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Diet and Cancer: What Dont We Know and When Didnt We Know it?Dileep G. Bal, M.D., Chief Cancer Control Branch Department of Health Services

WRITTEN DISCLAIMER

This presentation represents the opinions of Dileep G. Bal, M.D. and not the California Department of Health Services, in any way whatsoever. The opinions of either can change without further notice.

Objectives TodayPresent the American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Prevention Discuss the science base behind the recommendations Present current trends and statistics

On any given day in the United States...815 billion calories are consumed (200 billion more than needed) 47 million hot dogs 4 million pounds of bacon 60 million pounds of red meat 170 million eggs

On any given day in the United States...3 million gallons of ice cream 10 million pounds of candy 16 million gallons of beer and ale 1.5 million gallons of hard liquor (enough to make 26 million people drunk!)

WEDNESDAY, MAY 22, 1996

Thou Shalt Reduce Salt Intake:True? False? Choose Your StudyBy GINA KOLATA

All Sites (Invasive) Incidence RatesBy Year of Diagnosis All Races, Males and Females

2015 Goals 25% Reduction from Baseline550 500 450

1992 Baseline 511.22000 US Std. Population

1999 476.1

(

6.9% from Baseline)406.7 If Trend Continues

Rate

400 350 300Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard population SEER Cancer Statistics Review 1973-1999.

1970 US Std. Population

2015 Goal 383.4

319.5

250 '73 '76 '79 '82 '85 '88 '91 '94 '97 '00 '03 '06 '09 '12 '15

Year

Average Decline 1.0% per Year Between 1992-1999 If Trend Continues, 20% Reduction by 2015 Recent Trend Appears Level or Decreasing

All Sites Mortality RatesBy Year of Death All Races, Males and Females

2015 Goals 50% Reduction from Baseline220 210 200 190 180 170 160 150 140 130 120 110 100 90 80

1991 Baseline 215.4 2000 Std. Population 1970 Std. Population

1999 ( 202.8

5.9 % from Baseline)

R te a

180.4 If Recent Trend Continues 2015 Goal 107.7

Incidence and mortality rates are per 100,000 and are age-adjusted to the 2000 U.S. standard population. SEER Cancer Statistics Review 1973 - 1999.

86.7

'73 '76 '79 '82 '85 '88 '91 '94 '97 '00 '03 '06 '08 '11 '14 Year

Steeper Rate of Decrease, 1.4 % per Year, Beginning 1995 and Continuing through 1999 If trend Continues - 16% Reduction by 2015 Trend Continues

Actual Causes of Deathin the United States (1990)Tobacco

Diet/ActivityAlcohol Microbial Agents Toxic Agents Firearms Sexual Behavior Motor Vehicles0 5 10 15 Percent of all causes of deathData Source: McGinnis & Foege, JAMA, November, 1993

20

Causes of CancerEstimate percentage of total cancer deaths attributable to established causes of cancerTobacco

Adult diet/obesity Sedentary lifestyleOccupational factors Family history of cancer Viruses/other biologic agents Perinatal factors/growth Reproductive factors

AlcoholSocioeconomic status Environmental pollution Ionizing/ultraviolet radiation Prescription drugs Medical procedures Salt/other food additives or contaminants

0

5

10

15

20

25

30

35

Source: Harvard Report on Cancer Prevention, Cancer Causes and Control, November/December, 1996

CarcinogenesisNormal Cell Cell with DNA abnormality Tumor

*MUTATION Inherited Spontaneous Acquired PROMOTION PROGRESSION Hormones Growth factors

Obesity,Nutrition,and CancerGene-Nutrient Imbalance Energy Expenditure (Phytochemicals) Energy Intake (Carcinogen) High Fat/Calories High -6 fats Growth Factors

Physical Activity Fruits Vegetables Whole Grains Soy Protein

Genetic Susceptibility(Common Polymorphisms)

Purpose of the Nutrition and Physical Activity GuidelinesTo review current scientific data on diet and cancers To translate this into clear, defensible recommendations for the general public To promote changes in environments that support healthful eating and physical activity habits To reduce cancer risk

Which year?

(1)

In England, four and a half times as many people die now from cancer as half a century ago. Probably no single factor is more important in determining the outbreak of cancer in the predisposed than high feeding. Many indications point to the gluttonous consumption of meat as likely to be especially harmful.

Which year?

(2)

Statistics show that the consumption of meat has reached the amazing total of 131 pounds per head per year, which is more than double what it was half a century ago. No doubt other factors co-operate, among these I should be inclined to name deficient exercise and deficiency in fresh vegetable food.

W. Roger Williams in The Lancet So, what didnt we know and when didnt we know it?

December, 1898!

