DÄ internationalArchive35-36/2018Cancers Due to Excess Weight, Low Physical Activity, and Unhealthy Diet

Original article

Cancers Due to Excess Weight, Low Physical Activity, and Unhealthy Diet

Estimation of the attributable cancer burden in Germany

Dtsch Arztebl Int 2018; 115(35-36): 578-85; DOI: 10.3238/arztebl.2018.0578

Behrens, G; Gredner, T; Stock, C; Leitzmann, M F; Brenner, H; Mons, U

Background: Excess weight, low physical activity, low intakes of dietary fiber, fruits, and vegetables, and high meat and salt intake increase cancer risk.

Methods: Numbers and proportions (population-attributable fractions, PAF) of incident cancer cases in Germany in 2018 attributable to these factors were estimated by sex and age groups for ages 35 to 84 years using population projections, national cancer incidence and exposure data, and published risk estimates.

Results: Estimated numbers (percentages) of attributable cancers were 30 567 (7%) for excess weight, 27 081 (6%) for low physical activity, 14 474 (3%) for low dietary fiber intake, 9447 (2%) for low fruit and vegetable consumption, 9454 (2%) and 1687 (0.4%) for processed meat and high red meat consumption, respectively, and 1204 (0.3%) for high salt intake. Excess weight substantially contributed to endometrial, renal, and liver cancer (PAF = 24 to 35%). Low physical activity contributed to endometrial, renal, and lung cancer (PAF = 15 to 19%), and dietary factors mainly contributed to colorectal, breast, and lung cancer (PAF = 9 to 16%).

Conclusion: A considerable proportion of cancer cases are attributable to excess weight, physical inactivity, and unhealthy dietary habits. Major prevention efforts are needed to reduce the cancer incidence attributable to these avoidable factors.

LNSLNS

Excess weight, low physical activity, and unhealthy diet contribute substantially to the development of cancer (13). However, no information on the attributable cancer incidence is available for the general population in Germany. By applying the concept of population-attributable fractions (PAF), we estimated the incidence of cancers attributable to excess weight, low physical activity, and unhealthy diet in people aged 35–84 years in Germany in 2018. Health professionals and politicians need such information to design and implement effective measures to reduce the prevalence of obesity, physical inactivity, and unhealthy diet.

Methods

Lifestyle factors and site-specific cancer risk

Our definitions of normal body weight, recommended level of physical activity and a healthy diet followed the cancer prevention guidelines of the World Cancer Research Fund (WCRF) (eSupplement A) (4). We considered all cancer types that have been shown to be related to those lifestyle factors in published meta-analyses of prospective studies comprising 5000 or more cancer cases (eSupplement B–D, eTables 1–3).

le__">Statistical methods

In analogy to our alcohol analysis in this issue (5), we used PAFs (for details see the Box in Mons et al. [5], this issue) to estimate the proportion of lifestyle-associated cancers in the population aged 35 to 84 years, assuming a 10-year latency period between exposure and cancer incidence. We used prevalence data of 6962 men and women aged 25 to 74 years from the nationally representative German Health Interview and Examination Survey for Adults for the period 2008 to 2011 (DEGS1) (6) (eSupplement, eTables 4–8). We estimated the number of cancer cases attributable to each lifestyle factor by multiplying the PAF by the expected cancer incidence for the year 2018 (eSupplement E, eTables 9–21).

Results

Prevalence of lifestyle factors

>According to DEGS1, 63% of men and women aged 25 to 74 years living in Germany were overweight (38%) or obese (25%) (Figure 1, eTable 4). Furthermore, 81% of the study population were insufficiently physically active (49%; 1–149 min/week of moderate to vigorous physical activity) or physically inactive (32%; 0 min/week of moderate to vigorous physical activity) (eTable 5). In addition, 9% of the study population reported a high red meat consumption of ≥500 g/week (eTables 6–8), 96% of them ate processed meat (including hamburger/kebab, bratwurst/currywurst, sausage, and ham), 76% had a high salt intake of ≥6 g/day, 72% had a low dietary fiber intake (<32 g/day), and 71% did not consume enough fruit and non-starchy vegetables (<400 g/day).

Site-specific cancer risk

Published meta-analyses revealed that obesity (as compared to normal weight) increases the risk of cancers of the stomach (by 17%), colorectum (by 33%), liver (by 83%), gallbladder (by 67%), pancreas (by 36%), breast (postmenopausal, by 20%), endometrium (by 154%), ovary (by 27%), prostate (advanced, by 14%), kidney (by 77%), bladder (by 10%), thyroid gland (by 29%), and additionally the risks of non-Hodgkin lymphoma (by 19%), multiple myeloma (by 21%), and leukemia (by 26%) (eTable 1, eFigure 1).

