The China Study (27 page)

(OMMON (AN(ERS: BREAST, PROSTATE, LARGE BOWEl                     175
into the large bowel and promote colon cancer development. By binding
these bile acids, calcium is said to prevent colon cancer.
One research group demonstrated that high-calcium diets-generally
meaning diets high in dairy foods-inhibit the growth of certain cells in
the colon,84 but this effect was not entirely consistent for the various indica-
tors of cell growth. Furthermore, it is not clear whether these presumably
favorable biochemical effects really lead to less cancer growth.83 , 85Another
research group demonstrated that calcium does reduce the presum-
ably dangerous bile acids, but also observed that a high-wheat diet did
an even better job of reducing the bile acids.86 But-and this is the really
odd part-when a combination high-calcium and high-wheat diet was
consumed, the binding effect on bile acids was weaker than for each
individual supplement taken alone.86 It just goes to show that when
indiVidually-observed nutrient effects are combined, as in a dietary situ-
ation, the expected may become the unexpected.
I doubt that a high-calcium diet, obtained through calcium supple-
m e n t s or through calcium-rich cow's milk, has a beneficial effect on
colon cancer. In rural China where calcium consumption is modest and
almost no dairy food is consumed,87 colon cancer rates are not higher;
instead they are much lower than in the U.S. The parts of the world that
consume the most calcium, Europe and North America, have the high-
est rates of colorectal cancer.
Another lifestyle choice that is clearly important for this disease is
exercise. Increased exercise is convincingly associated with less colorec-
tal cancer. In one summary from the World Cancer Research Fund and
the American Institute for Cancer Research, seventeen out of twenty
studies found that exercise protected against colon cancer.64 Unfortu-
nately, there seems to be no convincing evidence as to why or how this
occurs.
SCREENING FOR TROUBLE
The benefits of exercise bring me back to President George W Bush. He
is known to enjoy staying physically fit with a regular running routine,
and that is undoubtedly one of the reasons why he received a clean bill
of health when he had a colonoscopy. But what is a colonoscopy anyway,
and is it really worth the effort to get checked? When people go to the
doctor to get a colonoscopy, the doctor inspects the large bowel using a
rectal probe and looks for abnormal tissue growth. The most commonly
found abnormality is a polyp. Although it is not yet clear exactly how tu-

THE CHINA STUDY
176
mors are related to polyps, most scientists would agree88,89 that they share
similar dietary associations and genetic characteristics. Those people who
have noncancerous problems in the large bowel, such as polyps, often are
the same people who later develop cancerous tumors.
So getting screened for polyps or other problems is a reasonable
way to establish risk for large bowel cancer in the future. But what if
you have a polyp? What is the best thing to do? Will surgical removal
of the polyp lessen colon cancer risk? A nationwide study has shown
that, when polyps were removed, there was a 76-90% decrease in the
expected cases of colon cancer,89,90 This certainly supports the idea of
routine screening. 89 , 91 It is commonly recommended that people get a
colonoscopy once every ten years starting at the age of fifty. If you have
a higher risk of colorectal cancer, it is recommended that you start at the
age of forty and screen more frequently.
How do you know if you are at a higher risk for colorectal cancer? We
can very roughly assess our personal genetic risk in several ways, We
can consider the probability of our getting colon cancer based on the
number of immediate family members who already have the disease, we
can screen for the presence of polyps, and we now can clinically test for
the presence of suspect genes. 92
This is an excellent example of how genetic research can lead to a bet-
ter understanding of complex diseases. However, in the enthusiasm for
studying the genetic basis for this cancer, two things often get overlooked.
First, the proportion of colon cancer cases attributed to known inherited
genes is only about 1_3%.89 Another 10-30%89 tend to occur in some
families more than others (called familial clustering), an effect possibly
reflective of a significant genetic contribution. These numbers, however,
exaggerate the number of cancers that are solely "due to genes."
Except for the very few people whose colon cancer risk is largely
determined by known inherited genes (1-3%), most of the family-con-
n e c t e d colon cancer cases (i.e, the additional 10-30%) are still largely
determined by environmental and dietary factors. After all, place of resi-
dence and diet are often shared experiences within families.
Even if you have a high genetic risk, a healthy plant-based diet is
capable of negating most, if not all, of that risk by controlling the ex-
p r e s s i o n of these genes. Because a high-fiber diet can only prevent colon
cancer-extra fiber won't ever promote colon cancer-dietary recom-
m e n d a t i o n s should be the same regardless of one's genetic risk.

