CANSA Interview about Importance of Balanced Lifestyle – Mail & Guardian

April 2018: Lorraine Govender (CANSA’s National Advocacy Co-ordinator), was interviewed by Adri Kotze (Africa Editor Centre for Health Journalism – Mail & Guardian – http://bhekisisa.org/).

CANSA was asked to respond to Cancer Research UK’s latest research, published earlier this year, regarding lifestyle factors which could contribute to an increased cancer risk, and to comment on how this pertains to South Africans.

1. The Cancer Research UK figures show 37.7% of all cancers diagnosed in the UK could be prevented through lifestyle changes. Please could you comment on what we know about the situation in South Africa: would these figures be similar?

South Africa can be described as a developing and lower middle income country (LMIC). LMICs attractive emerging markets for numerous products including tobacco and alcohol. Thus, lifestyle risk factors for cancer likely to undergo changes include smoking, alcohol consumption, and excess body weight, via changes in diet and physical activity, all of which are established carcinogens The major contribution of these five factors, as well as four others (unsafe sex, air pollution, indoor smoke, and contaminated injections), already account, in 2001, for 35% of cancer deaths worldwide.

Some common trends point to considerable increases in cancers in South Africa of the (i) lung in men due to tobacco smoking; (ii) upper aero digestive tract (UADT) due to increasing tobacco and alcohol consumption, worse in men; (iii) colon from increasing body mass index, alcohol and tobacco consumption; and (iv) in women, breast due particularly to consistent international trends of younger age at menarche, smaller family size, and, at postmenopausal ages, increasing body weight.

Table One includes stats taken from the SA National Cancer Registry 2009-2013, a period of five years. They show a steady increase in incidence of both lung and colorectal cancers. From 2011 the figures show that colorectal cancer incidence has increased in comparison to lung cancers .This could be the start of the impact of the obesity epidemic in SA.

Table Two’s stats have been taken from the SA National Cancer Registry and clearly show an increase in the incidence of certain cancers in South Africa among females. In 2009 there were 6219 reported new cases of breast cancer and in 2013 the figure rose to 8213 newly reported cases. One can also see an increase in colorectal cancer: In 2009 there were 1075 newly reported cases and 1542 in 2013, possibly resulting from the growing obesity epidemic in South Africa.

There isn’t sufficient research in South Africa to show the actual percentage of cancers that are lifestyle related. The table above shows some of the lifestyle cancers and the patterns thereof.

2. In the UK, smoking remains the biggest preventable cause of cancer (17.7 % of cancer in men and 12.4% in women). This is despite a decline in smoking rates. What do we see in South Africa?

Tobacco harms the health, the treasury, and the spirit of South Africa. Every year, more than 42100 of its people are killed by tobacco-caused disease. Still, more than 55000 children (10-14 years old) and 6321000 adults (15+ years old) continue to use tobacco each day. Complacency in the face of the tobacco epidemic insulates the tobacco industry in South Africa and ensures that tobacco’s death toll will grow every year.

Adult Smoking (15+ Y.O.) % using tobacco daily: 2015- Male 31.4% Even though fewer men smoke on average in South Africa than on average in medium-HDI countries, there are still more than 4691500 men who smoke cigarettes each day, making it an ongoing and dire public health threat. Female 6.5% – More women smoke in South Africa than on average in medium-HDI countries.

Deaths % caused by tobacco: 2016 – Male 10.11% Even though fewer men die from tobacco in South Africa than on average in medium-HDI countries, tobacco still kills 550 men every week, necessitating action from policymakers. Female 5.41% – More women die in South Africa than on average in medium-HDI countries. (1)

3. In the UK, excess weight is the second biggest preventable cause of cancer: 7.5% cases of cancer in women and 5.2% in men. The results suggest more than 1 in 20 cancer cases could be prevented by maintaining a healthy weight. I think it is very important to explain to our readers WHY obesity causes cancer. (I understand we are still not 100% certain, but it would be really useful to explain what we do know and what research indicates). Also: how does impact post-menopausal women?

Obesity can be described as an imbalance between energy intake and expenditure, such that excess energy is stored in fat cells, which enlarge or increase in number. However, the complex medical condition of obesity is affected by a host of contributing factors.
Obesity is defined as a body mass index (BMI) of more than 30 according to World Health Organization criteria.

Obesity as a risk factor for non-communicable diseases is a global public health concern. It is estimated that more than one billion adults are overweight, of which at least 300 million are obese. Countries in economic transition from undeveloped to developed, such as China, Brazil and South Africa, are particularly affected and have an increased rate of obesity across all economic levels and age groups.

Major studies confirm that being overweight or obese increases the risk of various cancers (Bianchini, et al., 2002; International Agency for Research on Cancer, 2002; Renehan, et al., 2008; Reeves, et al., 2007). The World Health Organization (WHO) says that overweight and obesity are the most important known avoidable causes of cancer after tobacco (World Health Organization, 2003).

