Trends of Antihypertensive Prescription Among US Adults From 2010 to 2019 and Changes Following Treatment Guidelines: Analysis of Multicenter Electronic Health Records

BACKGROUND

Guidelines for the use of antihypertensives changed in 2014 and 2017. To understand the effect of these guidelines, we examined trends in antihypertensive prescriptions in the United States from 2010 to 2019 using a repeated cross-sectional design.

METHODS AND RESULTS

Using electronic health records from 15 health care institutions for adults (20-85 years old) who had ≥1 antihypertensive prescription, we assessed whether (1) prescriptions of beta blockers decreased after the 2014 Eighth Joint National Committee (JNC 8) report discouraged use for first-line treatment, (2) prescriptions for calcium channel blockers and thiazide diuretics increased among Black patients after the JNC 8 report encouraged use as first-line therapy, and (3) prescriptions for dual therapy and fixed-dose combination among patients with blood pressure ≥140/90 mm Hg increased after recommendations in the 2017 Hypertension Clinical Practice Guidelines. The study included 1 074 314 patients with 2 133 158 prescription episodes. After publication of the JNC 8 report, prescriptions for beta blockers decreased (3% lower in 2018-2019 compared to 2010-2014), and calcium channel blockers increased among Black patients (20% higher in 2015-2017 and 41% higher in 2018-2019, compared to 2010-2014), in accordance with guideline recommendations. However, contrary to guidelines, dual therapy and fixed-dose combination decreased after publication of the 2017 Hypertension Clinical Practice Guidelines (9% and 11% decrease in 2018-2019 for dual therapy and fixed-dose combination, respectively, compared to 2015-2017), and thiazide diuretics decreased among Black patients after the JNC 8 report (6% lower in 2018-2019 compared to 2010-2014).

CONCLUSIONS

Adherence to guidelines on prescribing antihypertensive medication was inconsistent, presenting an opportunity for interventions to achieve better blood pressure control in the US population.

Cost Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S

INTRODUCTION

Calorie labeling of standard menu items has been implemented at large restaurant chains across the U.S. since 2018. The objective of this study was to evaluate the cost effectiveness of calorie labeling at large U.S. fast-food chains.

METHODS

This study evaluated the national implementation of calorie labeling at large fast-food chains from a modified societal perspective and projected its cost effectiveness over a 10-year period (2018-2027) using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model. Using evidence from over 67 million fast-food restaurant transactions between 2015 and 2019, the impact of calorie labeling on calorie consumption and obesity incidence was projected. Benefits were estimated across all racial, ethnic, and income groups. Analyses were performed in 2022.

RESULTS

Calorie labeling is estimated to be cost saving; prevent 550,000 cases of obesity in 2027 alone (95% uncertainty interval=518,000; 586,000), including 41,500 (95% uncertainty interval=33,700; 50,800) cases of childhood obesity; and save $22.60 in healthcare costs for every $1 spent by society in implementation costs. Calorie labeling is also projected to prevent cases of obesity across all racial and ethnic groups (range between 126 and 185 cases per 100,000 people) and all income groups (range between 152 and 186 cases per 100,000 people).

CONCLUSIONS

Calorie labeling at large fast-food chains is estimated to be a cost-saving intervention to improve long-term population health. Calorie labeling is a low-cost intervention that is already implemented across the U.S. in large chain restaurants.

Effects of in-store marketing on food and beverage purchases: a longitudinal study of households with children

OBJECTIVE

Most food retailers display foods in prominent locations as a marketing strategy (i.e. 'placement promotions'). We examined the extent to which households with children change their food and beverage purchases in response to these promotions.

DESIGN

We analysed a novel dataset of all products promoted in two supermarkets from 2016 to 2017, including promotion dates and locations (e.g. aisle endcaps and front registers). We linked promotions to all purchases from the supermarkets from 2016 to 2017 by a cohort of households with children. We calculated the number of weekly promotions in each of thirteen food and beverage groups (e.g. bread; candy) and used fixed effects regressions to estimate associations between number of weekly promotions and households' weekly food purchases, overall and by Supplemental Nutrition Assistance Program (SNAP) participation.

SETTING

Two large supermarkets in Maine, USA.

PARTICIPANTS

Eight hundred and twenty-one households with children.

RESULTS

Most promotions (74 %) were for less healthy foods. The most promoted food groups were sweet and salty snacks (mean = 131·0 promotions/week), baked goods (mean = 68·2) and sugar-sweetened beverages (mean = 41·6). Households generally did not change their food group purchases during weeks when they were exposed to more promotions for those groups, except that a 1-sd increase in endcap candy promotions (about 1 promotion/week) was associated with $0·19/week (about 14·5 %) increase in candy purchases among SNAP nonparticipants (adjusted P < 0·001).

CONCLUSIONS

In-store placement promotions for food groups were generally not associated with purchases of promoted food groups, perhaps because exposure to unhealthy food marketing was consistently high. Substantial changes to in-store food marketing may be needed to promote healthier purchases.

Different operationalizations of the 2018 WCRF/AICR cancer prevention recommendations and risk of cancer

BACKGROUND

The standardized scoring system assessing adherence to the 2018 World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) cancer prevention recommendations assigns equal weight for each recommendation, thereby giving higher weight to dietary factors collectively (5 points) than adiposity (1 point) and physical activity (1 point). An alternative score assigning equal weights to the adiposity, physical activity, alcohol, and other dietary (composite) recommendations may better predict cancer associations.

METHODS

We examined associations between standardized and alternative scores with cancer risk in two US prospective cohorts. Multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox regression.

RESULTS

During 28 years of follow-up, 16,342 incident cancer cases in women and 8729 cases in men occurred. Individuals in the highest versus lowest quintile of the standardized score had a reduced overall cancer risk (women: HR = 0.89, 95% CI: 0.85, 0.94; men: HR = 0.87, 95% CI: 0.81, 0.94). Results were slightly stronger for the alternative score (women: HR = 0.83, 95% CI: 0.79, 0.87; men: HR = 0.81, 95% CI: 0.75, 0.86). Similar patterns were observed for obesity-related, alcohol-related, smoking-related, and digestive system cancers.

CONCLUSIONS

Greater adherence to the WCRF/AICR cancer prevention recommendations was associated with lower cancer risk. A score assigning equal weights to the adiposity, physical activity, alcohol, and all remaining diet components yielded stronger associations than the standardized score.

