Disparities in Health and Economic Burdens of Cancer Attributable to Suboptimal Diet in the United States, 2015‒2018

Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States, 2019

In 2018, the authors reported estimates of the number and proportion of cancers attributable to potentially modifiable risk factors in 2014 in the United States. These data are useful for advocating for and informing cancer prevention and control. Herein, based on up-to-date relative risk and cancer occurrence data, the authors estimated the proportion and number of invasive cancer cases (excluding nonmelanoma skin cancers) and deaths, overall and for 30 cancer types among adults who were aged 30 years and older in 2019 in the United States, that were attributable to potentially modifiable risk factors. These included cigarette smoking; second-hand smoke; excess body weight; alcohol consumption; consumption of red and processed meat; low consumption of fruits and vegetables, dietary fiber, and dietary calcium; physical inactivity; ultraviolet radiation; and seven carcinogenic infections. Numbers of cancer cases and deaths were obtained from data sources with complete national coverage, risk factor prevalence estimates from nationally representative surveys, and associated relative risks of cancer from published large-scale pooled or meta-analyses. In 2019, an estimated 40.0% (713,340 of 1,781,649) of all incident cancers (excluding nonmelanoma skin cancers) and 44.0% (262,120 of 595,737) of all cancer deaths in adults aged 30 years and older in the United States were attributable to the evaluated risk factors. Cigarette smoking was the leading risk factor contributing to cancer cases and deaths overall (19.3% and 28.5%, respectively), followed by excess body weight (7.6% and 7.3%, respectively), and alcohol consumption (5.4% and 4.1%, respectively). For 19 of 30 evaluated cancer types, more than one half of the cancer cases and deaths were attributable to the potentially modifiable risk factors considered in this study. Lung cancer had the highest number of cancer cases (201,660) and deaths (122,740) attributable to evaluated risk factors, followed by female breast cancer (83,840 cases), skin melanoma (82,710), and colorectal cancer (78,440) for attributable cases and by colorectal (25,800 deaths), liver (14,720), and esophageal (13,600) cancer for attributable deaths. Large numbers of cancer cases and deaths in the United States are attributable to potentially modifiable risk factors, underscoring the potential to substantially reduce the cancer burden through broad and equitable implementation of preventive initiatives.

Enhancing food access in a comprehensive cancer center area of influence through local partner capacity building

BACKGROUND

Food insecurity, an economic and social condition of limited food access, is associated with poor diet quality-a risk factor for several common cancers. The University of Texas MD Anderson Cancer Center supports healthy food access through community-led evidence translation by actively partnering with community-based organizations (CBOs). These partnerships aim to enhance the capacity of food assistance CBOs to effectively implement evidence-based food insecurity mitigation programs in the cancer center's area of influence.

METHODS

This case study aims to describe the cancer center's model for local food access capacity building and detail operationalization in the context of a whole-community cancer prevention effort (Be Well Baytown) in Baytown, Texas.

RESULTS

Elements central to the capacity building model include (i) assessment of baseline needs and capacity, (ii) empowering a community champion within a relevant CBO, (iii) mapping inter-sectoral community partnerships, collaborations, and linkages, and (iv) leveraging systems, connections, and resources to provide an enabling environment for overall food access systems growth. Through this process, Be Well Baytown enhanced the capacity of a local food pantry leading to increases in total reach, pounds of food distributed, and number of food distribution events in collaboration with intersectoral partners from 2018 to 2023.

CONCLUSION

This case study highlights the model's implementation as a co-benefit community partnership strategy to maximize the impact of food security programs integrated with comprehensive cancer center prevention efforts.

