DRAFT AICR CPE 2010 1.28.11

Food & Physical Activity for Cancer Prevention:

How to Bring the Science to Life Food & Physical Activity for Cancer Prevention

Learning Objectives:

Learning Objectives Discuss the role for registered dietitians in cancer prevention. Use the Second Expert Report, “Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective,” and the Continuous Update Reports produced by AICR and World Cancer Research Fund as a foundation for cancer prevention advice to individuals and groups . Compare and contrast the different levels and types of evidence related to specific lifestyle factors and cancer prevention, using the various methods of data presentation in the Second Expert Report. Describe the five key components of the process used to develop the Second Expert Report.

Why Cancer Prevention?:

Why Cancer Prevention? The good news: New cancer diagnoses and deaths have decreased (1999 - 2006) It’s all relative. The other stats on cancer: Causes 1/4 of U.S. deaths #2 cause of death behind heart disease Half of men and 1 in 3 women will get cancer in their lifetime Global burden of cancer will increase (Edwards et al 2009; NCI, 2009; U.S. Mortality, 2007; WCRF/AICR, 2007)

AICR/WCRF Expert Reports:

AICR/WCRF Expert Reports Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective , 1997 Second Expert Report, 2007 Continuous Update Project: Breast Cancer, 2009 In development: Prostate, Colorectal, Pancreatic cancers; Breast Cancer Survivors

The Recommendations:

The Recommendations

Recommendations for Cancer Prevention:

Recommendations for Cancer Prevention Be as lean as possible within the normal range of body weight. Be physically active as part of everyday life. Limit consumption of energy dense foods. Avoid sugary drinks. Eat mostly foods of plant origin. Limit intake of red meat and avoid processed meat.

Recommendations for Cancer Prevention:

Recommendations for Cancer Prevention Limit alcoholic drinks. Limit consumption of salt. Aim to meet nutritional needs through diet alone. Mothers to breastfeed, children to be breastfed. For cancer survivors, follow the recommendations for cancer prevention.

Principles Guiding Cancer Prevention Recommendations:

Principles Guiding Cancer Prevention Recommendations Integrated Understanding of Evidence Broad-Based Pool of Evidence Global Experts, Global Relevance Pertain to Cancer at All Sites Designed for Major Impact Account for Prevention of Other Diseases Challenging to Implement

The RD at the Cancer/Chronic Disease Confluence:

The RD at the Cancer/Chronic Disease Confluence

The Process:

The Process

Slide 15:

Methodology Task Force Develop methodology to be used in reviews Panel Interpret the evidence Systematic Literature Review (SLR) Centers Review links between diet, physical activity, and cancer STAGE 2 STAGE 3 STAGE 1 Advisory Group Guidance and feedback to SLR Centers, AICR/WCRF Executive Peer Reviewers Review protocol and product developed by SLR Centers

Slide 16:

Methodology Task Force Develop methodology to be used in reviews Panel Interpret the evidence Systematic Literature Review (SLR) Centers Review links between diet, physical activity, and cancer STAGE 2 STAGE 3 STAGE 1 Peer Reviewers Review protocol and product developed by SLR Centers Advisory Group Guidance and feedback to SLR Centers , WCRF/AICR Executive

Slide 17:

Methodology Task Force Develop methodology to be used in reviews Panel Interpret the evidence Systematic Literature Review (SLR) Centers Review links between diet, physical activity, and cancer STAGE 2 STAGE 3 STAGE 1 Methodology Task Force Develop methodology to be used in reviews Advisory Group Guidance and feedback to SLR Centers , WCRF/AICR Executive Peer Reviewers Review protocol and product developed by SLR Centers

Slide 18:

Methodology Task Force Develop methodology to be used in reviews Panel Interpret the evidence Systematic Literature Review (SLR) Centers Review links between diet, physical activity, and cancer STAGE 2 STAGE 3 STAGE 1 Advisory Group Guidance and feedback to SLR Centers, AICR/WCRF Executive Peer Reviewers Review protocol and product developed by SLR Centers

