Obesity, Physical Inactivity and Cancer Risk: A Case for Policy Action
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Dr Kate Allen, Executive Director (Science and Public Affairs) of World Cancer Research Fund International, UK, spoke about the relationship of obesity and physical Activity on cancer, and consequential implications for policy.
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Obesity, Physical Inactivity and Cancer Risk: A Case for Policy Action
- 1. Obesity, Physical Activity & Cancer: implications for policy Dr Kate Allen Executive Director, Science and Public Affairs World Cancer Research Fund International European Week Against Cancer Conference, Dublin, 29th May 2013
- 2. Overview About World Cancer Research Fund The scale of the challenge Links between obesity, physical activity & cancer The policy approach we need The evidence Summary key points
- 3. WCRF: Who We Are • AICR (1982) • WCRF UK (1990) • WCRF Netherlands (1994) • WCRF Hong Kong (1997) • WCRF International (1999) National charities •Health information •Communications •Fundraising • Strategic direction & operational support • Science and policy
- 4. WCRF: What We Do • We fund research on the relationship of nutrition, physical activity and weight management to cancer risk • We interpret the accumulated scientific literature in the field of cancer, food, nutrition, body fatness, physical activity and alcohol, and use this to derive Recommendations for Cancer Prevention • We educate people through our national Health Information programmes • We advocate wider implementation of effective policies through our international Policy and Public Affairs activities • We do all this to help people and populations to implement our Recommendations and thereby reduce their chances of developing cancer
- 5. About World Cancer Research Fund The scale of the challenge Links between obesity, physical activity and cancer The policy approach we need The evidence Summary key points
- 6. Data from Parkin et al, Pisani et al, Globocan 2008, IARC * *Estimated new cases for 2030 from predictions in 2002
- 7. Obesity Globally, >40 million children under 5 were overweight in 2011 Sources: WHO, IASO
- 8. Physical Inactivity WHO estimates that in Europe, 63% of adults are not reaching the minimum recommended level of physical activity
- 9. About World Cancer Research Fund The scale of the challenge Links between obesity, physical activity and cancer The policy approach we need The evidence Summary key points
- 10. WCRF Findings on Links Between Obesity, Physical Activity & Cancer • New method (>250 scientists worldwide) • SLRs >15 cancer sites (>7,000 studies) - Epidemiology (observational); RCTs; mechanistic • Review of evidence separate from judgement • Panel of International experts • Predetermined criteria for judgements • Kept up to date with CUP
- 11. Number of Articles from Cohort Studies in the CUP Database for Various Cancers
- 12. What the Evidence Shows
- 13. Obesity and Cancer Risk: Mechanisms • General Mechanisms (all obesity related cancers): • Increased inflammatory state • Insulin resistance and excess growth factors (IGF etc.) • Site specific mechanisms • Breast & endometrial cancers – oestrogen production (body fat) • Gallbladder cancer – increased gallstone formation, causing chronic inflammation in biliary tract • Oesophageal cancer - chronic inflammation from gastric acid reflux (increased abdominal pressure caused by obesity)
- 14. • The top 3 Recommendations are directly obesity & physical activity-related • Following Recommendations reduces risk of dying from cancer & other chronic diseases • (Vergnaud et al. 2013; Inoue-Choi et al 2013, older female cancer survivors) Our Recommendations
- 15. WCRF Estimates of Preventable Fraction of Cancers from Body Fatness Source: http://www.wcrf.org/cancer_statistics/preventability_estimates/preventability_estimates_b
- 16. About World Cancer Research Fund The scale of the challenge Links between obesity, physical activity and cancer The policy approach we need The evidence Summary key points
- 17. Including Obesity and Physical Activity in Cancer Control Plans • National Cancer Control Plans should include prevention (including nutrition and physical activity as cancer risk factors), alongside early detection, diagnosis, treatment and palliative care
- 18. An Integrated Approach to NCD Prevention • Since obesity and physical inactivity are also risk factors for other NCDs, the cancer community should work together with the rest of the NCD community to develop, implement and advocate action
- 19. Raised blood pressure 25% reduction Salt/ sodium intake 30% reduction Tobacco use 30% reduction Physical inactivity 10% reduction Harmful use of alcohol 10% reduction Drug therapy and counseling 50% Premature mortality from NCDs 25% reduction Diabetes/ obesity 0% change Essential NCD medicines and technologies 80% WHO Voluntary Global Targets for the Prevention & Control of NCDs by 2025
- 20. How Can the Targets on Obesity, Physical Activity and Premature Mortality be Achieved? To effect real change, policies need to address the broader environment in which populations live & eat
- 21. About World Cancer Research Fund The scale of the challenge Links between obesity, physical activity and cancer The policy approach we need The evidence Summary key points