In-Store Marketing and Supermarket Purchases: Associations Overall and by Transaction SNAP Status

INTRODUCTION

In-store placement promotions are used widely in supermarkets, but their effects on customer purchases remain largely unknown. This study examined associations of supermarket placement promotions with customer purchases overall and by Supplemental Nutrition Assistance Program (SNAP) benefit use.

METHODS

Data on in-store promotions (e.g., endcaps, checkout displays) and transactions (n=274,118,338) were obtained from a New England supermarket chain with 179 stores from 2016 to 2017. Product-level analyses examined multivariable-adjusted changes in products' sales when they were promoted (versus not) across all transactions and stratified by whether the transaction was paid for with SNAP benefits. Food group-level analyses examined the extent to which a 20% increase from the mean number of weekly promotions for a food group (e.g., increasing the number of candy promotions from 17.0 to 20.4) was associated with total food group sales. Analyses were conducted in 2022.

RESULTS

Across stores, the mean (SD) number of promotions per week was highest for sweet/salty snacks (126.3 [22.6]), baked goods (67.5 [18.4]), and sugar-sweetened beverages (48.6 [13.8]) and lowest for beans (5.0 [2.6]) and fruits (6.6 [3.3]). Product sales were between 16% (low-calorie drinks) and 136% (candy) higher when promoted versus not promoted. In 14 of 15 food groups, associations were stronger among transactions made with SNAP benefits than among those not made with SNAP benefits. The number of in-store promotions was generally not associated with total food group sales.

CONCLUSIONS

In-store promotions, which were mostly for unhealthy foods, were associated with large product sales increases, particularly among SNAP purchasers. Policies limiting unhealthy in-store promotions and incentivizing healthy promotions should be explored.

Changes in Dental Outcomes After Implementation of the Philadelphia Beverage Tax

INTRODUCTION

Beverage taxes are associated with declines in sugar-sweetened beverage sales and consumption, but few studies have evaluated the associations of these taxes with health outcomes. This study analyzed changes in dental decay after the implementation of the Philadelphia sweetened beverage tax.

METHODS

Electronic dental record data were obtained on 83,260 patients living in Philadelphia and control areas from 2014 to 2019. Difference-in-differences analyses compared the number of new Decayed, Missing, and Filled Teeth with that of new Decayed, Missing, and Filled Surfaces before (January 2014-December 2016) and after (January 2019-December 2019) tax implementation in Philadelphia and control patients. Analyses were conducted in older children/adults (aged ≥15 years) and younger children (aged <15 years). Subgroup analyses stratified by Medicaid status. Analyses were conducted in 2022.

RESULTS

The number of new Decayed, Missing, and Filled Teeth did not change after tax implementation in Philadelphia in panel analyses of older children/adults (difference-in-differences= -0.02, 95% CI= -0.08, 0.03) or younger children (difference-in-differences=0.07, 95% CI= -0.08, 0.23). There were similarly no post-tax changes in the number of new Decayed, Missing, and Filled Surfaces. However, in cross-sectional samples of patients on Medicaid, the number of new Decayed, Missing, and Filled Teeth was lower after tax implementation in older children/adults (difference-in-differences= -0.18, 95% CI= -0.34, -0.03; -22% decline) and younger children (difference-in-differences= -0.22, 95% CI= -0.46, 0.01; -30% decline), with similar results for number of new Decayed, Missing, and Filled Surfaces.

CONCLUSIONS

The Philadelphia beverage tax was not associated with reduced tooth decay in the general population, but it was associated with reduced tooth decay in adults and children on Medicaid, suggesting potential health benefits for low-income populations.

Philadelphia Beverage Tax and Association With Prices, Purchasing, and Individual-Level Substitution in a National Pharmacy Chain

Importance

Taxes on sweetened beverages are being implemented around the globe; an understanding of these taxes on individual-level behavior is necessary.

Objective

To evaluate the degree to which the sweetened beverage tax in Philadelphia, Pennsylvania, was associated with changes in beverage prices and individual-level purchasing over time at a national pharmacy chain in Philadelphia compared with Baltimore, Maryland.

Design, Setting, and Participants

Using a difference-in-differences approach and generalized linear mixed models, this cohort study examined beverage purchases made by loyalty cardholders at a national chain pharmacy retailer with stores in Philadelphia and Baltimore (control city) from before tax to after tax. Beverage sales (in US dollars) were linked by unique loyalty card numbers to enable longitudinal analyses. Data were collected from January 1, 2015, through December 31, 2017 (2 years before tax and 1 year after tax); data analyses were conducted from January through October 2022.

Exposure

Implementation of Philadelphia's 1.5 cents/oz tax on sweetened beverages.

Main Outcomes and Measures

The outcomes were the change in mean beverage price per-ounce and mean beverage volume purchased per cardholder transaction. Individual-level point-of-sale scanner data from all beverage purchases were analyzed.

Results

A total of 1188 unique beverages were purchased from the same stores before tax and after tax. There were 231 065 unique cardholders in Philadelphia and 82 517 in Baltimore. Mean prices of taxed beverages (n = 2 094 220) increased by 1.6 (95% CI, 1.3-2.0) cents/oz (106.7% pass-through) in Philadelphia compared with Baltimore from before tax to after tax. Philadelphia cardholders purchased 7.8% (95% CI -8.1% to -7.5%) fewer ounces of taxed beverages and 1.1% (95% CI, 0.6%-1.7%) more ounces of nontaxed beverages per transaction. Taxed beverages made up a smaller percentage of cardholders' overall beverage purchases after tax (-13.4% [95% CI, -14.2% to -12.6%]), while nontaxed beverages made up a larger share (9.3% [95% CI, 7.7%-10.7%]).

Conclusions and Relevance

In this longitudinal cohort study of the Philadelphia beverage tax, the tax was completely passed through to prices and was associated with a 7.8% decline in ounces of taxed beverages purchased at a national pharmacy chain.

Changes in Body Mass Index Among School-Aged Youths Following Implementation of the Healthy, Hunger-Free Kids Act of 2010

Importance

The prevalence of obesity among youths 2 to 19 years of age in the US from 2017 to 2018 was 19.3%; previous studies suggested that school lunch consumption was associated with increased obesity. The Healthy, Hunger-Free Kids Act of 2010 (HHFKA) strengthened nutritional standards of school-based meals.

Objective

To evaluate the association between the HHFKA and youth body mass index (BMI).

Design, Setting, and Participants

This cohort study was conducted using data from the Environmental Influences on Child Health Outcomes program, a nationwide consortium of child cohort studies, between January 2005 and March 2020. Cohorts in the US of youths aged 5 to 18 years with reported height and weight measurements were included.

