Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Wednesday, April 23, 2008

The Shortcomings of Public Health in Promoting Nutrition to Fight Cancer - Jean Kim

Cancer is one of the leading causes of death in the United States. Its widespread nature has led to the development of numerous public health campaigns all aimed at its defeat. However, current campaigns place a great emphasis on clinical intervention, failing to shed light on primary prevention of cancer. Dietary habits are increasingly being recognized through research as an important contributing factor to the disease. Not having an optimal diet may contribute to as much as 35% of all cancer cases (1). Even as this knowledge emerges, though, it is often overshadowed by messages to the public advocating only clinical therapies. Due to the focus on cancer from a clinical perspective, there is limited awareness of the link between nutrition and cancer due to a lack of effective promotional activities.
The Relationship between Nutrition and Cancer
Despite successful efforts in bringing cancer to the forefront of public health, there are gaps in approaches to cancer that must be addressed. Nutrition is crucial in aspects of cancer prevention, treatment, and cures. An individual’s diet can help establish his or her risk of developing the disease. Thus, it is imperative that the public is aware of dietary guidelines, as well as the importance of detecting suboptimal nutritional statuses. Subsequent intervention for any nutritional problems can be a significant factor in the prevention of cancer, as well as other diseases. Issues such as malnutrition, weight loss, and muscle wasting prior to diagnosis will only be worsened with treatment if they are not addressed first (2).
Nutritional status is directly correlated with a cancer patient’s response to treatment. Malnutrition can play a major role in the deaths of as much as 20% of patients. Additionally, malnutrition is shown to significantly decrease quality of life and the effect of treatment (3). A patient will become more susceptible to infections and less responsive to chemotherapy (1). However, performing nutritional assessments and addressing symptoms from both a clinical and nutritional perspective can restore weight in 50% to 88% of undernourished cancer patients (2). Some experts recommend that nutritional support be started when the patient loses at least 5% of his or her body weight, but even less weight loss can be detrimental. Nutritional guidelines should be given early in the diagnosis so that patients can make the appropriate dietary changes. These guidelines are crucial because they lay the foundation for preventing harmful fat and muscle loss associated with the disease (1).
The nutritional needs of those fighting cancer can be different from the general public. Many patients are told to “eat whatever they want,” but nutritional professionals now realize that advocating foods that support the immune system and overall good health is more beneficial. The key point is allowing the body to have the greatest advantage in fighting cancer. A lot of patients respond to ill advice or total lack of guidance by adopting diets or taking supplements that might have negative effects unbeknownst to them. This indicates the need for increased awareness of nutritional support and the application of reliable guidelines that people can assuredly rely on (1).
Food components that have been shown to help fight carcinogens include selenium, folate, carotenoids, and dietary fiber. Folate affects the cell cycle, which can influence the growth and survival of cancer cells. Additionally, certain food components have been shown to be beneficial in fighting more specific cancers. For example, greater ability to fight the disease is associated with lycopene and prostate, lung and stomach cancers (3).
In addition to those looking to prevent cancer and patients who are undergoing treatment, nutrition is important for those who are in remission. The key concept is that adopting a healthy diet will improve overall health, protect the body against other diseases, and help prevent future malignancies (2). Epidemiologic results show that reducing intake of red meat, animal fat, excess calories and alcohol, while increasing intake of fruit, vegetables, and fiber can help prevent cancer (1). Not only will the risk of cancer be reduced, but the dietary changes could increase overall health to decrease risk of other diseases.
The American Institute for Cancer Research supports research related to preventing cancer with nutritional support. It has provided guidelines and reports announcing the link between fat and cancer, and a list of foods and their relationship with cancer, among numerous other findings. People can access their resources and learn more about nutritional guidelines (5). However, this type of research remains in the dark for many individuals. They are unaware not only of the findings, but also of the research’s very existence. This unawareness can be attributed to the failure of public health in placing nutrition and cancer on the agenda.
Public Health and Medical Professionals Fail to Emphasize Nutrition
In order to make proper nutritional interventions possible, the cooperation of doctors, nurses, registered dietitians, and other healthcare professionals is necessary (2). However, currently more focus is placed on clinical oncology, which approaches cancer with surgery, radiotherapy, and chemotherapy. A cancerous tumor itself can cause problems with absorption of nutrients and digestion of food. Additionally, the clinical therapies can cause fatigue, nausea, vomiting, pain, diarrhea, constipation, and changes in appetite, all which can affect adequate oral intake of foods. Thus the patient is unable to tolerate usual foods, which leads to weight and muscle loss. Although adverse reactions to the treatments can cause suboptimal nutritional statuses in patients, oftentimes the medical team lacks competence in nutrition and cancer (1).
Oncologists are generally unqualified or untrained in identifying patients at risk for malnutrition, and lack knowledge in appropriate nutritional interventions (4). Hospital surveys reveal that nutritional screenings and assessments are not carried out on a routine basis (6). However, the debilitative nature of cancer should make nutritional assessment of patients a priority. Nutritional status can help indicate the strength of a patient in responding to treatment, and his or her ability to recover. Health professionals may recognize the importance of nutrition, but mere recognition is not enough. There is no requirement in medical training for professionals to have a background in nutrition. Insufficient training prohibits them from advocating preventive nutritional counseling to patients, and assessing for malnutrition (4). These findings highlight the fact that nutritional education must be distinguished as a priority for professionals across a range of health fields.
