UICC World Cancer Congress 2006

Diet (nutrition and energy intake) is now considered second only to smoking as a preventable cause of cancer1. Whilst many aspects of diet can be harmful to human health (e.g potent carcinogens found in foodstuffs) the real disease burden is the western style, energy dense diet, low in fruits and vegetables consumed by sedentary populations. Energy imbalance in the form of overweight and obesity is the main manifestation of this disease risk which is now recognized as a major risk to the development of a number of cancers including breast and colon cancer – two of the most common cancers in the US and Europe2.

From the least to the most developed countries, the incidence of overweight and obesity continues to rise (often co-existing with under nutrition)3. The World Health Organization4 state clearly that national commitment to obesity control should be a shared responsibility involving multi-sector approaches and involving the active participants of consumers, government, food industry and the media. Civil society and nongovernmental organizations have an important role to play in influencing multi-sector cancer control programmes by providing a range of opportunities to facilitate and enhance population behaviour change . They can help to ensure that consumers ask governments to provide support for healthy lifestyles, and the food industry to provide healthy products. Actions such as raising awareness of the association between lifestyle and cancer and through information campaigns (e.g. awareness of energy dense foods, large portion sizes), health promotion activities (e.g. sponsoring walks, developing innovative peer-support exercise programmes), litigation (e.g addressing false promotions and claims on products) and research (exploring consumer preferences for how to increase activities, identify effective approaches to behavioural changes) are some of the activities that can add to the range and volume of action required to reduce obesity levels and help to counteract the actions of vested interests dedicated to over-consumption6.

NGO's such as cancer control agencies can play an important part in these activities as demonstrated through work in comprehensive community programmes such as the North Karelia programme in Finland6. This programme demonstrated that cardio-vascular and cancer rates (and associated risk factors) can be reduced by lifestyle change7. More recently, data on obesity in Finland suggests that community changes in diet may have been contributing to stablization of population mean BMI8. Such programmes have utilised both “top down” (e.g. legislative procedures) as well as “bottom up” approaches (e.g. local community initiatives). Partnership action between public, private and voluntary (e.g. cancer control agencies) sectors and long term plans (e.g. >20 years) are key to developing, implementing and evaluating interventions which can impact upon the individual, community and wider environment.

The importance of advocacy and lobbying should not be ignored. In England, the greatest ever change in the nutritional provision of school meals has not been attained by public health professionals presenting compelling scientific evidence on the diets of children and disease risk but by an advocacy campaign initiated by a television chef leading a very large parent consumer group9. This group successfully pressurized the government into a £280 million programme of change in school food provision for the health and well-being of children.

Considerable risk reduction can also be attained by health service programmes such as obesity clinics which have been shown to be successful in attaining small, but clinically relevant behavioural changes such as that achieved in the diabetes prevention programme10. However, to impact at population level, low cost transferable interventions that engage greater numbers of the population are required11. For example, increasing physical activity to greater than 4 hours per week or walking 10,000 steps per day can be a useful strategy for avoiding weight gain (and associated disease risk) providing safe, sheltered environments are available through local town planning.

The World Health Organisation4 in their global strategy on diet, physical activity and health (2004) has urged member states to act on lifestyle change to take actions based on the best available scientific evidence and the cultural context to encourage and foster a favourable environment for health through the adoption of lifestyles that include a healthy diet and physical activity. It is clear that a wide range of approaches are needed in these arenas in order to reduce the global burden of cancer and….. action is needed now! 1 Peto R (2004 ) cited in House of Commons Health Committee Obesity –third report of session 2003-04 http://www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/23/2302.htm

2 WHO (2002) IARC Handbooks of cancer prevention Vol 6 Weight control and Physical activity. IARC Press Lyon

3 Mendez MA (2005) Overweight exceeds underweight among women in most developing countries.Am J Clin Nutr.;81(3):714-21

4 WHO (2004) Global strategy on diet, physical activity and health. WHO Geneva http://www.who.int/dietphysicalactivity/goals/en/

5 UICC (2004) Evidence based cancer prevention http://www.uicc.org/index.php?id=976 (accessed 13/04/06)

6 Puska P (1999) The North Karelia Project: from community intervention to national activity in lowering cholesterol levels and CHD risk. http://www.cvhpinstitute.org/daniel/readings/northkareliacap.PDF 7Puska P. Korhonenn HJ, Torppa J et al (1993) Does community –wide prevention of cardiovascular diseases influence cancer mortality? Eur J Cancer Prev 2( 6) 457-60 8 WHO (2000) Preventing and managing the global epidemic WHO Techical report 894 WHO Geneva http://www.iotf.org/popout.asp?linkto=http://whqlibdoc.who.int/trs/WHO_TRS_894.pdf

9 Spence D (2005)jamies school dinners- a review BMJ 330 678

10 Yamaoka & Tango (2005) Efficacy of lifestyle education to prevent type 2 diabetes: a meta-analysis of randomized controlled trials. Diabetes Care 28(11):2780-6.

11 How much might achievement of diabetes prevention behaviour goals reduce the incidence of diabetes if implemented at the population level? Diabetologia. 2006