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Good evening everybody. Uh, we're live once again uh with the Metal Primary Care Network event. Um, my name is Tim Neal. I have the pleasure of being the chair for tonight's event. I'm an F one doctor in Northern Ireland and it's my absolute pleasure to be joined by Doctor Shean this evening. Uh We're really looking forward to tonight's cancer and lifestyle medicine update. Um, Doctor Qassam is a consultant hematologist, um, and lifestyle medicine physician, er, owns or operates and founded a, a plant based health Professionals UK, which is a nonprofit organization and is also involved with education at the University of Winchester. So we're absolutely delighted to have her on board this evening. As usual, we will run around 45 minutes for the presentation and we'll have plenty of time for, um, questions and answers at the end. Then, um, if you haven't already, I would just put this to you. Um, the med all up is absolutely brilliant in terms of functionality for joining our events, seeing what's coming up, getting your certificates, offering your feedback, it's all there. It's all central. Um, and while we are going through tonight's talk, I'm going to see what bits and Bobs I can find on the middle up in terms of the references section um to what could be useful for patients and that as well and hopefully share that briefly at the end. As everybody knows, we run free primary care events almost every week. Um Being on the app, you'll be the first to hear about what's coming up. Um You'll be able to be the first to get an invite, get access to our follow up content and on demand content as well. So without any further ado from me, we're going to get Doctor Qassams slides up hopefully and um we will get on with tonight's event. Fantastic. I can. Great. I think that's it. There isn't it all as clear as you can be? I'm going to pop off into the background, Doctor Sam, but I'm here listening if there's any problems, let me know. Perfect. I just pressed on another icon. So I just need to, right. We're good to go, I think. Um Thanks ever so much for the invitation. It really is a topic I feel passionate about. So I do hope I relay some of that to you um and will spark an interest to take it forward. Um So as I was introduced, I am a consultant hematologist and my practice is really looking after people with lymphoma histiocytic disorders. And I also have um a lab role as well, which is the joy of hematology. We are pathologists as well as clinicians and you've heard a little bit about me. So these are my disclosures. I guess the main one is that I am founder and director of a nonprofit called Plant Based Health Professionals UK, which you're welcome to look up. I can put a, a website um link in the chat later. Um So for the purposes of this evening, I'm planning to cover the role of nutrition and lifestyle for cancer prevention and then discuss the impact of nutrition and lifestyle approaches for improving quality of life and, and survival after a cancer diagnosis. Um So I tend to sort of um uh organize my talks around what patients ask me and maybe not in all of the same order, but in general, I hope you'll come away with being able to answer these questions for your patients. Is it something I did? Is it genetic? Is there anything I can do to improve my chances? And what about supplements? Um Now, II made an assumption that may or may not be correct that most of the audience are from the UK. So these are predominantly UK stats. Um But globally, cancer is a leading cause of death. It causes one in six deaths. The left hand diagram um is um showing you statistics around cancer in the UK. Um One in two people in the in the UK will develop cancer in their lifetime. So this condition is going to touch us all, either personally, our families, our loved ones, the commonest site, um uh which make up around 50% of cases are lung, breast prostate and colorectal cancer. And so you'll see that most of my examples um around diet and lifestyle do relate to these cancer subtypes because that's where we have the greatest body of evidence. Um And the simple answer to, you know, whether cancer is genetic or not, um the answer is no, it's not passed on from um you know, from parents to child. At most, our genes we inherit from our parents contribute to um 10% of cases, but less than this really in reality. Um So we know from a lot of data sets around the world, including cancer research UK that 40% of cases could be prevented by addressing behavioral and metabolic risk factors. Um So what are these modifiable factors? Well, just again to reiterate the sheer scale of um the problem. Um this was um a large analysis published very recently from the global burden of disease study, looking at the proportion of cancers that are due to modifiable risk factors. And um the up to statistics is that up to 45% of cancer deaths are due to preventable risk factors. And this can be put into categories of behavioral or metabolic and the leading risk factors remain smoking, but also alcohol and carrying excess weight in the form of high body mass index. I think the concern is also that cancers in the young, meaning cancer in, in people aged less than 50 years is rising at the highest rate. Um and particularly relates to colorectal cancer. And this change in sort of statistics in cancer in young people have really occurred over a few decades. Um You know, showing that it really isn't our genetics that's causing this and it's most likely our um current way of living our exposures like life lifestyle and environmental exposures. So this, um, graph on the right kind of shows you what, um, these modifiable risk factors might be that are driving this elevated risk of cancer in the young and it really comes back to lifestyle behaviors. So it's obesity, it's, um, sedentary behavior. It's a westernized diet full of ultra processed foods, um, and sugar sweetened beverages. It's our, uh, the fact that we don't prioritize sleep, um, you know, increase nighttime, um, light and, and so forth. Um, so when we look at the current cancer prevention guidelines, these are from 2018, but remain relevant. Um, and evidence based, there's nine recommendations be a healthy weight, be physically active, eat a diet rich in fruits, vegetables, whole grains, beans, nuts and seeds. So this is a predominantly plant based diet limit fast food and um, sugar sweetened beverages. And I'll come back to that. We may mainly those recommendations