![[Feedback]](/icons/banner/feedbackACT.gif){kind=icon}
![[For Subscribers]](/icons/banner/subscriberACT.gif){kind=icon}
![[Archive]](/icons/banner/archiveACT.gif){kind=icon}
![[Search]](/icons/banner/searchACT.gif){kind=icon}
![[Contents]](/icons/banner/tocACT.gif){kind=icon}
|
|
|
|
|
||
California Department of Health Services, Sacramento, CA 94234-7320.
2To whom correspondence should be addressed. HYPERLINK mail: dbal{at}dhs.ca.gov
 |
INTRODUCTION |
|---|
 TOP INTRODUCTION The evidence to dateSuccesses and challengesFuture directionREFERENCES |
|---|
|
The evidence to date |
|---|
|
TOPINTRODUCTIONThe evidence to dateSuccesses and challengesFuture directionREFERENCES |
|---|
). However, the
reality is that the downward trend in cancer incidence that started in
the 1990s (Fig. 1
) was due largely to tobacco control efforts started decades ago.
Without widespread changes in diet and physical activity now, further
decreases in incidence sufficient to meet our prevention goals are
unlikely. If we fail to reach our incidence targets, we also fail to
reach our mortality goals (Fig. 2
).
|
|
What, then, did we not know and when did we not know it?
Fast-forward nearly 100 years. McGinnis and Foege (1993)
concluded that 19% of all premature deaths were
attributable to tobacco use, 14% were due to poor diet and physical
inactivity and those from alcohol abuse ranked a distant third at 4%.
Of the 1.3 million deaths annually in the United States for which the
underlying cause is known, at least 300,000 are due to the way we eat
and our failure to exercise.
As for cancer, starting in the early 1980s, panels of experts have
reached essentially the same conclusion, i.e., diet and tobacco use are
roughly tied as the major causes of cancer and the antidote is a
straightforward shift to a plant-based diet that is lower in
saturated fat, more exercise and a normal body weight (Anonymous 1996
, Doll and Peto 1981
, National Cancer Institute 1986
, National Research Council 1982
).
Most recently, the American Cancer Society (1999)
produced an excellent summary of the science and made it operational
and user friendly for the general public (Table 1
). However, the official scorekeepers who monitor these exposures of
interest, that is, nutrition and physical activity, report that the
United States is no closer to reaching these goals than when
measurement began and, in fact, we are losing ground on the obesity
front (U.S. Department of Health and Human Services 2000
).
|
). For 16 different cancer sites, including breast
and prostate, the evidence of reduced risk with higher vegetable and
fruit consumption was deemed to be convincing, probable or possible
(Table 2
). This report estimated that from 7 to 31% of all cancer worldwide
could be reduced by diets high in fruits and vegetables and pointed out
that "for the large majority of Americans who do not smoke
cigarettes, dietary choices, in association with physical activity,
become the most important modifiable determinants of cancer risk"
(World Cancer Research Fund/American Institute of Cancer Research 1997
).
|
|
Successes and challenges |
|---|
|
TOPINTRODUCTIONThe evidence to dateSuccesses and challengesFuture directionREFERENCES |
|---|
Since turning over the general-market adult 5 A Day Program to NCI
in 1991, we have continued to develop what marketers call "line
extensions" (Table 3
). The campaigns have not been well funded, but each has enjoyed strong
leadership from the Departments of Health Services, Education and Food
and Agriculture. Participation by the fruit and vegetable industries,
supermarkets, public service media and partners such as the American
Cancer Society has been good. Simply put, we have found that when a
large-scale campaign is properly planned and conducted, fruit and
vegetable consumption goes up. When the campaign ends, consumption
falls. Consumption is directly related to advertising, public relations
and community-based efforts directed toward changing social norms.
|
). There was no other
promotion of the 5 A Day message during those years, and independent
commercial marketing data corroborate that the upward state trend was
different from the flat trend for the nation as a whole (NPD Group, unpublished data, 1999).
For our original California Latino 5 a Day Campaign, which was
conducted solely in Spanish between 1994 and 1996, reported consumption
rose more than 30% (Foerster et al. 1997
). Although not
statistically significant given the sample size of our surveys, the
results were promising.
For the California Children’s 5 a Day—Power Play! Campaign, we
found that after a 10-wk intervention, the increase in fruit and
vegetable consumption reported by children aged 9–11 y showed a
dose-response relationship. When the campaign occurred only in the
schools, reported consumption increased 7% compared with a drop in the
control schools. When interventions were conducted in schools and
multiple community channels simultaneously, then reported consumption
rose 14% (Foerster et al. 1998
).