According to a study by the National Department of Health, more than half of South African women are overweight or obese, with the figure for Black women nearly 60%. Fat intake among Blacks has jumped almost 65% since 1940, when records first started being kept. Obesity-related diseases like hypertension and diabetes are spiralling. More South African adults now die from obesity than from poverty (Health Systems Trust).

In a recent survey conducted by the SA Medical Research Council, it was found that 61% of the South African population is overweight, obese or morbidly obese. In addition, 70% of all South African women over the age of 35 were overweight or obese with 33% of Black women exposed to this risk and 25% of Coloured, White and Asian women following suit.

In contrast, 18% of White men over the age of 35 are obese, followed by 9% percent of Asian, 8% percent of Coloured, and 6% of Black men. With an estimated 2,8 million people annually dying as a result of being overweight or obese, it is time for South Africans to take stock, says the Self-Medication Association of South Africa (SMASA) (Self-Medication Association of South Africa; IOL News).

Please could you comment on this? On what types of cancer obesity causes? And what the figures show in South Africa?

Overweight and obesity are clearly associated with an increased risk of developing over 13 cancers cancers, including cancers of the breast in postmenopausal women, colon and rectum, endometrium, kidney and adenocarcinoma of the oesophagus, and pancreas; are probably associated with an increased risk of cancer of the gallbladder; and may also be associated with an increased risk of cancer of the liver, non-Hodgkin lymphoma, multiple myeloma, cancer of the cervix, cancer of the ovary, and aggressive prostate cancer. In addition, abdominal fatness is convincingly associated with colorectal cancer, and probably related to a higher risk of pancreatic, endometrial, and postmenopausal breast cancer.

Overweight and obesity are thought to affect the risk of these cancers through a variety of mechanisms, some of which are specific to particular cancer types. These mechanisms include effects on immune function and inflammation levels and metabolism of several hormones, including insulin and oestradiol; factors that regulate cell proliferation and growth, such as insulin-like growth factor (IGF)-1; and proteins that make hormones more or less available to tissues, such as sex hormone-binding globulin and IGF-binding proteins. Overweight and obesity may increase the risk of adenocarcinoma of the oesophagus by increasing the risk of gastroesophageal reflux disease and Barrett oesophagus.

Most research on energy imbalance and cancer focuses on increased risks associated with overweight and obesity. Some studies exploring intentional weight loss suggest that losing weight may reduce the risk of postmenopausal breast cancer and possibly other cancers. Results from large studies of lifestyle and behavioural weight loss interventions have shown that modest weight loss improves insulin sensitivity and biochemical measures of hormone metabolism, which have been postulated to contribute to the relationship between obesity and certain cancers. (2)

4. According to Cancer Research UK, only 15% of people are aware of the link between obesity and cancer. Do you think there is enough awareness of this link in South Africa?

In the absence of a functional and well resourced National Cancer Control plan NGO’S like CANSA play a vital role in creating the much needed awareness.

5. Cancer Research UK recently launched an ad campaign explicitly linking obesity to cancer. This has led to criticism of “fat shaming” and “body shaming”. Please can you comment on this? Is it time we spoke bluntly to get across the message or could this be counter-productive? Does is over-simplify the many causes of cancer?

Obesity is a highly stigmatized condition; many clinicians find it difficult to initiate a conversation about obesity with patients, and some may inadvertently use alienating language when they do.

Studies indicate that patients with obesity prefer the use of terms such as unhealthy weight or increased BMI rather than overweight or obesity and improved nutrition and physical activity rather than diet and exercise. However, it is unknown if switching to these terms will lead to more effective behavioral counselling. Effective clinical decision support tools to measure BMI and guide physicians through referral and counseling interventions can provide clinicians needed support within the patient-clinician encounter. Inclusion of recently developed competencies for prevention and management of obesity into the curricula of health care professionals may improve their ability to deliver effective care. Because few primary care clinicians are trained in behavior change strategies like cognitive behavioral therapy or motivational interviewing, other trained health care professionals, such as nurses, pharmacists, psychologists, and dietitians could assist by providing counseling and appropriate referrals and help people manage their own health. (3)

6. The research in the UK also estimates that more than seven in 10 millennials are set to be overweight or obese between the ages of 35-44 – and are the most overweight generation since current records began. What are the estimates in South Africa?

A cross sectional study employed secondary analyses of data for 6 411 South Africans aged 15 years and older who took part in the first South African National Health and Nutrition Examination Survey (SANHANES-1).

There was also a trend showing that the mean BMI increased with age, being highest in the 45-54 year (29.2 kg/m2) and 55-64 year age group (28.9 kg/m2), while the youngest age group (15-18 year olds) had a significantly lower mean BMI (21.9 kg/m2) than all other age groups. Less than a quarter (20.9 %) of the youngest age group were overweight (15.7 %) or obese (5.2 %) with 14.0 % underweight, while more than 30 % of participants in all other age groups were overweight or obese and less than 10 % were underweight.

