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

Cancers of 17 sites – 80% of incidence and deaths worldwide

Decreases RiskIncreases Risk RECOMMENDATIONS Convincing Physical activity Foods containing dietary fibre Red meat Processed meat Alcoholic drinks (men) Body fatness Abdominal fatness RECOMMENDATIONS ProbableGarlic Milk Calcium Alcoholic drinks (women) Food, Nutrition, Physical activity and cancers of the Colon and the Rectum – modifiable risk factors

Preventability estimates (PAF%) for cancers of the colon and rectum (UK) (WCRF, 2009) and Parkin (2011) ExposureWCRF PAF% (range) Parkin PAF% (range) Foods containing Fibre12 (5-18)12 Red meat 5 (0-21)21 (combined) Processed meat10 (0-23) Alcoholic drinks 7 (0-18)12 Physical Activity12 (4-20)3 Body Fatness 7 (0-17)13 Total estimate43 (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 exposure Meat21.1 Overweight and obesity13.0 Fibre12.2 Alcoholic drinks11.6 Tobacco8.1 Physical exercise3.3 Infections2.2 Radiation- ionising1.6 All of the above54.4

CONVINCING

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 MeatOR (CI) Grilled meat1.56 ( ) Well or very well done meat1.59 ( ) 2,amino-1-methyly-6-phenyl-imadzo4 (PhIP) 1.75 ( ) benzoapyrene1.53( ) Total mutagenic activity1.57 ( ) Total iron was inversely associated (0.69, ) 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 5kg/m 2 5% increased risk per inch of waist circumference Possible mechanisms include –impacts on insulin –oestrogens –stimulates inflammatory response

Weight perceptions (Yaemsiri et al, 2011) National Health and Nutrition Examination Survey (NHANES) 16,720 adults % of OW women and 48% of OW men perceived themselves as ‘right weight’ 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

Principally drinks with “added sugar” Colas, squashes, sodas Fruit juices (limited) 2007 to the future… Milk Shakes (2160 kcals)Milk Shakes (2160 kcals) Fruit Smoothies no sugar added… (120 to 190kcals)Fruit Smoothies no sugar added… (120 to 190kcals) With “Health added” e.g. Orange Juice Drink with 'Five Added Nutrients'With “Health added” e.g. Orange Juice Drink with 'Five Added Nutrients' Sugary Drinks- definitions

High Energy Dense >225 to 275 kcals +/100g Energy Density-definitions High Energy Dense >225 to 275 kcals+/100g High Energy Dense >225 to 275 kcals+/100g

Fast Foods Readily available convenience foods - Energy dense - Consumed frequently - Large portions 1420 Kcal Fast foods- definitions

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, ( )). 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 g/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 ( )NS If + Family History 2.02 ( ) Drinker with FH RR 2.80( ) 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 Cancer reduction Overweight and obesity reduction SCOTLAND Meeting current guidelines 32% aged 55 to 64 19% aged 65 to 74 8% aged 75 +

Energy Balance FoodKcal value per portion Sitting (light office work) Walking (3mph) Running (6mph or 10 min/mile) Muesli bar (35g) 1271hr 25mins 34 mins12 mins Big MAC (200g) 4815hrs 20mins 2hrs 10 mins 46 mins Adapted from "Energy Expenditure of Walking and Running," Medicine & Science in Sport & Exercise, Cameron et al, Dec (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? 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 setting? 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: /j.ypmed doi: /j.ypmed

Formative research Patients need to Be ware of the risk factors for adenoma Be able to relate these to personal behaviours 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: 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- FIN-D2D Population strategy High risk strategy Strategy of early diagnosis and management

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

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 changes 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

Conclusions 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 challenge Prevention is everyones business