Obesity: 'Like the new smoking'

Two out of three adult Americans are at greater risk for getting cancer — and for dying of it — than they need to be. Not because of smog in their air or radon in their basements. Not because of tobacco in their cigarettes or mutations in their genes.

No, the particular cancer risk shared by these 150 million or so Americans comes from having too many calories in their diet and too little exercise in their daily lives.

In other words, from being overweight.

Surprised?

It's widely known that simply being overweight, let alone obese, dramatically increases the risk for high blood pressure, heart attacks, strokes and diabetes. But according to a 2009 survey by the American Institute for Cancer Research, only about 50% of Americans know that size also matters when it comes to cancer.

The risk is not trivial. The same institute estimates that every year about 100,000 Americans get a cancer they wouldn't have gotten if they had kept their weight in check. And researchers have estimated that about 14% of cancer deaths in men and 20% in women could be avoided by this same restraint.

Obesity can raise the risk for a number of major cancers — colon, postmenopausal breast, endometrial, kidney and esophageal — the National Cancer Institute says, and when paired with physical inactivity, it can be held liable for 25% to 30% of cases of those cancers. Obesity has also been linked to a number of other cancers, including liver, gallbladder, pancreatic and ovarian."Obesity is almost like the new smoking," says Dr. Anne McTiernan, director of the Prevention Center at the Fred Hutchinson Cancer Research Center in Seattle. "The effect isn't as big for most cancers, but it's so prevalent that it will have a huge impact."

Indeed, the National Cancer Institute estimates that smoking accounts for 37.5% cancer deaths in men and 22.8% in women. But smoking does most of its dirty work in lung cancer victims. When lung cancer is taken out of the picture, smoking can only be blamed for 12% of cancer deaths in men and 6% in women — fewer than can be chalked up to excess pounds.

No one knows for sure exactly how weight increases cancer risk, but it's likely that it does so in multiple ways, with the precise mechanism differing from cancer to cancer. High levels of estrogen, insulin and inflammatory compounds are among the suspects that have been implicated in research to date.

A more precise understanding of the biology behind all this may someday lead to drugs that can mitigate the damage. In the meantime, of course, there's an excellent way to avoid the obesity risk, and that's to never become obese at all.

That would require major lifestyle changes for many of us, and making such changes is exceedingly hard, says Dr. John Glaspy, an oncologist at UCLA's Jonsson Comprehensive Cancer Center. "Sure, we could make it a death penalty offense to sell sugared drinks," he says. But short of such extreme modes of encouragement, a widespread thinning of America is not to be expected anytime soon.

Not only is there strong evidence that if you're overweight, you're more likely to die of cancer. It's also been shown that the more overweight you are, the more deadly the trend gets, according to a landmark study published in the New England Journal of Medicine in 2003.

Scientists at the American Cancer Society in Atlanta looked at cancer death rates for men and women in five weight categories: healthy (body mass index of 18.5 to 24.9); overweight (BMI, 25 to 29.9); and three levels beyond: "obese" (BMI, 30 to 34.9), "very obese" (BMI, 35 to 39.9) and "very, very obese" (BMI, 40 or more).

Compared with death rates for men and women of healthy weight, death rates from all cancers lumped together as a group rose consistently along with BMI: Rates were 52% higher for very, very obese men and 62% higher for very, very obese women.

But weight doesn't affect all cancers equally. For some cancers the researchers examined, such as bladder cancer, weight had no significant effect on the death rate. At the other extreme, the death rate from liver cancer was 350% higher for very obese men than for men of healthy weight (though only 68% higher for very obese women than for women of healthy weight).

And the death rate from uterine (endometrial) cancer was 525% higher for very, very obese women than for women of healthy weight.

How do those numbers stack up against other risks? Infection with the hepatitis C virus increases the death rate for liver cancer by 1,600%, which makes the 350% increase from obesity sound pretty measly. But only about 1.5% of Americans have a chronic hepatitis C virus infection, whereas about 30% are obese, notes Michael Karin, distinguished professor of pharmacology and pathology at UC San Diego. "So the overall contribution to liver cancer deaths from obesity far exceeds what hepatitis C infection does," Karin says.

In other words, even when obesity is responsible for a fairly small increase in the death rate for any particular cancer, it can affect many lives simply because so many people are obese.

The only sure way to avoid raising your cancer risk from hefting extra pounds is to maintain a healthy weight from the day you're born, says Dr. Dimitrios Trichopoulos, professor of cancer prevention and epidemiology at the Harvard School of Public Health. "The roots of cancer are early in life, and overweight children frequently become overweight adults," he says.

Unfortunately, for two-thirds of adult Americans, that ship has already sailed — and is often pretty far out of port.

Logic suggests that losing weight — or at the very least not gaining any more — should help those people. Oncologists and weight experts alike consider that a wise move because of the overall health benefits it can provide. But there's insufficient evidence to say for sure that holding the line on weight gain or even dropping some pounds once you're an adult will necessarily lower cancer risk. And conducting randomized clinical trials — the gold standard — to establish this connection would be very difficult and very expensive.

Still, there are positive indications.

In some population studies, those who gained weight after a cancer diagnosis were more likely to die or to have a recurrence of the cancer than were those who did not gain weight.

And in a 2009 study, researchers found that women who had bariatric surgery — so-called stomach stapling — not only reduced their size significantly but also reduced the size of their cancer risk by 40%. On the other hand, men who had the same surgery lost weight, but their cancer risk stayed put.

A clinical trial examining the effects of a low-fat diet on breast cancer risk may cast an indirect light on the effects of weight loss. In the Women's Intervention Nutrition Study, published in 2006, researchers found that when fat intake was dropped from 30% to 20% of total daily calorie consumption for women who had previously been treated for breast cancer, the risk of a recurrence of the cancer dropped too, by about 25% after five years of follow-up. Perhaps significantly, over the same period, the women on the low-fat diet lost an average of 6 pounds compared with those on their regular diet.

"If the trial were testing a drug instead of a diet, we would call it a very effective drug," says Dr. Joseph Sparano, professor of medicine and women's health at Albert Einstein College of Medicine and an oncologist at Montefiore Medical Center in Bronx, N.Y.

As scientists discover more about the ways that body fat acts to raise someone's cancer risk, a day may come when people can simply pop a pill to reduce that risk. Until then, their only real option is to be leaner, meaner cancer-fighting machines.

Can they do it?

Some, pointing to the miserable diet-study statistics — and evolutionary biology — have their doubts. "We're living in a world where fattening foods are cheap and easy to come by — but our brains evolved in a world where getting enough calories could be a tricky proposition, so if you could get your hands on a big glob of fat, you'd better eat it," UCLA's Glaspy says.

But others believe that cancer brings something special to the table. "It's a big motivator," says Jennifer Klemp, associate director of the Breast Cancer Survivorship Center at the University of Kansas Medical Center in Westwood. "People are really scared of cancer."

Source: By Karen Ravn, Special to the Los Angeles Times