IARC Handbooks of Cancer Prevention

Volume 6

Weight Control and Physical Activity

IARC Handbooks of Cancer PreventionProgramme Head: Harri Vainio

Volume 6: Weight Control and Physical Activity

Editors: Harri Vainio, M.D., Ph.D.Franca Bianchini, Ph.D

Technical editor: John Cheney, Ph.D.

Bibliographie assistance: Agnès Meneghel

Photographie assistance: Georges Mollon

Layout: Josephine Thévenoux

Printed by: Imprimerie Darantiere, BP 8,21801 Quetigny, FranceW d'impression: 22-0939 - Dépôt légal: janvier 2002

Publisher: IARCPressInternational Agency for Research on Cancer150 cours Albert Thomas, 69372, Lyon, FranceTeL. +33 4 72 73 84 85Fax. +33 4 72 73 8319

WORLD HEALTH ORGANIZATION

INTERNATIONAL AGENCY FOR RESEARCH ON CANCER

IARC Handbooks of Cancer Prevention

Volume 6

Weight Control and Physical Activity

IARCPress

Lyon, 2002

Published by the International Agency for Research on Cancer,150 cours Albert Thomas, F-69372 Lyon cedex 08, France

(Ç International Agency for Research on Cancer, 2002

Distributed by Oxford University Press, Walton Street, Oxford, OX2 6DP, UK (Fax: +44 1865 267782) and in the USA byOxford University Press, 2001 Evans Road, Carey, NC 27513, USA (Fax: + 1 919 677 1303).

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Ali rights reserved.

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concerning the legal status of any country, territory, city, or area or of its authorities,or concerning the delimitation of its frontiers or boundaries.

The mention of specifie companies or of certain manufacturers' products does not implythat they are endorsed or recommended by the World Health Organization in preference to others

of a similar nature that are not mentioned. Errors and omissions excepted,the names of proprietary products are distinguished by initial capitalletters.

The authors alone are responsible for the views expressed in this publication.

The International Agency for Research on Cancer welcomes requests for permission toreproduce or translate its publications, in part or in fulL. Applications and enquiries should be addressed

to the Communications Unit, International Agency for Research on Cancer,which will be glad to provide the latest information on any changes made to the tex!, plans for new

editions, and reprints and translations already available.

IARC Library Cataloguing in Publication Data

Weight control and physical activity/IARC Working Group on the Evaluation ofCancer-Preventive Strategies (2001 : Lyon, France)

(IARC handbooks of cancer prevention ; 6)

1. Body weight - congresses 2. Exercise - congresses 1. Working Group on the

Evaluation of Cancer-Preventive Strategies IL Series

ISBN 92 832 3006 XISSN 1027-5622

(NLM Classification: W1)

Printed in France

International Agency For Research On CancerThe International Agency for Research on Cancer (IARC) was established in 1965 by the World Health

Assembly, as an independently financed organization within the framework of the World Health Organization. Theheadquarters of the Agency are in Lyon, France.

The Agency conducts a programme of research concentrating particularly on the epidemiology of cancer andthe study of potential carcinogens in the human environment. Its field studies are supplemented by biological andchemical research carried out in the Agency's laboratories in Lyon and, through collaborative research agree-ments, in national research institutions in many countries. The Agency also conducts a programme for the edu-cation and training of personnel for cancer research.

The publications of the Agency contribute to the dissemination of authoritative information on different aspectsof cancer research. Information about IARC publications, and how to order them, is available via the Internet at:http://www.iarc.fr/

This publication represents the views andopinions of an IARC Working Group on the

Evaluation of Cancer-Preventive Strategies whichmet in Lyon, France, February 13-20, 2001

Note to the Reader

Anyone who is aware of published data that may influence any consideration in these Handbooks is encouraged tamake the information available ta the Unit of Chemoprevention, International Agency for Research on Cancer, 150Cours Albert Thomas, 69372 Lyon Cedex 08, France

Although ail efforts are made to prepare the Handbooks as accurately as possible, mistakes may occur. Readers arerequested ta communicate any errors ta the Unit of Chemoprevention, so that corrections can be reported in futurevolumes.

