Links between cancer and weight, nutrition and physical activity

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Links between cancer and weight, nutrition and physical activity

The links between body mass, nutrition, physical activity and cancer causation are complex, because each risk factor has a direct impact on cancer risk but the risk factors can also combine. It can be difficult to separate these combined effects. For example, poor nutrition contributes to overweight and obesity, which are independent cancer risk factors. In addition, inadequate consumption of fresh fruit and vegetables can increase cancer risk directly, as these healthy food choices can help to protect against some cancers. In the same way, physical inactivity contributes to overweight and obesity, and can also be a direct cancer risk factor, even in people who are not overweight. See Table 1 for a summary of the evidence of the link between overweight and obesity, physical activity, nutrition, and specific cancer types.


Table 1. Summary of evidence of the link between overweight and obesity, physical activity, nutrition, and cancer

Source: World Cancer Research Fund, American Institute for Cancer Research 2007[7], except where indicated

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Overweight and obesity

Evidence linking cancer and overweight and obesity or excess body fat has strengthened since the mid-1990s[7].

The World Cancer Research Fund (WCRF) as part of a comprehensive and systematic review of the evidence found convincing evidence that excess body fat causes bowel (colorectal) cancer, post-menopausal breast cancer and cancers of the kidney, pancreas, oesophagus and endometrium[7]. A more recent review by WCRF also found convincing evidence that being overweight or obese is a cause of liver cancer[8]. Excess body fat was also shown to be a probable cause of ovarian, gallbladder and prostate cancer[2][3][7]. Conversely, excess body fat probably decreases the risk of pre-menopausal breast cancer[7].

The distribution of excess body fat is important to cancer risk. Abdominal fat (based on waist circumference or waist-to-hip ratio) increases cancer risk compared to excess fat elsewhere on the body. There is convincing evidence that abdominal fatness causes bowel cancer; and probable evidence that abdominal fatness causes post-menopausal breast cancer, and cancers of the pancreas and endometrium[7].

While there is conclusive evidence that increased body weight and body fat increase cancer risk, there has been limited research on whether losing weight might lower cancer risk. Some evidence indicates that weight loss in those who are overweight lowers breast cancer risk[9][10][11].

There is some evidence that a healthy body weight may prevent cancer recurrence and improve survival for people diagnosed with certain cancers[12][13][14]. In addition, there is a reasonable level of evidence that weight management and physical activity positively impact on quality of life, cancer recurrence and overall survival for people who have been diagnosed with cancer[15].

Randomised controlled trials, such as the Women’s Intervention in Nutrition Study (WINS), have shown encouraging results of the effectiveness of nutrition and physical activity interventions in improving health outcomes for cancer survivors[12].

For more information on the link between overweight and obesity, and cancer, see the Position statement: Overweight, obesity and cancer prevention.

Causes of overweight and obesity

Reducing the risk of overweight and obesity would also reduce the risk of developing associated cancers (see Table 1)[7][16]. It is therefore critical to understand and address the main causes of overweight and obesity, and their impact on cancer risk.

Evidence shows the key determinants of obesity/overweight on a population basis are excess energy (kilojoules) in the diet, energy dense, nutrient poor foods, and inadequate energy expenditure, primarily due to physical inactivity[16].

The World Cancer Research Fund and the International Agency for Cancer Research recommend people should aim to be as lean as possible within the normal range of body weight (BMI 18.5-less than 25). People should try to avoid weight gain and growth in waist circumference throughout adulthood[7].

Physical activity

Convincing evidence shows that regular and sustained physical activity protects against overweight and obesity, while being sedentary (inactive) causes these conditions[7]. As well as contributing to a healthy body mass, being physically active reduces cancer risk in its own right, particularly the risk of developing cancers of the bowel and breast[7].

Nutrition

A report released in 2003 by the World Health Organisation advised that "...dietary factors contribute significantly to some types of cancer. Maintaining a healthy weight will reduce the risk for cancers of the oesophagus, colorectum (bowel), breast, endometrium and kidney... Ensuring an adequate intake of fruit and vegetables should further reduce risk for oral cavity, oesophagus, stomach and colorectal (bowel) cancer"[16]. Public policies that encourage improved nutrition therefore have significant potential to reduce cancer burden on a population basis (see the Policy priorities section of this chapter)[16].