Prevalence of selected lifestyle factors among men and women aged 25–74 years (N = 6087 for body weight, N = 6696 for physical activity, N = 6129 for dietary factors) from the nationally representative DEGS1 survey, 2008 to 2011, Germany
Prevalence of selected lifestyle factors among men and women aged 25–74 years (N = 6087 for body weight, N = 6696 for physical activity, N = 6129 for dietary factors) from the nationally representative DEGS1 survey, 2008 to 2011, Germany
Figure 1
Prevalence of selected lifestyle factors among men and women aged 25–74 years (N = 6087 for body weight, N = 6696 for physical activity, N = 6129 for dietary factors) from the nationally representative DEGS1 survey, 2008 to 2011, Germany

Because cohort studies of physical inactivity and cancer risk used heterogeneous physical activity assessments and categories, meta-analyses could only provide general estimates of the cancer risk among physically inactive individuals as compared to the cancer risk among individuals who were sufficiently physically active (eTable 2). In DEGS1, the comparison between sufficient physical activity and physical inactivity corresponded to the comparison of engaging in an average of 248 min/week of moderate to vigorous physical activity versus not engaging in any moderate to vigorous physical activity (0 min/week). According to this interpretation, a 150 min/week decrease in moderate to vigorous physical activity is associated with risk increases of 5% for gastric cancer, 11% for colorectal cancer, 3% for pancreatic cancer, 20% for lung cancer, 7% for breast cancer, 15% for endometrial cancer, 17% for renal cancer, and 9% for bladder cancer (eFigure 2).

Estimated number of site-specific incident cancer cases attributable to excess weight (BMI=25 kg/m²) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.
Estimated number of site-specific incident cancer cases attributable to excess weight (BMI=25 kg/m²) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.
Figure 2
Estimated number of site-specific incident cancer cases attributable to excess weight (BMI=25 kg/m²) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.

Dose–response meta-analyses of dietary factors and cancer risk reported a risk increase per 200 g/week increase in red meat consumption of 3% for colorectal cancer, 3% for pancreatic cancer, 7% for lung cancer, and 3% for breast cancer, and risk increases per 200 g/week increase in processed meat consumption of 9% for colorectal cancer and 5% for breast cancer (eTable 3, eFigure 3). A 2 g/day increase in salt intake increases the risk of gastric cancer by 5%. A 10 g/day decrease in dietary fiber intake is associated with an 11% increased risk of colorectal cancer and a 5% increased risk of developing breast cancer. A 200 g/day decrease in fruit and non-starchy vegetable consumption is associated with a risk increase of 2% for colorectal cancer and a 9% increase in the risk of lung cancer.

Cancers attributable to the selected lifestyle factors

We expected 440 373 incident cancers among adults aged 35 to 84 years in 2018 in Germany. Excess weight and low physical activity increased the cancer incidence substantially (excess weight: N = 30 567 cases, PAF = 7%; low physical activity: N = 27 081 cases, PAF = 6%), exerting a substantial effect on endometrial cancer (PAF for excess weight = 35%; PAF for low physical activity = 15%), renal cancer (PAF for excess weight = 25%; PAF for low physical activity = 17%), liver cancer (PAF for excess weight = 24%), and lung cancer (PAF for low physical activity = 19%) (Figures 2–3, eTables 12–17, eFigures 4–5).

Estimated number of site-specific incident cancer cases attributable to low physical activity (
Estimated number of site-specific incident cancer cases attributable to low physical activity (
Figure 3
Estimated number of site-specific incident cancer cases attributable to low physical activity (<150 min/week of moderate to vigorous physical activity) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.

Substantially lower contributions to total cancer risk were observed for intakes of dietary fiber, fruit, non-starchy vegetables, and processed meat (any consumption of processed meat: N = 9454, PAF = 2%; low intake of dietary fiber: N = 14 474, PAF = 3%; low consumption of fruit and non-starchy vegetables: N = 9447, PAF = 2%) (Figure 4, eTables 18–20, eFigure 6). Low intake of dietary fiber and the consumption of processed meat products favored the development of colorectal cancer and breast cancer (consumption of processed meat: PAF for colorectal cancer = 11 %, PAF for breast cancer = 5 %; low dietary fiber: PAF for colorectal cancer = 16 %, PAF for breast cancer = 9 %). Low consumption of fruit and non-starchy vegetables influenced the development of colorectal cancer (PAF = 4 %) and lung cancer (PAF = 14 %). High intakes of salt and red meat had considerable effects on gastric cancer (PAF for high salt intake = 9%) and lung cancer (PAF for high red meat consumption = 2%), but negligible effects on total cancer (high red meat consumption: N = 1687, PAF = 0.4%; high salt intake: N = 1204, PAF = 0.3%). We estimated that a total of 34 162 cancers (PAF = 8%) were attributable to all dietary factors combined (Figure 4, eTable 21).