COMMON CANCERS: BREAST, PROSTATE, LARGE BOWEL                177
PROSTATE CANCER
I suspect that most people do not know exactly what a prostate is, even
though prostate cancer is commonly discussed. The prostate is a male
reproductive organ about the size of a walnut, located between the blad-
d e r and the colon. It is responsible for producing some of the fluid that
helps sperm on its quest to fertilize the female's egg.
For such a little thing, it sure can cause a lot of problems. Several of
my friends now have prostate cancer or closely related conditions, and
they aren't alone. As one recent report pointed out, "Prostate cancer is
one of the most commonly diagnosed cancers among men in the United
States, representing about 25% of all tumors .... "93 As many as half of all
men seventy years and older have latent prostate cancer,94 a silent form
of the cancer which is not yet causing discomfort. Prostate cancer is not
only extremely prevalent, but also slow-growing. Only 7% of diagnosed
prostate cancer victims die within five years. 95 This makes it difficult to
know how and if the cancer should be treated. The main question for
the patient and doctor is: will this cancer become life threatening before
death comes from other causes?
One of the markers used to determine the likelihood of prostate can-
cer becoming life threatening is the blood level of prostate specific anti-
gen (PSA). Men are diagnosed as having prostate problems when their
PSA levels are above four. But this test alone is hardly a firm diagnosis
of cancer, especially if the PSA level is barely above four. The ambiguity
of this test leads to some very difficult deciSion-making. Occasionally
my friends ask for my opinion. Should they have a little surgery or a lot?
Is a PSA value of 6.0 a serious problem or just a wake-up call? If it's a
wake-up call, then what must they do to reduce such a number? While
I cannot speak to the clinical condition of an individual, I can speak to
the research, and of the research I have seen, there is no doubt that diet
plays a key role in this disease.
Although there is debate regarding the specifics of diet and this can-
cer, let's start with some very safe assumptions that have long been ac-
cepted in the research community:
• Prostate cancer rates vary widely between different countries, even
more than breast cancer.
• High prostate cancer rates primarily exist in societies with "West-
ern" diets and lifestyles.

178                          THE CHINA STUDY
• In developing countries, men who adopt Western eating practices
or move to Western countries suffer more prostate cancer.
These disease patterns are similar to those of other diseases of afflu-
ence. Mostly this tells us that although prostate cancer certainly has a
genetic component, environmental factors play the dominant role. So
what environmental factors are important? You can guess that I'm going
to say plant-based foods are good and animal-based foods are bad, but
do we know anything more specific? Surprisingly, one of the most con-
sistent, specific links between diet and prostate cancer has been dairy
consumption.
A 2001 Harvard review of the research could hardly be more convinc-
i n g9 6 :
... twelve of ... fourteen case-control studies and seven of ... nine
cohort studies [have] observed a positive association for some
measure of dairy products and prostate cancer; this is one of the
most consistent dietary predictors for prostate cancer in the published
literature [my emphasis]. In these studies, men with the highest
dairy intakes had approximately double the risk of total prostate
cancer, and up to a fourfold increase in risk of metastatic or fatal
prostate cancer relative to low consumers.96
Let's consider that again: dairy intake is "one of the most consistent
dietary predictors for prostate cancer in the published literature," and
those who consume the most dairy have double to quadruple the risk.
Another review of published literature done in 1998 reached a simi-
lar conclusion:
In ecologic data, correlations exist between per capita meat and
dairy consumption and prostate cancer mortality rate [one study
cited]. In case control and prospective studies, the major con-
t r i b u t o r s of animal protein, meats, dairy products and eggs have
frequently been associated with a higher risk of prostate cancer ...
[twenty-three studies cited]. Of note, numerous studies have
found an association primarily in older men [six studies cited]
though not all [one study cited] .... The consistent associations
with dairy products could result from, at least in part, their cal-
c i u m and phosphorous content. 97