- 22. WHO Action Plan (May 2013): Healthy Diet Changing environment through… Promoting breastfeeding Reducing marketing Economic tools Nutrition labelling Public institutions and workplaces Food producers, processors and caterers Food retailers and caterers Public campaigns & social marketing Agricultural sector
- 23. WHO Action Plan (May 2013): Physical Inactivity Changing environment through… National guidelines Governance Urban planning and transport policies Schools “Physical activity for all” Community-based campaigns Public awareness campaigns Evaluation
- 24. Governments & Other Stakeholders: Examples of Action So Far (on diet) Reducing marketing >22 countries have policies on marketing to children, but none are comprehensive Economic tools European countries taking an increasing interest in taxes in light of fiscal concerns Nutrition labelling >13 countries have mandated nutrition labelling; more attention on “interpretative” labels" Public institutions Numerous countries have distribution programmes (kids) for fruits and vegetables More school food standards: around 30 governments restricted soft drinks
- 25. Common Myths – And The Reality Myth 1. Government intervention will be ineffective Reality. There is an evidence-base on which to act, it just hasn’t been well-interpreted Myth 2. Government intervention is too costly Reality. Yes, it does cost money, but is cost effective; treatment is necessary but not cost-effective relative to prevention Myth 3. Government intervention interferes with people’s choices Reality. The current food and physical activity environment already shapes people’s choices, but in an unhealthy way
- 27. Convincing evidence Action needed N Consumers use nutrient lists, but far lower among low SES, and prefer interpretative labels WHO/EU/governments need to set guidance for interpretative labels O Schools-based interventions modestly increase fruit & veg intake in children while at school (stronger for fruit) All countries should take concerted action to increase fruit and vegetable intake in schools U Taxes and subsidies have the potential to lead to beneficial dietary changes when large All countries should introduce pilot initiatives to test out what might work on their populations R TV advertising influences food choice; partial restrictions reduce the amount of marketing in the restricted channels; but “migrates” elsewhere All countries should set a target to restrict food marketing to children and implement a comprehensive policy I S H ©WCRF International
- 28. About World Cancer Research Fund The scale of the challenge Links between obesity, physical activity and cancer The policy approach we need The evidence Summary key points
- 29. Key Messages 1. Convincing evidence linking overweight & obesity with increased cancer risk & physical activity with decreased cancer risk 2. Obesity prevention and promotion of PA must be core to cancer prevention plans 3. The cancer community should work with stakeholders concerned with obesity, PA & other NCDs 4. Numerous reports provide clear steer 5. WHO NCD Omnibus Resolution provides global framework 6. Governments have been taking action but more needs to be done 7. Evidence is available to point to the policy actions that can be taken
Notas do Editor
- Just a note about who does what within our organisation. The charitable fundraising and information programs are conducted at a national level in four countries. And then there is the part I work for – WCRF International – which provides strategic guidance to the charities and conducts most of the science and policy work.
- We fund research into diet and cancer. We interpret research in the field and we do that mainly through the development of scientific reports. That research effort then informs the educational messages that underpin our education programmes which are targeted at a variety of audiences from children to parents, teachers, health professionals and scientists. More recently we have become active in policy, so our focus on food, nutrition, physical activity and cancer now stretches from the basic science through to policy implementation. We do all this to help people and populations to implement our Recommendations – which I will come to later - and thereby reduce their chances of developing cancer
- We know that cancer is increasing….. We know it is a global problem, with 70% of the increase in cancer incidence up to 2020 is expected to occur in lower and middle income countries Right now there are about 14 million new cases of cancer/yr, and rates are projected to increase in the year 2030 to about 20 million new cases a year globally. There are some things driving this increase that we can’t do much about. We are all living longer, and cancer is mainly a disease of older age. There are more of us – and with rising population rates there are more people to get cancer There ’ s not so much we can do about aging and growing populations, so all the more reason to do something about the things we can do something about. Lifestyle factors are also fuelling this cancer epidemic, including the fact that we ’ re getting fatter and less active.. As we ’ ll see obesity and physical inactivity are both strongly linked to a number of cancers. We can take actions to change people ’ s behaviour with regard to food and nutrition and physical activity so this projection doesn't have to be inevitable and set in stone.