A review of dairy food intake for improving health among black adults in the US

The adult life stage encompasses a range of new experiences, opportunities, and responsibilities that impact health and well-being. During this life stage, health disparities continue to increase for Black Americans, with Black adults having a disproportionate burden of obesity, chronic diseases, comorbidities, and worse treatment outcomes compared to their White peers. While many of the underlying factors for these disparities can be linked to longstanding sociopolitical factors such as systemic racism, food insecurity, and poor access to healthcare, there are also several modifiable risk factors that are known to significantly impact health outcomes, such as improving diet quality, increasing physical activity, and not smoking. Of all the modifiable risk factors known to impact health, improving dietary habits is the factor most consistently associated with better outcomes for body weight and chronic disease. Of the major food groups recommended by the 2020-2025 Dietary Guidelines for Americans (DGA) for achieving healthier dietary patterns, dairy foods have a nutrient profile which matches most closely to what Black Americans are inadequately consuming (e.g., vitamin A, vitamin D, calcium, magnesium). However, Black adults tend to consume less than half the recommended daily servings of dairy foods, in part, due to issues with lactose intolerance, making higher intake of dairy foods an ideal target for improving diet quality and health in this population. This review examines the current body of evidence exploring the links between dairy intake, obesity, cardiometabolic disease risk, chronic kidney disease, and the most common types of cancer, with a special focus on health and disparities among Black adults. Overall, the evidence from most systematic reviews and/or meta-analyses published in the last decade on dairy intake and health outcomes has been conducted on White populations and largely excluded research on Black populations. The findings from this extensive body of research indicate that when teamed with an energy-restricted diet, meeting or exceeding the DGA recommended 3 daily servings of dairy foods is associated with better body weight and composition outcomes and lower rates of most common chronic diseases than lower intake (<2 servings per day). In addition to the number of daily servings consumed, the specific types (e.g., milk, yogurt, cheese) and subtypes (e.g., low-fat, fermented, fortified) consumed have also been shown to play major roles in how these foods impact health. For example, higher intake of fermented dairy foods (e.g., yogurt) and vitamin D fortified dairy products appear to have the most protective effects for reducing chronic disease risk. Along with lactose-free milk and cheese, yogurt is also generally low in lactose, making it an excellent option for individuals with lactose intolerance, who are trying to meet the DGA recommendations for dairy food intake.

Caregiver perceptions of a pediatric produce prescription program during the COVID-19 pandemic

Introduction

Produce prescription programs are rapidly expanding as a type of Food is Medicine intervention with prospects for mitigating food insecurity and reducing diet-related health disparities. Gaining insight into participant perspectives on program logistics and perceived impacts is crucial to program success and improvements.

Methods

Between May and June 2021, we conducted individual and small group interviews with 23 caregivers with children aged 1-5 years who participated in a produce prescription program from 2020 to 2021 in Texas, U.S. They were provided with a gift card to a major national grocery retailer to purchase fresh produce. The card was reloaded $60 monthly for 8 months with automatic roll-over of unused funds to the next month. Participants also received nutrition education in the form of two videos. A deductive analysis approach was employed, and NVivo qualitative data analysis software was used to perform coding and to assist with subsequent analyses.

Results

All 23 participants were female, with an average age of 37.5 years, and the majority identified as Hispanic/Latino (83%). About 43% of the families had three or more children. Six themes were generated from interviews. Three of these themes were related to program logistics: (1) ease of program use; (2) participant satisfaction with the incentive; and (3) desire for additional store options. The remaining main themes pertained to program impact: (1) the enhanced ability to purchase produce; (2) the usefulness of the nutrition education; and (3) persistent challenges encountered when preparing the produce for picky eaters and young children.

Conclusion

A pediatric produce prescription program was perceived as logistically easy and a helpful source of financial support for accessing fresh produce. Program features such as card-based incentive system and partnership with major grocery retailer were favored by participants. For future program design, it may be beneficial to consider collaborating with multiple grocery outlets and enhancing the intensity and targeting of nutrition education.

Health Inequities in the USA: a Role for Dietary Acid Load? Results from the National Health and Nutrition Examination Surveys

BACKGROUND

Cardiovascular disease and obesity affect racial and ethnic minorities disproportionally. Public health research suggests that suboptimal diet is an important contributor to health disparities. Limited evidence points at an increased dietary acid load (DAL) in certain ethnic groups. DAL is determined by the balance of acidifying foods and alkaline foods, and elevated DAL scores have been associated with numerous chronic lifestyle-related conditions. The present analysis investigated DAL scores among ethnic groups in the USA.

METHODS

Using cross-sectional data from the National Health and Nutrition Examination surveys (NHANES, 2007-2016), we contrasted several markers of DAL (potential renal acid load (PRAL) and net endogenous acid production (NEAP)) between Non-Hispanic Whites, Non-Hispanic Blacks, Mexican Americans, Other Hispanics, and Other Race. The comparison included crude scores and adjusted scores following multivariate linear regression.

