www.uicc.org
A healthy active childhood: giving children the best chance of a cancer-free future World Cancer Campaign 2009 Today’s Children, Tomorrow’s World
E V I T C A Y A HEALTH : D O O H D L I CH E H T N E R D L I H C G N GI V I A F O E C N A H C T S BE E R U T U F E E R F R E CANC isk r e c n a c a s a y t i Tackling obes
r
Terry Slevin Annie Anderson Colleen Doyle Fiona Bull Steve Pratt Mohandas Mallath
A healthy active childhood: giving children the best chance of a cancer-free future
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“Today’s children, tomorrow’s world” is a five-year cancer prevention campaign initiated by the International Union Against Cancer (UICC) and focused on children and prevention. We gratefully acknowledge • Pfizer Global Health Partnerships as lead sponsor of the campaign • GlaxoSmithKline, MDS and Merck as corporate sponsors of the campaign
www.worldcancercampaign.org
This report is published as a contribution to the campaign.
ISBN: 978-2-9700533-1-6 © International Union Against Cancer 2009 For more information about “Today’s children, tomorrow’s world” and the World Cancer Campaign, visit www.worldcancercampaign.org or contact Aline Ingwersen, global campaign coordinator, at wcc@uicc.org International Union Against Cancer (UICC) 62 route de Frontenex 1207 Geneva, Switzerland Tel +41 22 809 1811 Fax +41 22 809 1810 info@uicc.org
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World Cancer Campaign 2009
Table of contents
TABLE OF CONTENTS
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1. One of the world’s fastest growing health threats . . . . . . . . . . . . . . . 11 2. Healthy eating for cancer reduction . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3. Staying still is the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 4. Helping children achieve energy balance . . . . . . . . . . . . . . . . . . . . . . 29 5. Practical solutions and useful resources . . . . . . . . . . . . . . . . . . . . . . . 37 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
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World Cancer Campaign 2009
Preface
PREFACE
www.worldcancercampaign.org/reports
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Foreword
foreword
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World Cancer Campaign 2009
Introduction
Introduction
THE NEW NEWS IN CANCER: OVERWEIGHT AND OBESITY AND THEIR CONTRIBUTION TO CANCER RISK "If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.� Hippocrates (460-377 BC)
O
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Solutions for obesity benefit the planet
Urgency for action
Who should efforts to reduce obesity target?
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Chapter 1
Chapter one
ONE OF THE WORLD’S FASTEST GROWING HEALTH THREATS
Key messages
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The link between excess body weight, fatness and cancer
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What is a healthy weight?
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Chapter 1
Age
Adult equivalent BMI
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a) Healthy weight (18.5-25) b) Overweight (25-30) c) Obese (30+)
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BMI (Boys)
BMI (Girls)
a) 14-16.6 b) 16.6-18.3 c) 18.3+
a) 13.9-16.9 b) 16.9-18.8 c) 18.8+
a) 14.9-18.5 b) 18.5-21.4 c) 21.4+
a) 14.8-19 b) 19-22.6 c) 22.6+
a) 17.6-22.7 b) 22.7-27 c) 27+
a) 17.8-23.5 b) 23.5-28.2 c) 28.2+
Table 1: Body mass index values at nominated ages and by sex, identifying cut points for underweight, healthy weight, overweight and obese (WHO 2006b, 2007a). These standards may be modiďŹ ed locally to allow doctors to identify and clinically manage obesity among children and adolescents country by country
Healthy weight in children
What is the scale of the problem?
Figure 1. Estimated percentages of women who will be obese (1) or overweight (2) and men who will be obese (3) or overweight (4) in 2010 (WHO Global Database on BMI).
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Weight gain trends among children in emerging economies
Trends in adults in emerging economies
Figure 2. Prevalence of overweight and obesity by gender for ages 15 years and above in 2002 (Khor 2008)
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Chapter 1
The double burden of malnutrition Drivers of obesity
Composition of diets
Reductions in physical activity
• The intake of animal source food (meat, fish and milk) is increasing rapidly • The energy density of diets is increasing rapidly • Edible oil consumption has increased rapidly • The world’s food supply has become sweeter • Substantial reduction in food preparation time and increased consumption of food away from the home • Portions or serving sizes are increasing
• Major shift away from manual labour or energy-intense work (eg agriculture) to sedentary roles (eg service sector) • General reduction in physical activity linked to most occupations • Changes in transport from physical (walking, cycling, public transport) to motorized (car/motorcycle) • Greater mechanization of tasks in the home • Limited facilities for physical activity and recreation in overcrowded cities and towns
Table 2: Environmental drivers of obesity in developing countries (adapted from Popkin 2005)
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Where to from here?
