Physical activity of subjects aged 50-64 years involved in the European Prospective Investigation into Cancer and Nutrition (EPIC)

Multidomain Dementia Risk Reduction in Primary Care is Feasible: A Proof-of-concept study

Background

Dementia risk reduction is a public health priority, but interventions that can be easily implemented in routine care are scarce.

Objective

To evaluate the feasibility of integrating dementia risk reduction in regular consultations in primary care and the added value of a dedicated smartphone app ('MyBraincoach').

Methods

188 participants (40-60 years), with modifiable dementia risk factors were included from ten Dutch general practices in a cluster-randomized trial (NL9773, 06/10/2021). Practices were randomly allocated (1 : 1) to provide a risk-reduction consultation only or to additionally provide the app. During the consultation, participants learned about dementia risk reduction and how to improve their risk profile. The app group received daily microteaching-notifications about their personally relevant risk factors. Feasibility was evaluated after 3 months using questionnaires assessing knowledge on dementia risk reduction and health behavior change. The primary outcome was change in the validated "LIfestyle for BRAin health" (LIBRA) score. In-depth interviews were conducted with participants and primary care providers (PCPs).

Results

The interventions were positively perceived, with 72.0% finding the consultation informative and 69.2% considering the app useful. Drop-out was low (6.9%). LIBRA improved similarly in both groups, as did Mediterranean diet adherence and body mass index. Knowledge of dementia risk reduction increased, but more in the app group. Interviews provided insight in participants' and PCPs' needs and wishes.

Conclusions

Integrating dementia risk reduction in primary care, supported by a smartphone app, is a viable approach towards dementia risk reduction. Larger trials are needed to establish (cost-)effectiveness.

Greater adherence to the Healthy Nordic Food Index is associated with lower all-cause mortality in a population-based sample from northern Germany

PURPOSE

Dietary pattern scores reflecting a high intake of beneficial food groups were associated with reduced mortality risk. Data on associations of such dietary pattern scores in population-based samples from northern Germany are lacking. Therefore, we examined the association of three dietary pattern scores with all-cause mortality in a moderate-sized prospective sample from northern Germany.

METHODS

The study sample comprised 836 participants (43.8% females, median age 62.4 years). Based on a validated, self-administered Food Frequency Questionnaire, the dietary scores Dietary Approaches to Stop Hypertension (DASH), Modified Mediterranean Diet Score (MMDS), and Healthy Nordic Food Index (HNFI) were calculated. Cox proportional hazard regression models, adjusted for age, sex, body mass index, waist to hip ratio, education, smoking status, total energy intake, and physical activity, were used to separately relate DASH, MMDS, and HNFI to all-cause mortality.

RESULTS

During a median follow-up period of 11 years, 93 individuals died. While DASH and MMDS scores were not associated with all-cause mortality, greater adherence to HNFI was associated with lower mortality hazards (HR: 0.47 [95% CI 0.25-0.89] when comparing the highest score quartile to the lowest; HR: 0.79 [95% CI 0.64-0.98] for HNFI modeled as a 1-Standard Deviation increment). Among different HNFI components, higher intake of oats and cereals displayed the most conclusive association with all-cause mortality (HR: 0.59 [95% CI 0.38-0.91] when comparing high and low intake).

CONCLUSION

In an elderly general population sample from northern Germany, we observed greater adherence to HNFI to be associated with lower all-cause mortality.

Physical Activity and Risk of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Physical activity offers promise to protect against multiple non-hepatic primary cancers. We performed a systematic review to quantify the association between physical activity and hepatocellular carcinoma (HCC) risk.

METHODS

We searched the Cochrane Library, Embase, Medline and trial registries through December 2020 for studies that measured physical activity levels in adults at risk for HCC. The primary outcome was HCC. Subgroup analysis was performed limiting to vigorous physical activity. Proportions and random-effects odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated.

RESULTS

Seven studies met inclusion criteria, comprising 777,662 subjects (median age 55 years; 55% female). Greater amounts of physical activity were associated with less HCC (OR 0.65, 95% CI 0.45-0.95, p = 0.03) compared to lower amounts. Vigorous physical activity was associated with even less HCC (OR 0.62, 95% CI 0.49-0.79, p < 0.01).

CONCLUSIONS

This meta-analysis demonstrates that greater amounts of physical activity are associated with lower odds of HCC. These results support the use of regular physical activity as an effective way to prevent HCC and provide helpful data to support a for future exercise-based interventional study to better define the optimal exercise prescription for patients at risk for primary liver cancer.

Using mHealth for Primary Prevention of Dementia: A Proof-of-Concept Study on Usage Patterns, Appreciation, and Beliefs and Attitudes Regarding Prevention

BACKGROUND

Health- and lifestyle factors account for a substantial part of all dementia cases, which opens the opportunity for primary prevention. However, the required behavioral change is complex and involves targeting multiple risk factors. mHealth interventions can potentially contribute to improving motivation in a low-cost and scalable way.

OBJECTIVE

To explore usage patterns, appreciation, and beliefs and attitudes regarding dementia risk reduction during the use of the MyBraincoach mobile app.

METHODS

Participants were community-dwelling middle-aged adults from the Netherlands and used either the standard (education) or extended (education+motivational triggers) app version for three months. Two panel studies were combined in this paper. Chi-square tests, t-tests and linear mixed models were used, adjusted for age, sex, and education.

RESULTS

Of all participants (n = 299, 50.2% male), 167 (55.9%) had installed the app. The most reported reason for non-use was technical problems (47%). Those who used the app were at baseline already more positive about dementia risk reduction than those who did not use the app. Of all users who completed the evaluation (n = 102), 78.4% (n = 80) stated that the app provided a positive approach towards brain health and 80.4% (n = 82) felt better informed. Younger (<60y) and lower educated participants evaluated the app most positively.

CONCLUSION

Usage of the app was low, but users showed more positive beliefs and attitudes regarding dementia risk reduction. Most users evaluated the app positively and stated to have gained knowledge on the topic. Improving the use of the app must keep high priority in future studies.

Proinflammatory dietary pattern and depression risk in older adults: Prospective analyses from the Seniors-ENRICA studies

BACKGROUND & AIMS

Only a few studies have assessed the association between a proinflammatory diet and the risk of depression in older adults, and they have rendered weak results. The present study analysed the association between the Dietary Inflammatory Index (DII) and incident self-reported diagnosis or symptoms of depression in two cohorts of community-dwelling older adults in Spain.

METHODS

We used data from the Seniors-ENRICA-I (SE-I) and Seniors-ENRICA-II (SE-II) cohorts. In both cohorts, the baseline DII was calculated from habitual food consumption estimated with a validated computer-based diet history. The incidence of both physician self-reported diagnosis of depression and mild-to-major depressive symptoms (≥3 on the 10-item Geriatric Depression Scale) was analysed. Logistic regression models were adjusted for the main potential confounders, such as sociodemographics, lifestyles, and comorbidities. The results of both cohorts were pooled using a random effects model.

RESULTS

Among the 1627 participants in SE-I (mean age 71.5 ± 5.5 y, 53.1% women) and the 1579 in SE-II (mean age 71.4 ± 4.2, 46.7% women), 86 (5.3%) and 140 (8.9%) incident cases of depression were identified after a mean 3.2-y and 2.3-y follow-up, respectively. The fully adjusted odds ratio (95% confidence interval) of incident depression for the highest (the highest proinflammatory diet) versus the lowest quartile of DII was 2.76 (1.25-6.08, p-for-trend = 0.005) in the SE-I, 1.90 (1.04-3.40, p-for-trend = 0.005) in the SE-II and 2.07 (1.01-3.13) in the pooled cohorts. The results were consistent across strata defined by sex, age, physical activity, loneliness/poor social network, and morbidity.

CONCLUSIONS

A proinflammatory dietary pattern is associated with depression risk in older adults. Future research should evaluate whether reducing the inflammatory component of diet leads to reduced depression symptoms in this population.

Physical Activity and Cardiac Function in Long-Term Breast Cancer Survivors: A Cross-Sectional Study

Background

Higher levels of physical activity are associated with a lower risk of cardiovascular disease in the general population. Whether the same holds for women who underwent treatment for breast cancer is unclear.

Objectives

The aim of this study was to evaluate the association between physical activity in a typical week in the past 12 months and cardiac dysfunction in breast cancer survivors.

Methods

We used data from a cohort of breast cancer survivors who were treated at ages 40 to 50 years (N = 559). The association between physical activity and global longitudinal strain (GLS) and left ventricular ejection fraction (LVEF) was evaluated using both linear and modified Poisson regression analyses adjusted for relevant confounders.

Results

In total, 559 breast cancer survivors were included, with median age of 55.5 years and a median time since treatment of 10.2 years. GLS was less favorable in inactive survivors (−17.1%) than in moderately inactive (−18.4%), moderately active (−18.2%), and active survivors (−18.5%), with an adjusted significant difference for active versus inactive survivors (β = −1.31; 95% CI: −2.55 to −0.06)). Moderately active (n = 57/130) and active survivors (n = 87/124) had significantly lower risks of abnormal GLS (defined as >−18%) compared with inactive survivors (n = 17/26) (RR: 0.65 [95% CI: 0.45-0.94] and RR: 0.61 [95% CI: 0.43-0.87], respectively). LVEF, in normal ranges in all activity categories, was not associated with physical activity.

Conclusions

In long-term breast cancer survivors, higher physical activity levels were associated with improved GLS but not LVEF, with the relatively largest benefit for doing any activity versus none. This finding suggests that increasing physical activity may contribute to cardiovascular health benefits, especially in inactive survivors.

Physical Activity Is Associated with Improved Overall Survival among Patients with Metastatic Colorectal Cancer

Simple Summary

Physical activity is linked to longer survival among non-metastasized colorectal cancer patients. It is unclear if physical activity is also beneficial for survival among patients with metastatic colorectal cancer. We researched this question in our study of 293 patients with metastatic colorectal cancer. We found that participants who reported higher levels of physical activity at diagnosis lived longer compared to patients who reported low activity levels. Furthermore, adherence to the physical activity guidelines for cancer survivors was related to prolonged survival. Our findings suggest that patients with metastatic colorectal cancer also benefit from being physically active. Future studies are needed to investigate whether improving exercise levels after diagnosis of metastasis is also beneficial and what kind of exercise interventions are most optimal for possibly improving survival time of patients with metastatic colorectal cancer.