- We also know that obesity has risen to become a global public health problem since the 1980s/90s around the world. According to the International Association for the Study of Obesity, there are now one billion adults worldwide who are overweight, and a further 475 million are obese. According to the UN there are now just over 7 billion people on the planet and over 4 billion of those are adults. So around 1 in 4 adults are overweight or obese. In the UK around 2/3 of adults overweight or obese. Current Adult Population in the World: 15-64 years: 65.9% (male 2,234,860,865/female 2,187,838,153) (2011 est.). Current Youngest Population in the World: 0-14 years: 26.3% (male 944,987,919/female 884,268,378) (2011 est.) And as we all know, we also have a childhood obesity problem, with, according to the WHO, more than 40 million children under the age of five, overweight in 2011 In fact, 65% of the world's population live in countries where overweight &obesity kills more people than underweight.
- Another problem that affects overweight and obesity, but also affects health in lots of other ways independent of body weight, is physical inactivity. Globally, the WHO estimate that a low level of physical activity ranks in the top ten causes of death. That ’ s because physical inactivity is associated with things like diabetes, increased BP, heart disease and cancer. In Europe, the WHO estimates that in Europe 63% of adults are not reaching the minimum recommended level of physical activity. Adults aged 18–64 should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week, or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity. Aerobic activity should be performed in bouts of at least 10 minutes duration.For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate- and vigorous-intensity activity.Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.
- WCRF International has compiled the evidence on the links between obesity, pa and cancer, and we are continuing to do so. In 2007, we published a report on Food, Nutrition, Physical Activity and the Prevention of cancer. The report took 250 scientists and six years to produce. 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. The evidence base is kept up to date through the CUP, which is an ongoing review of cancer prevention research that provides up-to-date evidence on how people can reduce their cancer risk through diet and physical activity. Building on WCRF/AICR ’ s 2007 Second Expert Report, the CUP database is thought to be the biggest database of evidence in the world on how food, nutrition, physical activity and body fatness affect cancer risk.
- The evidence base on food, nutrition, physical activity and cancer is growing, and the CUP is a mechanism, a tool to keep on top of that. This slide shows the numbers of one particular kind of study, cohort studies, in the CUP database for various cancers. The green bars show the numbers of studies that went into the SER – the cut off point for data entry to the SER was 2006. the earliest relevant studies that were found were from the 1950s and 60s. So the green bars cover a total span of time of 40-50 years. The start point for the CUP was 2007. So the red sections on the chart cover a period of 5 years – 2007 to end 2012. So you can see that for a number of these cancers as much research has come out in the past 5 years as in the previous 50. That’s a huge amount of data and the CUP is a way of keeping on top of that and of giving an up to date picture of what the evidence is telling us. For us as an organisation that enables us to keep our Recommendations for cancer prevention current and based on the latest evidence.