Be as lean as possible within the normal range of body weight
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Chapter 2
Chapter two
HEALTHY EATING FOR CANCER REDUCTION Key messages
International trends in food consumption
D
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What’s contributing to these trends?
Challenges in researching the link between food and cancer
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World Cancer Campaign 2009
Chapter 2
Decrease risk (consume more)
Increase risk (consume less)
Food
Cancer site
Food
Cancer site
dietary ďŹ bre
colorectum
aflatoxins1
liver
non starchy vegetables
mouth pharynx, larynx, oesophagus, stomach
red meat
colorectum
allium vegetables
stomach
processed meats
colorectum
garlic
colorectum
Cantonese-style salted ďŹ sh
nasopharynx
fruits
mouth pharynx, larynx, oesophagus, lung
diets high in calcium
prostate
food containing folate
pancreas
salt
stomach
food containing carotenoids mouth pharynx, larynx
salted and salty foods
stomach
food containing beta carotene
oesophagus
inorganic arsenic in drinking water
lung
food containing lycopene
prostate
inorganic arsenic in drinking water
skin
food containing vitamin C
oesophagus
mate2
oesophagus
food containing selenium
prostate
alcoholic drinks
mouth pharynx, larynx, oesophagus, colorectum (men) breast
milk
colorectum
alcoholic drinks
liver, colorectum (women)
calcium supplements
colorectum
beta-carotene supplements
lung
selenium supplements
prostate
Table 3: Foods and drinks that increase or decrease cancer risk (WCRF 2007). Those links where evidence is convincing are in bold. Those not bolded are considered probable 1 Contaminant found in some nuts, seeds, cereals, seeds and vegetables 2 As drunk traditionally in parts of South America, scalding hot through a metal straw, likely to be due to the burning effect of the hot water rather than the herb
What do we know?
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Limit consumption of salty foods and foods processed with salt Limit consumption of energy-dense foods, and avoid sugary drinks
Eat a diet made up mostly of vegetables, fruits and whole grains
Limit intake of red meat, and avoid processed meat
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World Cancer Campaign 2009
Limit alcoholic drinks. If consumed at all, men should limit alcoholic drinks to no more than two a day, and women to no more than one a day
Chapter 2
Improving diets among children
Other benefits of a healthy diet
• Cardiovascular disease
• Diabetes
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Infancy and childhood
Foetal life
Development of cancer
Mother’s nutrition Carcinogen exposures Foetal growth birth weight
Breast feeding Infections/PEM Micronutrients Contaminants (air, food, water) Growth rate Stature Behaviours Physical activity Food choice Obesity
Adult life
Adolescence Smoking Contaminants (air, food, water) Timing of puberty Obesity Physical activity Inactivity (exercise and sedentarism)
Older ages
Pregnancy and lactation Established adult risky behaviours Diet and Physical activity Tobacco, Alcohol
Exposure to carcinogens Accumulated risk
Genetic susceptibility to cancer
Age Figure 3. The life-course prevention of cancer, illustrating how nutritional factors at various stages of the life course effect development of cancer (Uauy and Solomons 2005)
Conclusion
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Chapter 3
Chapter three
STAYING STILL IS THE PROBLEM
Key messages
The link between inactivity and cancer
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When: cancer-related time period PRE-DIAGNOSIS DIAGNOSIS Pre-screening
How: cancer control outcomes
Ways in which physical exercise may affect cancer control outcomes
Prevention
Screening
Detection
Pre-treatment
Buffering
POST-DIAGNOSIS Treatment
Post-treatment
Resumption
Rehabilitation
Health promotion Survival
Coping Palliation
Preponderance of Exercise may current research improve screening examines risk reduccompliance; tion and prevention; may also affect moderate to strong sensitivity and evidence found for specificity of decreased risk of screening tests colon, breast, prostate and endometrial with increased physical exercise
Exercise during pre-treatment period may boost physical and psychological functioning, resulting in better physical preparation for treatment
Studies beginning to accrue on benefits of physical exercise in cancer patients and survivors; improved functional capacity and quality of life have been demonstrated
Research has been initiated on how exercise may affect survival, the ultimate outcome; results are preliminary but exercise may improve immune function among others
Figure 4. Framework PEACE: an organizational model for examining when and how physical exercise may affect the cancer experience (Courneya and Friedenreich 2001, 2007)
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World Cancer Campaign 2009
Chapter 3
Decreased oestrogens and androgens (sex hormones)
Improved immune function
Reduced adiposity (less body fat)
Increased physical activity
Decreased risk of cancer
Decreased insulin and glucose
Altered adipocytokines [hadiponectin, ileptin, iinflammation] (cellular chemical messengers)
Figure 5. Hypothesized mechanisms linking physical activity to cancer risk or prognosis (McTiernan 2008))