Exposures

Full implementation of the HHFKA.

Main Outcomes and Measures

The main outcome was annual BMI z-score (BMIz) trends before (January 2005 to August 2016) and after (September 2016 to March 2020) implementation of the HHFKA, adjusted for self-reported race, ethnicity, maternal education, and cohort group. An interrupted time-series analysis design was used to fit generalized estimating equation regression models.

Results

A total of 14 121 school-aged youths (7237 [51.3%] male; mean [SD] age at first measurement, 8.8 [3.6] years) contributing 26 205 BMI measurements were included in the study. Overall, a significant decrease was observed in the annual BMIz in the period following implementation of the HHFKA compared with prior to implementation (-0.041; 95% CI, -0.066 to -0.016). In interaction models to evaluate subgroup associations, similar trends were observed among youths 12 to 18 years of age (-0.045; 95% CI, -0.071 to -0.018) and among youths living in households with a lower annual income (-0.038; 95% CI, -0.063 to -0.013).

Conclusions and Relevance

In this cohort study, HHFKA implementation was associated with a significant decrease in BMIz among school-aged youths in the US. The findings suggest that school meal programs represent a key opportunity for interventions to combat the childhood obesity epidemic given the high rates of program participation and the proportion of total calories consumed through school-based meals.

Nutritional Composition and Purchasing Patterns of Supermarket Prepared Foods Over Time

INTRODUCTION

Prepared (ready-to-eat) foods are sold in >90% of U.S. supermarkets, but little is known about their nutritional quality. This study examined trends in purchases of supermarket prepared foods and compared their nutritional profile with that of supermarket packaged foods and restaurant foods.

METHODS

Nutrition data were obtained on prepared foods sold from 2015 to 2019 in 2 supermarket chains (∼1,200 stores). One chain (193 stores) provided transaction-level sales data from 2015 to 2017. Analyses (conducted in 2021-2022) examined trends in the number of different prepared foods offered by the chains and trends in purchases of calories, total sugar, saturated fat, and sodium from prepared foods. Calorie and nutrient densities (i.e., per 100 g of food) and prevalence of being high in calories or nutrients (on the basis of Chilean standards) were analyzed among supermarket prepared foods, supermarket packaged foods, and restaurant foods consumed in the National Health and Nutrition Examination Surveys 2015-2018.

RESULTS

The number of different prepared foods offered at supermarket chains increased from 1,930 in 2015 to 4,113 in 2019. Calories per transaction purchased from supermarket prepared foods increased by 1.0 calories/month (95% CI=0.8, 1.1), a ∼3% annual increase, with similar trends for other nutrients. At supermarkets, >90% of prepared bakery and deli items and 61% of prepared entrees/sides were high in calories or another nutrient of concern, similar to supermarket packaged foods and restaurant foods.

CONCLUSIONS

Supply of and demand for supermarket prepared foods have grown substantially over time. These trends are concerning given these foods' overall poor nutritional quality.

Changes in obesity and BMI among children and adolescents with selected chronic conditions during the COVID-19 pandemic

OBJECTIVE

The aim of this study was to examine COVID-19 pandemic-related changes in obesity and BMI among patients aged 5 to <20 years with selected chronic conditions.

METHODS

A longitudinal study in 293,341 patients aged 5 to <20 years who were prescribed one of five medication classes (for depression, psychosis, hypertension, diabetes, or epilepsy) and who had BMI measures from January 2019 to March 2021 was conducted. Generalized estimating equations and linear mixed-effects models were used, accounting for within-child repeated measures and stratified by age, race, ethnicity, gender, and class of medication prescribed, to compare obesity and BMI z score during the pandemic (June through December 2020) versus pre-pandemic (June through December 2019).

RESULTS

Obesity prevalence increased from 23.8% before the pandemic to 25.5% during the pandemic; mean (SD) BMI z score increased from 0.62 (1.26) to 0.65 (1.29). Obesity prevalence during the pandemic increased at a faster rate compared with pre-pandemic among children aged 5 to <13 years (0.27% per month; 95% CI: 0.11%-0.44%) and 13 to <18 years (0.24% per month; 95% CI: 0.09%-0.40%), with the largest increases among children aged 5 to <13 years who were male (0.42% per month), Black (0.35% per month), or Hispanic (0.59% per month) or who were prescribed antihypertensives (0.28% per month).

CONCLUSIONS

The COVID-19 pandemic has exacerbated the obesity epidemic and widened disparities among children with selected chronic conditions. These findings highlight the importance of continuing efforts to specifically help high-risk populations who are experiencing weight gain from the pandemic.

Assessment of Calories Purchased After Calorie Labeling of Prepared Foods in a Large Supermarket Chain

IMPORTANCE

Calorie labels for prepared (ie, ready-to-eat) foods are required in large chain food establishments in the US. Large evaluations in restaurants suggest small declines in purchases of prepared foods after labeling, but to the authors' knowledge, no studies have examined how this policy influences supermarket purchases.

OBJECTIVE

To estimate changes in calories purchased from prepared foods and potential packaged substitutes compared with control foods after calorie labeling of prepared foods in supermarkets.

DESIGN, SETTING, AND PARTICIPANTS

This controlled interrupted time series compared sales 2 years before labeling implementation (April 2015-April 2017) with sales 7 months after labeling implementation (May 2017-December 2017). Data from 173 supermarkets from a supermarket chain with locations in Maine, Massachusetts, New Hampshire, New York, and Vermont were analyzed from March 2020 to May 2022.

INTERVENTION

Implementation of calorie labeling of prepared foods in April 2017.

MAIN OUTCOMES AND MEASURES

Purchased items were classified as prepared foods, potential packaged substitutes for prepared foods, or all other (ie, control) foods. The primary outcome was mean weekly calories per transaction purchased from prepared foods, and the secondary outcome was mean weekly calories per transaction purchased from similar packaged items (for substitution analyses). Analyses of prepared and packaged foods were stratified by food category (bakery, entrées and sides, or deli meats and cheeses).

RESULTS

Among the included 173 supermarkets, calorie labeling was associated with a mean 5.1% decrease (95% CI, -5.8% to -4.4%) in calories per transaction purchased from prepared bakery items and an 11.0% decrease (95% CI, -11.9% to -10.1%) from prepared deli items, adjusted for changes in control foods; no changes were observed for prepared entrées and sides (change = 0.3%; 95% CI, -2.5% to 3.0%). Labeling was also associated with decreased calories per transaction purchased from packaged bakery items (change = -3.9%; 95% CI, -4.3% to -3.6%), packaged entrées and sides (change = -1.2%; 95% CI, -1.4% to -0.9%), and packaged deli items (change = -2.1%; 95% CI, -2.4% to -1.7%).