are because it's associated with carrying excess weight. Um, but there is some data now suggesting that processed foods in general, um just by the nature of their processing, um and additives might be increasing risk of cancer. Limit red and processed meat. There's no place for this in the diet. In my view, it's not required for good health. It causes harm including increasing the risk of cancer and its production is um uh harming the environment as well. Limit alcohol. Again, we'll come back to that, do not use supplements and I'll review that later. Um And then if you're a mum, um breastfeed, if you can because there are benefits for the mom in terms of reduced rates of breast cancer. Um And for baby, in terms of maintaining a healthier weight and reducing the risk of type two diabetes. And all of these nine recommendations are relevant for um after a cancer diagnosis as well. Um Obviously, these recommendations don't mention tobacco um and excess sun. Um but we know for sure this is important to pay attention to. So avoid um tobacco exposure and um limit excess sun exposure. Um And together these recommendations are in line with preventative aspects of for other non communicable diseases. And you'll get the impression during this talk that I'm very interested in nutrition, which I am. But it's interesting that five of nine of these recommendations relate directly to dietary risk factors. Um, a really great document if you've not seen it already is the American Cancer Society guideline for Diet and physical activity, um, published in 2020. Um, it, it really answers every question that you'd want to know the answer to personally and for your patients as well. And I've just summarized the document in this table. So there's strong evidence to support a plant based dietary pattern for preventing cancer. I've talked about red and processed meat, sugar, sweetened beverages, processed foods and alcohol in general, increasing the risk of cancer. Keeping a healthy body weight and physical activity reduces the risk of cancer. Um And then we'll come back to dairy. There's a bit nuance, there's possible evidence for Teflon cookware, for example. Um, we've talked about um, getting adequate sleep might be important so that reduces the risk of cancer consuming soya foods. There's a body of evidence to show it's beneficial for cancer and green tea. I've added, that's not in the document because I think the, the data are quite compelling. Um And then there's no evidence for the, um, a list of uh potential risk factors on the right hand side. Um So no evidence doesn't mean they won't be in the future. But currently, there's no evidence that these um listed factors relate to cancer in any way. So I guess the question arises, you know, do these cancer guidelines really work? Um Well, this large systematic review and meta analysis um brought together results of 18 studies asking the question. Well, what happens to people who stick um or most adherent to the World Cancer Research Fund guidelines that I presented and what they were able to show is that if you were the most adherent to these guidelines, um that you were able to reduce your risk of developing cancer by 27%. Now, of course, that's less than the uh the predicted 40%. But the fact is we know, um for sure that people do not adhere to all nine recommendations and what they were able to show which is important. Um because it's true for any causal relationship that there was a dose response. So for every additional recommendation that you adhere to, there was a 10% reduction in cancer risk. Um And the significant reductions were seen specifically for breast colorectal and lung cancer. Um And then we have to ask, well, you know, if lifestyle is so important, um do, do lifestyle interventions actually work um to reduce the risk of cancer? And again, the answer is yes. Yes. This was a study in Swedish women. Nearly 30,000 followed. Um uh they, they looked at um changes in lifestyle habits. So they looked at whether during this long follow up, people change their smoking and alcohol behaviors, changed their weight with physical activity and created a lifestyle score. And what they showed was that over this 12 year period, if people improved upon their lifestyle, they reduced their risk of cancer by 20% with the greatest impact being. Um for stopping smoking and for weight loss. So, um that's quite empowering that, you know, it doesn't matter what we're doing now, we can make a difference in our future. Um And then coming back to the question of genetics. So, of course, you know, we all inherit genes that may or may not increase the risk of certain cancers and usually they are um um snips, so single nucleotide polymorphisms that may be 100s of them that um influence our risk. Um But overall, every study that's looked at, it shows that you can influence your risk of cancer despite your genetic predisposition. And this is just one of many that highlight this point. There was 350,000 participants in the UK Biobank followed for six years. They looked at health, eight healthy lifestyle factors and correlated it with a polygenic risk score of 95 different genetic variants that were known to influence your risk of colorectal cancer. And what they showed was that for every um risk group, having a healthy lifestyle, significantly reduced your risk of colorectal cancer. But interestingly, those in the highest genetic risk had the greatest benefit, reducing their risk of colorectal cancer during that follow up by 42% to a very common sense conclusion. Our study provides strong evidence to support lifestyle modification for colorectal cancer, primary prevention. So I guess this sort of preamble really brings me to the fact that the real solution to many of our problems. But today we're talking about cancer is the adoption of the principles of lifestyle medicine. Now, lifestyle medicine is an evidence based specialty. It's the most rapidly going specialty. Globally. It pays attention to the root cause of chronic conditions, including cancer. And there's six pillars that it addresses nutrition, physical activity, avoiding toxins, like tobacco and alcohol, managing stress, um maintaining um restorative regular sleep and also maintaining healthy relationships. And together, if we address all of these um aspects of lifestyle, we could prevent 80% of the chronic conditions we see in the NHS or whichever healthcare system you're in. Um So the stats are rather alarming. And so if we look at all of those