I thank the committee for inviting me to attend in this wonderful building. I will touch on many of the themes which have been aired already, but I will speak specifically about food, nutrition, physical activity and looking at the prevention of cancer from a global perspective. I have provided a handout which has been distributed. I will refer to the information on the handout and from time to time I will draw attention to particular points.
I will begin with some scene-setting information about cancer patterns and trends over time. I will deal in particular with a couple of extensive reports into diet and cancer which my organisation has developed and which include recommendations for reducing cancer risk, and I will speak about policy and present some conclusions.
I will begin by speaking about my organisation because I do not know if Members are familiar with our work. The World Cancer Research Fund Global Network is not a single organisation but rather a small network of charities based in a number of countries. The World Cancer Research Fund UK is based in London and we have offices in Hong Kong, France and the Netherlands. In the United States the organisation is called the American Institute for Cancer Research. I work for World Cancer Research Fund International UK and it is the umbrella organisation providing overall strategic and operational support for the countries.
All the charities have same the same vision and mission and we are all dedicated to preventing cancer by means of health lifestyle changes. By lifestyle in this context I mean diet, physical activity and weight management. This is achieved in a number of different ways. We fund research into diet and cancer. We then interpret that research to provide educational messages that underpin our education programmes which are targeted at a variety of audiences from children to parents, teachers, health professionals, scientists and policy-makers, for example. We take those big reports I mentioned and we use those as a kind of advocacy tour to use with policy-makers to advocate for healthy public policies.
I will speak in more detail about the reports shortly. The first report deals with food, nutrition and physical activity and the prevention of cancer. The other report deals with policy and action for cancer prevention. They are both global reports and they speak to a global audience.
I will explain why such reports are needed. Cancer rates are on the rise and increasing. They are projected to increase in the year 2030 to about 16 million new cases a year globally and about 12 million deaths. As we heard earlier, we cannot do much about some of the things that are fuelling that increase. We are all living longer, populations are living longer and cancer, as has been said, is mainly a disease of older age. There is not all that much that can be done in this regard.
Lifestyle factors are also fuelling this epidemic and we can take actions to change people's behaviour with regard to food and nutrition and physical activity and to make an impact on the cancer rates. This projection is not set in stone; cancer rates are neither fixed nor inevitable. Much of the information about this comes from migration studies. Members may be familiar with some very extensive and famous migration studies from the 1960s and 1970s. What they show is that when people move from one country to another, they adopt the patterns of the new country. For example, a famous study looked at women in Japan in the 1960s. When they lived in Japan, they had a classic Japanese pattern of cancers, so this meant a high rate of stomach cancer and very low rates of colorectal and breast cancer. These women moved to Hawaii and within a generation or so, the pattern was quite different. Now the stomach cancer rate had come down significantly but the breast and colorectal cancer rates had risen. Within another generation, it had changed further still. Now, the breast cancer rates had shot right up, colorectal cancer rates had levelled off and the stomach cancer rates had come down again. What happened was a change from a classic Japanese pattern of cancer to a classic western, Hawaiian-US pattern, within a couple of generations. This was a study of movement from one country to another.
However, a study of movement within a single country over time will show differences. Japan is the country in question. Over the past 40 to 50 years, cancer patterns have changed significantly within Japan. There continues to be a sustained increase in colorectal and breast cancers, and this is because people within Japan are transitioning through moving from a classic Japanese type of diet through to a more western type of diet. These patterns and changes are so rapid that they cannot be due to anything other than an environmental effect. Although genes are very important and certain cancers are linked to high risk genes, most cancers are not and most cancers are determined by the environment. We can change the environment in which people live.
Looking at the top ten cancer rates, this is definitely a top ten of which no one wants to be part. Ireland comes in at number two, but if one looks at all the countries in the top ten, they are all countries from Europe, from Australasia and North America. Although there are big differences between these countries, what they tend to share in common are typical western-type dietary patterns, diets which tend to be high in fat, high in sugar, quite a lot meat, not necessarily much fruit and vegetables, and a lot of alcohol. They share certain patterns.
On the question of what is happening to make these cancer patterns change at the most basic level, there is much evidence from both human and animal studies that what we eat and drink, how much alcohol we consume and our level of body fat all impact upon the actual processes in our cells that lead to the development of cancer. What we eat can either have a protective effect, for example, on the cells or it can have a pro-cancer effect. Cancer takes a very long time to develop so it can take ten to 20 years sometimes. During that journey of a cell from being a nice normal cell through to a cell with cancer potential, there are many opportunities for the cell to be affected by things that protect it. I refer to vitamin A and lycopene as two factors which have been shown to be protective of cells. On the other hand, things like obesity, inflammation and heterocyclic amines give the cell a push and accelerate it on its journey towards being a cancer cell. At a basic cellular level, what we eat and drink can affect our risk of cancer and cancer process, and this has been manifested in these cancer rates and trends and different patterns.
