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Aleksandrova K, Pischon T, Jenab M, Bueno-de-Mesquita HB, Fedirko V, Norat T, Romaguera D, Knüppel S, Boutron-Ruault MC, Dossus L, Dartois L, Kaaks R, Li K, Tjønneland A, Overvad K, Quirós JR, Buckland G, Sánchez MJ, Dorronsoro M, Chirlaque MD, Barricarte A, Khaw KT, Wareham NJ, Bradbury KE, Trichopoulou A, Lagiou P, Trichopoulos D, Palli D, Krogh V, Tumino R, Naccarati A, Panico S, Siersema PD, Peeters PHM, Ljuslinder I, Johansson I, Ericson U, Ohlsson B, Weiderpass E, Skeie G, Borch KB, Rinaldi S, Romieu I, Kong J, Gunter MJ, Ward HA, Riboli E, Boeing H. Combined impact of healthy lifestyle factors on colorectal cancer: a large European cohort study. BMC Med 2014; 12:168. [PMID: 25319089 PMCID: PMC4192278 DOI: 10.1186/s12916-014-0168-4] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/29/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Excess body weight, physical activity, smoking, alcohol consumption and certain dietary factors are individually related to colorectal cancer (CRC) risk; however, little is known about their joint effects. The aim of this study was to develop a healthy lifestyle index (HLI) composed of five potentially modifiable lifestyle factors--healthy weight, physical activity, non-smoking, limited alcohol consumption and a healthy diet, and to explore the association of this index with CRC incidence using data collected within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. METHODS In the EPIC cohort, a total of 347,237 men and women, 25- to 70-years old, provided dietary and lifestyle information at study baseline (1992 to 2000). Over a median follow-up time of 12 years, 3,759 incident CRC cases were identified. The association between a HLI and CRC risk was evaluated using Cox proportional hazards regression models and population attributable risks (PARs) have been calculated. RESULTS After accounting for study centre, age, sex and education, compared with 0 or 1 healthy lifestyle factors, the hazard ratio (HR) for CRC was 0.87 (95% confidence interval (CI): 0.44 to 0.77) for two factors, 0.79 (95% CI: 0.70 to 0.89) for three factors, 0.66 (95% CI: 0.58 to 0.75) for four factors and 0.63 (95% CI: 0.54 to 0.74) for five factors; P-trend<0.0001. The associations were present for both colon and rectal cancers, HRs, 0.61 (95% CI: 0.50 to 0.74; P for trend<0.0001) for colon cancer and 0.68 (95% CI: 0.53 to 0.88; P-trend<0.0001) for rectal cancer, respectively (P-difference by cancer sub-site=0.10). Overall, 16% of the new CRC cases (22% in men and 11% in women) were attributable to not adhering to a combination of all five healthy lifestyle behaviours included in the index. CONCLUSIONS Combined lifestyle factors are associated with a lower incidence of CRC in European populations characterized by western lifestyles. Prevention strategies considering complex targeting of multiple lifestyle factors may provide practical means for improved CRC prevention.
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Affiliation(s)
- Krasimira Aleksandrova
- Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany.
| | - Tobias Pischon
- Molecular Epidemiology Group, Max Delbrueck Center for Molecular Medicine (MDC), Berlin-Buch, Germany.
| | - Mazda Jenab
- International Agency for Research on Cancer (IARC-WHO), Lyon, France.
| | - H Bas Bueno-de-Mesquita
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands.
- Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, the Netherlands.
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - Veronika Fedirko
- International Agency for Research on Cancer (IARC-WHO), Lyon, France.
- Department of Epidemiology, Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
| | - Teresa Norat
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - Dora Romaguera
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
- Instituto de Investigacion Sanitaria de Palma (IdISPa), Hospital Universitario Son Espases, Palma de Mallorca, Spain.
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Santiago de Compostela, Spain.
| | - Sven Knüppel
- Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany.
| | - Marie-Christine Boutron-Ruault
- Inserm, Centre for research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Women's Health team, F-94805, Villejuif, France.