Consumption of alcohol, an important risk factor for overweight and obesity, and for cancer independently, is not covered in detail in this chapter. For more information on the link between alcohol consumption and cancer risk, see the Alcohol chapter of the National Cancer Prevention Policy.

'Obesogenic' environment

Nutrition and physical activity behaviours are influenced by a range of factors, including the physical environment and economic, social and personal factors, which are important determinants of cancer risk at the population level[17].

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Physical activity

Physical activity is important for good health and wellbeing and can help to prevent a range of health problems including heart disease, type 2 diabetes, osteoporosis and some cancers[16].

Being active can help to prevent cancer in two ways: physical activity can directly reduce the risk of specific cancers such as bowel cancer[7]; and by contributing to lower body mass, physical activity can help to reduce the risk of all cancers associated with obesity/overweight (see Table 1)[7].

There is convincing evidence that regular physical activity decreases the risk of weight gain, overweight and obesity, while inactivity increases risk[7]. On this basis, the evidence that adequate physical activity can reduce cancer risk is convincing[7].

Physical activity appears to protect against some cancers, independently of its contribution to weight control[7][18][19][20].

The strongest evidence for the protective effect of physical activity is for two of the most common cancers: breast cancer and bowel cancer[7][21]. It is estimated that, in the UK, 12% of all cases of bowel cancer are attributable to physical inactivity[17]. The risk reduction for the most active individuals is around 30% to 40%, compared with the least active[21]. However, the effect is not as clear for rectal cancer as it is for bowel cancer[7].

Evidence shows physical activity probably protects against breast cancer, especially in post-menopausal women[7]. Estimates indicate that, in the UK, 12% of breast cancers are attributable to physical inactivity[17]. A systematic review in 2007 found strong evidence of an inverse association between leisure-time physical activity and post-menopausal breast cancer, with risk reduction ranging from 20% to 80%[22]. However, the evidence was much weaker for pre-menopausal breast cancer. Nonetheless, each additional hour of physical activity per week decreased the risk of breast cancer overall by 6%[22].

There is probable evidence that physical activity protects against both endometrial cancer[23] and ovarian cancer[24], independently of its impact on body weight.

Dose-response relationship

Where there is evidence of a direct link between physical activity and reduced cancer risk, that evidence consistently suggests the more physically active people are (excluding extreme levels), the lower their cancer risk[7].

It has been estimated that 30-60 minutes per day of more intense types of activities may be needed to see the greatest reduction in risk[21]. Australian guidelines recommend 300 minutes of moderate intensity physical activity, or 150 minutes of vigorous intensity physical activity per week to help prevent cancer[25].

Research suggests that being sedentary for long periods, irrespective of the overall amount of physical activity, is associated with increased risk of bowel, endometrial, ovarian and prostate cancer, as well as increased overall cancer mortality in women[26].

Physical activity and cancer care

Physical activity has been shown to be beneficial to cancer patients, with positive patient outcomes consistently associated with physical activity before, during and after treatment[27]. Further, it may be important for reducing the risk of cancer recurrence particularly for bowel and breast cancer, and for extending overall cancer survival[28].

For more information on the benefits of physical activity for cancer survivors, see Position statement: Benefits of healthy diet and physical activity for cancer survivors

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Nutrition

Evidence on the impact of nutrition on cancer continues to develop. It has been a challenging area of epidemiology due to limited data on dietary patterns, the complexities of controlling for related risk factors such as physical inactivity, and the time lag between the impact of nutrition and the development of related cancers.

There is, however, growing evidence that shows specific nutrients (foods) can either increase or decrease cancer risk. Diets that protect against weight gain, overweight and obesity are thought to protect against cancers associated with excess body weight[7].

Dietary advice for reducing cancer risk is consistent with recommendations for promoting good health, including preventing cardiovascular disease and type 2 diabetes - a diet high in vegetables and fruit, grains and cereals (preferably wholegrain) and low in fat, salt and energy (sugar)[16].

The World Cancer Research Fund recently conducted a comprehensive review of the scientific evidence relating to nutrition, physical activity and cancer prevention. Following the review they published five summary recommendations:

  • Limit consumption of energy-dense foods and avoid sugary drinks
  • Eat mostly food of plant origin including relatively unprocessed cereals and pulses
  • Limit intake of red meat to less than 500g a week and avoid processed meat
  • Limit consumption of salt
  • Aim to meet nutritional needs through diet alone[7].