This has been the scene-setting and now I will move on to talk about the reports on food, nutrition, physical activity and the prevention of cancer. This report was produced by the World Cancer Research Fund Global Network and was published in 2007. It was and is the most authoritative report and is widely cited in the scientific literature on diet and cancer. It took more than six years to produce and more than 250 scientists from throughout the world contributed to producing it. The main output is ten recommendations on cancer prevention aimed at individuals and on which I will touch shortly.
I thought it would be useful to say a little about how the report was put together. When it was first considered in the early 2000s, a methodology which could be used to produce this type of report was not available. Therefore, a new method had to be developed especially for it. It was peer reviewed and rigorously tested and then used by nine teams of scientists all based in different centres in different countries. Between them they took groups of cancer sites such as breast, lung and prostate and systematically reviewed all the evidence that had ever been published on the links between diet and cancer. In their first trawl through the literature they identified approximately 500,000 papers of relevance. Using very rigorous selection criteria, they boiled down these to approximately 7,000 papers which were the most credible, rigorous and well conducted papers on animal and human work and various clinical and other trials and provided the substrate for the diet and cancer report. Importantly, their systematic review of the evidence was kept separate from the judging of the evidence. This was to ensure the judging of the evidence was as impartial and independent as possible. A panel of 21 international experts, leading scientists and clinicians chaired by Sir Michael Marmot examined the evidence, weighed it and made judgments which then became recommendations on the issue of whether a particular dietary component was convincingly linked, probably linked or not linked to causing cancer or protecting against it.
A handout has been presented on the summary of convincing and probable judgments. This is a complex graphic which takes a while to assimilate, but I will pull out a few messages. The 7,000 studies were percolated and resulted in a matrix which is a core component of the diet and cancer report. Included are the various exposures which were examined. They include fruit and vegetables, lycopene, meat, fish, energy-dense foods, sugary drinks and alcoholic drinks. Also included are the various cancer sites examined by the nine centres throughout the world, including mouth, oesophagus, lung, stomach, liver, breast and ovary. Weight gain, overweight and obesity get their own column because of the very strong evidence that emerged linking body fatness and obesity with seven cancer types, in particular.
Anything in the graphic coloured blue has a protective effect, while anything that is coloured pink has a cancer-causing effect. There is a raft of blue blocks across various cancer sites which are focused mainly on plant foods. There is a host of pink and red blocks which are mainly linked with physical inactivity, body fatness and weight generally. There are several red blocks which have to do with red and processed meat and the link with colorectal cancer. The various dietary constituents and cancer sites are summarised in this one graphic. Although it is a reductionist approach, it is a very useful tool to have.
The role of the panel was to take this rather reductionist approach and reconstitute it in a way that was meaningful and reflected how people actually ate and drank. The panel considered all of the evidence and made ten headline recommendations. The first eight are aimed at everyone throughout society, while the last two, on breast-feeding and cancer survivors, are aimed at special population groups. The first three recommendations are connected with weight and activity. It is recommended that one be as lean as possible within the normal weight range, be physically active as part of everyday life, limit consumption of energy-dense foods and avoid sugary drinks. The next five recommendations are to do with plant and animal foods. It is recommended that one eat mostly foods of plant origin, limit the intake of red meat, alcoholic drinks and the consumption of salt, aim to meet nutritional needs through diet alone and avoid mouldy cereals, which is not much of a problem for us but is a problem in large parts of the world. The recommendation on breast-feeding is very important because, as probably has been touched on, breast-feeding protects mothers from developing breast cancer and the child from becoming overweight and obese in later life, which protects them from a raft of cancers. Cancer survivors are also a special population group. At the time the report was published there was not enough evidence on cancer survivors available to make a particular recommendation, but there is much more evidence available now. These are the individual recommendations linked with public health goals. The physical activity goal is aimed at everyone and the aim linked with it is for the proportion of the population that is sedentary to be halved every ten years. Each of these recommendations is linked with a higher level population goal.
I mentioned the report was published in 2007. To keep the evidence updated and ensure as an organisation we can provide the most up-to-date evidence, we have a continuous update project which is undertaken in liaison with a team of scientists at Imperial College London. They work to the same principles as were used in the 2007 report. They are systematically reviewing all evidence published since 2007. There is a separate panel of independent experts who weigh the evidence and will draw conclusions and make recommendations in order that we can ensure the recommendations are kept current.