Abstract

Regular physical activity (PA) is associated with improved overall survival (OS) in stage I–III colorectal cancer (CRC) patients. This association is less defined in patients with metastatic CRC (mCRC). We therefore conducted a study in mCRC patients participating in the Prospective Dutch Colorectal Cancer cohort. PA was assessed with the validated SQUASH questionnaire, filled-in within a maximum of 60 days after diagnosis of mCRC. PA was quantified by calculating Metabolic Equivalent Task (MET) hours per week. American College of Sports and Medicine (ACSM) PA guideline adherence, tertiles of moderate to vigorous PA (MVPA), and sport and leisure time MVPA (MVPA-SL) were assessed as well. Vital status was obtained from the municipal population registry. Cox proportional-hazards models were used to study the association between PA determinants and all-cause mortality adjusted for prognostic patient and treatment-related factors. In total, 293 mCRC patients (mean age 62.9 ± 10.6 years, 67% male) were included in the analysis. Compared to low levels, moderate and high levels of MET-hours were significantly associated with longer OS (fully adjusted hazard ratios: 0.491, (95% CI 0.299–0.807, p value = 0.005) and 0.485 (95% CI 0.303–0.778, p value = 0.003), respectively), as were high levels of MVPA (0.476 (95% CI 0.278–0.816, p value = 0.007)) and MVPA-SL (0.389 (95% CI 0.224–0.677, p value < 0.001)), and adherence to ACSM PA guidelines compared to non-adherence (0.629 (95% CI 0.412–0.961, p value = 0.032)). The present study provides evidence that higher PA levels at diagnosis of mCRC are associated with longer OS.

Age at Menopause and Risk of Ischemic and Hemorrhagic Stroke

BACKGROUND AND PURPOSE

The few epidemiological studies that addressed the association between age at menopause and ischemic and hemorrhagic stroke risk in women had conflicting findings. We aimed to investigate whether age at (natural and surgical) menopause is a risk factor for total, ischemic, and hemorrhagic stroke in women.

METHODS

We analyzed data from 16 244 postmenopausal women, aged 26 to 70 years at recruitment who were enrolled in the European Prospective Investigation into Cancer and Nutrition-Netherlands cohort between 1993 and 1997. Participants were followed for the occurrence of stroke until January 1, 2011. At baseline, participants filled in questionnaires about health, reproductive history including age at menopause, diet, and lifestyle. Cox regression was used to investigate the association between age at menopause and stroke. All analyses were adjusted for age, smoking, systolic blood pressure, and body mass index.

RESULTS

Mean age of menopause was 46.4 (7.0) years. A total of 830 strokes (571 ischemic, 162 hemorrhagic, 97 unclassified) were identified. Earlier menopause was associated with an increased risk of total stroke. Compared with women who experienced menopause between 50 and 54 years old, women who underwent menopause before age 40 years had 1.48× higher risk (95% CI, 1.19-1.85) of total stroke. In continuous analyses, we observed a 2% lower total stroke risk for each year menopause was delayed (hazard ratio, 0.98 [95% CI, 0.97-0.99]). The risk between earlier menopause and stroke was confined to ischemic stroke, earlier menopause was not associated with hemorrhagic stroke. The association with age at menopause was stronger for natural menopause (hazard ratio <40 versus 50-54 years, 1.74 [95% CI, 1.12-2.70]) than for surgical menopause (hazard ratio <40 versus 50-54 years, 1.26 [95% CI, 0.84-1.89]).

CONCLUSIONS

The risk of total and ischemic stroke decreased with an increase in age at menopause. Whether this should have clinical consequences such as intensified risk factor control should be subject of further studies.

Post-diagnostic reliance on plant-compared with animal-based foods and all-cause mortality in omnivorous long-term colorectal cancer survivors

BACKGROUND

Plant-rich diets are associated with lower cardiometabolic risks and longer survival in the general population, but their association with mortality in cancer survivors is still unclear.

OBJECTIVES

We aimed to examine the associations of 3 postdiagnostic plant-based diet indices with all-cause mortality in omnivorous long-term colorectal cancer (CRC) survivors.

METHODS

Diet was assessed with FFQs at a median of 6 years after diagnosis in 1404 CRC survivors (56% male; median age, 69 years) in a Northern German prospective cohort study. An overall, a healthful plant-based, and an unhealthful plant-based diet index were derived by scoring intakes of animal foods reversely and intakes of healthy (whole grains, vegetables, fruits, legumes, nuts, oils, tea/coffee) and less healthy plant foods (refined grains, fruit juices, sugar-sweetened beverages, potatoes, sweets/desserts) positively or reversely, depending on the index. Vital status follow-up was conducted via population registries. Cox proportional hazards regression was applied to estimate HRs for all-cause mortality according to plant-based diet adherence.

RESULTS

Within 7 years (median) after diet assessment, 204 deaths occurred. The overall plant-based diet index displayed a significant, inverse association with all-cause mortality (HR per 10-point increase in diet index, 0.72; 95% CI, 0.57-0.91). Although not statistically significant, higher healthful plant-based diet scores showed a strong tendency towards lower mortality (HR, 0.82; 95% CI, 0.67-1.01). The unhealthful plant-based diet index was associated with higher mortality, but lost statistical significance after multivariable adjustment (HR, 1.19; 95% CI, 0.96-1.48). A subgroup analysis revealed that the tendency towards a positive association of the unhealthful plant-based diet with mortality was restricted to less physically active individuals (<95 metabolic equivalent of task hours/week).

CONCLUSIONS

An overall plant-based diet was inversely associated with all-cause mortality in long-term CRC survivors. However, more research is needed to further disentangle the impacts of different qualities of plant-based diets on cancer survivors' health.

Association between anthropometry and lifestyle factors and risk of B-cell lymphoma: An exposome-wide analysis

To better understand the role of individual and lifestyle factors in human disease, an exposome-wide association study was performed to investigate within a single-study anthropometry measures and lifestyle factors previously associated with B-cell lymphoma (BCL). Within the European Prospective Investigation into Cancer and nutrition study, 2402 incident BCL cases were diagnosed from 475 426 participants that were followed-up on average 14 years. Standard and penalized Cox regression models as well as principal component analysis (PCA) were used to evaluate 84 exposures in relation to BCL risk. Standard and penalized Cox regression models showed a positive association between anthropometric measures and BCL and multiple myeloma/plasma cell neoplasm (MM). The penalized Cox models additionally showed the association between several exposures from categories of physical activity, smoking status, medical history, socioeconomic position, diet and BCL and/or the subtypes. PCAs confirmed the individual associations but also showed additional observations. The PC5 including anthropometry, was positively associated with BCL, diffuse large B-cell lymphoma (DLBCL) and MM. There was a significant positive association between consumption of sugar and confectionary (PC11) and follicular lymphoma risk, and an inverse association between fish and shellfish and Vitamin D (PC15) and DLBCL risk. The PC1 including features of the Mediterranean diet and diet with lower inflammatory score showed an inverse association with BCL risk, while the PC7, including dairy, was positively associated with BCL and DLBCL risk. Physical activity (PC10) was positively associated with DLBCL risk among women. This study provided informative insights on the etiology of BCL.

Accelerated inflammatory aging in Alzheimer's disease and its relation to amyloid, tau, and cognition

It is unclear how pathological aging of the inflammatory system relates to Alzheimer's disease (AD). We tested whether age-related inflammatory changes in cerebrospinal fluid (CSF) and plasma exist across different stages of AD, and whether such changes related to AD pathology. Linear regression was first used model chronological age in amyloid-β negative, cognitively unimpaired individuals (Aβ- CU; n = 312) based on a collection of 73 inflammatory proteins measured in both CSF and plasma. Fitted models were then applied on protein levels from Aβ+ individuals with mild cognitive impairment (Aβ+ MCI; n = 150) or Alzheimer's disease dementia (Aβ+ AD; n = 139) to test whether the age predicted from proteins alone ("inflammatory age") differed significantly from true chronological age. Aβ- individuals with subjective cognitive decline (Aβ- SCD; n = 125) or MCI (Aβ- MCI; n = 104) were used as an independent contrast group. The difference between inflammatory age and chronological age (InflammAGE score) was then assessed in relation to core AD biomarkers of amyloid, tau, and cognition. Both CSF and plasma inflammatory proteins were significantly associated with age in Aβ- CU individuals, with CSF-based proteins predicting chronological age better than plasma-based counterparts. Meanwhile, the Aβ- SCD and validation Aβ- CU groups were not characterized by significant inflammatory aging, while there was increased inflammatory aging in Aβ- MCI patients for CSF but not plasma inflammatory markers. Both CSF and plasma inflammatory changes were seen in the Aβ+ MCI and Aβ+ AD groups, with varying degrees of change compared to Aβ- CU and Aβ- SCD groups. Finally, CSF inflammatory changes were highly correlated with amyloid, tau, general neurodegeneration, and cognition, while plasma changes were mostly associated with amyloid and cognition. Inflammatory pathways change during aging and are specifically altered in AD, tracking closely with pathological hallmarks. These results have implications for tracking AD progression and for suggesting possible pathways for drug targeting.

Adherence to a plant-based diet in relation to adipose tissue volumes and liver fat content

BACKGROUND

Better adherence to plant-based diets has been linked to lower risk of metabolic diseases but the effect on abdominal fat distribution and liver fat content is unclear.

OBJECTIVES

We aimed to examine the association between different plant-based diet indices and measures of abdominal fat distribution and liver fat content.

