How to Reduce Cancer Risk A presentation for health professionals by World Cancer Research Fund (WCRF UK)

Accompanying script

Our vision

World Cancer Research Fund (WCRF UK) helps people make choices that reduce their chances of developing cancer

Our heritage

We were the first cancer charity:

• To create awareness of the relationship between diet and cancer risk

• To focus funding on research into diet and cancer prevention

• To consolidate and interpret global research to create a practical message on cancer prevention

Our mission

Today World Cancer Research Fund (WCRF UK) continues:

• Funding research on the relationship of nutrition, physical activity and weight management to cancer risk

• Interpreting the accumulated scientific literature in the field

• Educating people about choices they can make to reduce their chances of developing cancer

About WCRF UK

WCRF UK is the charity which focuses on cancer prevention and survivorship through healthy diets, physical activity and body weight. About a third of the most common cancers could be prevented in this way. By raising awareness of this message, we hope that many thousands of lives will be saved.

The education and research programmes of WCRF UK are funded almost entirely by donations from the public. We fund cutting edge cancer research which, in turn, helps people make choices tht reduce their chances of developing cancer. We are part of a global network of charities that are committed to preventing cancer.

WCRF UK is part of the World Cancer Research Fund global network, which consists of the following charitable organisations: The American Institute for Cancer Research (AICR); World Cancer Research Fund UK (WCRF UK); World Cancer Research Fund Netherlands (WCRF NL); World Cancer Research Fund Hong Kong (WCRF HK); and the umbrella association, World Cancer Research Fund International (WCRF International)

How to Reduce Cancer Risk: a presentation for health professionalsAccompanying script

Part 1: About World Cancer Research Fund (WCRF UK) and the evidence on lifestyle and cancer risk

Slide 1. There is so much information in the media about diet, physical activity, obesity and cancer that it can be hard for people to know what to believe or whose advice to trust. In this presentation, we’ll look at the expert evidence on how food, nutrition, physical activity and body fatness affect cancer risk and offer some advice for how you can help people to lower their risk of developing cancer and other non-communicable diseases.

Slide 2. Contents (see slide).

Slide 3. The information in this presentation comes from World Cancer Research Fund (WCRF UK), a cancer prevention charity that was founded in London in 1990. WCRF UK was the second charity to become part of the WCRF global network, a network of charities dedicated to cancer prevention through healthy diet, physical activity and weight management.

When the WCRF global network was first established in 1980, the idea that diet could influence cancer risk was still contro-versial and there was little scientific research in this area. However, since then, the WCRF global network has funded over £86 million into research that has helped to further our understanding that cancer is a largely preventable disease.

Slide 4. WCRF UK’s vision and mission (see slide).

Slide 5. This slide shows you some of the key pieces of work that the WCRF global network has produced. Their First and Second Expert Reports were both groundbreaking independent reviews of the evidence which confirmed that lifestyle choices have a big impact on cancer risk.

Slide 6. Why cancer? (see slide).

Slide 7. Scientists estimate that about a third of the most common cancers in the UK could be prevented if everyone ate a healthy diet, drank less alcohol, was physically active, and maintained a healthy weight. In the UK, this equates to around 87,000 cases a year – enough to fill the Olympic Stadium! However, many people feel that cancer is out of their control and not everyone is aware of what they can do to lower their risk.

Slide 8. So how do we know that diet, physical activity and body fat affect cancer risk? Well, there are some clues. For example, if you look at causes of death in men in the UK and China, you will see that cancer makes up a significant proportion of deaths in both cases.

Slide 9. But, if you look at which cancers are most common in these countries, you’ll see that the types of cancer in each country are quite different; for example, the UK has a higher incidence of prostate cancer, whereas China has a higher incidence of stomach cancer. This presents a question: What makes people in one country more likely to get some types of cancer than people in another country? It could be genetic, but another answer is that it could be down to their environment – for example, where they live, how they live, what they eat and how active they are.