Slide 19:

Methodology Task Force Develop methodology to be used in reviews Panel Interpret the evidence Systematic Literature Review (SLR) Centers Review links between diet, physical activity, and cancer STAGE 2 STAGE 3 STAGE 1 Advisory Group Guidance and feedback to SLR Centers, WCRF/AICR Executive Peer Reviewers Review protocol and product developed by SLR Centers

Continuous Update Project:

Continuous Update Project

Judging the Evidence:

Judging the Evidence

Types of Evidence Included:

Types of Evidence Included Randomized Controlled Trials (RCTs) Ecological Studies Cohort Studies Case-Control Studies Meta-Analyses (only with sufficient data) Certain Experimental Studies Both inclusion and exclusion criteria specified

Slide 23:

NOTE: Weights are from random effects analysis Overall (I-squared = 68.4%, p = 0.000) Key, T. J. (1999) ** Lukanova A. (2006) Byrne, C. (1996) Galanis, D.J. (1998) Wu, K. (1999) Vatten, L. J. (1992) Tornberg, S. A. (1994) ID Silvera, S. A. (2005) Knekt, P. (1996) Wolk, A. (1998) Wu, M. H. (2006) ** Chun, J. et al. (2006) Rapp K. (2005) Mills, P. K. (1989) Wu, K. (1999) Study 1.02 (0.99, 1.05) 1.07 (1.00, 1.14) 0.97 (0.92, 1.03) 1.02 (0.91, 1.15) 1.11 (1.05, 1.18) 0.94 (0.79, 1.12) 0.96 (0.93, 0.99) 1.01 (0.97, 1.05) RR (95% CI) 1.02 (0.99, 1.05) 0.89 (0.79, 0.99) 1.05 (1.01, 1.09) 1.09 (0.84, 1.42) 1.17 (1.03, 1.32) 1.00 (0.98, 1.03) 1.11 (1.01, 1.21) 0.95 (0.81, 1.12) 2 units BMI 100.00 7.44 8.00 3.79 7.97 2.10 11.06 10.13 Weight 11.33 3.99 10.29 0.99 3.50 11.36 5.62 2.43 % BRE04758 BRE80100 BRE05719 BRE03058 BRE13618 BRE12828 BRE12417 WCRF_Code BRE24118 BRE04900 BRE13548 BRE24628 BRE80134 BRE23858 BRE17837 BRE63618 LSS Northern Sweden Health and Disease Cohort NHEFS Hawaii State Department of Health CLUE I Norway, 1974 Sweden, 1971 StudyDescription Canadian National Breast Screening Study Finland, 1966 The Swedish Mammography Cohort Taiwan 1990 Women at Risk Cohort, New York VHM&PP California Seventh-day Adventists Cohort CLUE II 1.02 (0.99, 1.05) 1.07 (1.00, 1.14) 0.97 (0.92, 1.03) 1.02 (0.91, 1.15) 1.11 (1.05, 1.18) 0.94 (0.79, 1.12) 0.96 (0.93, 0.99) 1.01 (0.97, 1.05) RR (95% CI) 1.02 (0.99, 1.05) 0.89 (0.79, 0.99) 1.05 (1.01, 1.09) 1.09 (0.84, 1.42) 1.17 (1.03, 1.32) 1.00 (0.98, 1.03) 1.11 (1.01, 1.21) 0.95 (0.81, 1.12) 2 units BMI 100.00 7.44 8.00 3.79 7.97 2.10 11.06 10.13 Weight 11.33 3.99 10.29 0.99 3.50 11.36 5.62 2.43 % 1 .704 1 1.42 Dose-response meta-analysis on BMI and breast cancer (menopause age unspecified)(**=new studies identified during the update) Displaying Meta-Analysis Results: Forest Plots

Displaying Meta-Analysis Results: Forest Plots:

Displaying Meta-Analysis Results: Forest Plots NOTE: Weights are from random effects analysis Overall (I-squared = 68.4%, p = 0.000) Key, T. J. (1999) ** Lukanova A. (2006) Byrne, C. (1996) Galanis, D.J. (1998) Wu, K. (1999) Vatten, L. J. (1992) Tornberg, S. A. (1994) ID Silvera, S. A. (2005) Knekt, P. (1996) Wolk, A. (1998) Wu, M. H. (2006) ** Chun, J. et al. (2006) Rapp K. (2005) Mills, P. K. (1989) Wu, K. (1999) Study 1.02 (0.99, 1.05) 1.07 (1.00, 1.14) 0.97 (0.92, 1.03) 1.02 (0.91, 1.15) 1.11 (1.05, 1.18) 0.94 (0.79, 1.12) 0.96 (0.93, 0.99) 1.01 (0.97, 1.05) RR (95% CI) 1.02 (0.99, 1.05) 0.89 (0.79, 0.99) 1.05 (1.01, 1.09) 1.09 (0.84, 1.42) 1.17 (1.03, 1.32) 1.00 (0.98, 1.03) 1.11 (1.01, 1.21) 0.95 (0.81, 1.12) 2 units BMI 100.00 7.44 8.00 3.79 7.97 2.10 11.06 10.13 Weight 11.33 3.99 10.29 0.99 3.50 11.36 5.62 2.43 % BRE04758 BRE80100 BRE05719 BRE03058 BRE13618 BRE12828 BRE12417 WCRF_Code BRE24118 BRE04900 BRE13548 BRE24628 BRE80134 BRE23858 BRE17837 BRE63618 LSS Northern Sweden Health and Disease Cohort NHEFS Hawaii State Department of Health CLUE I Norway, 1974 Sweden, 1971 StudyDescription Canadian National Breast Screening Study Finland, 1966 The Swedish Mammography Cohort Taiwan 1990 Women at Risk Cohort, New York VHM&PP California Seventh-day Adventists Cohort CLUE II 1.02 (0.99, 1.05) 1.07 (1.00, 1.14) 0.97 (0.92, 1.03) 1.02 (0.91, 1.15) 1.11 (1.05, 1.18) 0.94 (0.79, 1.12) 0.96 (0.93, 0.99) 1.01 (0.97, 1.05) RR (95% CI) 1.02 (0.99, 1.05) 0.89 (0.79, 0.99) 1.05 (1.01, 1.09) 1.09 (0.84, 1.42) 1.17 (1.03, 1.32) 1.00 (0.98, 1.03) 1.11 (1.01, 1.21) 0.95 (0.81, 1.12) 2 units BMI 100.00 7.44 8.00 3.79 7.97 2.10 11.06 10.13 Weight 11.33 3.99 10.29 0.99 3.50 11.36 5.62 2.43 % 1 .704 1 1.42 Dose-response meta-analysis on BMI and breast cancer (menopause age unspecified)(**=new studies identified during the update) 2 3 4 5 6 7 1 8

Slide 25:

Funnel plot for BMI and breast cancer (menopause age unspecified)

Issues in Interpretation of Evidence:

Issues in Interpretation of Evidence Dietary intakes and patterns highly variable Classification of behaviors inconsistent Measurement of data imprecise Disagreement regarding appropriate interpretation of various types of research and totality of evidence Confounding factors poorly controlled or unknown Effects of production, preservation, processing, preparation, and overall dietary patterns poorly understood

Inferring Causality:

Inferring Causality Causal relationships can be confidently inferred when epidemiological, experimental, and other biological findings are: Consistent Unbiased Strong Graded Coherent Repeated Plausible

Criteria for Grading Evidence: Justifies Recommendation:

Criteria for Grading Evidence: Justifies Recommendation Data that meet the criteria for Convincing or Probable cause of cancer justify making a recommendation for that factor. Convincing More than one type of study ≥ 2 independent cohort studies No substantial unexplained heterogeneity Quality of studies excludes random or systematic error Plausible biological dose-response relationship Strong and plausible experimental evidence that typical human exposures can lead to cancer outcomes Unlikely to change over time Probable ≥ 2 independent cohort OR ≥ 5 case-control studies No substantial unexplained heterogeneity Quality of studies excludes random or systematic error Biological plausibility