Estimated number of site-specific incident cancer cases attributable to high consumption of red meat (=500 g/week), any consumption of processed meat (>0 g/week), high intake of salt (=6 g/day), low intake of dietary fiber (
Estimated number of site-specific incident cancer cases attributable to high consumption of red meat (=500 g/week), any consumption of processed meat (>0 g/week), high intake of salt (=6 g/day), low intake of dietary fiber (
Figure 4
Estimated number of site-specific incident cancer cases attributable to high consumption of red meat (=500 g/week), any consumption of processed meat (>0 g/week), high intake of salt (=6 g/day), low intake of dietary fiber (<32 g/day) and low consumption of fruit and vegetables (<400 g/day) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.

We observed no strong correlations between the individual lifestyle factors in our population, but there were moderate correlations between high consumption of processed meat and high salt intake, and between high intake of dietary fiber and high intakes of salt, fruit and non-starchy vegetables (Spearman correlation coefficients = 0.22–0.45, eTable 22).

Sensitivity analyses using the 95% confidence limits of risk estimates in the PAF formulae indicated an estimated range of 19 513 to 41 723 cancer cases attributable to excess weight, 19 714 to 34 857 to low physical activity, and 16 695 to 52 547 to unhealthy diet (eTables 23–25).

Discussion

Our study revealed a high prevalence of excess weight, low physical activity, and unhealthy diet among the population in Germany in the period 2008 to 2011. For the population aged 35 to 84 years in 2018 in Germany, we therefore estimated that 30 567 incident cancers will be attributable to excess weight and 27 081 to low physical activity in 2018, corresponding to 7% and 6%, respectively, of the expected total of 440 373 incident cancers in this population. 9000 to 14 000 cancers (2–3%) will be attributable to low intakes of dietary fiber, fruit and non-starchy vegetables and high consumption of processed meat, and some 1000 to 2000 cases (<1%) to high intakes of salt and red meat.

Overweight and obesity

Earlier studies (711) estimated the cancer risk attributable to overweight and obesity under the model assumption that the natural logarithm of the relative risk depends linearly on BMI (log linearity). This assumption is not always true (12), potentially leading to distorted estimates. We therefore dispensed with this model assumption and instead used direct comparisons of the cancer risk for normal weight, overweight, and obesity. Some previous studies also used direct risk comparisons to calculate the cancer incidence attributable to overweight and obesity (1316). Due to lower prevalence rates for overweight and obesity, those studies yielded lower attributable cancer incidence estimates for overweight and obesity than our study (1316).

It is biologically plausible that overweight and obesity contribute to the development of cancer. Potential biological mechanisms and factors linking excess body fat to cancer incidence include insulin resistance, chronic inflammatory processes, sex hormones, and growth factors (1).

Low physical activity

Previous estimates of the cancer incidence attributable to low physical activity differ from our estimates because previous studies used lower physical activity target levels (13, 14), lower prevalence rates (15, 17), or lower or higher assumed cancer risks for their estimates (9, 11, 16, 18, 19).

A high level of physical activity may prevent cancer through reductions of adipose tissue and insulin resistance, through decreases in chronic inflammation, sex hormones, and growth factors, and through improved resistance to oxidative stress and DNA damage (3).

Unhealthy diet

Previous attributable cancer incidence studies reported a greater or lesser cancer prevention potential of a healthy diet because they applied more or less rigorous target intake levels than in our study (11, 2026), because their mean intake was further away from/closer to the target level than in our study (15, 16, 20, 21), and because they used higher or lower cancer risk estimates for an unhealthy diet (11, 14, 27). Our estimate for the combined impact of dietary factors on cancer incidence was comparable to that from previous studies from other countries (28, 29).

Low intakes of red meat, processed meat, and salt and high intakes of dietary fiber, fruit, and non-starchy vegetables may contribute to the prevention of cancer through (2, 3032):

  • Reduced exposure to exogenous and endogenous carcinogens including N-nitroso compounds
  • Decreased formation of cyto- and genotoxic aldehydes
  • Lower levels of chronic inflammation
  • Increased antioxidative capacities
  • Improved DNA repair
  • Modulated estrogen metabolism.