Shifting to the increasingly large body of published 5 A Day
intervention research, we believe that our results are fairly typical
and that, by and large, interventions work (National Cancer Institute 2000
). However, it is clear that with a lack of
real-world, large-scale interventions, the public cannot make the
shift toward a plant-based diet in today’s marketplace
environment. Nationwide, fewer than one in four adults eats five
servings of fruits and vegetables per day, rates that have been static
since monitoring started (Centers for Disease Control and Prevention 2000
). There is precious little national will to
mount the kind of effort that could remedy the situation. The state of
cancer prevention is deplorable considering the allocation of
resources, yet it is being tolerated.
This situation should be nothing less than appalling to scientists working in this area. Not only have the people who know the most science failed to insist that the knowledge be used proactively, but it is also left to the advocates to force the issue. Let us compare diet with tobacco yet again. The proportion of cancer risk due to diet is the same, in fact slightly greater than that due to tobacco. Only one in four adults uses tobacco whereas all adults eat multiple times each day; biology suggests that better diet could possibly reduce a population’s cancer risk in only 5 years, whereas for tobacco it takes about 15 years. For diet we have a national program but no national funding, whereas for tobacco an unprecedented amount of fiscal and, perhaps more importantly, political capital has been marshaled in less than a decade. As a nation we will spend >$1 billion on tobacco control next year and virtually every state has a multimillion dollar budget with which to attack the problem of tobacco use with strong, customized programs. For nutrition, should poor diet be fixed for free?
It is not easy. Even in California, resources have been hard to come
by. If we lack resolve, look at the numbers. For tobacco control, it
was the advocates who took numbers from the scientists to the voters
and in 1988 placed a $0.25 tax on each pack of cigarettes and, with the
fraction set aside for prevention, ensured that an average of 
$100
million would be spent every year to combat tobacco use. In 10 years we
have spent close to $1 billion on tobacco control in adults and youth,
whereas resources for nutrition have been minuscule, i.e., <$1 million
per year over the past 10 years—except in the recent past.
What happened? It took 10 years of continuous battle and nearly $1 billion, but adult tobacco prevalence fell >30% and per capita consumption dropped >40%. During the same period, for fruits and vegetables, having no sustained campaigns meant that we were not able to maintain the gains made with short-term campaigns; thus, long-term increases in fruit and vegetable consumption have been nil.
Is this a failure? No, not unless we fail to translate science into appropriate public policy. It costs big money to meet prevention goals, even the most elementary ones such as "don’t smoke" and "eat your vegetables." Look at breast and cervical cancer screening; look at the cancer registries—not one of these basic cancer control and surveillance measures has been either easy to implement or free.
|
Future direction |
|---|
|
TOPINTRODUCTIONThe evidence to dateSuccesses and challengesFuture directionREFERENCES |
|---|
), where smaller-scale programs are funded to scale and adapted by
the thousands of people who can do interventions on main streets across
the land. We need a core nutritional capacity in every state, with
dynamic leadership, funded through multiple funding streams. These
might include NCI, Centers for Disease Control and Prevention, USDA,
Department of Transportation and Department of Education funds; the
Tobacco Settlement monies; the cola tax and foundation grants. The
money must support a complementary mix of targeted programs in multiple
channels. The targets must be both the general market and targeted
subsegments, including but by no means limited to children. Each
population segment requires tailored mass media, community programs and
special projects. The campaign approach must be driven by consumer
research and formative evaluation and it must be administered to make
the best use of every dollar.
|
Is this a tall order? Yes, but it is not without precedent. From the natural history of other social movements compiled earlier this year through Tufts University (Chris Economos, personal communication, March 2000), we can see that for nutrition and physical activity, most of the essential ingredients (in italics) are in place. There is a crisis with huge economic costs to society—in this case, it is in the burden of preventable chronic disease, including cancer. The causal science base is incontrovertible. Coalitions are forming and demanding change. They are learning what to ask government for and to use the media to do it. They are demanding a plan of action.
Advocates are learning what intervention scientists have to teach, i.e., theory requires that the scope of intervention be directed not just to individuals, but more importantly, to people’s social and ecological surroundings. Because these dietary and exercise behaviors of interest relate inversely to education, income, social class and being Caucasian, some advocates take the position that this is an issue of social justice—and rightly so. This is especially important because these are usually the populations with the highest incidence and mortality rates.
Champions are asking for changes in surroundings that include institutions such as workplaces, retail food outlets and park or transportation departments; the complex fabric of community organizations that create the social norms; the physical environment in which food choices are made and exercise undertaken; the commercial marketplace that shapes consumer demand and policy set by private organizations and government. They are starting to propose economic solutions.