The same concept should apply to public health promotion strategies. The primary motto of major cancer campaigns is that early screening saves lives. Supporting this motto is focus placed on funding research to develop drugs for decreasing the incidence of breast cancer (8). The campaigns are placing the major cause of cancer incidence on lack of screening, or lack of medical prevention of the disease. No social factors are incorporated into the campaigns. Little focus is placed on primary prevention techniques, especially the self-efficacy of individuals with respect to modifying their diets. Individuals are fully capable of changing their lifestyle and behaviors to improve their health and possible outcomes with cancer. Most cancer patients would be willing to change their diets if that would mean a more positive result. If they had known of dietary guidelines in preventing cancer prior to their diagnosis, most would respond by saying they would have adopted the modifications. However, without proper promotion of nutrition, the public cannot put their self-efficacy to use. Instead, the current campaigns force them to look at cancer through only the aspect of medical screenings and treatment.
People are urged to receive mammograms starting as early as age 25, but there is much less encouragement of maintaining lifelong health through dietary changes. One such campaign that narrowly supports mainly clinical action is the Pink Ribbon Campaign for breast cancer (8). While it has been effective in increasing awareness and setting the agenda, it is being framed in a way that prevents full progress in fighting cancer.
Example of Flaws in Framing the Issue
The Pink Ribbon Campaign is framed largely around the concept that “early detection is the best protection.” Its successes are complicated by the fact that it does not acknowledge the need for reframing the breast cancer issue. The campaign calls upon different models from the social and behavioral sciences, including the agenda setting theory and advertising theory. It directly targets people’s core values of hope, survivorship, and courage. The pink ribbon itself acts as a symbol of the breast cancer movement, having been first handed out to cancer survivors by the Susan G. Komen Breast Cancer Foundation in 1990. Contributing to the movement’s success was the involvement of corporations including cosmetics companies such as Estee Lauder. The ribbons were distributed in stores across the U.S. Profits from the pink ribbon are to be donated to charities such as the Breast Cancer Research Fund (7).
Now, more products promoting the pink ribbon are being sold, including caps, t-shirts, etc. Thousands of women participate in functions such as Race for the Cure and other walks. There is no doubt that the pink ribbon has put breast cancer on the map, dispelling many of the social stigmas surrounding it and thus allowing affected women to open up about the issue. However, a major problem exists in that the federal funding for breast cancer research, which in recent years has increased to over $55o million, is not directed towards preventive strategies. Instead, research for more clinical therapies and clinical preventive techniques is being done (7).
Advocating early detection leaves the public with the impression that the major contributing factor to cancer is failure to receive a mammogram. The pink ribbon is still representative of setting the agenda for breast cancer, but further action against the disease has been long overdue. Most of the public is well aware of the need for screening, self-administered exams, and the progression of good treatment options. What they are much less aware of is how they can prevent malignancies through changes including dietary modifications. The role of physicians here is critical, as they can provide more personal recommendations, but public health campaigns themselves must also shift gears. The public and even patients, if their medical team is also unaware, often do not know where to go for reliable information on “cancer nutrition.”
The pink ribbon campaign does not address this issue. Leading breast cancer organizations, such as the Komen Foundation, are still making preventive research a low priority. In addition, the research that is carried out on prevention is related to pills for breast cancer, which may pose safety issues. Even while many medical advances have been made, the treatment options available to patients 35 years ago still remain to be surgery, radiation therapy, and chemotherapy (9). On the contrary, research on nutrition has been rapidly expanding. New findings such as the relation of soy and breast cancer, the positive effects of milk, and trends in total fat intake and breast cancer have emerged. A diet low in fat was found to help decrease breast cancer risk (10). Studies have also indicated that the consumption of alcohol may increase risk (11). Many other findings exist, but the public is largely unaware of them because most campaigns do not consider them high priority. In order to effectively incorporate preventive strategies, campaigns such as the pink ribbon must be reframed to focus on them.
Current Approach to Cancer Lacks Integration
Although the pink ribbon is one of the more widely publicized campaigns, most anti-cancer campaigns are less widely known. This is considerably due to the absence of effective marketing techniques, including the advertising theory. Health promotion agencies such as the National Cancer Institute spend much less on advertising than large corporations such as McDonald’s (12).
With less advertising promoting cancer prevention, it is even more difficult to reach a wider audience. In this case, public health needs to increase awareness among children, adults, healthcare professionals, and just the general public. However, a major missing link in the campaigns is an appropriate way to reach children. The most effective would be to counsel parents on nutrition, which would in turn affect their children (13). It is essential to broaden awareness among all people and begin prevention at an early age, which will decrease cancer incidence. Current approaches are mainly targeted towards an older audience, leaving adolescents in the dark about changes they can make to improve their health and future (14).
Existing public health interventions target cancer with either a rational-empirical or normative-reeducative approach, but fail to integrate a power-coercive approach. A combination of the three is necessary. Education and persuasion can help increase awareness through patient counseling and informing health care professionals. However, because behavior is largely influenced by social norms and other cultural factors, it can be difficult to apply actual changes with just promotion campaigns. With consideration of current nutrition research, government policies could be enforced in future years. This is an area that has not been touched on by anti-cancer campaigns. Legislation could help shift the nation’s diet towards more healthful options, thus promoting more optimal nutritional status (15).
As medical advances are continuously made, nutrition knowledge is also expanding. There is already adequate research to provide the basis for preventive strategies against cancer. However, the current state of public health campaigns addressing this issue does not evolve around prevention. Rather, campaigns are focused on early detection and other clinical therapies. This failure to reframe the cancer topic and incorporate a multidisciplinary approach acts as a barrier in preventing cancer. The key is to involve teams of healthcare professionals and combine different social theories and approaches to increase awareness among a wider audience.

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