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Int J Cancer. 2015 Aug 1;137(3):598-606. doi: 10.1002/ijc.29411. Epub 2015 Feb 13.

Healthy lifestyle index and risk of gastric adenocarcinoma in the EPIC cohort study.

Author information

  • 1Unit of Nutrition, Environment and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO-IDIBELL), Barcelona, Spain.
  • 2Department of Epidemiology, Murcia Regional Health Council, Murcia, Spain.
  • 3CIBER Epidemiology and Public Health CIBERESP, Melchor Fernández Almagro, Madrid, Spain.
  • 4National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
  • 5Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, The Netherlands.
  • 6The School of Public Health, Imperial College London, London, United Kingdom.
  • 7Department of Community Medicine, Faculty of Health Sciences, University of Tromsø - the Arctic University of Norway, Tromsø, Norway.
  • 8Department of Research, Cancer Registry of Norway, Oslo, Norway.
  • 9Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
  • 10Samfundet Folkhälsan, Helsinki, Finland.
  • 11Diabetes and Cardiovascular Disease, Genetic Epidemiology Department of Clinical Sciences, Malmö Lund University, Clinical Research Center 60:13, Malmö, Sweden.
  • 12Department of Clinical Sciences, Skåne University Hospital, Malmö, Sweden.
  • 13Division of Internal Medicine, Skåne University Hospital, Malmö, Sweden.
  • 14International Agency for Research on Cancer (IARC-WHO), Lyon Cedex 08, France.
  • 15German Cancer Research Center (DKFZ), Division of Cancer Epidemiology, Heidelberg, Germany.
  • 16Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy.
  • 17Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, St Mary's Campus, London, United Kingdom.
  • 18Hellenic Health Foundation, Athens, Greece.
  • 19Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece.
  • 20Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Goudi, Athens, Greece.
  • 21Department of Epidemiology, Harvard School of Public Health, Boston, MA.
  • 22Inserm, Centre for Research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Women's Health Team, Villejuif, France.
  • 23University of Paris-Sud, Villejuif, France.
  • 24IGR, Villejuif, France.
  • 25Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.
  • 26Dipartijmento Di Medicina Clinica E Di Chiruigia, Federico II University, Naples, Itlay.
  • 27Department for Biobank Research, Umeå University, Umeå, Sweden.
  • 28Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.
  • 29Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute - ISPO, Florence, Italy.
  • 30Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom.
  • 31University of Cambridge CB2 2QQ and Nick Wareham, Professor and Director of MRC Epidemiology Unit, University of Cambridge, United Kingdom.
  • 32Navarre Public Health Institute, Pamplona, Spain.
  • 33Aarhus University, Department of Public Health, Section for Epidemiology, Aarhus, Denmark.
  • 34Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark.
  • 35Public Health Direction and Biodonostia - Ciberesp, Basque Regional Health Department, San Sebatian, Spain.
  • 36Escuela Andaluza De Salud Pública, Instituto De Investigación Biosanitaria De Granada (Granada.Ibs), Granada, Spain.
  • 37Public Health Directorate, Oviedo, Spain.
  • 38HuGeF-Human Genetics Foundation, Molecular and Genetic Epidemiology Unit, Torino, Italy.
  • 39The Cancer Registry, Azienda Ospedaliera "Civile M.P. Arezzo", Ragusa, Italy.
  • 40The German Institute of Human Nutrition, Potsdam-Rehbücke, Germany.


Several modifiable lifestyle factors, including smoking, alcohol, certain dietary factors and weight are independently associated with gastric cancer (GC); however, their combined impact on GC risk is unknown. We constructed a healthy lifestyle index to investigate the joint influence of these behaviors on GC risk within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. The analysis included 461,550 participants (662 first incident GC cases) with a mean follow-up of 11.4 years. A healthy lifestyle index was constructed, assigning 1 point for each healthy behavior related to smoking status, alcohol consumption and diet quality (represented by the Mediterranean diet) for assessing overall GC and also body mass index for cardia GC and 0 points otherwise. Risk of GC was calculated using Cox proportional hazards regression models while adjusting for relevant confounders. The highest versus lowest score in the healthy lifestyle index was associated with a significant lower risk of GC, by 51% overall (HR 0.49 95% CI 0.35, 0.70), by 77% for cardia GC (HR 0.23 95% CI 0.08, 0.68) and by 47% for noncardia GC (HR 0.53 (95% CI 0.32, 0.87), p-trends<0.001. Population attributable risk calculations showed that 18.8% of all GC and 62.4% of cardia GC cases could have been prevented if participants in this population had followed the healthy lifestyle behaviors of this index. Adopting several healthy lifestyle behaviors including not smoking, limiting alcohol consumption, eating a healthy diet and maintaining a normal weight is associated with a large decreased risk of GC.

© 2014 UICC.


EPIC; cohort; gastric cancer; healthy lifestyle score

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