- Strong links = probable or convincing evidence (eg could form basis of a recommendation). Note that 100s of exposures were looked at for the report, the 30 in the matrix are the ones that came out as limited suggestive or above. First key message = t here is convincing evidence linking overweight and obesity with increased cancer risk and physical activity with decreased cancer risk The risk of cancer is higher the more overweight people are. Even within the healthy weight range there is evidence that being at the lower end offers the best protection. In terms of cancer risk we don’t have any conclusions for physical inactivity – it’s more about being physically active help prevent cancer. There is growing evidence looking at the effect of sedentary behaviour and new studies are suggesting that even if you are physically active there are health risks associated with spending long periods being sedentary – but more research is required. We don’t have clear mechanisms for physical inactivity and cancer yet as we don’t have any conclusions for this yet (we might have after the Panel meeting for endometrial cancer). We do have a conclusion on sedentary living and increased risk of obesity – based on television viewing. Television viewing can lead the weight gain through being inactive , displaces opportunities for more active pursuits and increases exposure to promotion and consumption of energy dense foods. Note: Increased body fatness decreases risk of breast cancer in pre menopausal women, probably because obesity in premenopausal women tends to reduce overall oestrogen exposure by interfering with menstrual cycle, while in post menopausal women it increases by providing a bigger source from adipose derived oestradiol via aromatase
- What are the mechanisms that underpin the link between body fatness and obesity and cancer? There are two main types. First general mechanisms that underpin all obesity related cancers. Many overweight and obese people have a degree of cellular inflammation. Over time that can lead to proliferation and differentiation, inhibit apoptosis (cell death) and induce angiogenesis (generation of new blood vessels). Because of the increase in cell proliferation the normal cellular repair mechanisms get overwhelmed and don ’ t function properly. Another general mechanism is insulin resistance and excess growth factors. So - as body fat increases it is accompanied by an increase in peripheral insulin resistance (in muscles and liver) where people become less sensitive to insulin. To maintain glucose homeostasis (albeit with higher insulin levels) the feedback homeostatic system increases the activity of the whole (quite complex) insulin and insulin-like growth factor axis. While this helps with the glucose, it also leaves higher IGFs, which are growth factors that promote proliferation (and so increase risk of malignant transformation in sensitive tissues). The second type of mechanism is a site specific one, relating to specific cancers. Of course you can also get both mechanism types running in parallel. Excess adiposity and breast cancers- mostly due to the relationship between adiposity and extra-ovarian oestrogen production (from all fat); endometrial cancers by the same mechanism. Gallbladder cancer : probably due to the connection between adiposity and gallstone formation and the consequent chronic inflammation by gallstones on the biliary tract. Oesophageal cancer : chronic inflammation caused by gastric acid that is refluxed into the oesophagus due to high intra-abdominal pressures caused by abdominal obesity. Colorectal cancer, kidney cancer, and pancreatic cancer: possibly due to hyper-inflammatory state induced by excess adiposity and/or to the combined effects of other circulating growth factors (IGF axis) induced by adiposity By and large physical activity affects the same pathways as obesity but in the opposite direction, so that it deceases insulin, decreases inflammation and decreases oestrogen production.
- The headline recommendations from the 2007 WCRF/AICR Expert Report are shown here. Importantly, the scientific panel of experts which developed them based on the evidence integrated the information they had, which was often on individual nutrients, into real dietary patterns in order to develop meaningful recommendations so that they were more like patterns of diets. Eg, the recommendations don ’ t talk about selenium, talk about plant foods – ie real diets. There are ten recommendations, grouped into main areas. As you can see, the first three relate DIRECTLY to overweight and obesity and physical activity. They are at the top as the Panel felt these were most important. Note that they talk about BODY FATNESS. This is because the evidence shows that there is an increase in risk of cancer across the range of BMIs even in the healthy range. Body fatness is the amount of fat a person has and therefore the more body fat the higher the risk (assuming people are not underweight). The evidence doesn't suggest a threshold in the impact of body fatness on cancer risk so the term"obesity" is a shorthand...and actually gains are to be made even within the so-called normal range. Just concentrating on "obesity" with its arbitrary definition of BMI 30 or more misses a lot of the problem - hence the panel use of the term body fatness The next six relate to recommendations centred around foods and drinks – and are not in any particular order (no factor was judged to be more/less important than the others). Of these recommendations, the recommendations on plan foods and animal foods, alcohol and breastfeeding all have implications for obesity. Then two special recommendations aimed at cancer survivors and about breastfeeding (mothers, babies). These latter two are special sub populations that are not relevant to the whole population in the way that the other recs are. There was a disappointing amount of evidence for Cancer Survivors (but this is starting to be rectified now in the CUP). First time recommendation on breastfeeding has been made in a diet and cancer report. For each headline rec there are personal recommendations and public health goals. Physical activity Public health goals The proportion of the population that is sedentary 1 to be halved every 10 years Personal recommendations Be moderately physically active, equivalent to brisk walking, 2 for at least 30 minutes every day Limit sedentary habits such as watching television Evidence that following WCRF Recommendations, compared to those with lowest level of compliance, reduce risk of dying from (Norat et al 2013) Cancers (20%) Respiratory diseases (50%) Circulatory diseases (44%) Following the recommendation for body fatness and physical activity had a larger effect on reducing deaths from circulatory and respiratory diseases in Vergnaud study. Choi study showed that adherence to guidelines associated with lower all cause mortality in older female cancer survivors, strongest association seen with PA recommendation.