RESULTS

The sample for this analysis comprised 19,565 participants, which may be extrapolated to represent 156,116,471 United States Americans. When compared to Non-Hispanic Whites, Non-Hispanic Blacks and Mexican Americans had significantly higher crude DAL scores. PRALR was highest in Mexican Americans (20.42 (0.61) mEq/day), followed by Non-Hispanic Blacks (17.47 (0.42) mEq/day). Crude NEAPF was highest in Non-Hispanic Blacks (64.66 (0.43) mEq/day), and almost 9 mEq/day higher compared to Non-Hispanic Whites (55.78 (0.39) mEq/day). Multivariate linear regression adjusting for confounders revealed comparable interracial DAL differences.

CONCLUSIONS

We found significant DAL differences across the investigated ethnic groups. Whether these differences potentially play a role in population health inequity in the USA will be subject to additional research.

Structural Racism, Lifestyle Behaviors, and Obesity-related Cancers among Black and Hispanic/Latino Adults in the United States: A Narrative Review

One in three adults in the United States has obesity; a chronic disease that is implicated in the etiology of at least 14 cancers. Cancer is the leading cause of death among U.S. Hispanic/Latino adults and the second most common cause of death, after cardiovascular disease, for Black adults. Our country's legacy in overt discrimination (e.g., slavery, segregation) generated inequities across all spheres in which people function as defined by the socioecological model-biological, individual, community, structural-and two of the many areas in which it manifests today are the disproportionate burden of obesity and obesity-related cancers in populations of color. Inequities due to environmental, social, and economic factors may predispose individuals to poor lifestyle behaviors by hindering an individual's opportunity to make healthy lifestyles choices. In this review, we examined the evidence on obesity and the lifestyle guidelines for cancer prevention in relation to cancer risk and outcomes for Black and Hispanic/Latino adults. We also discussed the role of structural and societal inequities on the ability of these two communities to adopt and maintain healthful lifestyle behaviors in accordance with the lifestyle guidelines for cancer prevention and control.

Health and Economic Impacts of Implementing Produce Prescription Programs for Diabetes in the United States: A Microsimulation Study

Background Produce prescription programs, providing free or discounted produce and nutrition education to patients with diet-related conditions within health care systems, have been shown to improve dietary quality and cardiometabolic risk factors. The potential impact of implementing produce prescription programs for patients with diabetes on long-term health gains, costs, and cost-effectiveness in the United States has not been established. Methods and Results We used a validated state-transition microsimulation model (Diabetes, Obesity, Cardiovascular Disease Microsimulation model), populated with national data of eligible individuals from the National Health and Nutrition Examination Survey 2013 to 2018, further incorporating estimated intervention effects and diet-disease effects from meta-analyses, and policy- and health-related costs from published literature. The model estimated that over a lifetime (mean=25 years), implementing produce prescriptions in 6.5 million US adults with both diabetes and food insecurity (lifetime treatment) would prevent 292 000 (95% uncertainty interval, 143 000-440 000) cardiovascular disease events, generate 260 000 (110000-411 000) quality-adjusted life-years, cost $44.3 billion in implementation costs, and save $39.6 billion ($20.5-58.6 billion) in health care costs and $4.8 billion ($1.84-$7.70 billion) in productivity costs. The program was highly cost effective from a health care perspective (incremental cost-effectiveness ratio: $18 100/quality-adjusted life-years) and cost saving from a societal perspective (net savings: $-0.05 billion). The intervention remained cost effective at shorter time horizons of 5 and 10 years. Results were similar in population subgroups by age, race or ethnicity, education, and baseline insurance status. Conclusions Our model suggests that implementing produce prescriptions among US adults with diabetes and food insecurity would generate substantial health gains and be highly cost effective.

Consumption of Key Food Groups by Individuals Consuming Popular Diet Patterns: Mixed Effects of Replacing Foods High in Added Sugar, Sodium, Saturated Fat, and Refined Grains

Adults in the United States are increasingly following 'popular' diet patterns that restrict food groups, macronutrients, or eating time. However, the intake of food groups associated with these diet patterns has not been well characterized. The objectives of this study were to (1) characterize the mean intake of food groups among consumers of popular diet patterns in the US, and (2) model the effect of targeted food substitutions on the intake of food groups. Data were acquired from the National Health and Nutrition Examination Survey, 2005-2018 (n = 34,411). A diet model was developed to assess the effects of replacing one serving each of foods highest in added sugar, sodium, saturated fat, and refined grains with healthy alternatives on the intake of key food groups for each diet pattern. Modeled replacement resulted in increased intake of fruit and whole grains and decreased intake of dairy for most diet patterns, while the effects on the intake of vegetables, protein foods, and oils were variable across diet patterns. The complexity of the natural eating environment, in which many people consume mixed dishes that include both healthy and less healthy ingredients, produces a challenge for health professionals when providing dietary counseling. Nevertheless, this substitution approach may help improve adherence to dietary guidelines, especially if used as a steppingstone for further dietary improvement.