In addition, changing from diets with high intakes of energy-dense foods to diets with high intakes of dietary fiber, fruit, and vegetables may decrease cancer risk through reductions in adipose tissue, insulin levels, chronic inflammation, and circulating sex and growth hormones (2).

Strengths and limitations

The present study of attributable cancer incidence followed the methodological recommendations issued by the World Health Organization (WHO, eSupplement F). Our study provides up-to-date estimates of the total number of cancers attributable to excess weight, low physical activity and unhealthy diet in Germany for the year 2018, assuming a 10-year latency period, based on the latest nationally representative prevalence and cancer incidence data. As discussed above, there is sufficient biological evidence in support of a causal relationship between the selected lifestyle factors and the development of cancer.

Our comprehensive systematic literature search yielded the most recent data on the relations of lifestyle factors to site-specific cancer risk. The present study is the first to consider, in estimating the attributable cancer incidence, the relation of obesity to bladder cancer, the relations of low physical activity to cancers of the stomach, lung, and bladder, and the relations of high consumption of red and processed meat and of low intake of dietary fiber to cancers of the pancreas, lung, and breast. All of these relations have been established in published meta-analyses of prospective studies including ≥5000 incident cancer cases.

As a limitation, we may have underestimated the cancer prevention potential of the selected lifestyle factors because we did not consider any potential relations of these factors to site-specific cancer risk that have not yet been confirmed in meta-analyses of prospective studies including ≥5000 incident cancer cases (eSupplement F).

We accounted for potential confounding by age and sex, the most important predictors of cancer incidence, by stratifying our analyses by age and sex. However, we were not able to consider additional potential confounding factors, including genetic traits, medical conditions, and sociodemographic factors, because cancer registries do not provide data stratified by such factors. Unfortunately we could not calculate any PAF for combinations of lifestyle factors, because the required risk estimators were insufficiently precise (33, 34). Therefore, we were also unable to take account of the potential biological interactions among the individual lifestyle factors and the resultant potential confounding. Because the concept of PAF does not allow the summation of attributable cancer cases across individual risk factors, we used the sequential PAF formula to assess the combined impact of dietary factors on cancer incidence. That formula requires the assumption of uncorrelated dietary factors, which was approximately met in our population.

For the selected lifestyle factors, the assumed cancer latency period of 10 years is within the realistic range of 5–15 years—a range in which attributable cancer incidence estimates vary little (eSupplement F). In sensitivity analyses, we used the lower and upper bounds of the cancer site–specific relative risk estimates in the PAF formulas and observed substantial numbers of attributable cancer cases across all scenarios. Potential changes in prevalence of lifestyle factors in recent years are probably small and should not affect our estimates substantially.

Conclusion

The present study identified excess weight (>30 000 annual cases, 7%) and low physical activity (>27 000 annual cases, 6%) as major contributors to the current cancer incidence (>440 000 annual cases) among adults aged 35–84 years in Germany. Substantial numbers of incident cancers were also due to dietary factors, including low intake of dietary fiber (>14 000 annual cases, 3%), low consumption of fruit and non-starchy vegetables (>9000 annual cases, 2%), any consumption of processed meat (>9000 annual cases, 2%), high consumption of red meat (>1600 annual cases, 0.4%) and high salt intake (>1200 annual cases, 0.3%). These figures suggest that adherence to a healthy lifestyle is vital in cancer prevention at both the individual level and the population level. In view of the high prevalence of unhealthy lifestyle factors in the population, health professionals and politicians should increase their efforts to encourage people to lead a healthy lifestyle. According to the World Cancer Research Fund (WCRF), a cancer-preventive lifestyle should include adherence to a normal weight (BMI 18.5–24.9 kg/m²), regular physical activity (≥150 min/week of moderate to vigorous physical activity), and a healthy diet (≥32 g/day of dietary fiber, ≥400 g/day of fruit and non-starchy vegetables, 0 g/week of processed meat, <500 g/week of red meat, <6 g/day of salt). Encouragement from physicians is an effective means of increasing adherence to a healthy lifestyle due to the trust that patients have in their doctors’ medical advice (35). Adherence to a healthy lifestyle may be effectively supported by the creation of healthy living environments and incentives. Potential strategies to promote physical activity and reduce overweight include physical activity interventions at school and work-places, the creation of sport facilities, parks, and nature recreation areas in neighborhoods, and the development of public transport, safe bike lanes, safe sidewalks, and pleasant walking environments (36). The extension of public transportation represents a health-enhancing option because people often walk or cycle to the next public transport station (36). A healthy diet may be promoted through price policies, advertising restrictions, nutrition labeling, school and workplace interventions, information campaigns, and greater availability of healthy foodstuffs in restaurants, kiosks, and fast-food outlets (3739).

