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Energy Balance and Body Fatness 2018 Diet, nutrition and physical activity: Energy balance and body fatness 2018 The determinants of weight gain, overweight and obesity 1 Diet, nutrition and physical activity: Energy balance and body fatness 2018 Contents World Cancer Research Fund Network 3 Executive summary 5 1. Summary of Panel judgements 10 2. Measures, trends and implications 12 3. Fundamental concepts 20 4. Other influences on energy balance and body weight 22 5. Interpretation of the evidence 24 6. Methodology 26 7. Evidence and judgements 27 7.1 Wholegrains 28 7.2 Fruit and vegetables 30 7.3 Foods containing dietary fibre 35 7.4 ‘Mediterranean type’ dietary pattern 37 7.5 Refined grains 41 7.6 Sugar sweetened drinks 44 7.7 ‘Fast foods’ 49 7.8 ‘Western type’ diet 55 7.9 Physical activity 65 7.9.1 Aerobic physical activity 65 7.9.1.1 Walking 70 7.10 Sedentary behaviours 73 7.11 Screen time 78 7.12 Having been breastfed 83 7.13 Lactation 88 7.14 Other 90 8. Integration of the evidence 91 9. Comparison to Second Expert Report 95 Acknowledgements 96 Abbreviations 99 References 101 Appendix 1: Criteria for grading evidence 116 Appendix 2: Mechanisms 119 Our Cancer Prevention Recommendations 123 2 Diet, nutrition and physical activity: Energy balance and body fatness 2018 WORLD CANCER RESEARCH FUND NETWORK Our Vision We want to live in a world where no one develops a preventable cancer. Our Mission We champion the latest and most authoritative scientific research from around the world on cancer prevention and survival through diet, weight and physical activity, so that we can help people make informed choices to reduce their cancer risk. As a network, we influence policy at the highest level and are trusted advisors to governments and to other official bodies from around the world. Our Network World Cancer Research Fund International is a not-for-profit organisation that leads and unifies a network of cancer charities with a global reach, dedicated to the prevention of cancer through diet, weight and physical activity. The World Cancer Research Fund network of charities is based in Europe, the Americas and Asia, giving us a global voice to inform people about cancer prevention. Diet, nutrition and physical activity: Energy balance and body fatness 2018 3 Our Continuous Update Project (CUP) The Continuous Update Project (CUP) is World Cancer Research Fund (WCRF) Network’s ongoing programme to analyse cancer prevention and survival research related to diet, nutrition and physical activity from all over the world. Among experts worldwide it is a trusted, authoritative scientific resource which informs current guidelines and policy on cancer prevention and survival. Scientific research from around the world is continually added to the CUP’s unique database, which is held and systematically reviewed by a team at Imperial College London. An independent panel of experts carries out ongoing evaluations of this evidence, and their findings form the basis of the WCRF Network’s Cancer Prevention Recommendations (see inside back cover). Through this process, the CUP ensures that everyone, including policymakers, health professionals and members of the public, has access to the most up-to-date information on how to reduce the risk of developing cancer. The launch of World Cancer Research Fund Network’s Third Expert Report, Diet, Nutrition, Physical Activity and Cancer: a Global Perspective, in 2018 brings together the very latest research from the CUP’s review of the accumulated evidence on cancer prevention and survival related to diet, nutrition and physical activity. Diet, nutrition and physical activity: Energy balance and body fatness is one of many parts that make up the CUP Third Expert Report. For a full list of contents, see dietandcancerreport.org The CUP is led and managed by World Cancer Research Fund International in partnership with the American Institute for Cancer Research, on behalf of World Cancer Research Fund UK, Wereld Kanker Onderzoek Fonds and World Cancer Research Fund HK. How to cite the Third Expert Report This part: World Cancer Research Fund/American Institute for Cancer Research. Continuous Update Project Expert Report 2018. Diet, nutrition and physical activity: Energy balance and body fatness. Available at dietandcancerreport.org The whole report: World Cancer Research Fund/American Institute for Cancer Research. Diet, Nutrition, Physical Activity and Cancer: a Global Perspective. Continuous Update Project Expert Report 2018. Available at dietandcancerreport.org Key See online glossary (wcrf.org/dietandcancer/glossary) for definitions of terms highlighted initalics . References to other parts of the Third Expert Report are highlighted in purple. 