Slide 10. Strong evidence that it is the environment comes from migration data, where a large group of people move from one area to another. For example, this slide shows the dramatic change in age-standardised rates of three different types of cancer in Japanese women in just two generations after they migrated to, and settled in, Hawaii. The Japanese women in Miyagi, with their traditional Japanese way of life, have a higher rate of stomach cancer, with lower rates of breast and bowel cancer. Second generation Japanese women living in Hawaii have a much lower rate of stomach cancer, while their rates of breast and bowel cancer have increased considerably. This change has happened so quickly that it can’t be down to genetics or evolution. It’s more likely that it is the change in lifestyle and environment that has altered their cancer profile so profoundly.

Slide 11. So what other evidence is there? Some of the terms may not be familiar to everyone, but this slide shows how food, nutrition, obesity and physical activity are involved in many of the cell processes that are linked to cancer.

Slide 12. And we know that these factors can also influence the processes that either protect healthy cells, or promote cancer. These processes occur at different stages of life, and over the natural course of cancer development, which typically takes decades.

Slide 13. The WCRF global network looked at this evidence and more when it produced its Second Expert Report in 2007. In fact, it looked at all the available scientific evidence on food, nutrition, physical activity, body fat and cancer risk from around the world. The Report was a huge undertaking and took six years to produce, involving over 200 scientists. It was overseen by independent observers like the World Health Organization and UNICEF.

Slide 14. The initial sweep for evidence found half a million scientific studies. These were screened down to 7,000 that were relevant. These were then systematically reviewed and the findings were reviewed by an independent Expert Panel of 21 of the world’s leading researchers. The Panel used the strongest evidence to develop WCRF UK’s 10 Recommendations for Cancer Prevention.

Slide 15.To keep this evidence as up-to-date as possible, WCRF UK and the rest of the global network have funded a team of scien-tists at Imperial College London to add any new scientific papers to their Continuous Update Project (CUP) database, which is the largest of its kind in the world.

This evidence goes through a similar review process to the one used for the Second Expert Report, and is judged by another independent Expert Panel. So far, none of the findings from the Continuous Update Project have changed any of the Recommendations, they have only strengthened them. This is how WCRF UK can be sure that their Recommendations are the best advice available in the world on how to lower your cancer risk through diet, physical activity and weight management.

Part 2: WCRF UK’s Recommendations for Cancer Prevention

Slides 16 and 17We are now going to look at WCRF UK’s Recommendations for Cancer Prevention in more detail. These were developed to reduce the risk of cancer, but they are also consistent with current advice on how to reduce the risk of other chronic diseases such as diabetes, heart disease and obesity. We will look at some of the practical ways that you can help people to achieve these Recommendations and lower their risk of cancer and other diseases.

Slide 18After not smoking, maintaining a healthy weight is the most important thing people can do to lower their cancer risk. For cancer prevention we should aim to be as lean as possible within the healthy weight range. Maintaining a healthy weight reduces the risk of many cancers such as bowel, oesophagus, pancreas, kidney, womb, breast (in post menopausal women) and gallbladder, as well as reducing the risk of heart disease and diabetes. Encourage patients to maintain or achieve a healthy weight by eating a diet based mostly on plant foods that is low in energy density. You can also advise patients to watch their portion sizes and encourage them to be physically active for at least 30 minutes every day.

Slide 19 There are two simple ways of measuring whether a person is a healthy weight. You can measure their Body Mass Index (BMI), which shows whether their weight is appropriate for their height. You can calculate BMI by using WCRF UK’s online BMI calculator. A healthy BMI is between 18.5 and 24.9. For cancer prevention we should aim to be as lean as possible within this range. Another technique you can use is to measure a patient’s waist. Carrying excess fat around the waist can be particularly harmful and is strongly linked to bowel, pancreas and endometrium (womb) cancer, as well as to breast cancer in postmenopausal women. As a guide, a healthy waist measurement is less than 31.5”/80cm for women, less than 37”/94cm for white and black men, and less than 35”/90cm for Asian men.