CONCLUSIONS AND RELEVANCE

In this longitudinal study of supermarkets, calorie labeling of prepared foods was associated with small to moderate decreases in calories purchased from prepared bakery and deli items without evidence of substitution to similar packaged foods.

Sustained Impact of the Philadelphia Beverage Tax on Beverage Prices and Sales Over 2 Years

INTRODUCTION

It is unclear whether changes in beverage price and sales after beverage tax implementation can be sustained long term. This study aims to quantify the changes in beverage prices and sales in large retailers 2 years after the implementation of the 1.5 cents per ounce Philadelphia beverage tax.

METHODS

Data on price and volume sales of beverages and potential food substitutes were collected from 109 supermarkets, 45 mass merchandizers, and 350 pharmacies in Philadelphia, Baltimore (control), and Pennsylvania ZIP codes bordering Philadelphia (to investigate potential cross-border shopping for tax avoidance). Difference-in-differences analyses compared beverage prices and volume sales in the year before tax implementation (2016) to 2 years after (2018). Data were analyzed in 2020-2021.

RESULTS

Difference-in-differences analyses found that after tax implementation, taxed beverage prices in Philadelphia increased by 1.02 cents per ounce (95% CI=0.94, 1.11; 68% pass through), and taxed beverage volume sales in stores decreased by 50% (95% CI=36%, 61%). After accounting for cross-border shopping, taxed beverage volume sales decreased in Philadelphia by 35% in 2018. Volume sales of nontaxed beverages did not change after tax implementation (difference-in-differences=4%, 95% CI= -3%, 12%). Volume sales of nontaxed beverage concentrates increased on average by 34% (95% CI=19%, 51%), but there was no evidence of substitution to high-calorie foods.

CONCLUSIONS

There was a large reduction in taxed beverage volume sales 2 years after Philadelphia tax implementation, even after accounting for cross-border shopping. Increases in nontaxed beverage concentrate sales likely partially offset this decline, but there was no evidence of post-tax food substitution.

Changes in Calorie Content of Menu Items at Large Chain Restaurants After Implementation of Calorie Labels

IMPORTANCE

Calorie labeling on menus is required in US chain food establishments with 20 or more locations. This policy may encourage retailers to offer lower-calorie items, which could lead to a public health benefit by reducing customers' calorie intake from prepared foods. However, potential reformulation of restaurant menu items has not been examined since nationwide enforcement of this policy in 2018.

OBJECTIVE

To examine the calorie content of menu items at large chain restaurants before and after implementation of federally mandated menu calorie labels.

DESIGN, SETTING, AND PARTICIPANTS

This pre-post cohort study used restaurant menu data from MenuStat, a database of nutrition information for menu items offered in the largest chain restaurants in the US, collected annually from 2012 to 2019. The study comprised 35 354 menu items sold at 59 large chain restaurants in the US. Statistical analysis was conducted from February 4 to October 8, 2021.

INTERVENTION

Nationwide implementation of menu calorie labeling.

MAIN OUTCOMES AND MEASURES

Changes in menu items' calorie content after restaurant chains implemented calorie labels were estimated, adjusting for prelabeling trends. All menu items, continuously available items, items newly introduced to menus, and items removed from menus were examined separately.

RESULTS

Among the 59 restaurant chains included in the study, after labeling, there were no changes in mean calorie content for all menu items (change = -2.0 calories; 95% CI, -8.5 to 4.4 calories) or continuously available items (change = -2.3 calories; 95% CI, -11.5 to 6.3 calories). Items that were newly introduced after labeling, however, had a lower mean calorie content than items introduced before labeling (change = -112.9 calories; 95% CI, -208.6 to -25.2 calories), although there was heterogeneity by restaurant type. Items removed from menus after labeling had similar calorie content as items removed before labeling (change = 0.5 calories; 95% CI, -79.4 to 84.0 calories).

CONCLUSIONS AND RELEVANCE

In this cohort study of large chain restaurants, implementing calorie labels on menus was associated with the introduction of lower-calorie items but no changes in continuously available or removed items.

Calorie Labeling and Product Reformulation: A Longitudinal Analysis of Supermarket-Prepared Foods

INTRODUCTION

The 2010 Affordable Care Act required chain retail food establishments, including supermarkets, to post calorie information for prepared (i.e., ready to eat) foods. Implementation of calorie labeling could spur companies to reduce the calorie content of prepared foods, but few studies have explored this. This study evaluates the changes in the calorie content of prepared foods at 2 large U.S. supermarket chains after they implemented calorie labels in April 2017.

METHODS

The chains (≈1,200 stores) provided data on the calorie content and labeling status of all items sold between July 2015 and January 2019. In 2021, analyses used a difference-in-differences approach to examine the changes in the calorie content of prepared bakery, entree, and deli items introduced before calorie labeling to those introduced after the labeling compared with changes in similar foods not subject to the new labeling requirement. Primary analyses examined continuously available items; exploratory analyses examined items newly introduced to the marketplace.

RESULTS

Relative to changes in comparison foods not subject to the labeling requirement, continuously available prepared bakery items decreased by 7.7 calories per item after calorie labels were implemented (95% CI= -12.9, -2.5, p=0.004, ≈0.5% reduction). In exploratory analyses, prepared bakery items introduced after calorie labeling contained 440 fewer calories per item than those introduced before calorie labeling (95% CI= -773.9, -106.1, p=0.01, ≈27% reduction), driven by reductions in product size. No changes were observed in the calorie content of continuously available or newly introduced prepared entrees or deli items.

CONCLUSIONS

Implementing calorie labels could encourage product reformulation among some types of prepared supermarket foods. These supply-side changes could lead to reductions in caloric intake.