To take stock, cancer is a major cause of death, disability and lost life years, but it does not have to be this way. Many cancers are environmentally determined which means they are largely preventable. All one needs is the will, particularly the political will, to grab the problem by the throat and do something about it. Not smoking is the most important thing one can do to affect one's cancer risk. Alongside this, body fatness, physical activity, diet and nutrition are the most important factors we can modify. As we heard, this is a very empowering message to be able to give. It is something very positive people can do, although, as we hear, it can sometimes be very difficult for people to do. The evidence that cancer is preventable is very strong, certainly strong enough to justify action.
This leads us to a report published in 2009 on policy and action aimed at cancer prevention which is a companion to the 2007 report. It was overseen by the same panel of 21 experts with the addition of three special policy experts. The aim of the report was to examine how the personal recommendations made in the diet and cancer report could be implemented to achieve public health objectives. As part of this, the panel which oversaw the report wanted to develop new preventability estimates to examine the level of cancer that was preventable. It showed that approximately a third of the most common cancers in high-income countries like Ireland can be prevented by having appropriate food, nutrition, physical activity and body fat levels. In lower-income countries, approximately a quarter of the most common cancers can be prevented in that way. Members can see a list of the most common cancers.
A previous speaker mentioned that it is important to bear in mind that what works for cancer also works for the big chronic diseases like diabetes, heart disease and lung disease. They share common risk factors, which means that a common approach to tackling them can be taken. That is easier said than done, however, especially when our environment works against us and sometimes makes it difficult for people to make healthy choices. It is easy to access cheap and plentiful alcohol. It is easy to consume highly processed and energy-dense foods. People can have no option other than to jump in the car if they want to get from A to B. Our environments are not always conducive to physical activity. One of the underpinning messages of any examination of public health policy should be that there is a need for the environment to be rebalanced to make it a healthier one in which to make choices.
As we have heard, the environment is very influential in shaping behaviour. People behave like those around them and in accordance with what is considered to be the social norm. It is important to provide education and raise awareness, but that on its own is going to be limited in terms of really achieving the scope of preventability. It is quite difficult to get people to change their behaviour in a sustained long-term way if they are being asked to do something that deviates strongly from what is considered the social norm. We need to go bigger by looking at the external environment in which people are making their choices. That is where people like the members of the committee are so important. They have an opportunity to influence and shape Government initiatives.
If we can go bigger by shaping the external environment, we can help to shape people's choices and behaviours and start to make a dent in the incidence of cancer and other chronic diseases. I will give a couple of examples. Smoke-free environments were pioneered in Ireland. When one goes into a pub and finds that nobody is smoking, it is hard for one to remember that it was not that long ago that pubs were horrible and smoky. One does not think about smoke in pubs because it is normal that nobody is smoking. Similarly, there was a great deal of controversy in the UK in the 1970s when legislation was introduced to require people to wear seat belts. It was argued that by forcing people to wear seat belts, one would remove a choice from them. It was suggested that people should be allowed not to wear seat belts. There was so much evidence that the wearing of seat belts reduced fatality rates that seat belt legislation was introduced in the end. It is now the social norm for everyone to wear a seat belt. I have given a couple of examples of how really big sustained effects and changes in behaviour can be achieved.
I will not dwell on the graphic from the policy report that depicts the factors which constrain personal choice. The graphic in question, which was used to help to shape the format of the policy report, makes it clear that many factors affect people's choices. We like to think our choices are free, but that is not really the case. Environmental, economic and social factors may operate at local, national and international levels. All of these things combine to influence the foods and drinks we consume. They affect how physically active we are. They can determine whether women breastfeed. They affect our body fat levels. All of those factors, in turn, translate into health outcomes. The bottom line is that if one can mend the external factors by making them conducive to healthier choices, one is much more likely to achieve a sustained long-term change in behaviour.
One of the over-arching messages from the policy report is that cancer prevention is everyone's business. Every member of society has a role to play. The report identifies nine groups of actors, including ordinary people, health professionals, workplaces, civil society organisations like WCRF International and the other organisations that will be here today, Government, industry and multinational bodies. The message from the report is that no single group can do it on its own. There is a need for sustained talk and action across the various groups. If that is to happen, there has to be leadership, ideally from the Government, which is important because it has front and central responsibility for the health of its citizens. Health professionals are also important because they are at the coal face every day. As they deal with patients, they are in a unique position to be able to influence them.