- Univ Paris Sud, UMRS 1018, F-94805, Villejuif, France.
- IGR, F-94805, Villejuif, France.
| | - Laure Dossus
- Inserm, Centre for research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Women's Health team, F-94805, Villejuif, France.
- Univ Paris Sud, UMRS 1018, F-94805, Villejuif, France.
- IGR, F-94805, Villejuif, France.
| | - Laureen Dartois
- Inserm, Centre for research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Women's Health team, F-94805, Villejuif, France.
- Univ Paris Sud, UMRS 1018, F-94805, Villejuif, France.
- IGR, F-94805, Villejuif, France.
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Centre, Heidelberg, Germany.
| | - Kuanrong Li
- Division of Cancer Epidemiology, German Cancer Research Centre, Heidelberg, Germany.
| | - Anne Tjønneland
- Diet, Genes and Environment Danish Cancer Society Research Center, Copenhagen, Denmark.
| | - Kim Overvad
- Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark.
| | | | - Genevieve Buckland
- Unit of Nutrition, Environment and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO-IDIBELL), Barcelona, Spain.
| | - María José Sánchez
- Escuela Andaluza de Salud Pública. Instituto de Investigación Biosanitaria de Granada (Granada.ibs), Granada, Spain.
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
| | - Miren Dorronsoro
- Epidemiology and Health Information, Public Health Division of Gipuzkoa, Basque Regional Health Department, San Sebastian, Spain.
| | - Maria-Dolores Chirlaque
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
- Department of Epidemiology, Murcia Regional Health Authority, Murcia, Spain.
| | | | - Kay-Tee Khaw
- Clinical Gerontology Unit, Addenbrooke's Hospital, University of Cambridge School of Clinical Medicine, Cambridge, UK.
| | - Nicholas J Wareham
- MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK.
| | - Kathryn E Bradbury
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Antonia Trichopoulou
- Hellenic Health Foundation, Athens, Greece.
- Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece.
| | - Pagona Lagiou
- Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece.
- Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece.
| | - Dimitrios Trichopoulos
- Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece.
- Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece.
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
| | - Domenico Palli
- Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute - ISPO, Florence, Italy.
| | - Vittorio Krogh
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Rosario Tumino
- Cancer Registry and Histopathology Unit, "M.P.Arezzo" Hospital, Ragusa, Italy.
| | - Alessio Naccarati
- HuGeF - Human Genetics Foundation - Torino, Molecular and Genetic Epidemiology Unit, Turin, Italy.
| | - Salvatore Panico
- Department of clinical and experimental medicine-Federico II University, Naples, Italy.
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, the Netherlands.
| | - Petra H M Peeters
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands.
| | - Ingrid Ljuslinder
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden.
| | | | - Ulrika Ericson
- Diabetes and Cardiovascular Disease, Genetic Epidemiology, Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden.
| | - Bodil Ohlsson
- Department of Clinical Sciences, Division of Internal Medicine, Skåne University Hospital Malmö, Lund University, Malmö, Sweden.
| | - Elisabete Weiderpass
- Department of Community Medicine, Faculty of Health Sciences, University of Tromso, The Arctic University of Norway, Tromsø, Norway.
- Department of Research, Cancer Registry of Norway, Oslo, Norway.
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
- Samfundet Folkhälsan, Helsinki, Finland.
| | - Guri Skeie
- Department of Community Medicine, Faculty of Health Sciences, University of Tromso, The Arctic University of Norway, Tromsø, Norway.
| | - Kristin Benjaminsen Borch
- Department of Community Medicine, Faculty of Health Sciences, University of Tromso, The Arctic University of Norway, Tromsø, Norway.
| | - Sabina Rinaldi
- International Agency for Research on Cancer (IARC-WHO), Lyon, France.
| | - Isabelle Romieu
- International Agency for Research on Cancer (IARC-WHO), Lyon, France.
| | - Joyce Kong
- International Agency for Research on Cancer (IARC-WHO), Lyon, France.
| | - Marc J Gunter
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - Heather A Ward
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - Elio Riboli
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - Heiner Boeing
- Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany.
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