Funding

The study was funded by German Cancer Aid (“Deutsche Krebshilfe”), grant number 70112097.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 16 April 2018, revised version accepted on
10 July 2018

Corresponding author
PD Dr. habil. med. Gundula Behrens
Klinische Epidemiologie und Alternsforschung
Deutsches Krebsforschungszentrum (DKFZ)
Im Neuenheimer Feld 581, 69120 Heidelberg, Germany
g.behrens@dkfz-heidelberg.de

Supplementary material
For eReferences please refer to:
www.aerzteblatt-international.de/ref3518

eSupplement, eTables, eFigures:
www.aerzteblatt-international.de/18m0578

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*1 Gundula Behrens and Thomas Gredner contributed equally to this work.
*2 Hermann Brenner and Ute Mons contributed equally to this work.
Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg: PD Dr. habil. med. Gundula Behrens; Thomas Gredner, MPH; PD Dr. sc. hum. Christian Stock, MSc; Prof. Dr. med. Hermann Brenner; PD Dr. sc. hum. Ute Mons
Medical Faculty Heidelberg, University of Heidelberg, Heidelberg: Thomas Gredner, MPH
Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg: Prof. Dr. med. Dr. P.H. Michael F. Leitzmann
Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg: Prof. Dr. med. Hermann Brenner
German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg: Prof. Dr. med. Hermann Brenner
Cancer Prevention Unit, German Cancer Research Center (DKFZ), Heidelberg: PD Dr. sc. hum. Ute Mons
Prevalence of selected lifestyle factors among men and women aged 25–74 years (N = 6087 for body weight, N = 6696 for physical activity, N = 6129 for dietary factors) from the nationally representative DEGS1 survey, 2008 to 2011, Germany
Prevalence of selected lifestyle factors among men and women aged 25–74 years (N = 6087 for body weight, N = 6696 for physical activity, N = 6129 for dietary factors) from the nationally representative DEGS1 survey, 2008 to 2011, Germany
Figure 1
Prevalence of selected lifestyle factors among men and women aged 25–74 years (N = 6087 for body weight, N = 6696 for physical activity, N = 6129 for dietary factors) from the nationally representative DEGS1 survey, 2008 to 2011, Germany
Estimated number of site-specific incident cancer cases attributable to excess weight (BMI=25 kg/m²) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.
Estimated number of site-specific incident cancer cases attributable to excess weight (BMI=25 kg/m²) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.
Figure 2
Estimated number of site-specific incident cancer cases attributable to excess weight (BMI=25 kg/m²) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.
Estimated number of site-specific incident cancer cases attributable to low physical activity (
Estimated number of site-specific incident cancer cases attributable to low physical activity (
Figure 3
Estimated number of site-specific incident cancer cases attributable to low physical activity (<150 min/week of moderate to vigorous physical activity) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.
Estimated number of site-specific incident cancer cases attributable to high consumption of red meat (=500 g/week), any consumption of processed meat (>0 g/week), high intake of salt (=6 g/day), low intake of dietary fiber (
Estimated number of site-specific incident cancer cases attributable to high consumption of red meat (=500 g/week), any consumption of processed meat (>0 g/week), high intake of salt (=6 g/day), low intake of dietary fiber (
Figure 4
Estimated number of site-specific incident cancer cases attributable to high consumption of red meat (=500 g/week), any consumption of processed meat (>0 g/week), high intake of salt (=6 g/day), low intake of dietary fiber (<32 g/day) and low consumption of fruit and vegetables (<400 g/day) among men and women aged 35 to 84 years in Germany for the year 2018, assuming a 10-year latency period between exposure and cancer incidence.
Key messages
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10.Kendall BJ, Wilson LF, Olsen CM, et al.: Cancers in Australia in 2010 attributable to overweight and obesity. Aust N Z J Public Health 2015; 39: 452–7 CrossRef MEDLINE PubMed Central
11. Islami F, Goding Sauer A, Miller KD, et al.: Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin 2018; 68: 31–54 CrossRef MEDLINE
12.Bhaskaran K, Douglas I, Forbes H, dos-Santos-Silva I, Leon DA, Smeeth L: Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5.24 million UK adults. Lancet 2014; 384: 755–65 CrossRef
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14.Inoue M, Sawada N, Matsuda T, et al.: Attributable causes of cancer in Japan in 2005—systematic assessment to estimate current burden of cancer attributable to known preventable risk factors in Japan. Ann Oncol 2012; 23: 1362–9 CrossRef MEDLINE
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