Energy balance
Type two diabetes mellitus
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Physical activity across the lifespan
Childhood and adolescent activity
Childhood and adolescent health
Adult activity
Adult health
Figure 6. Potential relationships between physical activity and health in childhood and adolescence, and physical activity and health during adulthood (Blair et al 1989; Malina 2001)
Children and adolescents
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Chapter 3
Adults
Older adults
Individual physical activity
Measuring physical activity
Population physical activity
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International physical activity trends
Sedentary recreation
Reducing physical inactivity
Active transport
Urban design
Conclusion
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Chapter 4
Chapter four
HELPING CHILDREN ACHIEVE ENERGY BALANCE Key messages
School-based programmes should
Family-based guidance should
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C Population-based programmes
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Chapter 4
Micro-environments
Macro-environments
• Intrapersonal (eg individual)
• Food processing industries
• Interpersonal (eg family and friends)
• Local government
• Institutional (eg school or workplace)
• Mass media
• Community
• Non- governmental organizations
Food marketing
• Political pressure groups • Legislators • International environments • Trade agreements Figure 7. Examples of micro- and macro-environments for action
Opportunities for effective prevention policy
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• Include food and health education in the school curriculum • Control the provision and sale of fatty snacks, confectionery and sweet drinks in public institutions such as schools and hospitals • Control the advertising and promotion of food and drink products • Provide public subsidies on healthy foods to improve patterns of food consumption • Encourage more physical activity by changing planning and transport policies • Improve provision of sports and recreational facilities in schools and communities • Improve training for health professionals in obesity prevention and diagnosing and counselling those at risk of obesity • Improve health education to enable citizens to make informed choices • Reform the EU’s common agricultural policy to help achieve nutritional targets • Make nutritional information labelling mandatory for all processed food, for example using an energy density “traffic light” system, with high energy density products labelled in red, low density products labelled in green, and intermediate products labelled yellow Figure 8. Policy options to prevent childhood obesity (European Heart Network 2007)
Evidence for effective prevention programmes
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Chapter 4
Overall educational message • Children told that decreasing sugar consumption would improve overall well-being and benefit dental health Class room delivery activities: One class (1 hour) per term • First session Focused on balance of good health Promoted water intake Tasted fruit to learn about the natural sweetness of products Gave each class a tooth immersed in a sweetened carbonated cola
Opportunities for effective prevention programmes
• Second and third sessions Music competition to produce a song or a rap with a healthy message. • Final session Presentations of art work related to theme Interactive approaches (quiz) Wider educational involvement • Encouraged to access information on project’s website Figure 9. CHOPPS: a successful school-based obesity reduction programme (James et al 2004)
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School policies and school environment • Ensure school policies and school environments encourage physical activity and a healthy diet. Consider building layout provision of recreational spaces catering, including vending machines food brought into school by children the curriculum, including PE (physical education) school travel plans, including provision for cycling extended schools Staff training • Teaching, support and catering staff should have training on how to implement healthy school policies Links with relevant organizations • Establish links with health professionals and those involved in local strategies and professional partnerships to promote sports for children and young people Interventions • Introduce sustained interventions to encourage pupils to develop life-long healthy habits. Short term, oneoff events are not effective on their own • Take pupils’ views into account – including differences between boys and girls and barriers such as cost or concerns about the taste of healthy food • PE/sport staff should promote activities that children enjoy and can take part in outside school and continue into adulthood • Children should eat meals in a pleasant sociable environment free from distractions • Younger ones should be supervised; if possible, staff should eat with them • Involve parents where possible; for example through special events, newsletters and information about lunch menus Figure 10. Recommendations for school settings (NICE 2006)
The family context
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Chapter 4
Figure 11.
