Now at: Imperial College Guy Nantel PhD Chapel Hill, NC, USA
Chinese Centre for Disease London, UK Prakash Shetty MD PhD
Control and Prevention Jane WardlePhD MPhil
Beijing, People’s Republic of Juan A Rivera PhD International Food Policy University College London, UK
China Instituto Nacional de Salud Research Institute (IFPRI)
Publica Washington DC, USA Nick CavillMPH
Tomio HirohataMD Cuernavaca, Mexico Lawrence Haddad PhD British Heart Foundation
DrScHyg PhD Marie Ruel PhD Health Promotion
Kyushu University Arthur SchatzkinMD DrPH Research Group
Fukuoka City, Japan National Cancer Institute International Union of University of Oxford, UK
Rockville, MD, USA Nutritional Sciences (IUNS)
Alan JacksonCBE MD FRCP Mark Wahlqvist MD AO
FRCPCH FRCPath Jacob C SeidellPhD
University of Southampton Free University Amsterdam Mechanisms Working Group
UK The Netherlands John Milner PhD
W Philip T JamesCBE MD David E G ShukerPhD FRSC Methodology Task Force
DSc FRSE FRCP The Open University Jos Kleijnen MD PhD
International Obesity Task Milton Keynes, UK Gillian Reeves PhD
Force
London, UK Ricardo UauyMD PhD Union Internationale Contre
Instituto de Nutricion y le Cancer (UICC)
Laurence N KolonelMD PhD Tecnologia de los Alimentos Geneva, Switzerland
University of Hawai’i Santiago, Chile Annie Anderson PhD
Honolulu, HI, USA Curtis Mettlin PhD
Walter C WillettMD DrPH Harald zur Hausen MD DSc
Shiriki KumanyikaPhD MPH Harvard School of Public
University of Pennsylvania Health United Nations Children’s
Philadelphia, PA, USA Boston, MA, USA Fund (UNICEF)
New York, NY, USA
Claus LeitzmannPhD Steven H ZeiselMD PhD Ian Darnton-Hill MD MPH
Justus Liebig University University of North Carolina Rainer Gross Dr Agr
Giessen, Germany Chapel Hill, NC, USA
viii
ACKNOWLEDGEMENTS
Systematic Rajendra Persad ChM FEBU Carlos A Gonzalez PhD MPH Karen Robinson MSc
Literature Review FRCS MD Johns Hopkins University
Centres United Bristol Healthcare Catalan Institute of Oncology Baltimore, MD, USA
Trust & Bristol Urological Barcelona, Spain
UUnniivveerrssiittyy ooff BBrriissttooll,, UUKK Institute, UK Xuguang (Grant) Tao MD
Vittorio Krogh MD MSc PhD
George Davey Smith Massimo Pignatelli MD PhD Istituto Nazionale Tumori Johns Hopkins University
FMedSci FRCP DSc FRCPath Milan, Italy Baltimore, MD, USA
University of Bristol , UK University of Bristol, UK
Sylvie Menard ScD
Jonathan Sterne PhD MSc Jelena Savovic PhD Istituto Nazionale Tumori UUnniivveerrssiittyy ooff LLeeeeddss,, UUKK
MA University of Bristol, UK Milan, Italy
University of Bristol, UK David FormanPhD FFPH
Steve Thomas MB BS PhD Eugenio Mugno ScD University of Leeds, UK
Chris Bain MB BS MS MPH FRCS Istituto Nazionale Tumori
University of Queensland University of Bristol, UK Milan, Italy Victoria J BurleyPhD MSc
Brisbane, Australia RPHNutr
Tim Whittlestone MA MD Valeria Pala ScD University of Leeds, UK
Nahida Banu MB BS FRCS Istituto Nazionale Tumori
University of Bristol, UK United Bristol Healthcare Milan, Italy Janet E Cade PhD BSc
Trust, UK RPHNutr
Trudy Bekkering PhD Sabina Sieri ScD University of Leeds, UK
University of Bristol, UK Luisa Zuccolo MSc Istituto Nazionale Tumori
University of Bristol, UK Milan, Italy Darren C Greenwood MSc
Rebecca Beynon MA BSc University of Leeds, UK
University of Bristol, UK
IIssttiittuuttoo NNaazziioonnaallee JJoohhnnss HHooppkkiinnss Doris S M Chan MSc
Margaret Burke MSc TTuummoorrii MMiillaann,, IIttaallyy UUnniivveerrssiittyy,, BBaallttiimmoorree,, University of Leeds, UK
University of Bristol, UK MMDD,, UUSSAA
Franco BerrinoMD Jennifer A Moreton PhD MSc
David de Berker MB BS MRCP Istituto Nazionale Tumori Anthony J AlbergPhD MPH University of Leeds, UK
United Bristol Healthcare Milan, Italy University of South Carolina
Trust, UK Columbia, SC, USA James D Thomas
Patrizia PasanisiMD MSc University of Leeds, UK
Anna A Davies MSc BSc Istituto Nazionale Tumori Kristina Boyd MS
University of Bristol, UK Milan, Italy Johns Hopkins University Yu-Kang Tu PhD MSc DDS
Baltimore, MD, USA University of Leeds, UK
Roger Harbord MSc Claudia Agnoli ScD
University of Bristol, UK Istituto Nazionale Tumori Laura Caulfield PhD Iris Gordon MSc
Milan, Italy Johns Hopkins University University of Leeds, UK
Ross Harris MSc Baltimore, MD, USA
University of Bristol, UK Silvana Canevari ScD Kenneth E L McColl FRSE
Istituto Nazionale Tumori Eliseo Guallar MD DrPH FMedSci FRCP
Lee Hooper PhD SRD Milan, Italy Johns Hopkins University Western Infirmary
University of East Anglia Baltimore, MD, USA Glasgow, UK
Norwich, UK Giovanni Casazza ScD
Istituto Nazionale Tumori James Herman MD Lisa Dyson MSc
Anne-Marie Mayer PhD MSc Milan, Italy Johns Hopkins University University of Leeds, UK
University of Bristol, UK Baltimore, MD, USA
Elisabetta Fusconi ScD
Andy Ness PhD FFPHM MRCP Istituto Nazionale Tumori Genevieve Matanoski MD
University of Bristol, UK Milan, Italy DrPH
Johns Hopkins University
Baltimore, MD, USA
ix