Dietary inflammatory potential, oxidative balance score, and risk of breast cancer: Findings from the Sister Study

Diet, inflammation, and oxidative stress may be important in breast carcinogenesis, but evidence on the role of the inflammatory and prooxidative potential of dietary patterns is limited. Energy adjusted-Dietary Inflammatory Index (E-DII™) and dietary oxidative balance score (D-OBS) were calculated for 43 563 Sister Study cohort participants who completed a Block 1998 food frequency questionnaire at enrollment in 2003-2009 and satisfied eligibility criteria. D-OBS was validated using measured F2 -isoprostanes and metabolites. High E-DII score and low D-OBS represent a more proinflammatory and prooxidant diet, respectively, and associations of quartiles of each index with breast cancer (BC) risk were estimated using multivariable Cox proportional hazards regression. There were 2619 BCs diagnosed at least 1 year after enrollment (mean follow-up 8.4 years). There was no overall association between E-DII and BC risk, whereas there was a suggestive inverse association for the highest vs lowest quartile of D-OBS (HR 0.92 [95% CI, 0.81-1.03]). The highest quartile of E-DII was associated with risk of triple-negative BC (HR 1.53 [95% CI, 0.99-2.35]). When the two indices were combined, a proinflammatory/prooxidant diet (highest tertile of E-DII and lowest tertile of D-OBS) was associated with increased risk for all BC (HR 1.13 [95% CI, 1.00-1.27]) and for triple-negative BC (1.72 [95% CI, 1.10-2.70]), compared to an antiinflammatory/antioxidant diet (lowest tertile of E-DII and highest tertile of D-OBS). Diets with increased inflammatory potential and reduced oxidative balance were positively associated with overall and triple-negative BC.

Adherence to the World Cancer Research Fund/American Institute for Cancer Research Cancer Prevention Recommendations and Colorectal Cancer Survival

BACKGROUND

Patients with cancer are recommended to follow cancer prevention guidelines due to inadequate evidence for specific recommendations for cancer survivors.

METHODS

We examined whether diet and lifestyle scores measuring adherence to the 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) cancer prevention guidelines were associated with colorectal cancer-specific and overall mortality among 1,491 patients with colorectal cancer in two prospective cohorts. Cox proportional hazards regression models were used to calculate the multivariable-adjusted HRs and 95% confidence intervals (CI).

RESULTS

During a median follow-up of 7.92 years, there were 641 deaths (179 colorectal cancer-specific deaths). Patients in the highest quartile of the post-diagnostic WCRF/AICR lifestyle score including diet, body mass index (BMI), and physical activity had a 24% lower risk (HR = 0.76, 95% CI: 0.49-1.18) of colorectal cancer-specific mortality and a 37% lower risk (HR = 0.63, 95% CI: 0.50-0.78) of overall mortality compared with the lowest quartile. When BMI was not included in the lifestyle score due to potential disease-related weight loss, stronger inverse associations were observed for both colorectal cancer-specific and overall mortality for the same comparison (colorectal cancer-specific: HR = 0.50, 95% CI: 0.32-0.79; overall: HR = 0.59, 95% CI: 0.47-0.75). The post-diagnostic WCRF/AICR diet score was not statistically significantly associated with either colorectal cancer-specific or overall mortality.

CONCLUSIONS

Greater adherence to the WCRF/AICR cancer prevention recommendations was associated with improved survival in patients with colorectal cancer.

IMPACT

This study provides support for patients with colorectal cancer to follow cancer prevention recommendations after diagnosis. Future studies on cancer survivors will continue to contribute to evidence-based diet and lifestyle recommendations for patients with cancer.

Changes in the calorie and nutrient content of purchased fast food meals after calorie menu labeling: A natural experiment

BACKGROUND

Calorie menu labeling is a policy that requires food establishments to post the calories on menu offerings to encourage healthy food choice. Calorie labeling has been implemented in the United States since May 2018 per the Affordable Care Act, but to the best of our knowledge, no studies have evaluated the relationship between calorie labeling and meal purchases since nationwide implementation of this policy. Our objective was to investigate the relationship between calorie labeling and the calorie and nutrient content of purchased meals after a fast food franchise began labeling in April 2017, prior to the required nationwide implementation, and after nationwide implementation of labeling in May 2018, when all large US chain restaurants were required to label their menus.

METHODS AND FINDINGS

We obtained weekly aggregated sales data from 104 restaurants that are part of a fast food franchise for 3 national chains in 3 US states: Louisiana, Mississippi, and Texas. The franchise provided all sales data from April 2015 until April 2019. The franchise labeled menus in April 2017, 1 year prior to the required nationwide implementation date of May 2018 set by the US Food and Drug Administration. We obtained nutrition information for items sold (calories, fat, carbohydrates, protein, saturated fat, sugar, dietary fiber, and sodium) from Menustat, a publicly available database with nutrition information for items offered at the top revenue-generating US restaurant chains. We used an interrupted time series to find level and trend changes in mean weekly calorie and nutrient content per transaction after franchise and nationwide labeling. The analytic sample represented 331,776,445 items purchased across 67,112,342 transactions. Franchise labeling was associated with a level change of -54 calories/transaction (95% confidence interval [CI]: -67, -42, p < 0.0001) and a subsequent 3.3 calories/transaction increase per 4-week period (95% CI: 2.5, 4.1, p < 0.0001). Nationwide implementation was associated with a level decrease of -82 calories/transaction (95% CI: -88, -76, p < 0.0001) and a subsequent -2.1 calories/transaction decrease per 4-week period (95% CI: -2.9, -1.3, p < 0.0001). At the end of the study, the model-based predicted mean calories/transaction was 4.7% lower (change = -73 calories/transaction, 95% CI: -81, -65), and nutrients/transaction ranged from 1.8% lower (saturated fat) to 7.0% lower (sugar) than what we would expect had labeling not been implemented. The main limitations were potential residual time-varying confounding and lack of individual-level transaction data.

CONCLUSIONS

In this study, we observed that calorie labeling was associated with small decreases in mean calorie and nutrient content of fast food meals 2 years after franchise labeling and nearly 1 year after implementation of labeling nationwide. These changes imply that calorie labeling was associated with small improvements in purchased meal quality in US chain restaurants.

A Natural Experiment to Evaluate the Nutritional Content of Restaurant Meal Purchases After Calorie Labeling

BACKGROUND

Calorie labeling is mandated in restaurant chains with ≥20 locations nationwide, but the effect of labeling on the nutritional quality of purchased meals in fast-food settings is unclear, especially for adolescents and children.

OBJECTIVE

To estimate the effect of calorie menu labeling on the nutrient content and composition of fast-food meal purchases in McDonald's restaurants vs control restaurants.

DESIGN

From 2010 to 2014, customers were sampled during repeated visits to McDonald's restaurants, which voluntarily labeled menus with calorie information in 2012, and 5 control fast-food restaurant chains that had not labeled their menus over the study period.

PARTICIPANTS/SETTING

Restaurant receipts and questionnaires were collected from 2883 adults, 2131 adolescents, and 433 children in 4 New England cities.