4 Diet, nutrition and physical activity: Energy balance and body fatness 2018 Executive summary The increasing prevalence of overweight and obesity has global and national Background and context economic implications. These can be direct, Overweight and obesity, characterised by through costs to social and healthcare excess body fat, are widely considered to systems, or indirect, through increased be one of the most pressing public health absences from work or people living with concerns of the 21st century. Over the last obesity being unable to work. The costs five decades, the global prevalence of people of obesity are well characterised in high- living with overweight and obesity has income countries; however, they have been increased dramatically. Current estimates difficult to assess globally due to a lack show that 1.97 billion adults are living with of data from lower-income countries. overweight or obesity [1], with numbers Maintenance of stable body weight in projected to rise if trends remain unchanged. adulthood depends on the close matching Although the rate of increase has begun to of energy intake (through food and drink) slow in some high income countries (albeit and energy expenditure (through the body’s at a high prevalence), the rate of increase of basic functions and physical activity) over obesity has tended to accelerate in low and the long term, called energy balance. Under middle income countries. These accelerations normal circumstances energy balance is have occurred in tandem with considerable achieved through interaction between the changes in food systems and dietary body’s regulatory systems, including appetite, patterns, commonly termed the ‘nutrition with important roles for learning, memory transition’ [2, 3]. Overweight and obesity are and physical activity. These interactions occurring at an ever earlier age, increasing can be influenced by a variety of factors, lifetime exposure to the associated risks. both internal (for example, genetic variation) Our Continuous Update Project (CUP) has and external (for example, changes in the identified 12 cancers causally linked to composition of food and drink and the social greater body fatness including cancers circumstances in which they are consumed). of the mouth, pharynx and larynx, In addition to the findings in this report oesophagus (adenocarcinoma), stomach related to diet, nutrition and physical (cardia), pancreas, gallbladder, liver, activity, other established influences on colorectum, breast (postmenopause), energy balance and body weight include: ovary, endometrium, prostate (advanced), and kidney (see Exposures: Body fatness and weight gain). Three additional cancer Genetics sites were reviewed by the World Health • Identical twin studies have identified many Organization’s International Agency for genetic variants that contribute to weight Research on Cancer which concluded that gain, principally by influencing appetite. However, mutations and chromosomal greater body fatness is a cause of thyroid rearrangements known to cause obesity, cancer, multiple myeloma and meningioma such as congenital leptin deficiency, Prader- [4]. In addition, having overweight or obesity Willi Syndrome and Bardet-Biedl syndrome, is associated with other comorbidities, are rare. including higher risks of type 2 diabetes, high blood pressure, heart disease and stroke. Epigenetics and maternal programming • The womb environment is an important determinant of fetal phenotype and Diet, nutrition and physical activity: Energy balance and body fatness 2018 5 disease risk in later life. Factors such as analysed the global scientific research on nutrition or infection influence the pattern diet, nutrition and physical activity and risk of fetal gene expression and risk of excess of weight gain, overweight and obesity. The weight gain, overweight and obesity. results were independently assessed by a • Infants of mothers who have obesity tend panel of leading international scientists in to have greater fetal size and increased fat order to draw conclusions about which of mass – both risk factors for obesity. these factors increase or decrease the risk of weight gain, overweight and obesity. Gut microbiota • There is early but growing evidence that Where available, quantification of exposures the bacteria residing in the colon – the in relation to outcomes has been reported microbiome – may be involved with the as in the published reviews. However, development of overweight and obesity, because of the methods used (a ‘review although the mechanisms are not fully of published reviews’), reliable summary established. estimates of quantified thresholds were not able to be calculated for this report. Psychosocial factors • Psychosocial factors which can influence Throughout the CUP, a standardised process body weight, including risk of overweight
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