factors that I've listed on um cancer, so this particular paper brought together um prospective studies, um which included um nearly 2 million participants in the form of a systematic review and meta analysis and looked at the combination of lifestyle factors and their impact on um cancer and mortality. And what they showed was um that indeed, um those lifestyle factors impacted um both cancer incident, reducing cancer incidence by 30% and cancer mortality by 52%. Um If we did not smoke, limited alcohol, kept a healthy body weight, healthy diet and were physically active, so hugely powerful. Um And why is it so powerful? Well, I mean, I put the word cancer in the middle here, but actually all conditions really share the same mechanisms of disease development. And I've listed them here because they're important for cancer development. But we know that lifestyle medicine addresses these key drivers. So insulin resistance, cellular stress, inflammation, exposure to carcinogens. And one, well, a few examples of carcinogens are, you know, alcohol, tobacco processed, red meat, um unhealthy gut microbiome will contribute to cancer risk and having elevated growth hormones such as estrogen or insulin like growth factor, which are related to diet and lifestyle also impacts our risk. So, addressing the six pillars, address these mechanisms. I think one of our biggest problem is that people including healthcare professionals are really not aware of the true power of lifestyle modification. Um This study um survey was from 2018 but um II, don't think anything has changed really. Um a public survey asking about their awareness um on the cancer prevention guidelines, I've pre prevented and more than half of respondents were not aware that eating processed red meat increases your risk of cancer. And they did not know that physi physical activity um was beneficial in, in, in reducing your risk of cancer. So we've got a lot of work to do to spread the um healthy lifestyle me message especially for cancer. No, I think a topic that's not given enough attention is the fact that other chronic conditions increase your risk of of cancer. So just the pure um you know, diagnosis of type two diabetes, cardiovascular disease um will increase your future risk of uh of cancer because going back to those shared mechanisms of cellular stress, inflammation, unhealthy gut microbiome. And this is one study that just outlines quite clearly how both um chronic conditions and lifestyle behaviors together impact our cancer risk and mortality. So, this was a study conducted in Taiwan. 400,000 participants followed for nearly eight years. And what they showed was um chronic conditions contributed to over a third of the risk of um getting cancer and then lifestyle factors around 40%. Um So together, if you had an un um if you had unhealthy lifestyle and underlying chronic conditions, you shortened your life by 13 to 16 years. Um So I think, you know, we need to also prevent other chronic conditions to prevent cancer. Um Now, the one area of lifestyle medicine that causes the most discourse and dialogue is what is a healthy diet. Um I can do a separate talk on that at some point if it's of interest. But for the cancer prevention and for chronic condition, um you know, um prevention and treatment. The American College of Lifestyle Medicine, the founding organization have a position statement that says they recommend an eating plan that's predominantly based around fruits, vegetables, whole grains, beans, nuts and seeds, as shown in the plate there. So predominantly plant based diet, what we call a whole food plant based diet, what you do around the edges with meat and processed foods and all the rest, it's entirely up to you. But the predominant 85 to 90% should be from fruits and vegetables, whole grains, about a quarter of the diet and then plant sources of protein like um pulses, chickpeas, nuts, seeds. Um soya foods mainly water for thirst. If you enjoy tea and coffee, that's absolutely fine. Add herbs and spices, cos they're delicious. But also because they have antiinflammatory and antioxidant Polier properties. So just to focus in on diet, given it's my favorite topic. Um Just to highlight the impact of um unhealthy diets. And for cancer, a globally, a million cancer deaths are due to unhealthy diet. II, feel like an underestimate is that one in 20 cancers according to cancer research UK are due to an unhealthy diet. But that doesn't take into account the impact of diet itself on obesity type two diabetes and so forth. Um And really our diets are unhealthy because they're too high in sodium. A reflection of our reliance on preprepared and packaged foods. Um They're too low in fiber because they're insufficient in all the healthy plant foods that I've mentioned. And they're too high in red and processed meat, which reminds me to tell you again, that processed red meat has been classified as a group one carcinogen. It directly causes cancer, particularly related to colorectal cancer and a group two carcinogen. Um It is the classification for red meat because it also increases the risk of um, colorectal cancer. But the strength of evidence isn't quite as much for, um, as for processed meat. So, again, no place for it in the diet. What is the impact of different dietary patterns on cancer risk? Um, well, this is one of many studies, but one of the most recent that I've seen, um, looking at cancer incidents in people that have participated as part of the UK Buy Bank. This looks particularly at um four different diet patterns, regular meat eaters, low meat eaters, fish eaters, and then vegetarians which include vegans as well. And what they showed was that meat free diets reduce the risk of cancer by around 14% with particular benefits for breast and prostate cancer. And these type type of statistics have been shown in other datasets. It's generally that meat free diets reduce your risk of cancer overall by around 15%. Um And then when you look at this table, it's rather busy. But I just wanted to show you the sheer number of studies we now have demonstrating that a healthy plant based diet, like I showed you in that plate really does impact cancer incidence and mortality. So I want you to look at the healthy plant based diet. Bit in the middle column here, you can see that um there's a positive impact as in reduced risk for prostate cancer, breast cancer, lung cancer, esophageal cancer and mortality as a whole. So um the the column in the right hand side is a