ACS & ACS CAN Comments on White House Conference on Hunger, Nutrition, and Health

These comments are being submitted on behalf of the American Cancer Society (ACS) and the American Cancer Society Cancer Action Network (ACS CAN). The American Cancer Society is the nation’s largest voluntary health organization, dedicated to eliminating cancer as a major health problem through research, education, and service. ACS CAN is the non-profit, non-partisan advocacy affiliate of the society. ACS CAN advocates for legislative, regulatory, and policy solutions that will make cancer a national priority.

In response to the President reigniting the Cancer Moonshot with a new commitment to “end cancer as we know it,” ACS and ACS CAN applauds the Biden-Harris Administration’s plan to convene a White House Conference on Hunger, Nutrition, and Health. Since the first White House Conference on Nutrition more than 50 years ago, the scientific literature has shown that nutrition, physical activity, and body weight play a direct role in the risk, development, and survival of some types of cancer. A large volume of literature exists linking diet, excess body weight, alcohol consumption, and physical inactivity with risk of many different types of cancer. Raising the importance of these issues and providing clear actions will contribute to the President’s Cancer Moonshot to “reduce the death rate from cancer by at least 50 percent over the next 25 years and improve the experience of people and their families living with and surviving cancer."

Consistent with the White House the Cancer Cabinet announcement, ACS and ACS CAN support the Conference highlighting this proven link between cancer and nutrition and physical activity and include strategies to address nutrition- and physical activity-related cancer risk, suffering and death. We would, be willing to work with you in framing and executing a diverse panel of speakers as part of an agenda for the Conference.

Background

Cancer is the second leading cause of death, exceeded only by heart disease, in both men and women in the United States.^[1] The burden of cancer extends beyond mortality. Individuals who are affected by a diagnosis of cancer may experience physical suffering, distress, and diminished quality of life associated with disease-related symptoms, diagnostic procedures, cancer therapies, and long-term and late adverse effects of treatment. Moreover, quality of life can also be substantially impacted for family, caregivers, and friends of patients with cancer.

For most Americans who do not use tobacco, the most important cancer risk factors that can be changed are diet, body weight, physical activity, and alcohol intake. Unhealthful diet, excess body weight, alcohol consumption and physical inactivity account for at least 18.2% of cancer cases and 15.8% of cancer deaths in the U.S., the second highest percentages for any risk factor (after cigarette smoking) in both men and women.^[2] Excess body fat causes cancers of the breast (postmenopausal), endometrium, kidney (renal cell), esophagus (adenocarcinoma), colon, rectum, gastric cardia, liver, gallbladder, pancreas, ovary, thyroid, myeloma and meningioma.^[3],[4] There is some evidence that excess body fat probably increases the risk of advanced, high-grade, or fatal prostate cancer and cancers of the oral cavity, pharynx, and larynx.^[5] There is growing evidence that adult weight gain is associated with the risk of several types of cancer, including cancers of the gallbladder, thyroid, pancreas, postmenopausal ovary, postmenopausal endometrium, and postmenopausal breast, as well as multiple myeloma.^{[6],[7],[8],[9],[10]} Sustained weight loss, even modest amounts, is associated with lower breast cancer risk among women over 50 years of age.^[11]

In addition to the risk of development of cancer, diet, body weight and physical activity are important factors in the risk of recurrence and mortality among cancer survivors. There are more than 18 million cancer survivors in the U.S.^[12] Cancer survivors can experience multiple symptoms from their cancer and their treatment. These symptoms and how they are managed can affect whether a cancer survivor is able to eat a healthy diet, be physically active, and maintain a healthy weight.^[13],[14] Although advances in cancer diagnosis and treatment have improved clinical outcomes, the inability to maintain a healthy diet because of cancer symptoms and treatment-related side effects is common and can negatively impact overall clinical outcomes. There is growing evidence that diet, body weight and physical activity can affect long term survivorship after completion of cancer treatment.