METHODS

In a population-based sample of 578 individuals from Northern Germany (57% male, median age 62 y), diet was assessed with a validated FFQ and an overall, a healthy, and an unhealthy plant-based diet index were derived. Participants underwent MRI to assess volumes of visceral and subcutaneous abdominal adipose tissue and liver signal intensity (LSI), a measure of liver fat content. Fatty liver disease (FLD) was defined as log LSI ≥3.0. Cross-sectional associations of the plant-based diet indices with visceral and subcutaneous abdominal fat volumes, LSI, and FLD were assessed in linear and logistic regression analyses. The most comprehensive model adjusted for age, sex, education, smoking, alcohol, physical activity, energy intake, diabetes, hyperlipidemia, and BMI.

RESULTS

Higher overall and healthy plant-based diet indices both revealed statistically significant associations with lower visceral and subcutaneous abdominal adipose tissue volumes and with lower odds of FLD in multivariable-adjusted models without BMI. Upon additional adjustment for BMI, only the association of the healthy plant-based diet with visceral adipose tissue remained statistically significant (per 10-point higher healthy plant-based diet index, percentage change in visceral adipose tissue: -4.9%, 95% CI: -8.6%, -2.0%). None of the plant-based diet indices was associated with LSI. The unhealthy plant-based diet index was unrelated to any of the abdominal or liver fat parameters.

CONCLUSIONS

Adherence to healthy plant-based diets was associated with lower visceral adipose tissue. None of the other examined associations remained statistically significant after adjustment for BMI.

Plasma Non-Enzymatic Antioxidant Capacity (NEAC) in Relation to Dietary NEAC, Nutrient Antioxidants and Inflammation-Related Biomarkers

(1) Background: Little is known about the interlinkages between dietary and plasma non-enzymatic antioxidant capacity (D-NEAC and P-NEAC, respectively) and the body’s antioxidant and inflammation response. Our aim was to explore these associations in 210 participants from two Spanish European Prospective Investigation into Cancer and Nutrition (EPIC) centers. (2) Methods: D-NEAC was estimated using published NEAC values in food. P-NEAC and total polyphenols (TP) were quantified by FRAP (ferric-reducing antioxidant power), TRAP (total radical-trapping antioxidant parameter), TEAC-ABTS (trolox equivalent antioxidant capacity-Azino Bis Thiazoline Sulfonic), ORAC (oxygen radical absorbance capacity) and Folin–Ciocalteu assays. Nutrient antioxidants (carotenes, α-tocopherol, ascorbic acid, retinol, uric acid, Q9 and Q10 coenzymes) and inflammation markers (IL-6, IL-8, CRP, TNF-α, PAI-I, resistin and adiponectin) were also analyzed. Spearman correlation and linear regression analyses were performed in association analyses. Analyses were stratified by covariates and groups were defined using cluster analysis. (3) Results: P-FRAP was correlated with D-NEAC, and significantly associated with P-NEAC in multivariate adjusted models. P-FRAP levels were also significantly associated with plasma antioxidants (log2 scale: TP β = 0.26; ascorbic acid β = 0.03; retinol β = 0.08; α-tocopherol β = 0.05; carotenes β = 0.02; Q10 β = 0.06; uric acid β = 0.25), though not with inflammation-related biomarkers. Different profiles of individuals with varying levels of P-NEAC and biomarkers were found. (4) Conclusions: P-NEAC levels were to some extent associated with D-NEAC and plasma antioxidants, yet not associated with inflammation response.

Hypoxia and exercise interactions on skeletal muscle insulin sensitivity in obese subjects with metabolic syndrome: results of a randomized controlled trial

BACKGROUND

Physical activity improves insulin sensitivity in obesity. Hypoxia training is claimed to augment this effect. We tested the hypothesis that normobaric hypoxia training would improve insulin sensitivity in obese patients with metabolic syndrome.

METHODS

In a randomized controlled trial, 23 obese men with metabolic syndrome who were not informed of the FiO₂ conditions underwent a 6-week physical exercise intervention under ambient (n = 11; FiO₂ 21%) conditions or hypoxia (n = 12; FiO₂ 15%) using a normobaric hypoxic chamber. Three 60-min sessions of interval training were performed each week at 60% of individual V̇O_2max. Assessment of myocellular insulin sensitivity by euglycemic hyperinsulinemic clamp was performed in 21 of these subjects before and after 6 weeks of training. Comprehensive phenotyping also included biopsies of subcutaneous adipose tissues.

RESULTS

The intermittent moderate physical exercise protocol did not substantially change the myocellular insulin sensitivity within 6 weeks under normoxic conditions (ISI_Clamp: 0.035 (IQR 0.016-0.075) vs. 0.037 (IQR 0.026-0.056) mg* kg^-1 *min^-1/(mU* l^-1); p = 0.767). In contrast, ISI_Clamp improved during hypoxia training (0.028 (IQR 0.018-0.035) vs. 0.038 (IQR 0.024-0.060) mg * kg^-1 *min^-1/(mU *l^-1); p < 0.05). Between group comparison of ISI_Clamp change revealed a small difference between groups (Cohen's d = 0.26). Within the hypoxic group, improvement of ISI_Clamp during training was associated with individual increase of circulating vascular endothelial growth factor (VEGF) levels (r = 0.678, p = 0.015), even if mean VEGF levels were not modified by any training condition. Atrial natriuretic peptide (ANP) system components were not associated with increased ISI_Clamp during hypoxic training.

CONCLUSIONS

Physical training under hypoxic conditions could partially augment the favorable effects of exercise alone on myocellular insulin sensitivity in obese men with metabolic syndrome. Concomitant changes in VEGF might represent an underlying pathophysiological mechanism.

Are our diets getting healthier and more sustainable? Insights from the European Prospective Investigation into Cancer and Nutrition - Netherlands (EPIC-NL) cohort

Objective:

To identify differences in dietary quality, dietary greenhouse gas (GHG) emissions and food consumption over 20 years in a Dutch cohort.

Design:

Participants (n 8932) filled out an FFQ in 1993–1997 and in 2015. The Dutch Healthy Diet index 2015 (DHD15-index) score, GHG emissions and consumption of food groups (g/4184 kJ (1000 kcal)) were compared between the time points with paired t tests.

Setting:

The Netherlands.

Participants:

European Prospective Investigation into Cancer and Nutrition – Netherlands (EPIC-NL) cohort, aged 18–65 years at baseline.

Results:

Total energy intake decreased by –678 (95 % CI –4908, 3377) kJ/d (–162 (95 % CI –1173, 807) kcal/d) for men and –372 (95 % CI –3820, 3130) kJ/d (–89 (95 % CI –913, 748) kcal/d) for women. DHD15-index scores increased by 11 % (from 64·8 to 71·9 points) and 13 % (from 65·2 to 73·6 points) in men and women, respectively (P < 0·0001), mainly due to an increased (shell)fish and nuts/seeds/nut paste consumption. After energy intake adjustment, dietary-related GHG emissions increased by 5 % in men (2·48–2·61 kg CO₂-eq/4184 kJ (1000 kcal), P < 0·0001) and were similar in women (0·4 %, 2·70–2·71 kg CO₂-eq/4184 kJ (1000 kcal), P = 0·3930) due to the increased consumption of (shell)fish, nuts/seeds/nut paste, poultry and higher GHG-intensive red meats such as beef.

Conclusions:

This Dutch cohort analyses showed more healthy diets without mitigated GHG emissions over a 20-year period, at similar energy intakes. Higher consumption of (shell)fish and poultry was not yet at the expense of red and processed meat. Lower consumption of animal-based foods is needed to achieve healthier as well as environmentally friendly diets.

Association between physical activity and risk of hepatobiliary cancers: A multinational cohort study

BACKGROUND & AIMS

To date, evidence on the association between physical activity and risk of hepatobiliary cancers has been inconclusive. We examined this association in the European Prospective Investigation into Cancer and Nutrition cohort (EPIC).

METHODS

We identified 275 hepatocellular carcinoma (HCC) cases, 93 intrahepatic bile duct cancers (IHBCs), and 164 non-gallbladder extrahepatic bile duct cancers (NGBCs) among 467,336 EPIC participants (median follow-up 14.9 years). We estimated cause-specific hazard ratios (HRs) for total physical activity and vigorous physical activity and performed mediation analysis and secondary analyses to assess robustness to confounding (e.g. due to hepatitis virus infection).

RESULTS

In the EPIC cohort, the multivariable-adjusted HR of HCC was 0.55 (95% CI 0.38-0.80) comparing active and inactive individuals. Regarding vigorous physical activity, for those reporting >2 hours/week compared to those with no vigorous activity, the HR for HCC was 0.50 (95% CI 0.33-0.76). Estimates were similar in sensitivity analyses for confounding. Total and vigorous physical activity were unrelated to IHBC and NGBC. In mediation analysis, waist circumference explained about 40% and body mass index 30% of the overall association of total physical activity and HCC.

CONCLUSIONS

These findings suggest an inverse association between physical activity and risk of HCC, which is potentially mediated by obesity.

LAY SUMMARY

In a pan-European study of 467,336 men and women, we found that physical activity is associated with a reduced risk of developing liver cancers over the next decade. This risk was independent of other liver cancer risk factors, and did not vary by age, gender, smoking status, body weight, and alcohol consumption.

Dietary folate intake and pancreatic cancer risk: Results from the European prospective investigation into cancer and nutrition

Pancreatic cancer (PC) has an exceptionally low survival rate and primary prevention strategies are limited. Folate plays an important role in one-carbon metabolism and has been associated with the risk of several cancers, but not consistently with PC risk. We aimed to investigate the association between dietary folate intake and PC risk, using the standardised folate database across 10 European countries. A total of 477,206 participants were followed up for 11 years, during which 865 incident primary PC cases were recorded. Folate intake was energy-adjusted using the residual method. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models. In multivariable analyses stratified by age, sex, study centre and adjusted for energy intake, smoking status, BMI, educational level, diabetes status, supplement use and dietary fibre intake, we found no significant association between folate intake and PC risk: the HR of PC risk for those in the highest quartile of folate intake (≥353 μg/day) compared to the lowest (<241 μg/day) was 0.81 (95% CI: 0.51, 1.31; ptrend = 0.38). In current smokers, a positive trend was observed in PC risk across folate quartiles [HR = 4.42 (95% CI: 1.05, 18.62) for ≥353 μg/day vs. <241 μg/day, ptrend = 0.01]. Nonetheless, there was no significant interaction between smoking and dietary folate intake (pinteraction = 0.99). We found no association between dietary folate intake and PC risk in this large European study.