The findings showed that while over half (50.8 %) of South Africans were overweight or obese, only 12.1 % reported having attempted to lose weight. Close to half (45.3 %) of the total sample were highly dissatisfied about their BI and 84.5 % had a largely distorted body image. The most preferred weight management methods were adjusting dietary intake and to a lesser extent physical activity. (4)

7. Researchers predict obesity can overtake smoking as the biggest cause of cancer. Please can you comment on that?

The obesity epidemic among South Africans reflects globalisation, which is the primary driving mechanism towards nutritional transition.
The high prevalence of overweight and obesity will continue to contribute to increases in health consequences related to obesity, including cancer.

Nonetheless, cancer is not inevitable; it is possible that many cancers related to overweight and obesity could be prevented, and physicians have an important responsibility in educating patients and supporting patients’ efforts to lead healthy lifestyles. It is important for all health care professionals to emphasize that along with quitting or avoiding tobacco, achieving and maintaining a healthy weight are also important for reducing the risk of cancer.

8. What are the other preventable causes of cancer in South Africa?

Please see below regarding causes of cancer, also the fact sheet.

Alcohol Consumption – The International Agency for Research on Cancer (IARC) produces reports that are widely seen as the gold standard for working out what causes cancer and what does not. According to IARC there is “sufficient evidence” that “alcoholic beverages are carcinogenic to humans”. IARC classified alcohol as a Group 1 carcinogen in 1988.

Alcohol causes at least seven types of cancer, including cancers of the mouth, oesophagus (food pipe), pharynx (upper throat), larynx (voice box), breast, bowel and liver. There is also increasing evidence linking alcohol to pancreatic cancer. (National Cancer Institute; Cancer Research UK).

Viral Infections-Cervical cancer, and other cancers of the genital and anal area, and the human papilloma virus (HPV) Primary liver cancer and the Hepatitis B and C viruses Lymphomas and the Epstein-Barr Virus T cell leukaemia in adults and the Human T cell leukaemia virus.

The Immune System – People who have problems with their immune systems are more likely to get some types of cancer.

Environmental Factors – This is around one each day that may help to cause cancer. This could include:

• Air pollution
• Man-made chemicals
• Tobacco smoke
• The sun – Radiation
• Ultraviolet-emitting Tanning Devices
• Natural and manmade radiation
• Work place hazards
• Asbestos
• Fungi-Aflatoxin, High-level aflatoxin exposure produces an acute hepatic necrosis, resulting later in cirrhosis, or carcinoma of the liver
• Radium and Its Decay Products
• Chemical Substances
• Parasites
• Metals

9. CANSA also focuses on the benefits of a healthy lifestyle. What practical, healthy choices do you recommend?

Yes, read more…

10. What should government’s role be?

Obesity cannot be managed solely at the individual level. Communities, governments, the media and the food industry need to work together to modify the environment so that it is less conducive to weight gain and to create a supportive environment using a multisectoral approach, including antipoverty measures, food production strategies, water, sanitation and proper housing. Strategies should include consumer education, appropriate food labelling, nutritional and physical activity education, as well as efforts to ensure scientific management of the content of advertising. Trade policies should prevent the flooding of local markets with cheap and unhealthy foods that also impact negatively on agricultural employment.

In South Africa, obesity management programmes should be established within healthcare and community services. Primary healthcare services should play a dominant role in identification of high-risk patients, but hospital and specialist services will be required to deal with complicated patients and to provide optimal treatment of the comorbid diseases.

Interventions should focus on education and address environmental and social factors to promote and support behaviour change:

• Increased physical activity.
• Sustainability of programmes is crucial to ensure positive change in diet, activity and obesity levels over time.
• Political support, intersectoral collaboration and community participation are essential for success. The introduction of the sugar tax is an important breakthrough in South Africa.
• Local actions within the context of national initiatives allow programmes to meet needs, expectations and opportunities.
• All parts of the population must be reached.
• Programmes must be adequately resourced.
• Integration of new programmes within existing initiatives.
• Programme planning should be evidence-based.
• Programmes should be properly monitored, evaluated and documented to ensure dissemination and transfer of experience
• Obesity prevention initiatives should be focussed on children to ensure the adoption of a healthy lifestyle from an early age. (5)

References:

[1] canceratlas.cancer.org

[2] Kushi, Lawrence H., et al. “American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity.” CA: a cancer journal for clinicians 56.5 (2006): 254-281.

[3] Greta M. Massetti, PhD, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341 (gmassetti@cdc.gov).Published Online: October 3, 2017. doi:10.1001/jama.2017.15519

[4] Mchiza, Zandile J., et al. “Body image and weight control in South Africans 15 years or older: SANHANES-1.” BMC public health 15.1 (2015): 992.

[5] Kruger, H. Salome, et al. “Obesity in South Africa: challenges for government and health professionals.” Public health nutrition 8.5 (2005): 491-500.

Posts Related to Cancer Research UK’s latest Research Findings:

• https://www.nature.com/articles/s41416-018-0029-6
• https://news.sky.com/story/obesity-could-soon-be-the-new-smoking-cancer-risk-study-shows-11300817
• http://www.bbc.co.uk/news/uk-wales-43512605