They also recommend that people should limit alcoholic drinks (see National Cancer Prevention Policy - Alcohol and cancer for further information).

An overview of the findings from this report, plus other relevant evidence, is summarised below.

Specific foods and nutrients

Dietary fibre and wholegrain cereals

Dietary fibre occurs naturally in foods such as wholegrain cereals, fruit, vegetables, seeds, nuts and legumes and is highest when these foods are minimally processed. Consumption of these foods is associated with a lower risk of a range of diseases including obesity, type 2 diabetes and cardiovascular disease[16], and may also prevent some cancers[7]. Foods high in dietary fibre may also indirectly affect cancer risk because their relatively low energy density may assist in weight management[7].

There is convincing evidence that dietary fibre decreases the risk of bowel cancer[1] and some limited evidence to suggest it may also be associated with a lower risk of oesophageal cancer[7]. Evidence of the link between dietary fibre and wholegrain cereal consumption in relation to the risk of developing other cancers, such as breast, prostate and ovarian cancers, is currently insufficient[7].

For further information see Position statement: Fibre, wholegrain cereals and cancer prevention.

Fruit and vegetables

There is evidence that fruit and vegetable consumption is both directly and indirectly protective against certain cancer types[7]. Directly, fruit and vegetables are high in nutrients that are potentially protective against cancer. Indirectly, their consumption as an alternative to high-energy foods plays an important role in weight management, reducing cancer risk (see above).

Despite a recent slight weakening of the evidence supporting a direct protective effect of fruit and vegetables in relation to specific cancers, overall the body of evidence supports that the consumption of fruit and vegetables has a protective effect against cancer[7].

There is strong evidence to indicate that non-starchy vegetables and fruit are protective against cancers of the digestive tract including cancers of the mouth, larynx, pharynx, oesophagus and stomach[7]. The body of evidence indicates that it is probable that fruit also protects against lung cancer, and garlic protects against bowel cancer[7]. Further, there is limited evidence suggesting that a higher intake of fruit and vegetables reduces the risk of cancers of the nasopharynx, lung, bowel, ovary and endometrium, and that fruit consumption protects against pancreatic and liver cancers[7][29][30].

There does not appear to be any association between fruit and vegetable consumption and prostate[3][31] or breast cancer [30][32]. Earlier studies had suggested that foods containing lycopene, such as tomato, probably protect against prostate cancer[33], whilst a more recent review by the World Cancer Research Fund in 2014 concluded that links between prostate cancer risk and foods containing lycopene have been downgraded from strong evidence of a decreased risk, to no conclusion possible[3].

For further information see Position statement: Fruit, vegetables and cancer prevention.

Meat

There is a strong body of evidence that red meat and processed meats such as sausages, bacon and ham can cause bowel cancer and that this risk increases with increased consumption[1][7]. Although the relationship between meat consumption and the bowel cancer has been questioned in some studies[34][35], the strength of evidence supporting this association has increased since the mid-1990s[1][7].

Some limited evidence suggests that red meat may cause cancers of the oesophagus, lung, pancreas and endometrium, and processed meats may cause cancers of the oesophagus, lung, stomach and prostate[7]. There is limited evidence to suggest that grilled or barbecued foods may cause stomach cancer, and foods containing iron may increase bowel cancer risk[7].

Currently, there is insufficient evidence to draw conclusions on the effect of poultry intake on cancer risk[7].

For further information see Position statement: Meat and cancer prevention.

Omega-3 fatty acids and fish

Epidemiological studies provide some limited evidence that suggests increased fish consumption may reduce the risk of breast and prostate cancers[4][7]. Limited evidence suggests that a diet comprising a higher ratio of omega-3 fatty acids to omega-6 fatty acids may reduce breast cancer risk[36][37]. However, there is insufficient evidence to link omega-3 fatty acid intake with risk for other cancer types[4].

For further information see Position statement - Food Marketing to children

Dairy foods and calcium

There is evidence that consumption of dairy foods and calcium is both protective against certain cancer types, and may lead to an increase in risk for other cancer types.

The evidence shows that milk and calcium (both dietary calcium and as a supplement) probably protect against bowel cancer[1][7]. There is limited suggestive evidence that milk reduces the risk of bladder cancer[7].

The evidence suggesting that diets high in calcium and that milk and dairy foods increase the risk of prostate cancer is limited[3]. There is limited evidence to suggest that cheese increases the risk of bowel cancer[7].