- We have also looked at how much cancer could be prevented purely by maintaining a healthy weight and what that would actually translate to in terms of numbers of cases. We took these countries as examples of high (UK, US), middle (Brazil) and low income (China) countries, respectively. In HIC around 20 % of the obesity related cancers could be prevented, and in LMIC 13-14%. The scope for prevention is less in LMIC because there are less overweight and obese people, but the figures will go up if the numbers of overweight and obese people in the population increase.
- The SECOND KEY MESSAGE TO EMERGE FROM THESE FINDINGS is that obesity prevention and promotion of PA must be core to cancer prevention plans A key priority for the cancer community is to ensure that governments develop and implement cancer control policies as part of the public health approach to reduce the burden of cancer. It is important that national cancer control plans include a focus on prevention alongside early detection, diagnosis, treatment and palliative care. Action to address obesity, food, nutrition and physical inactivity as cancer risk factors should feature prominently as part of work on prevention as many countries will have significant prevalence of these risk factors. This should include prevention goals, objectives, and policies with clear outcome measures. UICC has developed guidance and a tool kit for governments and civil society organisations to support national cancer control planning. The toolkit highlights the prevention of cancer as a priority area for action, through action on modifiable risk factors.
- THE THIRD KEY MESSAGE IS THAT since obesity and physical inactivity are also risk factors for other NCDs the cancer community should work with stakeholders concerned with obesity, PA & other NCDs In other words, to tackle obesity and help to prevent cancer, we need to work together with stakeholders concerned about other non-communicable diseases.The major reason for addressing these diseases collectively is their common modifiable risk factors (tobacco, unhealthy diet, alcohol consumption, physical inactivity). Cancer is now positioned alongside cardiovascular diseases, diabetes and chronic respiratory diseases as one of the major health challenges currently facing countries worldwide. In 2011, governments recognised this challenge in the UN Political Declaration, and – as of this May’s World Health Assembly – we now have a clear policy framework for NCDs, which includes a Global Action Plan on NCDs and a Global Monitoring Framework and Targets.
- THE FOURTH KEY MESSAGE IS THAT the WHO NCD Omnibus Resolution provides global framework within we we all can work Last week, at the World Health Assembly, governments adopted what they termed an “Omnibus Resolution” on NCDs which contained two crucial components comprising a global framework for addressing and monitoring NCDs. The first component was a Global Monitoring Framework with targets. This slide shows the targets set as part of the Global monitoring framework and voluntary global targets for the prevention and control of NCDs. (Note second component is GAP). You can see that Member States of the WHO have agreed that we should all be working towards reducing premature mortality from NCDs by 25% by 2025. It is clear that in order to achieve this, there will need to be progress in addressing the risk factors so as to reduce the burden of disease. To do so, governments have agreed at the WHA to targets that aim for a 10% reduction in physical inactivity and a zero increase in obesity. The adoption of these targets is significant – Member States could have decided not to ¬– and is recognition of the importance of these risk factors to the prevention of NCDs. These targets are a result of a long process of consultation and deliberation by Member States, and, while they may seem unambitious, they are still a major landmark achievement for NCD policy. Monitoring progress against the targets (including surveillance of obesity prevalence, dietary risk factors; levels of physical activity) will be a key lever for accountability
- How can the targets on reducing obesity, increasing PA and reducing premature mortality be achieved? The FIFTH KEY MESSAGE IS THAT numerous authoritative reports, strategies & action plans provide guidance on policies to tackle obesity and physical inactivity and give a steer for the direction we should be moving i. There is common agreement between them that policies addressing the broader environment in which populations live and eat will effect the greatest change. The aim is to reset the default setting away from unhealthy choices in the obesogenic environment to a new default where healthy choices are easy choices. To do that we need to remove or diminish the unhealthy external influences that powerfully determine people's behaviour. As practice-based evidence of population-level policies to address unhealthy diet and physical activity is limited although emerging (due to lack of policy implementation), expert reports have often been the best guidance. As