bit of a word of caution. If you're following an unhealthy plant based diet, you're not going to be doing yourself any justice. So, if it's a plant based diet so full of ultra processed foods, sugar, sweetened beverages and so forth, um, it's not going to be any good. The particular benefits to a plant based diet are for digestive cancers. Again, a huge dataset, 3 million participants, um are looking at the different diet patterns and what they found that was any sort of healthy um plant based diet, whether it's vegetarian, vegan Mediterranean, anything under the umbrella of predominantly plant based has significant benefits for reducing the risk of um gas uh uh digestive cancers, pancreatic, colorectal gastric and liver. And it makes sense because our food passes through our digestive tract is digested. Um It influences the gut microbiome, our gut microbiome then influences body organs and the immune system. So I said I'd come back to ultra processed foods. Um We haven't got certainty of evidence, but certainly it's building to suggest that it's not just the impact of ultra processed foods on chronic disease and weight. Um gain. It is the fact that these ultra processed foods as we increase them in dose in the diet increases the risk of cancer. Now, there's a number of hypotheses why this might be um is it the additives, is it the packaging and the leakage of um you know, plastic um particles into the food. Is it the high levels of heat that, that some um products are exposed to? We don't know, but I think we need to have a word of caution. Um Well, overall for processed food, but that it might be contributing to um cancer risk as well. Um Now again, dairy as a nuanced conversation, II tend not to really talk too much about dairy consumption with my patients, but I do tell them they could make a better choice. So in general, um dairy consumption um reduces the risk of colorectal cancer, but it's purely the calcium content. So we know that calcium supplements or calcium rich foods also do the same, but it does increase the risk of prostate cancer in men and may increase the risk of breast and endometrial cancer. And this is because of exposure to hormones and also insulin like growth factor that's present um from the cow in the dairy. Um And as I say, II, talk about better choices and we've got a great body of evidence supporting the role of soya in the diet for, for prevention of various cancers and including soya milk for reducing breast and prostate cancer. Um So I go with that view point that we can make a better choice. Dairy is not required in the diet and we can choose a, a milk or product that reduces our risk of cancer. Um I do go down hard on alcohol though there is no safe limit. Unfortunately, for cancer prevention, there's a dose um dependent um increase in cancer even when you start with sort of low doses in inverted commas of sort of one glass a day. So the recommendations are it's best not to drink um because they increase the risk of all of these cancers amounting to around 5 to 6% of cancers globally. Um And don't be fooled by any of the narrative you hear around any positive impacts because they're just not true. Um I'd urge you to read the World Heart Federation impacts of alcohol consumption on cardiovascular health myths and measures really, it is a myth. Um Alcohol consumption across the board has more harms and benefits. And more recently, we are worrying about the effects on brain health because people who drink alcohol have um lower grade matter density. Now I'm just gonna move track to exercise, which um is a really important part of lifestyle medicine with a lot of evidence supporting it. We know that regular physical activity that meets the guidelines of 100 and 50 minutes of moderate exercise a week or 75 minutes of vigorous activity. It really has a positive impact on our cancer risk. So reduces the risk of at least 13 cancers. And I've listed all of these mechanisms by which physical activity work. It's very, very similar to how, you know, diet and nutrition um impact, you know, they have uh it has a benefit, a beneficial impact on our um hormones on our gut microbiome, on gene expression. Um and our immune system. So, really important. Um So I'll come back to physical activity again. Um But just to say it's really important for, for prevention. So I'm just gonna move on to lifestyle inventions during cancer treatment. Now, we have less evidence um for how to support patients during their cancer treatment. Anyone who's been through or seen people go through cancer treatments, it's intensive, it's all consuming. It's difficult to em embrace lifestyle medicine. But I think we really should try. And I think, you know, some of the most exciting um data is emerging in the field of um gut health and the gut microbiome. So just a reminder of what we said already, um the gut microbiome, you know, um live in our, mainly in our large intestine. Um they metabolize um dietary components. So mainly fiber polyphenols. Um fermented foods are useful to provide um live bacteria. Um and these types of foods that are fueling the gut microbiome, really a variety plant foods leads to a flourishing of healthy bacteria that can make short chain fatty acids. And these um short chain fatty acids are responsible for their the impact of the gut microbiome. They communicate with different body organs and they're also involved in immune regulation. So what we are beginning to understand um with the accumulating data that the health of the gut microbiome impacts our response to anticancer treatments, which is so exciting because we really can improve our the health of our gut microbiome very quickly. Um So, studies have shown so more than one that high fiber foods um and people eating more plant foods. Um ak a more fiber have a better response to certain types of treatments known as immunotherapy. Um So, therapies that harness the power of the immune system, whether that be PD one inhibitors, stem cell transplantation and so forth. And there's a dose response like with everything in medicine, um the more fiber you eat, the better your response and the lower the risk of um progression or death. Um So I love this paper if you haven't come across it. Um One of the coauthors is Tim Tim spector, the gut microbiome, what the oncologist ought to know. Um And there's lots to read about it. But what we can do now and today tomorrow is dietary interventions that promote a healthier gut microbiome, eat a variety of plants, eat