MAIN OUTCOME MEASURES

Saturated fat, sugar, sodium, and fiber content of purchased meals, as well as nutrient densities (ie, nutrient content adjusted for total calories), were calculated after linking purchases to nutrition data from restaurant websites.

STATISTICAL ANALYSES

Difference-in-differences analyses and linear mixed models were used to examine whether calorie labeling in McDonald's was associated with changes in nutrient content and nutrient density of purchased meals separately in adults, adolescents, and children.

RESULTS

After implementation of calorie labeling at McDonald's, adult meals contained on average 4.0% fewer calories from sugar (95% confidence interval: -7.5 to -0.5), but 1.8% more calories from saturated fat (95% confidence interval: 0.7 to 2.9) compared with control chains. The fiber content of children's purchased meals was lower at McDonald's after calorie labeling (change = -1.4 g, 95% confidence interval: -2.5 to -0.3). Calorie labeling was not associated with changes in nutrient quality of adolescent meals.

CONCLUSIONS

Calorie labeling at McDonald's was associated with a possibly small positive change in the nutritional quality of meals in adults but not in adolescents or children. Efforts are needed to improve the nutritional quality of restaurant meals.

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OBJECTIVE:

To examine associations of hair cortisol concentration (HCC) in mid-childhood and change in HCC from mid-childhood to early adolescence (ΔHCC) with early adolescent adiposity and cardiometabolic biomarker measures.

METHODS:

In Project Viva, a pre-birth cohort of mothers and children, we measured HCC in 599 white children in mid-childhood and in 426 of these participants in early adolescence. We used multivariable linear regression to examine associations of mid-childhood HCC and ΔHCC with BMI-for-age-and-sex z-score, waist circumference, waist-height ratio, dual X-ray absorptiometry total and trunk fat mass, a metabolic risk z-score, adiponectin, HOMA-IR, high-density lipoprotein, C-reactive protein, interleukin-6, leptin, and systolic blood pressure.

RESULTS:

Over a mean (SD) follow-up of 5.2 (0.8) years, we did not find associations of mid-childhood HCC with BMI-for-age-and-sex z-score (β=0.00 per 1-interquartile range of HCC, 95% confidence interval [CI]: −0.08, 0.07), waist circumference (β=−0.04cm, 95% CI: −0.83, 0.74), metabolic risk z-score (β=0.04, 95% CI: −0.03, 0.11), or other cardiometabolic measures except for an increase in log-transformed HOMA-IR (β=0.10, 95% CI: 0.04, 0.17). ΔHCC was not associated with any outcome measures.

CONCLUSIONS:

We found that mid-childhood HCC was not associated with early adolescent adiposity or cardiometabolic biomarkers except for a slight increase in HOMA-IR.

Prenatal and childhood predictors of hair cortisol concentration in mid-childhood and early adolescence

Background

Hair cortisol concentration (HCC) is an increasingly used measure of systemic cortisol concentration. However, determinants of HCC in children and adolescents are unclear because few prospective studies have been conducted to date.

Study design

We followed 725 children in Project Viva, a pre-birth cohort study of mothers and children, who provided hair samples at mid-childhood (median age: 7.7 years) or early adolescence (median age: 12.9 years). We examined associations of various factors measured from pregnancy to mid-childhood with HCC in mid-childhood and early adolescence, as well as change in HCC between these time points (ΔHCC).

Results

There were 426 children with HCC measurements in both mid-childhood and early adolescence, 173 children with measures only in mid-childhood, and 126 with measures only in early adolescence. HCC was lower in mid-childhood (median 1.0pg/mg [interquartile range, IQR: 0.5, 2.4]) than early adolescence (2.2pg/mg [1.1, 4.4]). In multivariable-adjusted regression models, female sex (β = -0.41, 95% CI: -0.67, -0.15) and birth weight-for-gestational age z-score (β = -0.19, 95% CI: -0.33, -0.04) were associated with lower mid-childhood HCC, while prenatal smoking was associated with higher mid-childhood HCC (β = 0.53, 95% CI: 0.04, 1.01). In early adolescence, child age (β = 0.34 per year, 95% CI: 0.21, 0.46) female sex (β = 0.33, 95% CI: 0.10, 0.57), and maternal pre-pregnancy body mass index (β = 0.15 per 5-kg/m², 95% CI: 0.01, 0.29) were positively associated with HCC. Child anthropometric measures and biomarker concentrations were not associated with HCC.

Conclusion

Maternal pre-pregnancy BMI, maternal prenatal smoking, and low birth weight were associated with higher mid-childhood and adolescent HCC. However, few postnatal characteristics were associated with HCC.

Evaluation of the impact of calorie labeling on McDonald's restaurant menus: a natural experiment

Background

The long-term effect of calorie labeling on fast-food purchases is unclear. McDonald’s voluntarily labeled its menus with calories in 2012, providing an opportunity to evaluate this initiative on purchases.

Methods

From 2010 to 2014, we collected receipts from and administered questionnaires to 2971 adults, 2164 adolescents, and 447 parents/guardians of school-age children during repeated visits to 82 restaurants, including McDonald’s and five control chains that did not label menus over the study period in four New England cities. In 2018, we analyzed the data by using difference-in-differences analyses to estimate associations of calorie labeling with calories purchased (actual and estimated) and predicted probability of noticing calorie information on menus.

Results

Calorie labeling at McDonald’s was not associated with changes in calories purchased in adults (change = − 19 cal pre- vs. post-labeling at McDonald’s compared to control chains, 95% CI: − 112, 75), adolescents (change = − 49 cal, 95% CI: − 136, 38), or children (change = 13 cal, 95% CI: − 108, 135). Calorie labeling generally increased the predicted probability of noticing calorie information, but did not improve estimation of calories purchased.

Conclusions

Calorie labeling at McDonald’s was not associated with changes in calories purchased in adults, adolescents, or children. Although participants were more likely to notice calories on menus post-labeling, there was no improvement in ability to accurately estimate calories purchased.

Estimating the effect of calorie menu labeling on calories purchased in a large restaurant franchise in the southern United States: quasi-experimental study

OBJECTIVE

To evaluate whether calorie labeling of menus in large restaurant chains was associated with a change in mean calories purchased per transaction.

DESIGN

Quasi-experimental longitudinal study.

SETTING

Large franchise of a national fast food company with three different restaurant chains located in the southern United States (Louisiana, Texas, and Mississippi) from April 2015 until April 2018.

PARTICIPANTS

104 restaurants with calorie information added to in-store and drive-thru menus in April 2017 and with weekly aggregated sales data during the pre-labeling (April 2015 to April 2017) and post-labeling (April 2017 to April 2018) implementation period.