YES
SELECT WITH CARE
NO
Drinking water must be avail- Other drinks that are allowed to be provided if specific able: criteria are met:
Examples of drinks that are no longer allowed:
Free drinking water must
No soft drinks (still or
be available in schools at all times
Drinks that are allowed to be provided:
Mineral water (still or carbonated)
Semi-skimmed, skimmed milk or lower-fat milks
There is a range of other drinks permitted by the regulations but these drinks must be carefully selected (see the “SELECT WITH CARE” column
Milk drinks (hot or cold) containing: no more than 1.8g of total fat per 100ml no more than 10g of total sugars per 100ml and no more than 20g of total sugars per portion size. Drinking yoghurts containing: no more than 1.8g of total fat per 100ml no more than 10g of total sugars per 100ml and no more than 20g of total sugars per portion size. Soya, rice or oat drinks enriched with calcium containing: no more than 1.8g of total fat per 100ml no more than 5g of total sugars per 100ml and no more than 10g of total sugars per portion size. Any variety of fruit juice or vegetable juice (including fruit juice made from concentrate or partially made from concentrate) that meets the following criteria: unsweetened a portion size of no more and unsalted than 200 ml. A blend containing any of the following ingredients, either singly or combination: fruit vegetable fruit juice vegetable juice and with no added sugar or salt and a maximum portion size of 200ml
carbonated) including flavoured waters (the only exception is the combination drinks that meet the criteria set out int the “SELECT WITH CARE” column).
No sugar-free soft drinks
(still or carbonated) including flavoured waters
No sweetened fruit juice No sweetened or salted vegetable juice
No squashes/cordials in-
cluding lower sugar and “no added sugar versions
No whole milk No sport drinks
Drinks made with a combination of water (still or carbonated) and fruit and/or vegetable juice that contain: no added sugar no more than 20g of sugar per portion size 50% or more fruit or vegetable juice and no more than 200ml fruit or vegetable juice. Tea and coffee – the use of any milk in these drinks should be restricted to semi-skimmed, skimmed milk and other lower-fat milks.
www.scotland.gov.uk/Publications/2008/09/12090355/
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If you eat…
KJ
Kcal
Sitting still
Walking (5.6km/hr)
Running (12km/hr)
Swimming (freestyle)
1 small apple (106g)
230
55
57 min
19 min
7 min
10 min
Muesli bar – fruit (35g)
531
127
2hr 12min
45 min
16 min
22 min
Chocolate - Mars bar (60g)
1152
276
4hr 46min
1hr 37 min
35 min
48 min
Luxury ice-cream (91g)
1185
283
4hr 53min
1hr 39 min
35 min
50 min
Meat pie (200g)
1989
476
8hr 13min
2hr 47 min
59 min
1hr 23 min
Big Mac (200g)
2010
481
8hr 18min
2hr 49 min
1 hr
1hr 24 min
40% fruit juice/cordial (200ml)
302
72
1hr 14min
25 min
9 min
13 min
No-added- sugar orange juice (300ml)
480
115
1hr 59min
40 min
14 min
22 min
Can of cola (375ml)
675
161
2hr 47min
57 min
20 min
28 min
412
7hr 7 min
2hr 25min
51min
1hr 12 min
Food
Drink
Large juice bar low-fat smoothie (650ml) 1723
Table 4. : Energy balance: time taken in different kinds of activity to burn off some common foods. (McArdle et al 2001; Stewart 2007) Reference child: 10 year old boy. Height 150cm (~50th percentile) Weight 40 kg (~50th percentile) BMI 17.77 (50th percentile) Food and drink weights sourced from www.calorieking.com.au
Diet • Children and young adults should eat regular meals, including breakfast, in a pleasant, sociable environment without distractions (such as watching television) • Parents and carers should eat with children – with all family members eating the same foods Activity • Encourage active play – for example, dancing and skipping • Try to be more active as a family – for example, walking and cycling to school and shops, going to the park or swimming • Gradually reduce sedentary activities – such as watching television or playing video games – and consider active alternatives such as dance, football or walking • Encourage children to participate in sport or other active recreation, and make the most of opportunities for exercise at school Figure 11. Recommendations for parents and carers (NICE 2006)
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World Cancer Campaign 2009
Conclusion
Chapter 5
Chapter five
PRACTICAL SOLUTIONS AND USEFUL RESOURCES
G Improving diets