Society RecommendationsIndividual ChoicesEat a variety of foods, with an emphasis on plant sources. Adopt a physically active lifestyle. Maintain a healthful weight throughout life. If you drink alcoholic beverages, limit consumption.

Society Recommendations Community ActionPublic, private, and community organizations should work to create social and physical environments that support the adoption and maintenance of healthful nutrition and physical activity behaviors

Society Recommendations Community ActionIncrease access to healthful foods in schools, worksites, and communities. Provide safe, enjoyable, and accessible environments for physical activity in schools, and for transportation and recreation in communities.

Society Recommendations Individual ChoicesEat a variety of healthful foods, with an emphasis on plant sources.Eat 5 or more servings of a variety of vegetables and fruit each day. Choose whole grains in preference to processed (refined) grains and sugars. Limit consumption of red meats, especially those high in fat and processed. Choose foods that help maintain a healthful weight.

Eat five or more servings of a variety of vegetables and fruits each dayInclude vegetables or fruits in every meal and for snacks. Limit french fries, snack chips, and other fried vegetable products. Choose 100% juice if you drink fruit or vegetable juices.

Why Fruits and Vegetables?Fruits and Vegetables and the Prevention of CancerDecreases Risk ConvincingMouth and pharynx Oesophagus Lung Stomach Colon, rectum**Vegetables only

Decreases Risk ProbableLarynx Pancreas Breast Bladder

Decreases Risk PossibleLiver* Ovary Endometrium Cervix Prostate* Thyroid Kidney*

Food, Nutrition and the Prevention of Cancer: A Global Perspective American Institute for Cancer Research, 1997

Origins of the 5 a Day Campaign1986 National Cancer Institute grant to the California Department of Health Services Original plan called for addressing fat, fruits and vegetables, and fiber Plan revised to focus on promoting 5 daily servings of fruits and vegetables because strong science win-win-win feasibility

California 5 a Day Campaign 1988: California 5 a Day Campaign developed 1988-1991: Campaign promotions conducted 1991: 5 A Day goes national

California 5 a Day Campaign SpinoffsChildrens 5 a Day--Power Play! Campaign (1993) Latino 5 a Day Campaign (1994) Network 5 a Day Campaign for low-income families (1998) Womens 5 a Day Campaign (1999)

Relative Risk What it meansRR = Relative Risk = Risk Ratio Risk among exposed/Risk among non-exposed Null association, RR = 1.00 RR of 1.5 means exposed group has 50% greater risk of disease than non-exposed; RR of 0.60 means 40% lower risk

Vegetables and Colorectal Cancer Prospective Cohort StudiesThun, 1992- Men Thun, 1992- Women Steinmetz, 1994 Pietinen, 1999 Voorrips, 2000- Men Voorrips, 2000-Women Michels, 2000 Terry, 20010 .2 0.5 1Relative Risk

1.5

2

Lung cancer incidence associated with beta-carotene treatment versus placeboRR 2 1.5 1 0.5 0Current smoker Never Former Current smoker smoker smoker Former Current smoker smoker

ATBC

Physicians Health

CARET

Percent of adults eating 5 or more fruits and vegetables per day, 1998

26.6 to 31.9

United States Median: 23.9Source: BRFSS, NCCDPHP, CDC, 2000

23.9 to 26.5 20.7 to 23.8 9.1 to 20.6

Choose whole grains in preference to processed (refined) grains and sugars.Include grain products such as breads, cereals rice, pasta, or beans in every meal. Eat other foods from plant sources several times each day. Limit consumption of refined carbohydrates, including pastries, sweetened cereals, soft drinks, and sugars.

Whole grains & cancer Prospective cohort studiesThun, 1992-men*

Thun, 1992-women*

Jacobs, 1999-women

Jacobs, 2001

0

0.5

1 Relative Risk

1.5

2

*colon cancer mortality; others = all cancers

Limit consumption of red meats, especially those high in fat and processedChoose fish, poultry, or beans as an alternative to beef, pork, and lamb When you eat meat, select lean cuts and smaller portions Prepare meat by baking, broiling, poaching, rather than by frying or charbroiling

Red meat (1 portion) and colorectal cancer

Source: Sandhu MS et al. CEBP 2001;10:439 4 - 46

Processed meat (1 portion) and colorectal cancer

Source: Sandhu MS et al. CEBP 2001;10:439 4 - 46

Current research about meatHeterocyclic amines Cooking methods Food safety

What about fat?Total fat? Type of fat? Calories from fat? Some other factor in the fat in foods?

Prevalence of Overweight among U.S. Adults, BRFSS, 198