Slide 20Encourage patients to be physically active for at least 30 minutes every day. As they get fitter they can aim for 60 minutes of moderate activity or 30 minutes of vigorous activity every day. Physical activity can reduce cancer risk and will also help

patients avoid weight gain, which reduces cancer risk in itself. Moderate activity is anything that gets our hearts beating a little faster and makes us breathe more deeply; for example, walking, gardening, cleaning and bowling. Vigorous activity means increasing the heart rate so that we warm up, start to sweat and feel out of breath; for example, running, swimming and tennis.

Slide 21Encourage patients to get their 30 minutes of physical activity a day by building physical activity into their everyday lives. The more they can do each day, the more they reduce their cancer risk. Encourage patients to find something they enjoy doing. If 30 minutes seems like too much, encourage them to break it up into three 10-minute sessions and build these slowly into their day. Being physically active does not have to mean joining a gym.

Slide 22WCRF UK’s third Recommendation for Cancer Prevention is to avoid sugary drinks and limit consumption of energy-dense foods. Foods containing a lot of calories per gram are known as energy-dense foods. They tend to be high in fat and/or sugar and can contribute to weight gain and obesity which in turn can increase cancer risk. It is easy to eat a lot of these foods without feeling full as we don’t need to eat much to consume a lot of energy, so therefore it is harder to control calo-rie intake. Sugary drinks such as soft drinks and cordials also add to calorie intake but are easy to drink as they tend not to fill you up. Foods that are low in energy density tend to be high in water and fibre and help us to feel fuller for longer; for example fruits, vegetables, wholegrains and pulses are low in energy density. They are also good choices for weight maintenance. Encourage patients to choose more of these foods and fewer processed foods, as these are often high in fat and sugar.

Slide 23You could try suggesting food swaps to patients to help them reduce their intake of energy-dense foods. For example, eating a whole fruit will fill you up more than drinking a glass of juice and will often contain less energy too. The energy density scale is a good tool to demonstrate this to patients. At the bottom of the scale are less energy-dense foods such as vegeta-bles, fruits, pulses and wholegrains. At the top are energy-dense foods such as chocolate, crisps, biscuits, burgers, chips, fried chicken and most pizzas. Patients should aim to base their diet on foods from the lower end of the scale.

Slide 24The traffic light labelling guide is another useful tool for patients to help them work out if foods are energy-dense by look-ing at the nutrition label. People should aim to eat more foods that fall into the green column, moderate amounts of foods from the amber column and to limit foods from the red column. Advise patients to look at the sugar and fat content of their food. High-sugar foods have more than 22.5g of total sugar per 100g; high-fat foods have more than 17.5g of fat per 100. Energy-dense foods contain more than 225 – 275 calories per 100g.

Slide 25Encourage patients to eat a wide variety of vegetables, fruits, wholegrains and pulses such as beans. Plant foods such as vegetables and fruits can help to protect against cancers including mouth, pharynx, larynx, oesophagus and stomach cancer. Encourage patients to eat at least five portions of a variety of vegetables and fruits every day. You can also advise patients to include wholegrains and pulses such as bread, rice, beans and lentils in every meal. These foods are rich in fibre and can help reduce the risk of bowel cancer. Advise patients to watch the toppings and sauces they use as these can be high in fat, sugar or salt.

Slide 26Another tool you can use with patients is the two-thirds, one-third plate rule. When preparing a meal, it’s a good idea to fill two-thirds or more of our plates with plant foods like vegetables, rice, pasta, lentils and cereals, and one-third or less with animal foods such as dairy products and meat. You can explain what a portion of fruits or vegetables looks like; for ex-ample one portion is equivalent to one large fruit, two medium fruits, a handful of small fruits such as grapes and berries, three heaped tablespoons of cooked vegetables or a tablespoon of dried fruits.