Acknowledgements

The Foundation for Promotion of Cancer Research, Japan (the 2nd Term Comprehensive 10-Year Strategy for CancerControl), is gratefully acknowledged for its generous support ta the meeting of the Working Group and the productionof this volume of the IARC Handbooks of Cancer Prevention.

ContentsPreface. Why a Handbook on weight control 4. Metabolic consequences of overweight,and physical activity ? xii underweight and physical activity/

inactivity1. Characteristics of weight control and Humans 53

physical activity Insulin resistance 53Weight control 1 IGF-I and IGF-binding pro teins 56Anthropometric measures 1 Total and bioavailable sex steroids 59Definition of obesíty, overweight, underweight 2 Other hormones 63Causes of obesíty 2 Immune function 63Timing of obesíty 4 Intervention trials 65Measures of weight 5 Experimental models 78Physical activity 6 Methodological issues 78Definiton of physical activity 6 Decreasing dietary intake for weight control 79Measurement of physical activity 6 Physical activity 80Concluding comments 12 Combined exercise and decreased energy

intake 822. Occurrence, trends and analysis

Weight profiles 13 5. Cancer-preventive effectsPrevalence of obesity in developing/developed Human studiescountries 13 Methodological considerations 83Age, sex, social class and education 18 Weight and weight control 85Obesity during childhood and adolescence 20 Colorectal cancer 85Physical activity 23 Breast cancer 95National surveys 23 Endometrial cancer 112Total pre valence of physical activity 30 Ovarian cancer 115Prevalence of physical activíty according Prostate cancer 117to sociodemographic characteristics 31 Kidney cancer 120Trends in physical actívity prevalence 38 Lung cancer 124Children and adolescents 38 Oesophageal cancer 126Concluding comments 38 Pancreatic cancer 126

Cancer of the head and neck 1293. Preventing weight gain and promoting Testicular cancer 129

physical activity Cancer of the thyroid 131Diet and prevention of weight gain 41 Gall-bladder cancer 131Prevention of weight gain through Malignant melanoma 133physical activity 42 Cervical cancer 133Community interventions for prevention Other cancer sites 133of weight gain 45 Population attibutable risk 133Prevention of weight regain after prior Physical activíty 134weight reduction 46 Colorectal cancer 134How to increase physical activity 49 Breast cancer 144Lessons to be learned from other Endometrial cancer 155successful public health campaigns 51 Ovarian cancer 158

vii

Table of contents ~----_._---~---Prostate cancer 158 8. Other adverse effects of weight control andKidney cancer 162 physical activityLung cancer 163 Health effects 229Testicular cancer 163 Human studies 229Population attributable risk 167 Experimental studies 233

Intervention studies of intermediate Reproductive and developmental effects 233markers of cancer 167 Human studies 233

Experimental systems 169 Experimental studies 234Design issues in diet, exercise and Genetic effects 234experimental carcinogenesis 169 Human studies 234Weight control 170 Experimental studies 234Physical actívity 184Intermediate biomarkers 188 9. Summary of dataMechanisms of cancer prevention 192 Characteristics, occurrence, trends andHuman studies 193 analysis of weight and physical activity 235Experimental studies 199 Metabolic consequences of overweight

and physical activity 2366. Other beneficial effects Cancer-preventive effects 237

Weight control 207 Carcinogenicity 242Ali-cause mortality 207 Other beneficial effects 242Cardiovascular disease 213 Other adverse effects 242Hypertension 213Type Il diabetes 213 10. RecommendationsOther morbidity 215 Recommendations for research 245Effects on surrogate markers 215 Recommendations for public health 247Visceral adipose tissue 215Psychosocíal aspects and quality of life 216 11. EvaluationPhysical activity 216 Cancer-preventive activity 249Total morta/ity 217 Overall evaluation 250Cardiovascular disease 217Type Il diabetes 220 References 251Hip fracture 221Other health outcomes 221 Glossary 305Effects on surrogate markers 221

Sources of figures 3077. Carcinogenicity

Human studies 225 Working Procedures 309Experimental models 225Weight control 225Physical activity 227

viii

List of participants

R. Ballard-BarbashApplied Research ProgramNational Cancer InstituteEPN 40056130 Executive Blvd - MSC 7344Bethesda, MD 20892-7344USA