polyphenol rich foods, which are the dark colored fruits and vegetables, increase dietary fiber, which only comes from plant foods and add some fermented foods to the diet like Kimchi kombucha, um sauerkraut Tempe. Um So just to touch on supplements and cancer, um many patients um if you ask will be taking some sort of supplement really, there's no data to support higher doses of nutritional. I'll say that again, there's no data to pre uh to support higher than nutritional doses, um of supplements to prevent cancer. In fact, the studies that have been done often show harm rather than good. So it's best to get your nutrients from the diet. Obviously, if you're not meeting nutrient requirements, um you might need supplements. And if you're on a fully plant based diet, then you do need to take a B12 vitamin b12 supplement and you do need to be cautious about interactions with chemotherapy for these higher doses. So always check with your cancer pharma. Um uh oncologist. Um So and and again, another word of caution in that, you know, it might be that antioxidant supplements during cancer treatments, especially for um traditional chemotherapy and radiotherapy that rely on oxidative stress to kill the cancer cells. If you're taking antioxidants, you might inhibit the effect of the anticancer treatment. So, um we should be cautious amongst patients when considering the use of supplements, especially antioxidants during chemotherapy. The only supplement I do um tend to recommend to my patients is Vitamin D Of course, during winter months, October to March in the UK, we should all be taking a supplement because we don't get enough exposure to the sun. I think I don't get exposure to the sun most of the year round. So I take one all year round but where there is some evidence for supplementation for cancer is um to prevent or reduce cancer mortality. So, for people with a diagnosis of cancer, there may be um some degree of evidence to suggest that getting the levels into what we consider the therapeutic range. I know there's a nuance there um may be beneficial. Now, to me, I, you know, the, the strength of evidence isn't, you know, in the realms of certain, but um taking a Vitamin D supplement, um really is um low risk um with sort of a, a tolerable level up to sort of quite high doses of 4000 international units a day. Now, I think lifestyle medicine approaches come into their own after a cancer diagnosis. Um and for improving survivorship. So again, the question arises, do the guidelines I showed you at the beginning of the talk actually matter after a diagnosis of cancer. And again, the answer is yes, I've chosen a study in colorectal cancer. It looked at lifestyle and habits during chemotherapy and six months after chemotherapy and followed people for seven years and they found that people who were adhering to these lifestyle um habits that I've um talked to you about had a 42% lower risk of dying from colorectal cancer. And so that meant a, a 9% absolute risk at five years of dying. And that's not bad. You know, if a new treatment reduced your risk of dying by 9% that would probably be adopted by um you know, cancer agencies. So really important um where lifestyle intervention may be also important is for early stages of cancer where you have a watchful waiting approach where we know that actually treating the cancer is not gonna benefit um mortality. And that's the case for early stages of prostate cancer in men. So the father of lifestyle medicine, if you haven't come across him is Dean Ornish. He's just published a study in people with Alzheimer's disease that hit the the the media. So do check, check that out. But he's for decades used his lifestyle intervention with patients and also studied it in clinical trials. His approach is a low fat plant based diet, stress management group support and physical activity and stopping smoking so very much uh pillars of lifestyle medicine. And he randomized 93 patients with early stages of prostate cancer to um either his lifestyle group or to carry on just usual care. Um And what he found after a year was that in the um usual care, the prostate specific antigen level had gone up, but in the control group, it had gone down albeit small um differences, but statistically significant what matters most to us is patient outcomes. And after two years, over a quarter of the control group had to go and have radiation or surgery whereas only 5% of the lifestyle group went on to have con conventional cancer treatment. Um So it's a no brainer because these lifestyle habits are great for cardiovascular risk, um prevention um type two diabetes, keeping a healthy weight. And in a separate study in 30 men, he was able to show the mechanisms that might be at play in the results he'd shown in the prostate cancer study. So again, 30 people with prostate cancer, he looked at telomere length and gene expression. And just after three months, he was able to show lengthening of the telomeres and peripheral blood monuc psls and in repeat um prostate cancer biopsies before and after he was able to show us change in gene expression from switching off um uh cancer promoting genes to switching on cancer suppressor genes. So really impressive and other people have replicated these, these type of results. Um you know, it's always impossible to know which aspect of his lifestyle program is having the most impact. It doesn't really matter, they're all healthy habits. But this study looked purely at physical activity in people with early stage prostate cancer. Under watchful waiting, 52 patients randomized to really brief intervention which was 20 minutes, three times a week of high intensity interval, training, 12 weeks only. But in that 12 weeks, they were able to show that psa levels are coming down and reduce proliferation of um cells in the laboratory as well. So really impressive um er, evidence we can take forward to the clinic and the more we look into prostate cancer, which is a nice sort of example of a slow growing cancer that people live with with it for a long time. This study published recently looked at dietary patterns in people, um who'd had a diagnosis of prostate cancer, um and had, had some treatment. Um And what they showed was that those people sticking to a healthy plant based diet had improved quality of life as um measured through improved sexual function, urinary, um symptoms, incontinence, and hormonal um function. So, um really makes a difference and in general for cancer survivorship, the