Criteria for Grading Evidence: Justifies Recommendation:

The criteria for Substantial Effect on Risk Unlikely are similar to the criteria for a Convincing cause of cancer. It has resulted in certain factors ( eg , coffee) being ruled out as a cancer concern. Substantial E ffect on Risk Unlikely More than one type of study ≥ 2 independent cohort studies Summary estimate of effect close to 1.0 No substantial unexplained heterogeneity Quality of studies excludes random or systematic error Absence of dose-response relationship Absence of strong and plausible experimental evidence that typical human exposures can lead to cancer outcomes Unlikely to change over time Criteria for Grading Evidence: Justifies Recommendation

Criteria for Grading Evidence: No Recommendation Can Be Made:

In contrast, data that meet the criteria only for limited-suggestive or limited-no conclusion are insufficient to justify a recommendation. More evidence is needed in these cases. Limited-suggestive ≥ 2 independent cohort OR ≥ 5 case-control studies Some heterogeneity, although direction of effect generally consistent Biological plausibility Limited-no conclusion Sufficient data to warrant Panel consideration, insufficient to inform conclusion Criteria for Grading Evidence: No Recommendation Can Be Made

Displaying Judgment of Evidence:

Displaying Judgment of Evidence TOP BOX : Convincing or Probable relationship , justifies recommendation MIDDLE BOX : Limited suggestion of relationship, no recommendation BOTTOM BOX : Convincing evidence of NO effect, justifies recommendation

Communicating the Cancer Prevention Message:

Communicating the Cancer Prevention Message

Americans are Concerned with Body Weight:

Q: How concerned are you about your weight?* [Select one] (n=1024 ) Source: IFIC Foundation Food & Health Survey, 2010 Concerned: 70% Americans are Concerned with Body Weight

Obesity Among U.S. Adults: An Issue of National Concern:

Obesity Among U.S. Adults: An Issue of National Concern (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: BRFSS, 2009

A Message for All Occasions:

A Message for All Occasions

What do you mean I have to eat a plant-based diet?!:

What do you mean I have to eat a plant-based diet?!

Getting Started:

Getting Started Physical activity Eating in front of the TV Replace high with low energy density foods

The New American Plate:

The New American Plate Proportion 2/3 vegetables, fruits, whole grains, beans 1/3 or less animal proteins Portion Serving Size Finder Recipes AICR Test Kitchen

Reshaping Meals:

Reshaping Meals Be prepared Focus on healthful fats Monitor portions Start with soup or salad Pile on veggies and fruits Choose beverages wisely

When changes are tough…:

When changes are tough… Motivation is Key

When changes are tough…:

When changes are tough… Specific alternatives are important Incorporate fiber and fluids to improve satiety Address convenience

The Cancer Prevention Message is Clear:

The Cancer Prevention Message is Clear Be as lean as possible within the normal range of body weight. Be physically active as part of everyday life. Limit consumption of energy dense foods. Avoid sugary drinks. Eat mostly foods of plant origin. Limit intake of red meat and avoid processed meat. Limit alcoholic drinks. Limit consumption of salt. Aim to meet nutritional needs through diet alone. Mothers to breastfeed, children to be breastfed. For cancer survivors, follow the recommendations for cancer prevention.

The Cancer Prevention Message is Clear:

The Cancer Prevention Message is Clear Many questions warrant further research, and the data will be assessed on an ongoing basis. Today, the RD plays a critical role in bringing the cancer prevention message to life for the public in a manner that is meaningful and sustainable.

To Obtain CPE Credit…:

To Obtain CPE Credit… Complete the Learning Assessment Quiz and check the Answer Key to evaluate your understanding of the material in this module. Print the Certificate of Completion and retain for your records. Record completion of the module in your Learning Plan. Complete the Program Evaluation so that AICR may continually improve its CPE offerings. THANK YOU!