well as emphasising the need to address the broader environment, the reports have other common recommendations that can inform the policy approach we need to take if we are to move towards achieving the targets. Population-based interventions Multiple interventions likely to have substantial beneficial impact Tackle the determinants of dietary and food choices and physical inactivity Create an environment that is consistently able to support healthy diet and physical activity Opt for policies that have greater population coverage Support policies with legislation in places These reports include: WCRF/AICR (2009) Policy and Action for Cancer Prevention A report on bridging the evidence gap in obesity prevention by the Institute of Medicine took a systems perspective to gain a broader understanding of the context of obesity and its underlying determinants. A report by the Organisation for Economic Cooperation and Development (OECD), called ‘Obesity and the Economics of Prevention’ that examined the effectiveness and cost-effectiveness of prevention policies. The Foresight Project, a 2007 report commissioned by the UK government, was instrumental in projecting the obesity epidemic and in its attempt to map the range of obesity influences and deliver a long-term vision of how government can deliver a response. The WHO has also issued guidance on population-based prevention strategies for unhealthy diet, physical inactivity and for the prevention of childhood obesity. It has also previously developed a Global Strategy on Diet, Physical Activity and Health and a Global Action Plan on NCDs (2008-2013). The update Global Action Plan on NCDs (2013-2020) is a continuation of this work.
- As mentioned, authoritative reports have identified the need for a broad environmental multi level approach as well as other areas that provide a steer for action. And in the past couple of years there has been greater clarity on the package of policies that’s needed, largely due to new reports coming out which highlight particular policies, more evidence on these types of actions, and more pressure on the nutrition community to tell people "what works". This is reflected in the adoption last week at the WHA in a menu of policies to promote healthy eating and physical activity, within the context of a broad environmental multi-level approach. These policies are included in the new WHO GAP which was adopted in the Omnibus Resolution at the WHA last week. The GAP is the second main component of the new Global Policy NCD Framework. It addresses the major risk factors as challenges that cut across disease groups (in addition to sections on treatment and care). It provides guidance for Member States and sets out policy options in the area of unhealthy diet and physical inactivity. For unhealthy diet the GAP represents the best guidance by WHO to date in this area. The Action Plan will help Member States to identify actions that they can take to prevent and control NCDs, which will thus contribute to achieving the targets. The slide shows the main areas around healthy diet covered in the GAP, each of which is supported by specific actions. This is a major improvement on previous guidance and represents a move towards a clearer package of policies. WCRF International has supported the development of this guidance and welcomed its adoption at the WHA as part of the wider Action Plan. Thus the NEXT KEY MESSAGE (REITERATION OF MESSAGE 4) IS THAT we now have much clearer guidance on specific food policy actions to achieve the obesity and physical inactivity targets.
- The WHO Global Action Plan also includes guidance on actions needed to address physical inactivity, as shown here
- With the new GAP we now have much clearer guidance on specific food policy actions to achieve the obesity and physical inactivity targets. But it’s not that governments have done nothing. Many countries have started to introduce policies to address obesity through healthy diet and physical activity. Here, again using examples from diet only, it is clear that over the past decade, that governments have been developing policies and plans, so therefore it ’ s feasible to take action in these areas. Some countries have and some haven ’ t. Progress in developing and implementing policies often isn ’ t comprehensive or coordinated. Education and information approaches to obesity prevention are often favoured over a policy approach. Policies that have been developed are not necessarily implemented. This halting and somewhat compromised development of policy has occurred in the context of concern about, as well as outright opposition to, policies. Many stakeholders, including governments, members of the research community, and particularly the private sector, have articulated a range of concerns about the ineffectiveness, unfairness and unpopularity of policies. So the SIXTH KEY MESSAGE IS THAT governments have been taking action but more needs to be done. C ountries need to introduce more policies and the policies they choose need to be those that are likely to be more effective.