the evidence is pointing to eating a plant rich diet. We need more studies. But you know, the data we've got already shows a positive impact for the common cancers um were breast colorectal and prostate cancer. Um Similarly for exercise and cancer um building and exercise programs um during and after a cancer diagnosis is hugely important. It um not only improves survival but it, it deals with certain symptoms that are common such as anxiety, depression fatigue, um and improves physical functioning. Um and it may be bone health and sleep quality. Um And the American Society of Clinical Oncology have a guideline and recommend exercise um therapy or exercise interventions during cancer treatment because it's known to reduce fatigue, preserve cardiorespiratory fitness, physical functioning strength, improve quality of life and reduce anxiety and depression. Um And in the pre op session setting, there's quite a lot of data in the lung cancer field to show that um this type of exercise intervention will improve outcomes postoperatively because you've got better cardiorespiratory fitness before you go in. And as I briefly mentioned before, we know that exercise after diagnosis of cancer improves survival. So for all of the big cancers that are, you know, um easier to see the signal, you can reduce your risk of dying from cancer by about 30% in, in breast colorectal and prostate cancer. And this is just shown in a different way um that both aerobic and muscle strength strengthening um activity is important. Um This large study published in the BMJ looked at the impact of exercise on cancer survival. That's the pink here. Um So compared to insufficient activity, if you do muscle strengthening, you reduce your risk of dying from cancer by around um 18%. Um if you add an aerobic or if you do aerobic, it's around 20%. But if you do both together, you reduce your risk of dying from cancer by 40%. Um And the other area where physical activity seems to be really important is to support people through this side effect of treatment, which people always refer to as chemo brain where you get cognitive dysfunction, um poor concentration, poor memory. Um Yeah. Um difficulty sort of performing um usual exe tasks. It's a real phenomenon thought to be due to sort of oxidative stress and inflammation that occurs as a side effect of the therapies we give. But studies have shown that people undertaking regular physical activity before and during chemo have much less in the way of symptoms um uh regarding chemo brain. And so I am coming towards the end. Um and I just wanted to mention that there's an um expanding field of integrative medicine. Um And um we're now in the stage of accepting integrative ii integrative approaches for people with a diagnosis of cancer. Um so much so that there's been three recent guidelines that I'm going to highlight. So, um this is particularly focusing on cancer pain where there's recommendations from the American Society of Clinical Oncology for the use of acupuncture, acupressure, reflexology, massage, and hypnotherapy, and the use of these um uh sort of complementary therapies and reduces reliance on opioid analgesia. We've then got um the role of integrative medicine for anxiety and depression during a cancer diagnosis with evidence supporting mindfulness based interventions, yoga, hypnotherapy, relaxation, music therapy, and reflexology. And then just hot off the press last month. Um looking at fatigue in cancer survivors, anyone who's looked after people with cancer, this feeling of fatigue goes on and on for some people without um an easy way to combat it. Um but it can be benefit by regular physical activity, um cognitive behavioral therapy, mindfulness and Tai Chi or QQ. And then finally, just to um remind us um that lifestyle um habits are important for living well, disease free after a diagnosis of cancer. Again, a large dataset from the UK ban 35,000 people with a diagnosis of cancer then followed for 14 years, looking at the impact of these five healthy lifestyle factors on the left. And you can see that people who are most adherent to all five, reduce their risk of getting cardiovascular disease by 44% and reduce their risk of type two diabetes by uh by 38%. With again a dose response each lifestyle factor, reducing the risk of developing cardiovascular disease and type two diabetes by about 10 to 13% respectively. And of course, these healthy lifestyle factors will reduce your risk of getting a second cancer. And of course, second cancers are more frequently, um around 10% more frequent than the background population if you've already had one cancer diagnosis. So we face a lot of challenges in cancer care. We have a rising burden of cancer globally. We have an aging population. We've got this rising incidence in the young that I've described. We've got increasing levels of comorbidity that has a knock on effect on cancer incidence. We over emphasize treatment versus prevention. I'm sure those in the in the secondary care really notice this, that there's very little attention paid to lifestyle interventions. Despite the fact that it could have major benefits, money is spent on treatments that will only benefit a few often at the last stages of cancer. And we've got poor investment by policy makers for making healthy lifestyle environments accessible to all communities because lifestyle is not about a choice in general. People don't choose to be unhealthy, but we know that people have different access and ability to adopt healthy lifestyle behaviors. Now, I no longer do a talk without mentioning the climate and ecological crisis. This is the biggest threat to humanity as stated by the WH O and it's going to affect cancer as well. Not only will we see cancer incidents rising with exposure to air pollution, for example, but we will see cancer care disrupted through migration through extreme heat, through flooding through food scarcity and all those things that are currently happening and only worsening be because of our climate breakdown. So I wanted to leave you on a positive note. This is my father um cancer thriver. Um He is 81 in a couple of weeks. Um He had the usual um South Asian risk factors in September 2020. Um He was overweight, had elevated triglycerides and elevated hemoglobin A1C. And of note, he'd had a whipple back in 2004 for pancreatic cancer. So being alive 20 years later, clearly remarkable for which we're grateful for. But 50% of people after Whipples that removed two thirds of