There appears to be no significant association between the consumption of dairy products and the risk of breast[38][39] or ovarian cancer[40][41].

For further information see Position statement: Dairy foods, calcium and cancer prevention.

Soy and phyto-oestrogens

There is limited suggestive evidence that soy foods may lower the risk of prostate and stomach cancer[7]. There is insufficient evidence to determine any link between soy foods and the risk of other cancers[7][42].

Soy beans and other foods containing soy are rich sources of phyto-oestrogens. While evidence suggests phyto-oestrogens may have a protective effect against cancer, there is some evidence that they may stimulate the growth of existing hormone-dependent cancers[5][6].

For further information see Position statement: Soy, phyto-oestrogens and cancer prevention.

Tea

Epidemiological evidence regarding the impact of tea on cancer risk is mixed and often inconclusive. Overall, it appears that drinking tea, especially green tea, is more likely to be beneficial than harmful in terms of cancer risk, although the risk of cancer appears to be reduced only slightly[7].

For further information see Position statement: Tea and cancer prevention.

Salt

The evidence indicates that both salt and salt preserved foods are probably associated with an increased risk of stomach cancer[7]. Although it is difficult to measure salt intake, the effect of salt on stomach cancer is thought to be mainly due to a regular intake of salted and salt preserved foods[7].

For further information see Position statement: Salt and cancer risk.

Dietary constituents and supplements

Certain foods are rich in micronutrients and phytochemicals that may have a protective effect against cancer. The current body of evidence on dietary supplements containing such micronutrients and phytochemicals and their role in cancer prevention has not generated conclusive evidence. In general, it seems to be the combination and interaction of nutrients and phytochemicals found together in whole foods that helps reduce the risk of chronic diseases. The use of supplements in place of a well-balanced diet is generally not recommended.

Beta-carotene

Beta-carotene is a carotenoid (a chemical in the pigment of plants that are usually yellow or red) that our body converts to Vitamin A. Beta-carotene can be obtained from dark-green leafy vegetables, some yellow and orange coloured fruits and vegetables, and as a dietary supplement.

The body of evidence indicates a convincing association between beta-carotene supplements and an increased risk of lung cancer in current smokers[7]. However, foods containing carotenoids probably reduce the risk of lung, mouth, pharynx, and larynx cancer, and dietary beta-carotene probably reduces the risk of oesophageal cancer[7].

For further information see Position statement: Beta-carotene and cancer risk.

Folate

Folate is a water soluble B-vitamin present naturally in foods such as wholemeal bread, legumes, green leafy vegetables and liver. In Australia, wheat flour for bread-making purposes has been fortified with folic acid since 2009 to reduce the incidence of neural tube defects in babies.

There is probable evidence that foods containing folate reduce the risk of pancreatic cancer and limited suggestive evidence that they reduce the risk of oesophageal and bowel cancer[1][7]. Evidence suggests that high dietary folate intake may reduce the risk of post-menopausal breast cancer, particularly for women with a family history of breast cancer[43][44][45].

Some studies have suggested that high doses of folic acid as a supplement may promote the progression of undiagnosed premalignant and malignant lesions of the bowel[46][47].

For further information see Position statement: Folate and reducing cancer risk.

Selenium

Selenium is a trace mineral found in cereals, meat, poultry, seafood and eggs[48].

Limited evidence suggests that selenium may reduce the risk of lung and stomach cancer, but that selenium supplements may increase the risk of skin cancer[7].

While some evidence has suggested a probable protective effect of selenium on prostate cancer risk[7], a recent review of current data has indicated that there is no protective effect of selenium supplements against prostate [3] and skin cancers, inconclusive evidence of an effect on liver cancer, and no conclusive evidence of protection against cancer over all[49].

For further information see Position Statement:Selenium.

Sugar-sweetened beverages

The consumption of sugar-sweetened beverages is associated with increased energy intake and in turn, weight gain and obesity. Consumption of these drinks is associated with increased energy intake, and there is evidence of at least a probable association between sugar-sweetened beverages consumption and weight gain, body mass index, overweight and obesity (among adults and children)[50][51]. While sugar-sweetened beverages may contribute to cancer risk through its effect on overweight and obesity, there is no evidence to suggest that these drinks are an independent risk factor for cancer[7].


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