F. BerrinoDivisione di EpidemiologiaIstituto Nazionale per 10 Studio e laCura dei TumoriVia Venezian20133 MilanItaly

D. BirtDepartment of Food Science andHuman Nutrition2312 Food Sciences BuildingIowa State UniversityAmes, lA 50011-1061USA

H. BoeingGerman Institute of Human NutritionDepartment of EpidemiologyArthur Scheunert Allee 114-11614558 Potsdam RehbrückeGermany

P. Buffer (Vice-Chairman)University of CaliforniaSchool of Public Health Division ofEpidemiology140 Warren HallBerkeleyCA 94720USA

T. ByersDepartment of Preventive Medicine &BiometricsUniversity of Colorado, School ofMedicineBox C2454200 East Ninth AvenueDenver, CO 80262USA

C. CaspersenDivision of Diabetes TranslationNational Center for Chronic DiseasePrevention and Health PromotionCenters for Disease Control andPrevention(mailstop K-10)4770 Buford Highway NEAtlanta GA 30341-3717USA

M. FogelholmUKK Institute for Health PromotionResearchKaupinpuistonkatu 1

P.O. Box 30FIN-33501TampereFinland

C. FriedenreichDivision of EpidemiologyPrevention and ScreeningAlberta Cancer Board1331-29 St. N.W.Calgary AB T2N 4N2Canada

A. HardmanDepartment of Physical EducationSports Science, and Recreation

ManagementLoughborough UniversityAshby Raad

LoughboroughLeicestershire LE11 3TUUnited Kingdom

J. KaukuaHelsinki Medical CenterBulevardi 22 AH krs00100 HelsinkiFinland

L. Le MarchandEtiology ProgramCancer Research Center of HawaiiUniversity of Hawaii1236 Lauhala St., Suite 407Honolulu HI 96813USA

A. McTiernanCancer Prevention ResearchProgramFred Hutchinson Cancer ResearchCenter1100 Fairview Avenue NM P 900Seatte, WA 98109-1024USA

J. E. Fulton, of the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention,USA, also contributed to the preparation of chapters 1 and 2.

ix

IARC Handbooks of Cancer Prevention, Volume 6: Weight Control and Physical Activity

N. OwenAssociate DeanFaculty of Health and BehaviouralSciencesUniversity of WollongongWollongong NSW 2522Australia

P. Pietinen*Department of NutritionNational Public Health InstituteMannerheimintie 166

00300 HelsinkiFinland

J. SeidellDepartment for Chronic DiseasesEpidemiologyNational Institute of Public Health andthe EnvironmentPostbus 1

NL 372- BA BilthovenThe Netherlands

M. Slattery

Health Research CenterDepartment of Family and PreventiveMedicineUniversity of Utah391 Chipeta Way, Suite GSalt Lake CityUT 84108

USA

H. ThompsonCenter for Nutrition in DiseasePreventionAMC Cancer Research Center1600 Pierce StreetLakewood,CO 80214USA

i. ThuneNorwegian Cancer SocietyFaculty of MedicineUniversity of TromsøN 9037 TromsøNorway

A. TjonnelandInstitute of Cancer EpidemiologyDanish Cancer SocietyStrandboulvarden 49

OK 2100 CopenhagenDenmark

H. TsudaExperimental Pathology andChemotherapy DivisionNational Cancer Center ResearchInstitute5-1-1 TsukijiChuo-kuTokyo 104-0045Japan

A. TurturroDivision of Biometry and RiskAssessmentNational Center for ToxicologicalResearchHFT-203900 N.C.TR. RdJeffersonAR 72209USA

W. Willett (Chairman)Department of NutritionHarvard School of Public Health andChanning LaboratoryBostonMA 02115USA

Secretariat

R. BaanF. BianchiniP. BrennanJ. CheneyS. Franceschiy. GrosseR. KaaksS. LewisA. LukanovaE. LundM. FriesenA.B. MillerH. OhshimaN. Slimani

E. SuonioH. Vainio

E. Weiderpass

Technical assistance

S. EgrazA. MeneghelJ. Mitchell

E. PerezJ. Thévenoux

* Current address: NCD Prevention and Health Promotion, World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27,Switzerland

x

Preface

hy a Handbook on weight control and physicalactivity ?