your pancreas become diabetic. So it was quite remarkable that it took a good 16 years before he became prediabetic. Um But we weren't ready to sort of accept that as a, as a kind of, you know, fait accompli. Um So he saw one of my colleagues who's a lifetime medicine physi uh professional and a nutritionist. He adopted a healthy plant based diet. Um He was pretty much plant based anyway, but um uh improved the quality of the diet, added daily walks and resistance exercise. And just after six months has been able to um reverse those trajectories. He's no longer diabetic. He doesn't meet the criteria for metabolic syn syn syndrome and that's actually been uh maintained for um how long is that? Nearly four years? So I think uh this goes to show that lifestyle interventions are possible even when you think um the outcome is not going to be favorable with only a third of the pancreas. So second, lot of conclusions, a large proportion of cancers are preventable diet and lifestyle factors are a major contributor to um are rising cancer incidence and mortality. Um And diet and lifestyle interventions can have a significant impact on cancer outcomes. Um And I think that just leaves you to just me to run through just my top tips. So eat a variety of healthy plant foods, swap meat for beans, add soy foods, swap your dairy for soy milk, use herbs and spices, add nuts and seeds, exercise regularly, avoid a alcohol. I don't need to tell you to avoid tobacco. Um So if you want to learn more, I offer this course at the University of Winchester. If you want to learn more, more on plant based nutrition, I offer this course as well. Um And um just to get um into the groove, we have a podcast which is fantastic, led by two GPS, um Claire and Daisy who um talk about um healthy plant based diets and their role for all sorts of aspects of our health and wellbeing. Um And I think, yeah, and these are my two books that I've authored um can find them wherever you buy books and that really is the end. So, thank you very much. That is absolutely classic. I was captivated there. I really was. That was absolutely brilliant. Thank you so much. That was, that was great. Um I go some of my absolute takeaways there, like I think going through medical school and the whole way through, even whenever we hear about our own health, like the big factors are big, but they are absolutely huge, the processed meat one, I guess that's always topical. That's something that, uh you know, we see so much about now, but it's great to actually have the proof and evidence behind that. That is absolutely brilliant. Um And the other thing, the plant based diet benefits, the thing that stood out for me was the prostate cancer, increased quality of life with that. That, that was, it's just incredible. Um I do. There are a couple of questions, so I'm just going to flick over here and uh pull up the Q and A. There's a, there's a few questions that came through um a wee bit of a clarification for Alison asking um about soy milk. Is it not processed? And, and kind of related to that? Um Sapana has asked, is there some of the added ingredients in that to some of the milks being artificial? Are they OK? Is there any kind of um guidance around that? Yeah, no good question. And I think, you know, there's a lot of dialogue around o processed foods and there are a lot of misunderstanding because um you know, kind of media portray it as black and white. Um So soy milk has been consumed for um you know, centuries in certain cultures. Um There's a long history of that. Yes, we manufacture it, but um it comes directly from the soybean. Um And so in most people would consider soy milk in general minimally processed because there's very little that goes into extracting. I mean, it's extracted, but we extract lots of nutrients from different foods. Um I think where you can be mindful is kind of the type of soy milks that you buy. And so yes, absolutely. You use unsweetened soy milks. Um We recommend as in plant based health professionals and in general for people on a plant based diet to choose the fortified versions with calcium Vitamin D because then the sort of nutrient profile is, is very similar to cow's milk. Again, I don't have a problem with those um additives and the amount of additives of, there may be a bit of emulsifier just to sort of um give it that sort of milky texture, there's such tiny amounts and when you look at the overall data um sets and in fact, something a a very large paper in Lancet was published very recently, looking at the impacts of plant based alternatives including milks and, and meats and zero impact oo on health outcomes, meaning no negative impact, You know, most of the negative impact of ultra processed foods come purely from a few food groups, processed meat, sugar, sweetened beverages. And then that category of sort of cakes, pastries, biscuits, I mean, the things that are obvious. Um So no, I don't have any problems with that. Um uh and so just, you know, choose, choose the version that has the ingredients that you're happy with, but unsweetened, fortified with calcium. Um and you're usually fine. Most supermarket own brands are around the 55 P mark. So they, they can be even less than um cow's milk. And I do want to just sort of point out also that it does annoy me that people want to hear about the processing of sort of plant milks, but don't sort of really talk about the processing of actual uh cow's milk, you know. Yeah, I mean, I could spend half an hour telling you how that that's um produced and perhaps people wouldn't um, consider it sort of natural and inverted commas So I think, you know, there's pros and cons, but in general, there are some useful ways of processing um foods um such as fortification. Um And um you know, yeah, so I hope that answers your question. No. Fantastic. I jumped in um probably jumped the gun a little bit because I think you then subsequently be brought up a slightly that, that potentially answered this. But with regards to exercise, it's a bit selfish because I currently work on a respiratory ward. And I see a lot of, of um I LD, obviously, there has to be evidence there um from a lifestyle medicine point of view for improving outcomes for patients with non-cancerous long term um conditions. Yes, I mean, absolutely. I think the strongest evidence is in the categories of the common conditions. So cardiovascular disease and type two diabetes, managing a healthy, healthy weight or weight maintenance. Certainly. Um and