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Menu-labelling legislation
Changes in school nutrition policies
Supermarket rating systems
Availability of fruit and vegetables in schools Advocating for change
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World Cancer Campaign 2009
Chapter 5
Reducing the commercial promotion of highenergy, low-nutrient food
Improving levels of physical activity
The Sydney principles (IOTF 2008) Actions to reduce commercial promotions to children should 1. support the rights of children Regulations need to align with and support the United Nations Convention on the Rights of the Child and the Rome Declaration on World Food Security which endorse the rights of children to adequate, safe and nutritious food. 2. afford substantial protection to children Children are particularly vulnerable to commercial exploitation, and regulations need to be sufficiently powerful to provide them with a high level of protection. Child protection is the responsibility of every section of society – parents, governments, civil society, and the private sector. 3. be statutory in nature Only legally enforceable regulations have sufficient authority to ensure a high level of protection for children from targeted marketing and the negative impact that this has on their diets. Industry selfregulation is not designed to achieve this goal. 4. take a wide definition of commercial promotions Regulations need to encompass all types of commercial targeting of children (eg television advertising, print, sponsorships, competitions, loyalty schemes, product placements, relationship marketing, Internet) and be sufficiently flexible to include new marketing methods as they develop. 5. guarantee commercial-free childhood settings Regulations need to ensure that childhood settings such as schools, childcare and early childhood education facilities are free from commercial promotions that specifically target children. 6. include cross-border media International agreements need to regulate cross-border media such as Internet, satellite and cable television, and free-to-air television broadcast from neighbouring countries. 7. be evaluated, monitored and enforced The regulations need to be evaluated to ensure the expected effects are achieved, independently monitored to ensure compliance, and fully enforced.
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Specific examples in developing countries
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World Cancer Campaign 2009
Chapter 5
Conclusion
Organization
Document
Summary
Website
World Health Organization
WHO global strategy on diet, physical activity and health
WHO aims to mobilize countries, as well as all concerned social and economic groups, and engage them in implementing the global strategy on diet, physical activity and health
www.who.int/dietphysicalactivity/en/
British Government OfďŹ ce for Science
Foresight report – tackling obesities: future choices
The obesity epidemic cannot be prevented by individual action alone and demands a social approach. Tackling obesity requires far greater change than anything tried so far, and at multiple levels: personal, family, community and national. Preventing obesity is a social challenge, similar to climate change. It requires partnership between government, science, business and civil society.
www.dh.gov.uk/ en/Publichealth/ Healthimprovement/Obesity/D H_079713
Australia’s Preventative Health taskforce
Obesity in Australia: a need for urgent action
The taskforce will provide evidence-based advice to governments and health providers on preventative health programmes and strategies, focusing on the burden of chronic disease currently caused by obesity. This is a work in progress.
www.preventativehealth.org.au /internet/preventativehealth/publ ishing.nsf/Content/tech-obesity
International Obesity Task Force
Many
The IOTF as part of the International Association for the Study of Obesity (IASO) is working with partners in the Global Prevention Alliance to support new strategies to improve diet and activity and prevent obesity and related chronic diseases with a special focus on preventing childhood obesity
www.iotf.org/ind ex.asp
Table 5. Useful sources of information on overweight and obesity prevention and control
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A healthy active childhood: giving children the best chance of a cancer-free future Tackling obesity as a cancer risk