Slide 27Encourage patients to limit their consumption of red meat and to avoid processed meat wherever possible. To reduce cancer risk, we should eat no more than 500g (cooked weight) a week of red meat such as beef, pork and lamb. This is equivalent to around 700 – 750g in raw weight. To help patients reduce their intake of red meat you can show them some examples of normal portion sizes, for example, a medium steak is 145g and a 70g portion of red meat is approximately the size of a deck of cards. Processed meats such as ham, bacon, salami, hot dogs and some sausages should be avoided as much as possible. Processed meat is meat that has been salted, smoked or cured, or meat that has added preservatives. These types of meats are convincingly linked to bowel cancer.

Slide 28

Using portion size pictures and suggesting protein alternatives such as white meat, eggs, fish and beans are both practical ways to help patients reduce their intake of red meat.

Slide 29Alcohol increases the risk of five common cancers including mouth, oesophagus, liver, breast and bowel. It is especially harmful when combined with smoking. For cancer prevention, it is actually best to drink no alcohol at all. However WCRF UK recognises that modest amounts can be protective against heart disease in postmenopausal women and men who are over 40. This is why WCRF UK recommends that, if consumed at all, alcoholic drinks should be limited to two drinks a day for men and one drink a day for women. ‘One drink’ contains 10-15g of pure alcohol.

Slide 30You can help patients reduce their alcohol intake by showing them what one drink looks like, for example half a pint of normal strength beer, lager or cider, one 25ml measure of spirits such as vodka or whiskey or one small 125ml glass of wine. Encourage patients to reduce their alcohol intake by ordering smaller serving sizes, alternating alcoholic drinks with non-alcoholic drinks, diluting alcoholic drinks and making sure some nights of the week are alcohol-free.

Slide 31Alcoholic drinks also contain a lot of calories while offering little nutritional benefit. For example, a pint of ordinary strength beer or lager contains about 250 calories, which is the equivalent of eating a doughnut. Cutting down the amount we drink could therefore play an important role in helping us to maintain a healthy weight, which can also help to reduce cancer risk.

Slide 32World Cancer Research Fund’s seventh Recommendation for Cancer Prevention is to limit consumption of salty foods and foods processed with salt. Consuming too much salt can be harmful to our health, increasing our risk of stomach cancer as well as high blood pressure and kidney disease. Daily intake of salt should be no more than 6g, which is around a level teaspoon. Some food labels list the sodium content instead of the amount of salt. Sodium is a component of salt. To work out how much salt a food contains, multiply the sodium content by 2.5.

Slide 33Explain to patients that around 80 per cent of the salt in our diets comes from processed foods and they may not always be aware that these foods are high in salt because they may not taste ‘salty’. Encourage patients to read food labels and choose lower-salt versions where possible. A product is ‘low-salt’ if it contains less than 0.3g per 100g. Even sweet foods like biscuits can contain high levels of salt. Give patients tips on how to reduce salt intake such as not adding salt whilst cooking or at the table, using herbs and spices to flavour food instead of salt, and choosing low salt or reduced salt options. You can also help patients to improve their cooking skills so they rely less on processed foods.

Slide 34WCRF UK recommends not using supplements, for example vitamin pills, to protect against cancer. A balanced diet is the most effective way to reduce cancer risk. This is because, although some studies do show that some supplements protect against some cancers, these have usually been tested in just one particular group of people, so the benefits may not apply to the general population. Research also shows that taking high doses of some supplements could actually be harmful to our health. By eating a balanced diet, rich in vegetables, fruit and other plant foods, most of us should be able to obtain all the nutrients we need. However, some groups of people may benefit from taking supplements, for example women of childbearing age wishing to conceive are advised to take a folic acid supplement and vitamin A, C and D drops are recom-mended for children aged 6 months to 5 years old. If patients want more advice about supplements you can direct them to their GP who will be best placed to advise them.

Slide 35World Cancer Research Fund has two Recommendations which are for specific groups of people.