Economic, social and technologicaldevelopments in the second half of the20th century have led to major changesin the lifestyle of large segments of thepopulations of industrialized and industri-alizing nations. Over the past twodecades, significant gains in averageweight among many human populationsand within particular social groups havebeen observed. There are now highoverall rates of overweight and obesity inthe urbanized populations of industriallydeveloped countries, in the affuentsubgroups of developing nations andamong socially disadvantaged groups indeveloped countries (Figure 1) (WHOConsultation on Obesity, 1998). Forindustrialized countries, it has beensuggested that such increases in bodyweight have been caused primarily byreduced levels of physical activity, ratherthan by changes in food intake or byother factors (Jebb & Moore, 1999). Theproblem of obesity is now also becomingapparent in developing countries, due tochanges in the food supply and decreas-ing physical activity (Zimmet, 2000).

The typical time sequence of emer-gence of chronic diseases following theincreasing prevalence of obesity isimportant in public health planning for

anticipation of future obesity-caused

health problems (Figure 2). The firstadverse effects of obesity ta emerge inpopulations in transition are hyperten-

sion, hyperlipidaemia and glucose Intol-erance, while cardiovascular disease

and the long-term complications ofdiabetes, such as renal failure, begin to

emerge several years (or decades) later.This sequence has already beenobserved in many developing countries

(Popkin & Doak, 1998). Incidence ofcancers associated in part with obesity

typically increases over a longertimescale. Therefore, countries that arenow seeing increasing obesity, and thesentinel events of diabetes and cardio-vascular disease risk, but where rates ofthe obesity-related cancers are still low,should nonetheless consider preventionof future cancers as an important addi-tional justification for controllng excessbody weight in their populations.

ln populations where weight gains arerelated to reductions in ove rail metabolicenergy expenditure due to decreased

physical activity, how does this comeabout? is it due ta reduced energy

requirements of occupational and

domestic tasks because of automation

and computerization? is it caused byreductions in leisure-time exercising andrecreational energy expenditure? Arethe most influential changes those intransport and commuting, with motorvehicle use replacing walking or cycling?

Or is the most important influence the

amount of time spent in sedentary

occupations such as watching televisionand video, computer and Internet use?Currently, population prevalence andtrend data are available primarily onleisure-time physical activity and

are largely unavailable for several ofthese other physical activity domains, ailof which can contribute to energybalance.

The expanding and strengthening evi-dence on the relationship betweenavoidance of overweight, physical activ-ity and cancer prevention led to the initi-ation of this volume 6 of the IARCHandbooks of Cancer Prevention.Although the science of overweight, obe-sity and physical activity is complex andits relationship to cancer occurrence is atopic of intense research activity, muchevidence already suggests that cleargains in public health can be achievedthrough adequate action and preventivestrategies.

Current recommendations for thetreatment and control of obesity andoverweight are based on the recognitionthat this condition is a multifactorial

chronic disease with strong environ men-tal and genetic etiologies. Treatment ofsuch a complex chronic conditionrequires multi-modal approaches thatare maintained over years, with mainte-nance phases that should be continuedover life. The bases of such approachesare diet, physical activity and behaviourmodification. For some individuals,medication is added, most commonly forshort periods of three months or less.Surgical treatment may be required fortreatment of morbid obesity. The detailsof current recommendations for the treat-ment and control of obesity andoverweight are summarized in theNHLBI Obesity Education InitiativeExpert Panel Report (National Institutesof Health and National Heart, Lung, andBlood Institute, 1998) and are notreviewed in the present volume.

xi

IARC Handbooks of Cancer 'prevention, Volu~_~_Weig~!Control and Physical Activity

60

50

;:40..

(ñCI.00- 300CI(.i:

20CI

ii;:CI..i: 10

0

England Mexico Jordan1997 1995 1994/6

Il Men

Women

India1997

USA

1991

E. Germany Netherlands Japan1992 1995 1993

Australia1995

Figure 1 Prevalence of obesity in various parts of the worldAdapted from Seidell & Rissanen (2002)

o ~\\ .... """\', '"'\ "',,\. '" "\.. ~'-.""-''';\ "\ 1970

1960

USA

EnglandMauriti us

Australia

50 - /--;:...~ 40.0oÕ 30CI

g 20CI

ii~ 10..i:

Brazil--",

2030

1980

Figure 2 Obesity rates: current and projected

xii