There is no paucity of opportunity to use what is already known. Indeed, today’s challenge comes down to an ethical question of taking responsibility for ensuring that the known science is applied for human benefit. Those are questions of political will, few of which have as yet been adequately researched. As a start, let us pose some rather critical questions that invite interdisciplinary research:
A recent book on the great modern philosopher of science, Thomas
Kuhn, argues at length that science as we know it has outlived its
usefulness (Fuller 2000
). The author charges that the
paradigms of science today are not ideal but rather that they are
"... an arrested social movement in which the natural spread of
knowledge is captured by a community that gains relative advantage by
forcing other communities to rely on its expertise to get what they
want." (Communities, as you probably inferred, are used in the
context of loci or groups of influence, not a geographic location.)
Although we do not necessarily subscribe to this notion—and no one in legitimate scientific circles would knowingly be part of something so sinister—we nevertheless ask that you examine the information presented at this conference in the larger context of what is known about diet and cancer or diet and chronic disease. Are we balancing our investment in primary research with our investment in action? If the answer is no—as we believe is abundantly clear—then so too is the course of action. We hope that you will join us in this next, biggest frontier of disease prevention. As Mahatma Gandhi once said, "If you want to change the world, be that change."
|
FOOTNOTES |
|---|
|
REFERENCES |
|---|
|
TOPINTRODUCTIONThe evidence to dateSuccesses and challengesFuture directionREFERENCES |
|---|
1. American Cancer Society Cancer Facts and Figures-1999 1999 American Cancer Society Atlanta, GA.
2. Anonymous The Harvard report on cancer prevention. Causes of human cancer. Cancer Causes Control 1996;7:S7-S9
3. Byers T., Mouchawar J., Marks J., Cady B., Lins N., Swanson G. M., Bal D. G., Eyre H. The American Cancer Society challenge goals: how far can cancer rates decline in the U.S. by the year 2015?. Cancer 1999;86:715-727[Medline]
4. Centers for Disease Control and Prevention (2000). Behavioral risk factor surveillance system, not enough fruits and vegetables. Available at http://198.246.97.130/brfss/Trends/TrendData.asp.
5. Doll R., Peto R. Quantitative estimates of avoidable risks of cancer in the United States. J. Natl. Cancer Inst. 1981;66:1191-1308
6. Foerster S. B., Gregson J., Hudes M. California dietary practices survey: focus on fruits and vegetables, trends among adults 1997:1989-1995 Topline report. California Department of Health Services and Public Health Institute Sacramento, CA.
7. Foerster S. B., Gregson J., Beall D. L., Hudes M., Magnuson H., Livingston S., Davis M. A., Joy A. B., Garbolino T. The California Children’s 5 a Day—Power Play! campaign: evaluation of a large-scale social marketing initiative. Fam. Community Health 1998;21:46-64
8. Fuller S. Thomas Kuhn: A Philosophical History for Our Times 2000 University of Chicago Press Chicago, IL.
9. McGinnis J. M., Foege W. H. Actual causes of death in the United States. J. Am. Med. Assoc. 1993;270:2270-2212
10. National Cancer Institute (1986) Cancer Control Objectives for the Nation: 1985–2000, Prevention of Cancer. NCI Monographs Number 2: 15–24. National Cancer Institute, Bethesda, MD.
11. National Cancer Institute (2000) 5 A Day Research Publications. Available at www.5aday.gov.
12. National Research Council Diet, Nutrition, and Cancer 1982 National Academy Press Washington, DC.
13. Ries L.A.G., Eisner M. P., Kosary C. L., Hankey B. F., Miller B. A., Clegg L., Edwards B. K. SEER Cancer Statistics Review 2000:1973-1997 National Cancer Institute Bethesda, MD.
14. U.S. Department of Health and Human Services Healthy People 2010 2000 Washington, DC.
15. World Cancer Research Fund/American Institute for Cancer Research Food, Nutrition and Prevention of Cancer: A Global Perspective 1997 American Institute for Cancer Research Washington, DC.
This article has been cited by other articles:
|
|
 |
|
  K. W. Rahman and F. H. Sarkar Inhibition of Nuclear Translocation of Nuclear Factor-{kappa}B Contributes to 3,3'-Diindolylmethane-Induced Apoptosis in Breast Cancer Cells Cancer Res., January 1, 2005; 65(1): 364 - 371. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Li, X. Li, and F. H. Sarkar Gene Expression Profiles of I3C- and DIM-Treated PC3 Human Prostate Cancer Cells Determined by cDNA Microarray Analysis J. Nutr., April 1, 2003; 133(4): 1011 - 1019. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