Association of IL1RAP-related genetic variation with cerebrospinal fluid concentration of Alzheimer-associated tau protein

A possible involvement of the gene IL1RAP (interleukin-1 receptor-associated protein) in the pathogenesis of Alzheimer’s disease (AD) has been suggested in GWASs of cerebrospinal fluid (CSF) tau levels and longitudinal change in brain amyloid burden. The aim of this study was to examine previously implicated genetic markers in and near IL1RAP in relation to AD risk, CSF tau and Aβ biomarkers, as well as cognitive decline, in a case (AD)-control study and an age homogenous population-based cohort. Genotyping of IL1RAP-related single nucleotide polymorphisms (SNPs), selected based on previous GWAS results, was performed. 3446 individuals (1154 AD cases and 2292 controls) were included in the analyses of AD risk, 1400 individuals (cognitively normal = 747, AD = 653) in the CSF biomarker analyses, and 861 individuals in the analyses of cognitive decline. We found no relation between IL1RAP-related SNPs and AD risk. However, CSF total-tau and phospho-tau were associated with the SNP rs9877502 (p = 6 × 10⁻³ and p = 5 × 10⁻⁴). Further, nominal associations (p = 0.03–0.05) were found between three other SNPs and CSF biomarker levels, or levels of cognitive performance and decline in a sub-sample from the general population. These results support previous studies suggesting an association of IL1RAP with disease intensity of AD.

Timing of eating across ten European countries - results from the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study

OBJECTIVE

To examine timing of eating across ten European countries.

DESIGN

Cross-sectional analysis of the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study using standardized 24 h diet recalls collected during 1995-2000. Eleven predefined food consumption occasions were assessed during the recall interview. We present time of consumption of meals and snacks as well as the later:earlier energy intake ratio, with earlier and later intakes defined as 06.00-14.00 and 15.00-24.00 hours, respectively. Type III tests were used to examine associations of sociodemographic, lifestyle and health variables with timing of energy intake.

SETTING

Ten Western European countries.

SUBJECTS

In total, 22 985 women and 13 035 men aged 35-74 years (n 36 020).

RESULTS

A south-north gradient was observed for timing of eating, with later consumption of meals and snacks in Mediterranean countries compared with Central and Northern European countries. However, the energy load was reversed, with the later:earlier energy intake ratio ranging from 0·68 (France) to 1·39 (Norway) among women, and from 0·71 (Greece) to 1·35 (the Netherlands) among men. Among women, country, age, education, marital status, smoking, day of recall and season were all independently associated with timing of energy intake (all P<0·05). Among men, the corresponding variables were country, age, education, smoking, physical activity, BMI and day of recall (all P<0·05).

CONCLUSIONS

We found pronounced differences in timing of eating across Europe, with later meal timetables but greater energy load earlier during the day in Mediterranean countries compared with Central and Northern European countries.

Association between the dietary inflammatory index and all-cause mortality in colorectal cancer long-term survivors

Pro-inflammatory dietary factors have been shown to be associated with the incidence of a range of cancers. However, there are many fewer studies on the association between the inflammatory potential of diet and survival after cancer diagnosis. We examined the association between post-diagnosis dietary inflammatory index (DII®) scores and all-cause mortality in long-term survivors of colorectal cancer (CRC). DII scores were calculated from dietary data of 1,404 CRC survivors collected at a median of 6 years after CRC diagnosis. Using multivariable-adjusted Cox proportional hazards regression models, hazard ratios (HR) and 95% confidence intervals (CI) were estimated for the association of DII scores, modeled continuous and in quartiles, with all-cause mortality. After a median follow-up time of 7 years (after dietary assessment), 204 study participants had died. Overall, in the fully adjusted model there was a suggestion of a positive association between DII score and all-cause mortality (HR_{DIIquartile4vs1} : 1.36; 95% CI: 0.88-2.09 and HR_{DIIcontinuous} : 1.08; 95% CI: 0.97-1.20). However, in subgroup analyses, we found significant differences in individuals with metastatic disease (HR_{DIIcontinuous} : 1.34; 95% CI: 1.07-1.67) and the absence of stoma (HR_{DIIcontinuous} : 1.15; 95% CI: 1.02-1.29). Overall, the post-diagnosis DII was not statistically significantly associated with all-cause mortality in CRC long-term survivors; however, there was suggestive evidence of an association in select subgroups.

Health-related quality of life in long-term survivors of colorectal cancer and its association with all-cause mortality: a German cohort study

Background

The group of colorectal cancer (CRC) survivors continues to grow worldwide. Understanding health-related quality of life (HRQOL) determinants and consequences of HRQOL impairments in long-term CRC survivors may help to individualize survivorship care plans. We aimed to i) examine the HRQOL status of CRC long-term survivors, ii) identify cross-sectional sociodemographic and clinical correlates of HRQOL, and iii) investigate the prospective association of HRQOL after CRC diagnosis with all-cause mortality.

Methods

We assessed HRQOL within a Northern German cohort of 1294 CRC survivors at a median of 6 years after CRC diagnosis using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Cross-sectional correlates of different HRQOL dimensions were analyzed using multivariable-adjusted logistic regression models with HRQOL as a binary variable. With multivariable-adjusted Cox proportional hazards regression models, hazard ratios (HR) of all-cause mortality were estimated per 10-point-increments of an HRQOL summary score, a global quality of life scale, and HRQOL functioning and symptom domains.

Results

The median HRQOL summary score was 87 (interquartile range: 75–94). Sex, age, education, tumor location, metastases, other cancers, type of therapy, and current stoma were identified as correlates of different HRQOL scales. After a median follow-up time of 7 years after HRQOL assessment, 175 participants had died. Nearly all HRQOL domains, except for cognitive functioning and diarrhea, were significantly associated with all-cause mortality. A 10-point-increment in the summary score decreased the risk of death by 24% (HR: 0.76; 95% CI: 0.70–0.82).

Conclusions

HRQOL in CRC survivors appeared to be relatively high in the long term. Various clinical and sociodemographic factors were cross-sectionally associated with HRQOL in long-term CRC survivors. Lower HRQOL was associated with increased all-cause mortality. Individualized healthcare programs for CRC survivors (including psychosocial screening and interventions) are needed to detect decreased HRQOL and to further improve long-term HRQOL and survival.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5075-1) contains supplementary material, which is available to authorized users.

Fatty acids from dairy and meat and their association with risk of coronary heart disease

PURPOSE

The relationship of total, saturated, mono-unsaturated and poly-unsaturated fatty acids (SFA, MUFA, PUFA) with coronary heart disease (CHD) is debated. We hypothesized that the association of dairy-derived FA with CHD may be different than the association of meat-derived FA with CHD. We therefore aimed to directly compare association of FA intakes from dairy and meat with risk of CHD using substitution models.

METHODS

Baseline (1993-1997) FA intake was measured using a validated food frequency questionnaire among 35,767 participants from the European Prospective Investigation into Cancer and Nutrition-Netherlands cohort (EPIC-NL). Incident CHD events (n = 2374) were obtained through linkage with national registries during a mean follow-up of 15 years. Association of FA from dairy substituted with FA from meat with CHD risk was estimated through multivariable Cox regression.

RESULTS

Participants consumed 81.9 (SD 28.7) grams of FA per day, of which 17.9 (SD 5.2) was from dairy and 15.3 (SD 9.5) from meat. Substituting 1 en% of dairy-derived SFA with meat-derived SFA was associated with higher CHD risk (HR 1.06, 95% CI 1.02-1.10), but substituting dairy-derived MUFA or PUFA did not (HR_MUFA 1.03, 95% CI 0.97-1.09; HR_PUFA 1.17, 95% CI 0.90-1.53).

CONCLUSIONS

Our modelling suggests that substituting dairy SFA with meat SFA is associated with a higher risk of CHD, but substituting dairy MUFA or PUFA with meat FA is not. These results need to be replicated in other cohorts with different fat intakes, preferably with larger variation in the intake of MUFA and PUFA from dairy and meat.

The risk of cardiovascular disease following breast cancer by Framingham risk score

OBJECTIVES

This study evaluates the risk of cardiovascular disease (CVD) following breast cancer, accounting for baseline CVD risk.

METHODS

Within the EPIC-NL (Dutch part of the European Prospective Investigation into Nutrition and Cancer) cohort, 1103 women were diagnosed with breast cancer. For every breast cancer patient, 3-4 women without breast cancer (n = 4328) were selected matched for age, year, and time since cohort enrollment. Based on CVD risk factors at cohort enrollment, 10-year risk of CVD was calculated and categorized: low (< 10%), intermediate (10-20%), high (> 20%). Cox proportional hazard models assessed the risk of CVD events (hospitalization or mortality) and CVD mortality of women with versus without breast cancer, adjusted for baseline CVD risk.

RESULTS

After median follow-up of 5 and 6 years, 92 (8.3%) and 325 (7.5%) CVD events occurred in women with and without breast cancer, respectively. In the low CVD risk group, women with breast cancer had 1.44 (95% CI 1.00-2.06) times higher risk of CVD events than women without breast cancer. In the intermediate and high CVD risk categories, risk of CVD events was similar in women with and without breast cancer. Overall, women with breast cancer had 1.77 (95% CI 1.10-2.86) times higher risk of CVD mortality than women without breast cancer.

CONCLUSIONS

Among women with low CVD risk, women with breast cancer have a higher risk of CVD event than women without breast cancer. Overall, women with breast cancer have a higher risk of CVD mortality than women without breast cancer.