Slide 36We recommend breastfeeding exclusively for six months in line with the Department of Health and World Health Organiza-tion’s recommendations. Many people are aware of the benefits of breastfeeding, such as bonding, reducing the baby’s risk of developing asthma, passing on vital immunity and reducing the baby’s risk of infections. However, only one in five women knows that it can also reduce the mother’s risk of breast cancer. Studies have also shown that having been breastfed prob-ably protects children against overweight and obesity. Overweight and obese children tend to remain overweight in adult life. Slide 37World Cancer Research Fund’s second special population Recommendation is that after treatment, if able to do so, and unless otherwise advised, cancer survivors should aim to follow these Recommendations for Cancer Prevention. Cancer survivors are people who are living with or have recovered from a diagnosis of cancer. Unfortunately, there is not enough

evidence to make more specific recommendations for cancer survivors, but there is growing evidence that physical activity and other measures that help us to maintain a healthy weight, such as a balanced diet, may help to prevent cancer recur-rence, particularly for people who have had breast cancer. Anyone who has received a diagnosis of cancer should receive specialist dietary advice from an appropriately trained professional.

Slide 38Finally, remember never to smoke or chew tobacco. If a patient is interested in stopping smoking they should be directed to the NHS Stop Smoking Service by calling Smokefree on 0800 022 4332 or visiting www.smokefree.nhs.uk to find out about services in their area.

Part 3: The role of health professionals, current awareness levels and how WCRF UK can help

Slide 39So what else can health professionals do to help people lower their cancer risk? Health professionals are one of the nine actor groups identified by World Cancer Research Fund’s 2009 Policy Report as having a role in improving public health.

Slide 40Your role as a health professional opens up opportunities to talk to patients about cancer prevention at a time when they are most susceptible to health messages. You can also take the lead in educating your colleagues about how diet, physical activity and body fatness affect cancer risk.

Slide 41One of the issues that we as health professionals face is that many people feel that cancer is out of their control – they don’t realise that there are things they can do to lower their cancer risk. In fact, many people don’t know what the risk factors for cancer are. For example, in October 2012, WCRF UK carried out a YouGov survey of 2,012 people, which asked ‘Which, if any, of the following do you think increases your risk of getting cancer?’. Participants were given the following options: smoking, poor diet, being overweight, physical inactivity, alcohol, processed meat, coffee, and stress. As you would expect, lots of people knew that smoking is a risk factor, but only half of people knew that being inactive is a risk factor, and only around 60 per cent identified a poor diet, being overweight or drinking alcohol.

Slide 42Even fewer people knew that processed meat is a cancer risk factor, and, interestingly, 50 per cent of people thought that stress is a risk factor, even though there is no consistent evidence to show that this affects cancer risk. This shows that work still needs to be done to raise awareness of these risk factors so that people can make informed choices about how best to reduce their risk of developing cancer.

Slide 43WCRF UK can help you to talk about cancer prevention with your patients. They produce a wide range of resources for the general public…

Slide 44…and for health professionals to use with patients. These can be ordered or downloaded from the website.

Slide 45There is a dedicated web section for health professionals which has the most up-to-date information on cancer prevention, details of upcoming conferences, statistics on UK cancer rates and online tools including a BMI calculator. There is also a selection of free, downloadable resources including meal planners, diaries, factsheets and more.

Slide 46 WCRF UK also produces a monthly eNews for health professionals, which gives the latest news on diet, physical activity, obesity and cancer prevention as well as the opportunity to hear about any new resources, workshops and grants before they are more widely advertised.

Slide 47 Finally, World Cancer Research Fund also has a children’s programme, the Great Grub Club, which shows children aged four to 11 that ‘Being healthy is fun!’. You can find recipes, games, physical activity ideas and resources for teachers, parents and children online at www.greatgrubclub.com.

Slide 48 Thank you for listening. If you have any questions about this presentation, please email informed@wcrf.org.

Review date: December 2014

World Cancer Research Fund (WCRF UK)22 Bedford Square, London WC1B 3HHTel: 020 7343 4200 Fax: 020 7343 4201Web: www.wcrf-uk.org Email: wcrf@wcrf.org

“Stopping cancer before it starts”

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