In order to reduce cancer incidence, suffering and death, weight, diet, alcohol consumption and physical activity must be addressed. The ACS recently published an updated Guideline for Diet and Physical Activity for Cancer Prevention.^[15] The guideline provides guidance, support, and evidenced-based strategies for individuals and populations to reduce cancer risk. Research has shown that people who follow the majority of the diet, physical activity, weight, and alcohol recommendations in the ACS Guideline are less likely to develop or die of cancer,^{[16], [17]} cardiovascular disease, or any cause compared with people who follow very few, if any, of the recommendations in the Guideline.^[18] To reduce risk for recurrence and mortality among cancer survivors, the newly released ACS Guidelines for Nutrition and Physical Activity Guideline for Cancer Survivors^[19] includes nutrition and physical activity recommendations during the continuum of cancer care and following recovery from treatment.

Social determinants of health also impact an individual’s ability to access nutritious food and be physically active.  Further, structural, economic, and social barriers can prevent people from successfully maintaining their own health to reduce their risk of cancer. Recognizing the important role a person’s community plays in influencing their access to nutritious food, beverage, and other healthy lifestyle choices, the ACS Guideline includes recommendations for communities to facilitate and promote healthy individual behaviors.

While data on food security among cancer survivors are scarce, studies indicate that cancer survivors experience food insecurity at high rates. A study by Charkhchi et al using data from the Behavioral Risk Factor Surveillance System showed that patients with cancer had a 39% higher likelihood of experiencing food insecurity compared with individuals without chronic conditions, even after controlling for sociodemographic characteristics.^[20] Although data are lacking on levels of food insecurity among patients with cancer for different sociodemographic groups, it is possible that inequities exist given that food insecurity is influenced by factors such as income, employment, disability, and race/ethnicity. For example, one study by Gany and colleagues of primarily Latino (45%) and Black (41%) patients with cancer, the majority of whom had incomes below the national poverty level (82%), reported that 41% of patients were food-insecure, and 17% had very low food security.^[21] Therefore, it is important to recognize that we must address food equity as a goal for all cancer survivors.

Recommendations

ACS and ACS CAN recommend the Conference acknowledge the proven link between cancer and nutrition, body weight, and physical activity, and include strategies to address nutrition and physical activity related cancer risk, suffering and death.

ACS and ACS CAN recommend the Conference acknowledge and address the inequities in communities that can lead to an individual’s increased risk or decreased survival from diet-related cancers. Social, economic, and cultural factors can strongly influence a person’s body weight, physical activity, dietary patterns, and alcohol intake which can influence their risk for cancer. Furthermore, many cancer survivors face environmental, social, and structural barriers that impact their ability to adhere to nutrition and physical activity recommendations. Making healthy choices and translating guidance into feasible and consistent diet and physical activity behaviors can be a challenge for many individuals. The Conference should acknowledge and address the inequities in communities that can lead to an individual’s increased risk or decreased survival from diet-related cancers.

ACS CAN and ACS recommend the Conference include strategies for policy and environmental changes to facilitate and promote a healthy diet to prevent cancer and improve survival. ACS and ACS CAN recommend public, private, and community organizations work together at national, state, and local levels to develop, advocate for, and apply policy and environmental changes that increase access to affordable, healthy foods; provide safe, enjoyable, and accessible opportunities for physical activity; and limit alcohol for individuals. For cancer survivors, there is a need to expand the evaluation of physical activity and risk for recurrence and mortality among survivors, including type of activity, dose, intensity, and time frame, across the cancer survivorship continuum. In addition, more research is needed to evaluate the complex interactions between body composition and cancer progression, recurrence, site-specific mortality, and all-cause mortality.

Lastly, ACS and ACS CAN recommend the Conference include a diverse panel of experts and we are happy to work with you to develop and recruit cancer researchers and cancer survivors as part of the Conference agenda.

Conclusion

Thank you for the opportunity to provide input on this important topic. ACS and ACS CAN look forward to working with the Conference and the White House to address hunger, nutrition, and health. If we can provide additional information, please contact Christy Cushing, MPP, Senior Analyst, Prevention & Health Equity, at ACS CAN at 801-844-1848 or [email protected]. Thank you.

Sincerely,

Lisa A. Lacasse, MBA