Coffee and Tea Consumption and the Contribution of Their Added Ingredients to Total Energy and Nutrient Intakes in 10 European Countries: Benchmark Data from the Late 1990s

BACKGROUND

Coffee and tea are among the most commonly consumed nonalcoholic beverages worldwide, but methodological differences in assessing intake often hamper comparisons across populations. We aimed to (i) describe coffee and tea intakes and (ii) assess their contribution to intakes of selected nutrients in adults across 10 European countries.

METHOD

Between 1995 and 2000, a standardized 24-h dietary recall was conducted among 36,018 men and women from 27 European Prospective Investigation into Cancer and Nutrition (EPIC) study centres. Adjusted arithmetic means of intakes were estimated in grams (=volume) per day by sex and centre. Means of intake across centres were compared by sociodemographic characteristics and lifestyle factors.

RESULTS

In women, the mean daily intake of coffee ranged from 94 g/day (~0.6 cups) in Greece to 781 g/day (~4.4 cups) in Aarhus (Denmark), and tea from 14 g/day (~0.1 cups) in Navarra (Spain) to 788 g/day (~4.3 cups) in the UK general population. Similar geographical patterns for mean daily intakes of both coffee and tea were observed in men. Current smokers as compared with those who reported never smoking tended to drink on average up to 500 g/day more coffee and tea combined, but with substantial variation across centres. Other individuals' characteristics such as educational attainment or age were less predictive. In all centres, coffee and tea contributed to less than 10% of the energy intake. The greatest contribution to total sugar intakes was observed in Southern European centres (up to ~20%).

CONCLUSION

Coffee and tea intake and their contribution to energy and sugar intake differed greatly among European adults. Variation in consumption was mostly driven by geographical region.

Circulating Fetuin-A and Risk of Type 2 Diabetes: A Mendelian Randomization Analysis

Fetuin-A, a hepatic-origin protein, is strongly positively associated with risk of type 2 diabetes in human observational studies, but it is unknown whether this association is causal. We aimed to study the potential causal relation of circulating fetuin-A to risk of type 2 diabetes in a Mendelian randomization study with single nucleotide polymorphisms located in the fetuin-A-encoding AHSG gene. We used data from eight European countries of the European Prospective Investigation into Cancer and Nutrition (EPIC)-InterAct case-cohort study including 10,020 incident cases. Plasma fetuin-A concentration was measured in a subset of 965 subcohort participants and 654 case subjects. A genetic score of the AHSG single nucleotide polymorphisms was strongly associated with fetuin-A (28% explained variation). Using the genetic score as instrumental variable of fetuin-A, we observed no significant association of a 50 µg/mL higher fetuin-A concentration with diabetes risk (hazard ratio 1.02 [95% CI 0.97, 1.07]). Combining our results with those from the DIAbetes Genetics Replication And Meta-analysis (DIAGRAM) consortium (12,171 case subjects) also did not suggest a clear significant relation of fetuin-A with diabetes risk. In conclusion, although there is mechanistic evidence for an effect of fetuin-A on insulin sensitivity and secretion, this study does not support a strong, relevant relationship between circulating fetuin-A and diabetes risk in the general population.

Circulating Metabolites Associated with Alcohol Intake in the European Prospective Investigation into Cancer and Nutrition Cohort

Identifying the metabolites associated with alcohol consumption may provide insights into the metabolic pathways through which alcohol may affect human health. We studied associations of alcohol consumption with circulating concentrations of 123 metabolites among 2974 healthy participants from the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Alcohol consumption at recruitment was self-reported through dietary questionnaires. Metabolite concentrations were measured by tandem mass spectrometry (BIOCRATES AbsoluteIDQTM p180 kit). Data were randomly divided into discovery (2/3) and replication (1/3) sets. Multivariable linear regression models were used to evaluate confounder-adjusted associations of alcohol consumption with metabolite concentrations. Metabolites significantly related to alcohol intake in the discovery set (FDR q-value < 0.05) were further tested in the replication set (Bonferroni-corrected p-value < 0.05). Of the 72 metabolites significantly related to alcohol intake in the discovery set, 34 were also significant in the replication analysis, including three acylcarnitines, the amino acid citrulline, four lysophosphatidylcholines, 13 diacylphosphatidylcholines, seven acyl-alkylphosphatidylcholines, and six sphingomyelins. Our results confirmed earlier findings that alcohol consumption was associated with several lipid metabolites, and possibly also with specific acylcarnitines and amino acids. This provides further leads for future research studies aiming at elucidating the mechanisms underlying the effects of alcohol in relation to morbid conditions.

Dietary patterns within educational groups and their association with CHD and stroke in the European Prospective Investigation into Cancer and Nutrition-Netherlands cohort

Higher-educated people often have healthier diets, but it is unclear whether specific dietary patterns exist within educational groups. We therefore aimed to derive dietary patterns in the total population and by educational level and to investigate whether these patterns differed in their composition and associations with the incidence of fatal and non-fatal CHD and stroke. Patterns were derived using principal components analysis in 36 418 participants of the European Prospective Investigation into Cancer and Nutrition-Netherlands cohort. Self-reported educational level was used to create three educational groups. Dietary intake was estimated using a validated semi-quantitative FFQ. Hazard ratios were estimated using Cox Proportional Hazard analysis after a mean follow-up of 16 years. In the three educational groups, similar 'Western', 'prudent' and 'traditional' patterns were derived as in the total population. However, with higher educational level a lower population-derived score for the 'Western' and 'traditional' patterns and a higher score on the 'prudent' pattern were observed. These differences in distribution of the factor scores illustrate the association between education and food consumption. After adjustments, no differences in associations between population-derived dietary patterns and the incidence of CHD or stroke were found between the educational groups (P interaction between 0·21 and 0·98). In conclusion, although in general population and educational groups-derived dietary patterns did not differ, small differences between educational groups existed in the consumption of food groups in participants considered adherent to the population-derived patterns (Q4). This did not result in different associations with incident CHD or stroke between educational groups.

Vitamin E (α- and γ-Tocopherol) Levels in the Community: Distribution, Clinical and Biochemical Correlates, and Association with Dietary Patterns

Little is known about the distribution and determinants of circulating vitamin E levels in a German population. In this cross-sectional study we assessed the distribution of both α- and γ-tocopherol levels, identified their clinical and biochemical correlates, and assessed their relationships with a priori and a posteriori derived dietary patterns. Plasma α- and γ-tocopherol concentrations were measured using high performance liquid chromatography (HPLC) with fluorescence detection in 641 individuals (mean-age: 61 years; 40.6% women). Correlates of both markers were determined using linear regression with backward selection. Using a validated food-frequency questionnaire (FFQ), an a priori defined vitamin E-rich dietary pattern was constructed, and three a posteriori derived dietary patterns were identified by principal component analysis. Each pattern was related to α- and γ-tocopherol levels using linear regression. Median concentrations of α- and γ-tocopherol were 31.54 μmol/L and 1.35 µmol/L, respectively. 57.6% of participants had α-tocopherol levels >30 µmol/L. Triglycerides, high density lipoprotein (HDL)- and low density lipoprotein (LDL)-cholesterol, and vitamin E supplementation were identified as correlates of vitamin E levels. After excluding supplement users, a dietary pattern rich in meat, bread, fats, potatoes, and sugar/confectionery was inversely related to α-tocopherol levels (β, −0.032, SE = 0.016; p = 0.047). Prospective studies are warranted to evaluate the actual impact of the reported findings in terms of nutrition and health outcomes.

Physical activity, mediating factors and risk of colon cancer: insights into adiposity and circulating biomarkers from the EPIC cohort

Background

There is convincing evidence that high physical activity lowers the risk of colon cancer; however, the underlying biological mechanisms remain largely unknown. We aimed to determine the extent to which body fatness and biomarkers of various biologically plausible pathways account for the association between physical activity and colon cancer.

Methods

We conducted a nested case-control study in a cohort of 519 978 men and women aged 25 to 70 years followed from 1992 to 2003. A total of 713 incident colon cancer cases were matched, using risk-set sampling, to 713 controls on age, sex, study centre, fasting status and hormonal therapy use. The amount of total physical activity during the past year was expressed in metabolic equivalent of task [MET]-h/week. Anthropometric measurements and blood samples were collected at study baseline.

Results

High physical activity was associated with a lower risk of colon cancer: relative risk ≥91 MET-h/week vs <91 MET-h/week = 0.75 [95% confidence interval (CI): 0.57 to 0.96]. In mediation analyses, this association was accounted for by waist circumference: proportion explained effect (PEE) = 17%; CI: 4% to 52%; and the biomarkers soluble leptin receptor (sOB-R): PEE = 15%; 95% CI: 1% to 50% and 5-hydroxyvitamin D (25[OH]D): PEE = 30%; 95% CI: 12% to 88%. In combination, these factors explained 45% (95% CI: 20% to 125%) of the association. Beyond waist circumference, sOB-R and 25[OH]D additionally explained 10% (95% CI: 1%; 56%) and 23% (95% CI: 6%; 111%) of the association, respectively.

Conclusions

Promoting physical activity, particularly outdoors, and maintaining metabolic health and adequate vitamin D levels could represent a promising strategy for colon cancer prevention.

Postdiagnostic physical activity, sleep duration, and TV watching and all-cause mortality among long-term colorectal cancer survivors: a prospective cohort study

BACKGROUND

Lifestyle recommendations for cancer survivors are warranted to improve survival. In this study, we aimed to examine the association of total physical activity, different types of physical activity, hours of sleeping at day and night, and hours spent watching television (TV) with all-cause mortality in long-term colorectal cancer (CRC) survivors.

METHODS

We assessed physical activity in 1376 CRC survivors (44% women; median age, 69 years) at median 6 years after CRC diagnosis using a validated questionnaire. Multivariable-adjusted Cox regression models were used to estimate hazard ratios (HRs) for all-cause mortality according to categories of physical activities, sleep duration, and TV watching.