The diet and cancer report makes ten recommendations. The policy report makes 47 or 48 recommendations, which are divided among the nine groups of actors. Each group has its own set of recommendations. The policy report emphasises that there is a direct evidence trail between the ten recommendations made in the diet and cancer report and the recommendations made in the policy report. The policy report also makes recommendations about how the various groups can work together to achieve public health goals and recommendations. I am sure the committee will not be surprised to hear that the biggest number of recommendations in the policy report relate to the governmental sector. I will briefly mention four of them.
One of the recommendations involves examining and auditing legislation and regulations to ensure they protect public health and prevent disease. That is about taking stock and seeing what the situation is now. Another recommendation relates to the built and external environments. We have heard that the environment is really important. If one does not feel safe walking around, or if one does not have easy access to places where one can walk and engage in physical activity, that will have an effect on how physically active one is. Another recommendation involves encouraging nutrient-dense unprocessed foods and discouraging highly processed foods and sugary drinks. The final recommendation I would like to mention is that proposing that the advertising and marketing of fast food to children should be restricted.
The report emphasises that governments should think about doing these things by means of legislation, pricing or other regulation unless there is good independent evidence that voluntary codes have been effective. This is a really good time to be thinking about the prevention of cancer and other chronic non-communicable diseases. A great deal of emphasis is currently being placed on the scope of cancer and non-communicable diseases. It has been recognised at the highest level as being a problem for all countries throughout the world. It is not just a problem for western developed countries. Developing countries have an equally big problem, especially as they start to make the transition to the types of diets and lifestyles that are associated with the west.
Some members might be aware that a General Assembly high-level meeting took place in New York last September. It was just the second time in history that a United Nations meeting focused on a health issue. Governments from around the world signed up to a political declaration on the prevention and control of non-communicable diseases, which was the outcome of the meeting. A tremendous amount of activity is taking place on the question of how best to implement the political declaration that now exists. It is no more than a roadmap at present. It needs to be fleshed out.
A global strategy for the prevention and control of non-communicable diseases has been developed by the World Health Organization, which is currently in the process of drawing up a new action plan to run from 2014. It is intended that the WHO action plan will dovetail into the political declaration to make sure there is a global framework for reducing the rates of cancer and other non-communicable diseases. That will need to be fleshed out and acted upon at national level.
I will give examples of some of the action areas where policies need to be implemented. The Government, in particular, can take an important role in these areas. The committee has heard a great deal about some of these already. There should be an examination of the commercial marketing activities that target children. Consideration should be given to extending the age range to make it wider. The watershed could be extended to take account of the fact that children - especially these days - tend to look at television at all sorts of different times and not necessarily just before the watershed. We should also examine emerging social media, including online marketing.
We heard a little about fiscal measures earlier. We need to make sure we balance incentives and disincentives. We could increase the level of tax that applies to energy-dense foods. It would not necessarily be a fat tax. If a fat tax were to be introduced in the absence of a multinutrient approach, people might end up eating more foods that have lots of sugar or lots of salt on them. We need to look at the whole profile of the food and how it can be balanced with subsidies of fruit and vegetables so that the impact at the end of the day on a household budget is fairly economically neutral.
On the activities of food manufacturers around labelling, there is a great deal of evidence available which indicates that the system which people prefer and find the most easy to understand is the traffic light system. Consideration could be given to extending front of pack labelling with the traffic light system, which communicates quite complex nutritional information but is easy to understand. Action could also be taken in the area of portion size. The trend of super-sizing - when one orders a glass of wine or coffee in a restaurant, one is regularly asked if one wants a large one - is invidious and entrenched in our society. Consideration must also be given to food reformulation not only in respect of salt, but sugar and fat, so as to develop healthier options. The industry has a vital role to play in terms of coming up with healthier options. Issues such as retailers-supermarkets engaging in price promotions, such as buy one get one free, buy one get two free offers, and selling cheap alcohol as a loss leader and so on also need to be looked at. On urban planning, we heard about the importance of planning environments so that they are conducive to physical activity and other healthy behaviours. Another area for consideration is policy around food supply and agriculture, for example, not incentivising the production of cheap meat, animal fats, sugar, corn syrup and so on and perhaps positively incentivising the production of fruit and vegetables.
As evidenced from our discussion today this is a really complex area. It has already been mentioned that people's choices are not made in a vacuum and that many complex and inter-related factors will impact on their behaviour and choices. As such, there is a real need for leadership from the Government. It has also been mentioned that this is not just a health issue. As such, there is a need for a whole of Government response, including by the trade, transport, agriculture and finance Ministries. Although it is important to provide education and awareness - which is a large part of what WCRF International does - to do this in the absence of wider population strategies makes getting a sustained effective change in people's behaviour much more difficult. Governments like short-term quick fix type solutions. The type of interventions about which we are speaking often require long-term implementation, monitoring and review.