MAIN OUTCOME MEASURES

Primary outcome was the overall level and trend changes in mean purchased calories per transaction after implementation of calorie labeling compared with the counterfactual (ie, assumption that the pre-intervention trend would have persisted had the intervention not occurred) using interrupted time series analyses with linear mixed models. Secondary outcomes were by item category (entrees, sides, and sugar sweetened beverages). Subgroup analyses estimated the effect of calorie labeling in stratums defined by the sociodemographic characteristics of restaurant census tracts (defined region for taking census).

RESULTS

The analytic sample comprised 14 352 restaurant weeks. Over three years and among 104 restaurants, 49 062 440 transactions took place and 242 726 953 items were purchased. After labeling implementation, a level decrease was observed of 60 calories/transaction (95% confidence interval 48 to 72; about 4%), followed by an increasing trend of 0.71 calories/transaction/week (95% confidence interval 0.51 to 0.92) independent of the baseline trend over the year after implementation. These results were generally robust to different analytic assumptions in sensitivity analyses. The level decrease and post-implementation trend change were stronger for sides than for entrees or sugar sweetened beverages. The level decrease was similar between census tracts with higher and lower median income, but the post-implementation trend in calories per transaction was higher in low income (change in calories/transaction/week 0.94, 95% confidence interval 0.67 to 1.21) than in high income census tracts (0.50, 0.19 to 0.81).

CONCLUSIONS

A small decrease in mean calories purchased per transaction was observed after implementation of calorie labeling in a large franchise of fast food restaurants. This reduction diminished over one year of follow-up.

Adherence to the World Cancer Research Fund/American Institute for Cancer Research 2018 Recommendations for Cancer Prevention and Risk of Colorectal Cancer

BACKGROUND

The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) 2018 diet, nutrition, and physical activity recommendations aim to reduce cancer risk. We examined adherence to the WCRF/AICR recommendations and colorectal cancer risk in two prospective cohorts.

METHODS

We followed 68,977 women in the Nurses' Health Study and 45,442 men in the Health Professionals Follow-up Study from 1986 until 2012. We created cumulatively averaged WCRF/AICR scores using updated diet, adiposity, and physical activity data from questionnaires, and used Cox regression to estimate sex-specific HRs and 95% confidence intervals (CI) for incident colorectal cancer.

RESULTS

We documented 2,449 colorectal cancer cases. Men in the highest quintile of the WCRF/AICR lifestyle score had a lower risk of colorectal cancer compared with those in the lowest quintile (HR_Q5vsQ1 = 0.64; 95% CI, 0.52-0.77). The result was weaker in women (HR_Q5vsQ1 = 0.86; 95% CI, 0.72-1.02; P _{heterogeneity by sex} = 0.006). When analyzing the diet recommendations alone, we similarly observed stronger inverse associations in men (HR_Q5vsQ1 = 0.74; 95% CI, 0.61-0.90) compared with women (HR_Q5vsQ1 = 0.93; 95% CI, 0.77-1.12; P _{heterogeneity by sex} = 0.06). In men, the lifestyle score was more strongly inversely associated with risk of distal colon cancer compared with proximal colon or rectal cancer (P _{common effects} = 0.03); we did not observe significant differences between anatomic locations in women.

CONCLUSIONS

The 2018 WCRF/AICR cancer prevention recommendations are associated with lower colorectal cancer risk in men, with weaker results in women.

IMPACT

Consideration of adiposity and physical activity in conjunction with diet is important for colorectal cancer prevention.

Dietary index scores and invasive breast cancer risk among women with a family history of breast cancer

BACKGROUND

Many epidemiologic studies have analyzed the relations of individual foods and nutrients and breast cancer risk with inconsistent results. Few studies have examined recommendation-based dietary indices and breast cancer risk.

OBJECTIVE

The aim of this study was to determine associations between recommendation-based dietary index scores and incident invasive breast cancer.

METHODS

The Sister Study is a prospective cohort of 50,884 US women (baseline: 2003-2009) who had a sister with breast cancer but no prior breast cancer themselves. We created scores for the Dietary Approaches to Stop Hypertension (DASH) diet, Alternative Mediterranean Diet (AMED), and Alternative Healthy Eating Index-2010 (AHEI-2010) from dietary intakes estimated by a baseline-validated Block food-frequency questionnaire (FFQ). We used Cox regression to estimate multivariable-adjusted HRs and 95% CIs for total invasive breast cancer risk and by estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2) status.

RESULTS

We documented 1,700 invasive breast cancer cases through 2015 (mean follow-up, 7.6 y). Individuals in the highest quartile of DASH scores had a lower risk of invasive breast cancer compared with those in the lowest quartile (HR: 0.78; 95% CI: 0.67, 0.90; P-trend = 0.001), with stronger associations for ER- (HR: 0.61; 95% CI: 0.40, 0.94; P-trend = 0.006) as well as ER-/PR- and ER-/PR-/HER2- subtypes. AHEI-2010 (HR for highest compared with lowest quartile: 0.90; 95% CI: 0.78, 1.03; P-trend = 0.15) and AMED (HR for highest compared with lowest quartile: 0.90; 95% CI: 0.77, 1.06; P-trend = 0.07) were weakly and nonsignificantly associated with breast cancer risk, but after excluding alcohol, AHEI-2010 was inversely associated with risk of ER-/PR- (HR: 0.64; 95% CI: 0.42, 0.98; P-trend = 0.04) and ER-/PR-/HER2- subtypes. We did not observe any significant interactions by menopausal status or other participant characteristics.

CONCLUSIONS

DASH scores were inversely associated with breast cancer risk; DASH and AHEI-2010 scores excluding alcohol were particularly inversely associated with risk of ER-/PR- and ER-/PR-/HER2- breast cancers. This trial was registered at clinicaltrials.gov as NCT00047970.