RESULTS

During a median follow-up time of 7 years, 200 participants had died. Higher total physical activity was significantly associated with lower all-cause mortality (HR: 0.53; 95% CI: 0.36-0.80, 4th vs. 1st quartile). Specifically, sports, walking, and gardening showed a significant inverse association with all-cause mortality (HR: 0.34; 95% CI: 0.20-0.59, HR: 0.65; 95% CI: 0.43-1.00, and HR: 0.62; 95% CI: 0.42-0.91, respectively for highest versus lowest category). Individuals with ≥2 h of sleep during the day had a significantly increased risk of all-cause mortality compared to individuals with no sleep at day (HR: 2.22; 95% CI: 1.43-3.44). TV viewing of ≥4 h per day displayed a significant 45% (95% CI: 1.02-2.06) higher risk of dying compared to ≤2 h per day of watching TV.

CONCLUSIONS

Physical activity was inversely related to all-cause mortality; specific activity types might be primarily responsible for this association. More hours of sleep during the day and a higher amount of TV viewing were each associated with higher all-cause mortality. Based on available evidence, it is reasonable to recommend CRC survivors to engage in regular physical activity.

Association of Vitamin E Levels with Metabolic Syndrome, and MRI-Derived Body Fat Volumes and Liver Fat Content

We aimed to relate circulating α- and γ-tocopherol levels to a broad spectrum of adiposity-related traits in a cross-sectional Northern German study. Anthropometric measures were obtained, and adipose tissue volumes and liver fat were quantified by magnetic resonance imaging in 641 individuals (mean age 61 years; 40.6% women). Concentrations of α- and γ-tocopherol were measured using high performance liquid chromatography. Multivariable-adjusted linear and logistic regression were used to assess associations of circulating α- and γ-tocopherol/cholesterol ratio levels with visceral (VAT) and subcutaneous adipose tissue (SAT), liver signal intensity (LSI), fatty liver disease (FLD), metabolic syndrome (MetS), and its individual components. The α-tocopherol/cholesterol ratio was positively associated with VAT (β scaled by interquartile range (IQR): 0.036; 95%Confidence Interval (CI): 0.0003; 0.071) and MetS (Odds Ratio (OR): 1.83; 95% CI: 1.21–2.76 for 3rd vs. 1st tertile), and the γ-tocopherol/cholesterol ratio was positively associated with VAT (β scaled by IQR: 0.066; 95% CI: 0.027; 0.104), SAT (β scaled by IQR: 0.048; 95% CI: 0.010; 0.087) and MetS (OR: 1.87; 95% CI: 1.23–2.84 for 3rd vs. 1st tertile). α- and γ-tocopherol levels were positively associated with high triglycerides and low high density lipoprotein cholesterol levels (all P_trend < 0.05). No association of α- and γ-tocopherol/cholesterol ratio with LSI/FLD was observed. Circulating vitamin E levels displayed strong associations with VAT and MetS. These observations lay the ground for further investigation in longitudinal studies.

Lean Body Mass Is the Predominant Anthropometric Risk Factor for Atrial Fibrillation

BACKGROUND

Obesity is repeatedly emphasized as a risk factor for atrial fibrillation or flutter (AF). However, the underlying evidence may be questioned, as the obvious correlations between various anthropometric measures hamper identification of the characteristics that are biologically driving AF risk, and recent studies suggest that fat carries limited or no independent risk of AF.

OBJECTIVES

This study sought to assess mutually adjusted associations among AF risk and height, weight, body mass index, hip and waist circumference, waist-to-hip ratio, and bioelectrical impedance-derived measures of fat mass, lean body mass, and fat percentage.

METHODS

Anthropometric measures and self-reported life-style information were collected from 1993 to 1997 in a population-based cohort including 55,273 persons age 50 to 64 years who were followed in Danish registers until June 2013.

RESULTS

During a median of 17 years of follow-up, 3,868 persons developed AF. Adjusted hazard ratios per population SD difference (HRs) showed highly statistically significant, positive associations for all 9 anthropometric measures (HRs ranging from 1.08 [95% confidence interval (CI): 1.05 to 1.12] for waist-to-hip ratio to 1.37 [95% CI: 1.33 to 1.42] for lean body mass). Pairwise mutual adjustment of the 9 measures left the association for lean body mass virtually unchanged (lowest HR: 1.33 [95% CI: 1.28 to 1.39] when adjusting for height), whereas no other association remained substantial when adjusted for lean body mass (highest HR: 1.05 [95% CI: 1.01 to 1.10] for height).

CONCLUSIONS

Lean body mass was the predominant anthropometric risk factor for AF, whereas no association was observed for either of the obesity-related anthropometric measures after adjustment for lean body mass.

Does a better adherence to dietary guidelines reduce mortality risk and environmental impact in the Dutch sub-cohort of the European Prospective Investigation into Cancer and Nutrition?

Guidelines for a healthy diet aim to decrease the risk of chronic diseases. It is unclear as to what extent a healthy diet is also an environmentally friendly diet. In the Dutch sub-cohort of the European Prospective Investigation into Cancer and Nutrition, the diet was assessed with a 178-item FFQ of 40 011 participants aged 20-70 years between 1993 and 1997. The WHO's Healthy Diet Indicator (HDI), the Dietary Approaches to Stop Hypertension (DASH) score and the Dutch Healthy Diet index 2015 (DHD15-index) were investigated in relation to greenhouse gas (GHG) emissions, land use and all-cause mortality risk. GHG emissions were associated with HDI scores (-3·7 % per sd increase (95 % CI -3·4, -4·0) for men and -1·9 % (95 % CI -0·4, -3·4) for women), with DASH scores in women only (1·1 % per sd increase, 95 % CI 0·9, 1·3) and with DHD15-index scores (-2·5 % per sd increase (95 % CI -2·2, -2·8) for men and -2·0 % (95 % CI -1·9, -2·2) for women). For all indices, higher scores were associated with less land use (ranging from -1·3 to -3·1 %). Mortality risk decreased with increasing scores for all indices. Per sd increase of the indices, hazard ratios for mortality ranged from 0·88 (95 % CI 0·82, 0·95) to 0·96 (95 % CI 0·92, 0·99). Our results showed that adhering to the WHO and Dutch dietary guidelines will lower the risk of all-cause mortality and moderately lower the environmental impact. The DASH diet was associated with lower mortality and land use, but because of high dairy product consumption in the Netherlands it was also associated with higher GHG emissions.

Plasma tau in Alzheimer disease

Objective:

To test whether plasma tau is altered in Alzheimer disease (AD) and whether it is related to changes in cognition, CSF biomarkers of AD pathology (including β-amyloid [Aβ] and tau), brain atrophy, and brain metabolism.

Methods:

This was a study of plasma tau in prospectively followed patients with AD (n = 179), patients with mild cognitive impairment (n = 195), and cognitive healthy controls (n = 189) from the Alzheimer's Disease Neuroimaging Initiative (ADNI) and cross-sectionally studied patients with AD (n = 61), mild cognitive impairment (n = 212), and subjective cognitive decline (n = 174) and controls (n = 274) from the Biomarkers for Identifying Neurodegenerative Disorders Early and Reliably (BioFINDER) study at Lund University, Sweden. A total of 1284 participants were studied. Associations were tested between plasma tau and diagnosis, CSF biomarkers, MRI measures, ¹⁸fluorodeoxyglucose-PET, and cognition.

Results:

Higher plasma tau was associated with AD dementia, higher CSF tau, and lower CSF Aβ₄₂, but the correlations were weak and differed between ADNI and BioFINDER. Longitudinal analysis in ADNI showed significant associations between plasma tau and worse cognition, more atrophy, and more hypometabolism during follow-up.

Conclusions:

Plasma tau partly reflects AD pathology, but the overlap between normal aging and AD is large, especially in patients without dementia. Despite group-level differences, these results do not support plasma tau as an AD biomarker in individual people. Future studies may test longitudinal plasma tau measurements in AD.

Changes in physical activity after bariatric surgery: using objective and self-reported measures

BACKGROUND

Many studies using self-reported physical activity (PA) assessment tools have suggested there is an increase in PA after bariatric surgery.

OBJECTIVES

Our aim was to assess PA and sedentary behavior before bariatric surgery and at 6 months after, using subjective and objective tools.

SETTING

Bariatric surgery candidates were recruited from a single center.

METHODS

Demographic data, medical history, current medications, and anthropometric measurements were recorded. Participants were asked to complete a PA and lifestyle questionnaire and to wear an accelerometer on their nondominant wrist. Data were collected before and at 6 months after surgery.

RESULTS

Twenty-two participants were included (17 gastric bypass; 4 sleeve gastrectomy; 1 intragastric balloon). Mean age was 46 years and the majority were female (72%). At a median of 6.3 months follow-up, there were significant reductions in measures of body fatness with a mean reduction of 27 kg in weight. The majority of daytime (12.5±1.1 out of 16 h) was spent in sedentary behavior presurgery with little change postsurgery (12.2±1.2; P = .186). Objectively measured mean moderate-vigorous PA did not change significantly from pre- to postsurgery (mean 11.5±13.9 and 11.6±13.1 min/d, respectively; P = .971). Self-reported total nonoccupational PA did not change significantly (P = .390).

CONCLUSIONS

The majority of bariatric surgery candidates were physically inactive presurgery, and there was no significant change in either subjectively or objectively measured PA at follow-up. This patient group may benefit from objective PA assessment and interventions aimed at increasing PA.

Variation in population levels of physical activity in European adults according to cross-European studies: a systematic literature review within DEDIPAC

BACKGROUND

Physical inactivity is a well-known public health risk that should be monitored at the population level. Physical activity levels are often surveyed across Europe. This systematic literature review aims to provide an overview of all existing cross-European studies that assess physical activity in European adults, describe the variation in population levels according to these studies, and discuss the impact of the assessment methods.

METHODS

Six literature databases (PubMed, EMBASE, CINAHL, PsycINFO, SportDiscus and OpenGrey) were searched, supplemented with backward- and forward tracking and searching authors' and experts' literature databases. Articles were included if they reported on observational studies measuring total physical activity and/or physical activity in leisure time in the general population in two or more European countries. Each record was reviewed, extracted and assessed by two independent researchers and disagreements were resolved by a third researcher. The review protocol of this review is registered in the PROSPERO database under registration number CRD42014010334.