Global food systems transitions have enabled affordable diets but had less favourable outcomes for nutrition, environmental health, inclusion and equity

Over the past 50 years, food systems worldwide have shifted from predominantly rural to industrialized and consolidated systems, with impacts on diets, nutrition and health, livelihoods, and environmental sustainability. We explore the potential for sustainable and equitable food system transformation (ideal state of change) by comparing countries at different stages of food system transition (changes) using food system typologies. Historically, incomes have risen faster than food prices as countries have industrialized, enabling a simultaneous increase in the supply and affordability of many nutritious foods. These shifts are illustrated across five food system typologies, from rural and traditional to industrial and consolidated. Evolving rural economies, urbanization and changes in food value chains have accompanied these transitions, leading to changes in land distribution, a smaller share of agri-food system workers in the economy and changes in diets. We show that the affordability of a recommended diet has improved over time, but food systems of all types are falling short of delivering optimal nutrition and health outcomes, environmental sustainability, and inclusion and equity for all. Six ‘outlier’ case studies (Tajikistan, Egypt, Albania, Ecuador, Bolivia and the United States of America) illustrate broad trends, trade-offs and deviations. With the integrated view afforded by typologies, we consider how sustainable transitions can be achieved going forward.

Association of Socioeconomic and Geographic Factors With Diet Quality in US Adults

IMPORTANCE

Poor diet quality is a key factor associated with obesity and chronic disease. Understanding associations of socioeconomic and geographic factors with diet quality can inform public health and policy efforts for advancing health equity.

OBJECTIVE

To identify socioeconomic and geographic factors associated with diet quality in a large US cohort study.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included adult men and women who enrolled in the Cancer Prevention Study-3 at American Cancer Society community events in 35 US states, the District of Columbia, and Puerto Rico between 2006 and 2013. Participants completed a validated food frequency questionnaire between 2015 and 2017. Data were analyzed from February to November 2021.

EXPOSURES

The main exposures included self-reported race and ethnicity, education, and household income. Geocoded addresses were used to classify urbanization level using Rural-Urban Commuting Area codes; US Department of Agriculture's Food Access Research Atlas database classified residence in food desert.

MAIN OUTCOMES AND MEASURES

Poor diet quality was defined as lowest quartile of dietary concordance with the 2020 American Cancer Society recommendations for cancer prevention score, based on sex-specific intake categories of vegetables and legumes, whole fruits, whole grains, red and processed meat, highly processed foods and refined grains, and sugar-sweetened beverages.

RESULTS

Among 155 331 adults, 123 115 were women (79.3%), and the mean (SD) age was 52 (9.7) years), and there were 1408 American Indian or Alaskan Native individuals (0.9%); 2721 Asian, Native Hawaiian, or Pacific Islander individuals (1.8%); 3829 Black individuals (2.5%); 7967 Hispanic individuals (5.1%); and 138 166 White individuals (88.9%). All key exposures assessed were statistically significantly and independently associated with poor diet quality. Compared with White participants, Black participants had a 16% (95% CI, 8%-25%) higher risk of poor diet quality, while Hispanic/Latino had 16% (95% CI, 12%-21%) lower risk and Asian, Native Hawaiian, and Pacific Islander participants had 33% (95% CI, 26%-40%) lower risk of poor diet quality. After controlling for other characteristics, rural residence was associated with a 61% (95% CI, 48%-75%) higher risk of poor diet quality, and living in a food desert was associated with a 17% (95% CI, 12%-22%) higher risk. Associations of income with diet quality and education with diet quality varied by race and ethnicity (income: P for interaction = .01; education: P for interaction < .001). All diet score components were associated with disparities observed.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that multiple individual-level socioeconomic and geographic variables were independently associated with poor diet quality among a large, racially and ethnically and geographically diverse US cohort. These findings could help to identify groups at highest risk of outcomes associated with poor diet to inform future approaches for advancing health equity.