The case for action is strong. There is tremendously good evidence that diet and physical activity are linked to different types of cancer. We know at a basic cellular level why and how this has come about. There is much evidence available on the impact of different policies, including the addition of different types of taxes and subsidies. The World Economic Forum recently did a study on different types of policy. Investing in primary prevention now will result in huge savings down the line because people will generally be healthier and have a better quality of life, leading to a more productive workforce. Any investment and effort made now will pay off down the line.
I referred earlier to the national regional summaries of the policy reports on other countries' experience which are global reports and speak to a global audience. These local reports are from Brazil, Latin America, the US and Canada, and there are others in the pipeline. The summaries focus on the policy and recommendations contained in the reports in the context of what recommendations and activities therein are most relevant in a particular local context and are most likely to be effective in that regard. The summaries, which are quite short documents, are tailored to the local context. The Brazilian summary, done in liaison with INCA, the Brazilian national cancer institute, has been used by the Brazilian Government in a number of ways. It is a tool for use by policy makers and has informed a number of Brazilian Government actions, including the steering committee on the national policy on health promotion and the national plans for obesity and chronic disease control. It has also fed into many policy discussions on marketing to children, which is a really hot topic in Brazil and on the taxation of unhealthy products. It, along with many other studies, has been used by policy makers.
An example of good practice policies in Brazil is in the area of school meals. The Brazilian Government recently passed a new law which legislates for local authorities to spend 70% of their budget on fruit and vegetables. Networks of health professionals have been set up to advise and assist them in this regard. As mentioned, schools are an important environment as they enable us to encourage children at an early stage of life to develop healthy habits which can then be carried through into adulthood. As mentioned also, overweight children tend to become overweight adults. As such, if we can establish healthy eating habits with children we are half way towards having healthy adults.
Ciclovias is a cycle lane project which is being pioneered across Latin America. It started out in Argentina, was then introduced in Chile and is now being established in Brazil. The aim is to have a car free Sunday. Huge amounts of cars, such as there are on the big city streets in Latin America, can be very dangerous to people trying to cross the road. This project aims to encourage a car free Sunday and to get people out of their cars and onto their bikes or feet. There has been a great deal of public education and promotion around the project and it has been quite successful. The aim is to reach at least two million people across the region in Brazil every Sunday.
Another particular area of focus in Brazil is promotion and protection of breastfeeding. I mentioned earlier that breastfeeding is important in two ways: it protects the mother against breast cancer and protects the child from becoming overweight or obese in later life, which significantly reduces their risk of getting a whole host of different cancers. This is the reason the diet and cancer report specifically recommends breastfeeding. The Brazilian Government has also increased its length of paid maternity leave and has increased promotion of breastfeeding in the community, hospitals and so on. It has also made available facilities for expressing and storing milk. For example, hospitals in Brazil will often have a milk bank to which women who cannot breastfeed can go to obtain milk. These actions have led to an increase in breastfeeding in Brazil. There is also a great deal of training of health professionals to support this.
On ongoing challenges, first, to capitalise on how preventable cancer is and to get the most effective policies, governments need to use all of the tools in the toolbox, including incentives, disincentives, legislation, regulation and so on. Second, public sector stakeholders can be really important in terms of helping to promote healthy environments such as schools and workplaces, where many of us spend most of our time. For example, there are all sorts of subsidies in place in my own office, including gym membership, loans for bikes, special healthy eating lunches and so on, all of which can assist in promoting healthy behaviours at work. Third, industry is an important stakeholder in terms of incentivising manufacturers to advance reformulations and come up with healthier options. It is not always easy to do this because the taste and texture of foods can be affected. However, that is one way of providing much healthier option foods.
There is strong evidence that many cancers are preventable. Getting the best results will require concerted action across the groups I mentioned, including leadership from the Government and health professionals. In that way, sustained longer term population level activities that are coherent and joined up can be achieved. These activities are much more likely to be successful than isolated initiatives which focus on individual behavioural change, although that is important in providing education and awareness programmes. Also, cancer prevention activities and plans will need to be integrated with a country's overall national cancer plan. We must be mindful of the fact that what will work in terms of cancer prevention programmes will also work in the case of other chronic diseases such as heart disease, lung disease and diabetes. If one is thinking about local implementation, it is a good idea to obtain locally relevant evidence to help inform policies in that regard.
I have given a lot of information in a relatively short time. However, I hope it has given a reasonable overview. I am sure it picked up on some of the issues raised earlier in terms of lifestyle factors.