RESULTS

Of the 9,756 unique identified articles, twenty-five were included in this review, reporting on sixteen different studies, including 2 to 35 countries and 321 to 274,740 participants. All but two of the studies used questionnaires to assess physical activity, with the majority of studies using the IPAQ-short questionnaire. The remaining studies used accelerometers. The percentage of participants who either were or were not meeting the physical activity recommendations was the most commonly reported outcome variable, with the percentage of participants meeting the recommendations ranging from 7% to 96% across studies and countries.

CONCLUSIONS

The included studies showed substantial variation in the assessment methods, reported outcome variables and, consequently, the presented physical activity levels. Because of this, absolute population levels of physical activity in European adults are currently unknown. However, when ranking countries, Ireland, Italy, Malta, Portugal, and Spain generally appear to be among the less active countries. Objective data of adults across Europe is currently limited. These findings highlight the need for standardisation of the measurement methods, as well as cross-European monitoring of physical activity levels.

Distribution of energy intake throughout the day and weight gain: a population-based cohort study in Spain

Experimental research suggests that food timing is associated with weight regulation. However, the association between the distribution of energy intake (EI) throughout the day and weight gain in the population is uncertain. A cohort of 4243 individuals (49·9 % men, 50·1 % women) aged ≥18 years was selected in 2008–2010 and followed-up through 2012. At baseline, food consumption for a typical week in the previous year was collected with a validated dietary history, and EI was assessed at six eating occasions: breakfast, mid-morning meal, lunch, mid-afternoon meal, dinner and snacking (at any other moment). Individuals were classified into sex-specific quartiles of %EI for each eating occasion. The cut-off points for increasing quartiles of %EI at lunch were 34·4, 40·8 and 47·7 % in men and 33·2, 39·4 and 46·1 % in women. Weight was self-reported at baseline and at the end of follow-up. During a 3·5-year follow-up, 16·3 % of study participants gained >3 kg. Compared with those in the lowest quartile of %EI at lunch, the multivariate OR of gaining >3 kg was 0·79 (95 % CI 0·63, 0·99) in the second quartile, 0·82 (95 % CI 0·64, 1·04) in the third quartile and 0·62 (95 % CI 0·47, 0·80) in the highest quartile (Ptrend: 0·001). The association was stronger among women and those with overweight or obesity. No association was found between the %EI at the rest of the eating occasions and weight gain. In conclusion, a higher %EI at lunch was associated with a lower risk of weight gain; this may help weight control through the appropriate distribution of daily EI.

Pre-diagnostic vitamin D concentrations and cancer risks in older individuals: an analysis of cohorts participating in the CHANCES consortium

The associations of circulating 25-hydroxyvitamin D [25(OH)D] concentrations with total and site-specific cancer incidence have been examined in several epidemiological studies with overall inconclusive findings. Very little is known about the association of vitamin D with cancer incidence in older populations. We assessed the association of pre-diagnostic serum 25(OH)D levels with incidence of all cancers combined and incidence of lung, colorectal, breast, prostate and lymphoid malignancies among older adults. Pre-diagnostic 25(OH)D concentrations and cancer incidence were available in total for 15,486 older adults (mean age 63, range 50-84 years) participating in two cohort studies: ESTHER (Germany) and TROMSØ (Norway); and a subset of previously published nested-case control data from a another cohort study: EPIC-Elderly (Greece, Denmark, Netherlands, Spain and Sweden) from the CHANCES consortium on health and aging. Cox proportional hazards or logistic regression were used to derive multivariable adjusted hazard and odds ratios, respectively, and their 95% confidence intervals across 25(OH)D categories. Meta-analyses with random effects models were used to pool study-specific risk estimates. Overall, lower 25(OH)D concentrations were not significantly associated with increased incidence of most of the cancers assessed. However, there was some evidence of increased breast cancer and decreased lymphoma risk with higher 25(OH)D concentrations. Our meta-analyses with individual participant data from three large European population-based cohort studies provide at best limited support for the hypothesis that vitamin D may have a major role in cancer development and prevention among European older adults.

Physical activity and risk of Amyotrophic Lateral Sclerosis in a prospective cohort study

Previous case-control studies have suggested a possible increased risk of Amyotrophic Lateral Sclerosis (ALS) with physical activity (PA), but this association has never been studied in prospective cohort studies. We therefore assessed the association between PA and risk of death from ALS in the European Prospective Investigation into Cancer and Nutrition. A total of 472,100 individuals were included in the analysis, yielding 219 ALS deaths. At recruitment, information on PA was collected thorough standardised questionnaires. Total PA was expressed by the Cambridge Physical Activity Index (CPAI) and analysed in relation to ALS mortality, using Cox hazard models. Interactions with age, sex, and anthropometric measures were assessed. Total PA was weakly inversely associated with ALS mortality with a borderline statistically significant trend across categories (p = 0.042), with those physically active being 33% less likely to die from ALS compared to those inactive: HR = 0.67 (95% CI 0.42-1.06). Anthropometric measures, sex, and age did not modify the association with CPAI. The present study shows a slightly decreased-not increased like in case-control studies-risk of dying from ALS in those with high levels of total PA at enrolment. This association does not appear confounded by age, gender, anthropometry, smoking, and education. Ours was the first prospective cohort study on ALS and physical activity.

Dietary Patterns and Risk of Inflammatory Bowel Disease in Europe: Results from the EPIC Study

BACKGROUND

Specific nutrients or foods have been inconsistently associated with ulcerative colitis (UC) or Crohn's disease (CD) risks. Thus, we investigated associations between diet as a whole, as dietary patterns, and UC and CD risks.

METHODS

Within the prospective EPIC (European Prospective Investigation into Cancer) study, we set up a nested matched case-control study among 366,351 participants with inflammatory bowel disease data, including 256 incident cases of UC and 117 of CD, and 4 matched controls per case. Dietary intake was recorded at baseline from validated food frequency questionnaires. Incidence rate ratios of developing UC and CD were calculated for quintiles of the Mediterranean diet score and a posteriori dietary patterns produced by factor analysis.

RESULTS

No dietary pattern was associated with either UC or CD risks. However, when excluding cases occurring within the first 2 years after dietary assessment, there was a positive association between a "high sugar and soft drinks" pattern and UC risk (incidence rate ratios for the fifth versus first quintile, 1.68 [1.00-2.82]; Ptrend = 0.02). When considering the foods most associated with the pattern, high consumers of sugar and soft drinks were at higher UC risk only if they had low vegetables intakes.

CONCLUSIONS

A diet imbalance with high consumption of sugar and soft drinks and low consumption of vegetables was associated with UC risk. Further studies are needed to investigate whether microbiota alterations or other mechanisms mediate this association.

Detailed comparison of amyloid PET and CSF biomarkers for identifying early Alzheimer disease

Objective:

To compare the diagnostic accuracy of CSF biomarkers and amyloid PET for diagnosing early-stage Alzheimer disease (AD).

Methods:

From the prospective, longitudinal BioFINDER study, we included 122 healthy elderly and 34 patients with mild cognitive impairment who developed AD dementia within 3 years (MCI-AD). β-Amyloid (Aβ) deposition in 9 brain regions was examined with [¹⁸F]-flutemetamol PET. CSF was analyzed with INNOTEST and EUROIMMUN ELISAs. The results were replicated in 146 controls and 64 patients with MCI-AD from the Alzheimer's Disease Neuroimaging Initiative study.

Results:

The best CSF measures for identifying MCI-AD were Aβ42/total tau (t-tau) and Aβ42/hyperphosphorylated tau (p-tau) (area under the curve [AUC] 0.93–0.94). The best PET measures performed similarly (AUC 0.92–0.93; anterior cingulate, posterior cingulate/precuneus, and global neocortical uptake). CSF Aβ42/t-tau and Aβ42/p-tau performed better than CSF Aβ42 and Aβ42/40 (AUC difference 0.03–0.12, p < 0.05). Using nonoptimized cutoffs, CSF Aβ42/t-tau had the highest accuracy of all CSF/PET biomarkers (sensitivity 97%, specificity 83%). The combination of CSF and PET was not better than using either biomarker separately.

Conclusions:

Amyloid PET and CSF biomarkers can identify early AD with high accuracy. There were no differences between the best CSF and PET measures and no improvement when combining them. Regional PET measures were not better than assessing the global Aβ deposition. The results were replicated in an independent cohort using another CSF assay and PET tracer. The choice between CSF and amyloid PET biomarkers for identifying early AD can be based on availability, costs, and doctor/patient preferences since both have equally high diagnostic accuracy.

Classification of evidence:

This study provides Class III evidence that amyloid PET and CSF biomarkers identify early-stage AD equally accurately.

Psychological distress as a determinant of changes in body mass index over a period of 10years

OBJECTIVE

To examine the longitudinal relationship between psychological distress and body mass index (BMI) changes over a period of five and ten years.

METHOD

Data were used from the Dutch, prospective, population based Doetinchem Cohort study over the period 1995/1999 until 2005/2009 (N=5504). Psychological distress was assessed using the Mental Health Inventory (MHI-5). BMI (kg/m(2)) was calculated from measured body height and body weight. GEE analyses were used to examine the relationship between psychological distress at baseline and BMI change, and the development of overweight over five years. Linear and logistic regression analyses were used to examine these relations over ten years.

RESULTS

Psychological distress predicted an extra overall increase in BMI of 0.14kg/m(2) (95% CI 0.03-0.25) over five years and an increase of 0.18kg/m(2) (95% CI 0.01-0.35) over ten years, when comparing psychologically distressed participants to psychologically healthy participants. This was especially the case among persons with normal weight (five years; B=0.26kg/m(2), 95% CI=0.12-0.40/ten years; B=0.32kg/m(2) 95% CI=0.11-0.53) and moderate overweight (five years: B=0.18kg/m(2), 95% CI=0.02-0.35) at baseline. Psychological distress did not predict the development of overweight five and ten years later.