( 0 MM0 N (A NCE RS: BREA ST, PRO STATE, LA RGE BOW EL       179
In other words, an enormous body of evidence shows that animal-
based foods are associated with prostate cancer. In the case of dairy, the
high intake of calcium and phosphorus also could be partly responsible
for this effect.
This research leaves little room for dissent; each of the above stud-
ies represents analyses of over a dozen individual studies, providing an
impressive bulk of convincing literature.
THE MECHANISMS
As we have seen with other forms of cancer, large-scale observational
studies show a link between prostate cancer and an animal-based diet,
particularly one based heavily on dairy. Understanding the mechanisms
behind the observed link between prostate cancer and dairy clinches
the argument.
The first mechanism concerns a hormone that increases cancer
cell growth, a hormone that our bodies make, as needed. This growth
hormone, Insulin-like Growth Factor 1 (IGF-l), is turning out to be a
predictor of cancer just as cholesterol is a predictor for heart disease.
Under normal conditions, this hormone efficiently manages the rates at
which cells "grow"-that is, how they reproduce themselves and how
they discard old cells, all in the name of good health.
Under unhealthy conditions, however, IGF-l becomes more active,
increasing the birth and growth of new cells while simultaneously in-
hibiting the removal of old cells, both of which favor the development
of cancer [seven studies cited98 ]. So what does this have to do with the
food we eat? It turns out that consuming animal-based foods increases
the blood levels ofthis growth hormone, IGF_P9101    -
With regard to prostate cancer, people with higher than normal blood
levels of IGF-I have been shown to have 5.1 times the risk of advanced-
stage prostate cancer.98 There's more: when men also have low blood
levels of a protein that binds and inactivates IGF_I,lo2 they will have 9.5
times the risk of advanced-stage prostate cancer,98 Let's put a few stars by
these numbers. They are big and impressive-and fundamental to this
finding is the fact that we make more IGF-I when we consume animal-
based foods like meat and dairy.99-101
The second mechanism relates to vitamin D metabolism. This "vi-
tamin" is not a nutrient that we need to consume. Our body can make
all that we need simply by being in sunlight fifteen to thirty minutes
every couple of days. In addition to the production of vitamin D being

180                          THE CHINA STUDY
affected by sunlight, it is also affected by the food that we eat. The for-
m a t i o n of the most active form of vitamin D is a process that is closely
monitored and controlled by our bodies. This process is a great example
of our bodies' natural balancing act, affecting not only prostate cancer,
but breast cancer, colon cancer, osteoporosis and autoimmune diseases
like Type 1 diabetes. Because of its importance for multiple diseases,
and because of the complexity involved in explaining how it all works,
I have provided in Appendix C an abbreviated scheme, just enough to
illustrate my point. This web of reactions illustrates many similar and
highly integrated reaction networks showing how food controls health.
The main component of this process is an active form of vitamin D
produced in the body from the vitamin D that we get from food or sun-
shine. This active or "supercharged" D produces many benefits through-
o u t the body, including the prevention of cancer, autoimmune diseases
and diseases like osteoporosis. This all-important supercharged D is not
something that you get from food or from a drug. A drug composed of
isolated supercharged D would be far too powerful and far too danger-
o u s for medical use. Your body uses a carefully composed series of con-
trols and sensors to produce just the right amount of supercharged D for
each task at exactly the right time.
As it turns out, our diet can determine how much of this super-
charged D is produced and how it works once it is produced. Animal
protein that we consume has the tendency to block the production of
supercharged D, leaving the body with low levels of this vitamin D in
the blood. If these low levels persist, prostate cancer can result. Also,
persistently high intakes of calcium create an environment where super-
charged D declines, thus adding to the problem.
So what food substance has both animal protein and large amounts
of calcium? Milk and other dairy foods. This fits in perfectly with the
evidence that links dairy consumption with prostate cancer. This infor-
m a t i o n provides what we call biological plausibility and shows how the
observational data fit together. To review the mechanisms:
• Animal protein causes the body to produce more IGF-l, which in
turn throws cell growth and removal out of whack, stimulating
cancer development.
• Animal protein suppresses the production of "supercharged" D.
• Excessive calcium, as found in milk, also suppresses the produc-
t i o n of "supercharged" D.