also um dementia, um the specifics of those individual respiratory conditions, I might have to go away and read the books. But only to say that I know in for, for example, COPD. So if we could extrapolate from COPD into ILD, then the answer would be yes, because we know that sort of that pulmonary rehab, that's actually part of every day. Um you know, practice makes a, makes a difference um to people. So um absolutely. And so does eating more fruits and vegetables improves quality of life, respiratory function and for people with COPD and asthma. So, um, yeah, I don't know the for, but for commoner conditions they definitely a data set to prove that. Absolutely. And then there's a couple of questions just through more sort of general things just about the podcast. What about where it's called, where it's available for people to access? Yeah, on all the usual platforms and it's in a nutshell. Um, yeah, it's called in a nutshell. II tend to listen to it on Apple. So I've got it up here and I'll post the link in the chat very shortly. Fantastic. That would be great. Um While you're pulling that up and a few more details just about the course that you mentioned University of Winchester course J has asked about. Yes. Well, I offer two. They generally run during the kind of academic terms. They're both eight weeks long. Um and they um uh fully online self paced. Um just need to complete everything in, in eight weeks. Um um with sort of a mixture of ways of learning like um uh reading, um recorded lectures, um CQ sa bit of written assignment and then the option for some live Q and A s if people can meet that, um, make that with me. So, yeah, do have a look at the University of Winchester's website. I'm, I'm also, I mean, um Sue's got my slides. So if you guys want to have my slides, that's absolutely fine. You can share them and then all the links to the websites and the resources are there too brilliant. Um And absolutely, for, for folks still on, we will get those posted as catch up content along with the recording of tonight's session. Um Alison very helpfully has shared this link just about supporting um folks with cancer staying active, that move, move against cancer.org, which I had heard about as well, actually. So yes, and there's also a great organization called Moving Medicine as well which covers um you know, movement for all specialties and actually has some great resources. So I'm just gonna pop that into the Oh, why can't I put it, pop it into the chat? Um I'm just gonna try and pop that into the chat. So Moving Medicine um goes beyond just the 00 no, I don't know. Am I still there? Yeah. Yeah, you're still here. OK. I still, I've lost my screen. I'll, I'll stop trying to do that but Moving Medicine and it comes up, no worries. No. Perfect, perfect. Um Little question in from Jan about tinned and canned food. Um obviously, you know, um probably processed in extent but no, I mean that, II think that's absolutely fine. I mean, uh you know, the ideal would be that we use BPA free tins, it would be better to buy in glass bottles. But really the data supports however best you can increase plant foods in your diet like the minimally processed ones fruits, vegetables, whole grains, beans, nuts and seeds is beneficial. Um regardless of whether you can afford organic or in a glass or, you know, you're, you're cooking right from scratch. So, um yes, in the ideal world, um, you know, we would all buy the dried dried beans and pulses, but we live in a world that requires us to have some convenience. Um It is much cheaper, of course, buying, you know, dried beans and pulses in bulk. So if cost is an issue and you've got storage space, then that's good. And I'd say the same about frozen fruits and vegetables. It's a great way to have fruits and vegetables handy. Having them frozen in the freezer tend to be cheaper as well. Um So, so yeah, yeah, and prolonged shelf life and convenience you say? Yeah, absolutely, Doctor Cosan. That is absolutely fantastic. I don't see any other um questions coming through at the minute. So um we will, we'll maybe wrap things up there. Um Can I just extend another massive thank you for coming along and for sharing with us tonight. We really, really appreciate it. Um For the folks still lingering on the call, there are just going to share a couple of links to the upcoming events. I encourage you just to scan the QR code on your screen. Now, the Med All app will have all the detail there. Um We're back tomorrow night actually um at the same time uh Kevin Fernando is going to be covering commonly abnormal blood tests in primary care and then we have a little bit of a, of a break. Um, but our next one up after that is with V gram Tar, we're going to be looking at testosterone's role in menopause management. So another, um, quite topical topic, I'm going to Nip in, we've got time. I'm going to Nip in with mbas question. Um, she, if you don't mind, what are your thoughts on sausages that just came through? Yes. From somebody called, um, salami. Is this true? Yes. Anyway, I can ask about sausage as well. I mean, like it depends, doesn't it? What type of sausage? I have no problem eating a bean sausage that I've made in, in, in my house. Are we allowed to call it a sausage? I don't know. Um, but if we're talking about processed red meat made from, um, beef or, or, um, pork, which is usual. I mean, to be honest, I've never really eaten sausages. Um, but, um, so, II think pork is probably more common than beef, isn't it? But, um, they, they are classified as a, as a processed meat. Um, they generally have, you know, um, the nitrates added and things like that. So, unfortunately, it is classified as a group, one carcinogen. Um, so would be a, no, no for me. And then processed meat in general increases your risk of cardiovascular disease. Type two diabetes, excess weight, fatty liver. I could go on the list. The list is the list goes on. I will believe. Um Shereen. That's absolutely fantastic. I really appreciate it. Um Folks, we will get Doctor Cain's slides uploaded as soon as we can as well as the recording of tonight's event up as soon as we can for catch up content feedback forms been shared in the chat. There will also be coming out to you by email as well and by notification uh on the app and I look forward to hopefully seeing some of you again tomorrow night. Another great big thank you to Shereen um for your time tonight and we will leave it there. Thank you so much, everybody. Bye. Thanks everyone.