Mediation of associations between adiposity and colorectal cancer risk by inflammatory and metabolic biomarkers

Inflammation and hyperinsulinemia may drive associations between adiposity and colorectal cancer (CRC) risk, but few studies have examined this hypothesis using mediation analysis. We used inverse odds ratio weighting and logistic regression to calculate odds ratios (OR) and 95% confidence intervals (CI) for estimated total effects (OR^TE ) of body mass index, waist circumference, and adult weight gain on CRC risk, and estimated effects operating through seven inflammatory and metabolic biomarkers (natural indirect effect; OR^NIE ) or through paths independent of these biomarkers (natural direct effect; OR^NDE ) among 209 CRC cases and 382 matched controls nested within the Health Professionals Follow-up Study, a prospective cohort of male health professionals. A one-interquartile range (IQR) increase in body mass index (3.6 kg/m² ) was associated with an OR^TE of 1.40 (95% CI: 1.13, 1.73), which decomposed into an OR^NIE of 1.26 (95% CI: 0.97, 1.52) and an OR^NDE of 1.11 (0.87, 1.42), with possibly stronger mediation by these biomarkers for adult weight gain (IQR = 10.4 kg; OR^TE = 1.32 [95% CI: 1.06, 1.64]; OR^NIE = 1.47 [95% CI: 1.01, 1.81]; OR^NDE = 0.89 [95% CI: 0.72, 1.11]), but no mediation for waist circumference. Mediation appeared to be stronger for the metabolic biomarkers than the inflammatory biomarkers. Inflammatory and metabolic mechanisms may mediate associations between both body mass index and adult weight gain with CRC risk.

Coffee, tea, and caffeine intake and amyotrophic lateral sclerosis mortality in a pooled analysis of eight prospective cohort studies

BACKGROUND AND PURPOSE

Caffeine is associated with a lower risk of some neurological diseases, but few prospective studies have investigated caffeine intake and risk of amyotrophic lateral sclerosis (ALS) mortality. We therefore determined associations between coffee, tea and caffeine intake, and risk of ALS mortality.

METHODS

We conducted pooled analyses of eight international, prospective cohort studies, including 351 565 individuals (120 688 men and 230 877 women). We assessed coffee, tea and caffeine intake using validated food-frequency questionnaires administered at baseline. We used Cox regression to estimate study- and sex-specific risk ratios and 95% confidence intervals (CI) for ALS mortality, which were then pooled using a random-effects model. We conducted analyses using cohort-specific tertiles, absolute common cut-points and continuous measures of all exposures.

RESULTS

During follow-up, 545 ALS deaths were documented. We did not observe statistically significant associations between coffee, tea or caffeine intake and risk of ALS mortality. The pooled multivariable risk ratio (MVRR) for ≥3 cups per day vs. >0 to <1 cup per day was 1.04 (95% CI, 0.74-1.47) for coffee and 1.17 (95% CI, 0.77-1.79) for tea. The pooled MVRR comparing the highest with the lowest tertile of caffeine intake (mg/day) was 0.99 (95% CI, 0.80-1.23). No statistically significant results were observed when exposures were modeled as tertiles or continuously.

CONCLUSIONS

Our results do not support associations between coffee, tea or total caffeine intake and risk of ALS mortality.

Recommendation-based dietary indexes and risk of colorectal cancer in the Nurses' Health Study and Health Professionals Follow-up Study

Background

Many dietary indexes exist for chronic disease prevention, but the optimal dietary pattern for colorectal cancer prevention is unknown.

Objective

We sought to determine associations between adherence to various dietary indexes and incident colorectal cancer in 2 prospective cohort studies.

Design

We followed 78,012 women in the Nurses' Health Study and 46,695 men in the Health Professionals Follow-up Study from 1986 and 1988, respectively, until 2012. We created dietary index scores for the Dietary Approaches to Stop Hypertension (DASH) diet, Alternative Mediterranean Diet (AMED), and Alternative Healthy Eating Index-2010 (AHEI-2010) and used Cox regression to estimate HRs and 95% CIs for risk of colorectal cancer (CRC) and by anatomic subsite. We also conducted latency analyses to examine associations between diet and CRC risk during different windows of exposure. We conducted analyses in men and women separately, and subsequently pooled these results in a random-effects meta-analysis.

Results

We documented 2690 colorectal cancer cases. Pooled multivariable HRs for colorectal cancer risk comparing the highest to lowest quintile of diet scores were 0.89 (95% CI: 0.74, 1.08; P-trend = 0.10) for DASH, 0.89 (95% CI: 0.73, 1.10; P-trend = 0.31) for AMED, and 0.95 (95% CI: 0.83, 1.09; P-trend = 0.56) for AHEI-2010 (P-heterogeneity ≥ 0.07 for all). In sex-specific analyses, we observed stronger associations in men for all dietary indexes (DASH: multivariable HR = 0.81, 95% CI: 0.66, 0.98; P-trend = 0.003; AMED: multivariable HR = 0.80, 95% CI: 0.65, 0.98; P-trend = 0.02; AHEI-2010: multivariable HR = 0.88, 95% CI: 0.72, 1.07; P-trend = 0.04) than in women (multivariable HRs range from 0.98 to 1.01).

Conclusions

Adherence to the DASH, AMED, and AHEI-2010 diets was inversely associated with colorectal cancer risk in men. These diets were not associated with colorectal cancer risk in women. This observational study was registered at http://www.clinicaltrials.gov as NCT03364582.

A Pooled Analysis of 15 Prospective Cohort Studies on the Association between Fruit, Vegetable, and Mature Bean Consumption and Risk of Prostate Cancer

Background: Relationships between fruit, vegetable, and mature bean consumption and prostate cancer risk are unclear.Methods: We examined associations between fruit and vegetable groups, specific fruits and vegetables, and mature bean consumption and prostate cancer risk overall, by stage and grade, and for prostate cancer mortality in a pooled analysis of 15 prospective cohorts, including 52,680 total cases and 3,205 prostate cancer-related deaths among 842,149 men. Diet was measured by a food frequency questionnaire or similar instrument at baseline. We calculated study-specific relative risks using Cox proportional hazards regression, and then pooled these estimates using a random effects model.Results: We did not observe any statistically significant associations for advanced prostate cancer or prostate cancer mortality with any food group (including total fruits and vegetables, total fruits, total vegetables, fruit and vegetable juice, cruciferous vegetables, and tomato products), nor specific fruit and vegetables. In addition, we observed few statistically significant results for other prostate cancer outcomes. Pooled multivariable relative risks comparing the highest versus lowest quantiles across all fruit and vegetable exposures and prostate cancer outcomes ranged from 0.89 to 1.09. There was no evidence of effect modification for any association by age or body mass index.Conclusions: Results from this large, international, pooled analysis do not support a strong role of collective groupings of fruits, vegetables, or mature beans in prostate cancer.Impact: Further investigation of other dietary exposures, especially indicators of bioavailable nutrient intake or specific phytochemicals, should be considered for prostate cancer risk. Cancer Epidemiol Biomarkers Prev; 26(8); 1276-87. ©2017 AACR.