- These concerns can feed into the development of myths that surround policies to address obesity, which result in obstacles to policy adoption and implementation. We need to consider how the evidence can be used to overcome these obstacles. Three arguments are used frequently to oppose the adoption of policy: First, that Government intervention will be ineffective. One of the main arguments is that there is insufficient scientific evidence linking consumption of certain foods and products to obesity, limited evidence on the effectiveness of interventions in achieving improved health behaviours and/or outcomes, But in fact, there is a growing evidence base – it just needs to be better interpreted in order for it to help point to more effective action. This is something which WCRF International is very concerned with, as I will touch on shortly. Second, that policies will cost too much . In fact, while Government intervention does cost some money, policies are mainly cost-effective. Treating the outcomes of obesity down the line in the form of medical and social care costs is not cost-effective relative to prevention. Third, that government policies are unfair to consumers because they interfere with their individual choices. In fact, it is the current food and physical activity environment that creates unhealthy preferences, and in turn stimulates demand for unhealthy lifestyle choices. There is also popular support for some policies, including many school-based interventions and interventions to support healthier lifestyles among children.
- Civil society and other stakeholders can play a role here by tackling some of these myths. WCRF International is particularly concerned with empowering decision makers to make better decisions by helping to interpret the evidence base in a way that points to the most effective possible actions to achieve those global goals. THE SEVENTH KEY MESSAGE IS THAT Evidence is available to point to the policy actions that can be taken to help achieve those global goals. As part of our work in this area, we are in the process of developing this ‘ NOURISHING ’ framework to complements the WHO guidance, and is a way of categorising the many different policy options, in a way that’s consistent with the WHO Action Plan. To effect comprehensive change, governments will need to implement some policy in each of these areas – this is for diet only – but make a decision of exactly what the intervention is that fits with their national context. There is no “magic bullet” single policy that will address obesity, for example. Just as with the science the synergy comes in policies working together to effect change. It is possible to identify a portfolio of policies, but the more restrictive this is the less likely to be effective. We have started with the nutrition side, but our understanding of the available evidence on physical activity also suggests that the evidence points towards governments taking particular actions.
- In the same way that we systematically review the scientific evidence, we’re doing the same for policy in order to point towards the most effective action and help decision makers prioritise. I’ve shown here the same four areas highlighted on the previous slide and in the WHO GAP slide.This is what our internal assessment of the evidence, which is a work in progress, shows so far within the context of the Nourishing framework. This is based on systematic reviews of the evidence conducted by WCRF International, drawing on the greatly increasing number of existing systematic reviews. Note on marketing to children: With partial restriction children get targeted in other ways, including on other media channels, on TV broadcasts that are not directly targeted at them but that they nevertheless watch, by companies that are not covered by voluntary pledges, and with foods that find it easier to slip out of the covered categories. So the restrictions are effective at reducing the marketing in those particular channels - and this may be good if they are particularly powerful ways to reach children. But we have no idea if actual total exposure of children to unhealthy marketing is reduced as a result of these "partial" restrictions. So a comprehensive approach is needed – but worth trying step-by-step restrictions if only political option. Under a comprehensive approach, it is unlikely that exposure would completely disappear, but: - there would be no other communications channels that the marketing could move to - a much stricter audience definition for broadcast would mean there would be significantly less on all TV ads viewed by children, not just the ones during children's TV - stricter definitions of food would mean that the company could not tweak the sugar by one gram and still advertise it etc.
- There is convincing evidence linking overweight and obesity with increased cancer risk and physical activity with decreased cancer risk. Obesity prevention and the promotion of physical activity must therefore be a core component of any strategy or policy to reduce the incidence of cancer. To be stronger and more effective, the cancer community should work together with stakeholders concerned with obesity and physical inactivity. Since these risk factors are also shared with other NCDs, we should also work together with stakeholders concerned with other NCDs. Numerous authoritative reports provide a clear steer for this work - addressing the broader environment in which populations eat and exercise. The recently adopted WHO NCD Omnibus Resolution provides a global framework within which we all can work. The framework includes obesity and physical inactivity targets and clearer guidance on the specific policy actions needed to achieve them. Governments have been taking action but more needs to be done. WCRF International would like to support and empower national and international policy-makers to make decisions that enable populations and individuals to follow the WCRF International/AICR Recommendations for Cancer Prevention. One of the key obstacles are the myths that surround policies to address obesity, such as “ there is inadequate evidence for policy. “Yet evidence is available to help policy makers make better decisions. It is up to us as a community to better interpret and communicate that evidence to policy makers.
- If your organisation is interested in obesity, physical activity and cancer and are interested in engaging policy wise, pls get in touch.