CONCLUSION

The results in this study indicated that psychological distress predicted an increased risk in gaining weight, but did not result in an increased risk for developing overweight.

Identifying cardiovascular risk factor-related dietary patterns with reduced rank regression and random forest in the EPIC-NL cohort

BACKGROUND

Several methods are used to determine dietary patterns. Hybrid methods incorporate information on nutrient intake or biological factors to extract patterns relevant to disease etiology.

OBJECTIVE

We explore differences between patterns derived with 2 hybrid methods with those obtained by a posteriori methods and compare associations of these patterns with coronary artery disease (CAD) and stroke risk.

DESIGN

Food-frequency questionnaires were used to estimate dietary intake in 34,644 participants of European Prospective Investigation into Cancer-Netherlands at baseline (1993-1997). Follow-up was complete until 31 December 2007. Hybrid methods to determine dietary patterns were reduced rank regression (RRR) and random forest with classification tree analysis (RF-CTA). Included risk factors were body mass index, total:high-density lipoprotein cholesterol ratio, and systolic blood pressure. Results were compared with those from principal component analysis (PCA) and k-means cluster analysis (KCA), respectively.

RESULTS

Both RRR and PCA derived a "Western," "prudent," and "traditional pattern." All RRR patterns were significantly associated with CAD risk [highest vs. lowest quartile factor score; HR: 1.45 (95% CI: 1.25, 1.69), 0.86 (0.74, 0.99), and 1.25 (1.07, 1.47), respectively]. Only the prudent RRR factor was statistically significant associated with stroke (HR: 0.76; 95% CI: 0.59, 0.97). From the PCA patterns, only the traditional pattern was associated with CAD (HR: 1.29; 95% CI: 1.11, 1.50). RF-CTA derived 7 dietary patterns that could be categorized as "Western-like," "prudent-like," and "traditional-like." KCA established a prudent and Western cluster. Compared with the RF-CTA "prudent-like 1" pattern, only the "traditional-like 1" pattern was associated with CAD (HR: 1.36; 955 CI: 1.12, 1.65). None of the RF-CTA groups were associated with stroke. Compared with the Western KCA cluster, the prudent cluster was not associated with CAD or stroke.

CONCLUSION

Including risk factors in RRR and RF-CTA resulted in small differences in food groups, contributing to similar patterns that showed in general stronger associations with CAD than PCA and KCA, respectively.

The combined impact of adherence to five lifestyle factors on all-cause, cancer and cardiovascular mortality: a prospective cohort study among Danish men and women

Individual lifestyle factors have been associated with lifestyle diseases and premature mortality by an accumulating body of evidence. The impact of a combination of lifestyle factors on mortality has been investigated in several studies, but few have applied a simple index taking national guidelines into account. The objective of the present prospective cohort study was to investigate the combined impact of adherence to five lifestyle factors (smoking, alcohol intake, physical activity, waist circumference and diet) on all-cause, cancer and cardiovascular mortality based on international and national health recommendations. A Cox proportional hazards model was used to estimate hazard ratios (HR) with 95 % CI. During a median follow-up of 14 years, 3941 men and 2827 women died. Among men, adherence to one additional health recommendation was associated with an adjusted HR of 0·73 (95 % CI 0·71, 0·75) for all-cause mortality, 0·74 (95 % CI 0·71, 0·78) for cancer mortality and 0·70 (95 % CI 0·65, 0·75) for cardiovascular mortality. Among women, the corresponding HR was 0·72 (95 % CI 0·70, 0·75) for all-cause mortality, 0·76 (95 % CI 0·73, 0·80) for cancer mortality and 0·63 (95 % CI 0·57, 0·70) for cardiovascular mortality. In the present study, adherence to merely one additional health recommendation had a protective effect on mortality risk, indicating a huge potential in enhancing healthy lifestyle behaviours of the population.

Adherence to the Dutch Guidelines for a Healthy Diet and cancer risk in the European Prospective Investigation into Cancer and Nutrition-Netherlands (EPIC-NL) cohort

OBJECTIVE

To examine the association between adherence to the Dutch Guidelines for a Healthy Diet created by the Dutch Health Council in 2006 and overall and smoking-related cancer incidence.

DESIGN

Prospective cohort study.

SETTING

Adherence to the guidelines, which includes one recommendation on physical activity and nine on diet, was measured using an adapted version of the Dutch Healthy Diet (DHD) index. The score ranged from 0 to 90 with a higher score indicating greater adherence to the guidelines. We estimated the hazard ratios (HR) and 95 % confidence intervals for the association between the DHD index (in tertiles and per 20-point increment) at baseline and cancer incidence at follow-up.

SUBJECTS

We studied 35 608 men and women aged 20-70 years recruited into the European Prospective Investigation into Cancer and Nutrition-Netherlands (EPIC-NL) study during 1993-1997.

RESULTS

After an average follow-up of 12·7 years, 3027 cancer cases were documented. We found no significant association between the DHD index (tertile 3 v. tertile 1) and overall (HR = 0·97; 95 % CI 0·88, 1·07) and smoking-related cancer incidence (HR = 0·89; 95 % CI 0·76, 1·06) after adjustment for relevant confounders. Excluding the components physical activity or alcohol from the score did not change the results. None of the individual components of the DHD index was significantly associated with cancer incidence.

CONCLUSIONS

In the present study, participants with a high adherence to the Dutch Guidelines for a Healthy Diet were not at lower risk of overall or smoking-related cancer. This does not exclude that other components not included in the DHD index may be associated with overall cancer risk.

Prediagnostic circulating vitamin D levels and risk of hepatocellular carcinoma in European populations: a nested case-control study

The association between vitamin D status and hepatocellular carcinoma (HCC) has not been well investigated, despite experimental evidence supporting an important role of vitamin D in liver pathophysiology. Our objective was to investigate the association between prediagnostic circulating 25-hydroxyvitamin D [25(OH)D] serum levels and the risk of HCC in a prospective, nested case-control study among 520,000 participants in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. Each case (n = 138) diagnosed between 1992 and 2010 was matched to one control by age, sex, study center, date and time of blood collection, and fasting status. Serum baseline levels of 25(OH)D were measured by liquid chromatography/tandem mass spectrometry. Multivariable incident rate ratios (IRRs) of HCC associated with continuous (per 10 nmol/L) or categorical levels (tertiles or a priori-defined categories) of prediagnostic 25(OH)D were calculated using conditional logistic regression. Higher 25(OH)D levels were associated with a 49% reduction in the risk of HCC (highest versus lowest tertile: multivariable IRR = 0.51, 95% confidence interval [CI], 0.26 to 0.99; Ptrend  = 0.04; per 10 nmol/L increase: IRR = 0.80, 95% CI, 0.68-0.94). The finding did not vary substantially by time from enrolment to diagnosis, and did not change after adjustment for biomarkers of preexisting liver damage, nor chronic infection with hepatitis B or C viruses. The findings were not modified by body size or smoking status.

CONCLUSION

In this prospective study on western European populations, serum levels of 25(OH)D were inversely associated with the risk of HCC. Given the rising incidence of this cancer in low-risk developed countries and the strong public health interest surrounding the potentially cancer-protective roles of vitamin D, additional studies in different populations are required.

Body fat, body fat distribution, lean body mass and atrial fibrillation and flutter. A Danish cohort study

OBJECTIVE

It is recognized that higher height and weight are associated with higher risk of atrial fibrillation or flutter (AF) but it is unclear whether risk of AF is related to body fat, body fat location, or lean body mass.

METHODS

This article reports the Danish population-based prospective cohort Diet, Cancer and Health study conducted among 55,273 men and women 50-64 years of age at recruitment. The associations between bioelectrical impedance derived measures of body composition and combinations of anthropometric measures of body fat distribution and risk of an incident record of AF in the Danish Registry of Patients were investigated.

RESULTS

During follow-up (median 13.5 years) AF developed in 1,669 men and 912 women. Higher body fat at any measured location was associated with higher risk of AF. The adjusted hazard ratio (HR) per 1 sex-specific standard deviation (SD) increment in body fat mass was 1.29 (95% confidence interval [CI], 1.24-1.33). Higher lean body mass was also associated with a higher risk of AF. The adjusted HR for 1 sex-specific SD increment was 1.40 (95% CI, 1.35-1.45).

CONCLUSION

Higher body fat and higher lean body mass were both associated with higher risk of AF.

Adherence to predefined dietary patterns and incident type 2 diabetes in European populations: EPIC-InterAct Study

AIMS/HYPOTHESIS

Few studies have investigated the relationship between predefined dietary patterns and type 2 diabetes incidence; little is known about the generalisability of these associations. We aimed to assess the association between predefined dietary patterns and type 2 diabetes risk in European populations.

METHODS

From among a case-cohort of 12,403 incident diabetes cases and 16,154 subcohort members nested within the prospective European Prospective Investigation into Cancer and Nutrition study, we used data on 9,682 cases and 12,595 subcohort participants from seven countries. Habitual dietary intake was assessed at baseline with country-specific dietary questionnaires. Two diet-quality scores (alternative Healthy Eating Index [aHEI], Dietary Approaches to Stop Hypertension [DASH] score) and three reduced rank regression (RRR)-derived dietary-pattern scores were constructed. Country-specific HRs were calculated and combined using a random-effects meta-analysis.

RESULTS

After multivariable adjustment, including body size, the aHEI and DASH scores were not significantly associated with diabetes, although for the aHEI there was a tendency towards an inverse association in countries with higher mean age. We observed inverse associations of the three RRR-derived dietary-pattern scores with diabetes: HRs (95% CIs) for a 1-SD difference were 0.91 (0.86, 0.96), 0.92 (0.84, 1.01) and 0.87 (0.82, 0.92). Random-effects meta-analyses revealed heterogeneity between countries that was explainable by differences in the age of participants or the distribution of dietary intake.

CONCLUSIONS/INTERPRETATION

Adherence to specific RRR-derived dietary patterns, commonly characterised by high intake of fruits or vegetables and low intake of processed meat, sugar-sweetened beverages and refined grains, may lower type 2 diabetes risk.