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BMC Med. 2014 Oct 10;12:168. doi: 10.1186/s12916-014-0168-4.

Combined impact of healthy lifestyle factors on colorectal cancer: a large European cohort study.

Author information

1
Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany. krasimira.aleksandrova@dife.de.
2
Molecular Epidemiology Group, Max Delbrueck Center for Molecular Medicine (MDC), Berlin-Buch, Germany. tobias.pischon@mdc-berlin.de.
3
International Agency for Research on Cancer (IARC-WHO), Lyon, France. jenabm@iarc.fr.
4
National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands. bas.bueno.de.mesquita@rivm.nl.
5
Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, the Netherlands. bas.bueno.de.mesquita@rivm.nl.
6
Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK. bas.bueno.de.mesquita@rivm.nl.
7
International Agency for Research on Cancer (IARC-WHO), Lyon, France. veronika.fedirko@emory.edu.
8
Department of Epidemiology, Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA, USA. veronika.fedirko@emory.edu.
9
Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK. t.norat@imperial.ac.uk.
10
Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK. d.romaguera-bosch@imperial.ac.uk.
11
Instituto de Investigacion Sanitaria de Palma (IdISPa), Hospital Universitario Son Espases, Palma de Mallorca, Spain. d.romaguera-bosch@imperial.ac.uk.
12
CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Santiago de Compostela, Spain. d.romaguera-bosch@imperial.ac.uk.
13
Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany. sven.knueppel@dife.de.
14
Inserm, Centre for research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Women's Health team, F-94805, Villejuif, France. marie-christine.boutron@igr.fr.
15
Univ Paris Sud, UMRS 1018, F-94805, Villejuif, France. marie-christine.boutron@igr.fr.
16
IGR, F-94805, Villejuif, France. marie-christine.boutron@igr.fr.
17
Inserm, Centre for research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Women's Health team, F-94805, Villejuif, France. Laure.DOSSUS@lyon.unicancer.fr.
18
Univ Paris Sud, UMRS 1018, F-94805, Villejuif, France. Laure.DOSSUS@lyon.unicancer.fr.
19
IGR, F-94805, Villejuif, France. Laure.DOSSUS@lyon.unicancer.fr.
20
Inserm, Centre for research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Women's Health team, F-94805, Villejuif, France. Laureen.DARTOIS@gustaveroussy.fr.
21
Univ Paris Sud, UMRS 1018, F-94805, Villejuif, France. Laureen.DARTOIS@gustaveroussy.fr.
22
IGR, F-94805, Villejuif, France. Laureen.DARTOIS@gustaveroussy.fr.
23
Division of Cancer Epidemiology, German Cancer Research Centre, Heidelberg, Germany. r.kaaks@dkfz.de.
24
Division of Cancer Epidemiology, German Cancer Research Centre, Heidelberg, Germany. k.li@Dkfz-Heidelberg.de.
25
Diet, Genes and Environment Danish Cancer Society Research Center, Copenhagen, Denmark. annet@cancer.dk.
26
Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark. KO@SOCI.AU.DK.
27
Public Health Directorate, Asturias, Spain. JOSERAMON.QUIROSGARCIA@asturias.org.
28
Unit of Nutrition, Environment and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO-IDIBELL), Barcelona, Spain. gbuckland@iconcologia.net.
29
Escuela Andaluza de Salud Pública. Instituto de Investigación Biosanitaria de Granada (Granada.ibs), Granada, Spain. mariajose.sanchez.easp@juntadeandalucia.es.
30
CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. mariajose.sanchez.easp@juntadeandalucia.es.
31
Epidemiology and Health Information, Public Health Division of Gipuzkoa, Basque Regional Health Department, San Sebastian, Spain. m-dorronsoro@ej-gv.es.
32
CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. mdolores.chirlaque@carm.es.
33
Department of Epidemiology, Murcia Regional Health Authority, Murcia, Spain. mdolores.chirlaque@carm.es.
34
Navarre Public Health Institute, Pamplona, Spain. aurelio.barricarte.gurrea@cfnavarra.es.
35
Clinical Gerontology Unit, Addenbrooke's Hospital, University of Cambridge School of Clinical Medicine, Cambridge, UK. kk101@medschl.cam.ac.uk.
36
MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK. Nick.Wareham@mrc-epid.cam.ac.
37
Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK. kathryn.bradbury@ceu.ox.ac.uk.
38
Hellenic Health Foundation, Athens, Greece. antonia@nut.uoa.gr.
39
Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece. antonia@nut.uoa.gr.
40
Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece. pdlagiou@med.uoa.gr.
41
Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece. pdlagiou@med.uoa.gr.
42
Bureau of Epidemiologic Research, Academy of Athens, Athens, Greece. dtrichop@hsph.harvard.edu.
43
Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece. dtrichop@hsph.harvard.edu.
44
Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA. dtrichop@hsph.harvard.edu.
45
Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute - ISPO, Florence, Italy. d.palli@ispo.toscana.it.
46
Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy. vittorio.krogh@istitutotumori.mi.it.
47
Cancer Registry and Histopathology Unit, "M.P.Arezzo" Hospital, Ragusa, Italy. rtumino@tin.it.
48
HuGeF - Human Genetics Foundation - Torino, Molecular and Genetic Epidemiology Unit, Turin, Italy. alessio.naccarati@hugef-torino.org.
49
Department of clinical and experimental medicine-Federico II University, Naples, Italy. spanico@unina.it.
50
Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, the Netherlands. P.D.Siersema@umcutrecht.nl.
51
Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK. P.H.M.Peeters@umcutrecht.nl.
52
Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands. P.H.M.Peeters@umcutrecht.nl.
53
Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden. Ingrid.Ljuslinder@vll.se.
54
Department of Odontology, Umeå University, Umeå, Sweden. ingegerd.johansson@odont.umu.se.
55
Diabetes and Cardiovascular Disease, Genetic Epidemiology, Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden. ulrika.ericson@med.lu.se.
56
Department of Clinical Sciences, Division of Internal Medicine, Skåne University Hospital Malmö, Lund University, Malmö, Sweden. bodil.ohlsson@med.lu.se.
57
Department of Community Medicine, Faculty of Health Sciences, University of Tromso, The Arctic University of Norway, Tromsø, Norway. Elisabete.Weiderpass.Vainio@ki.se.
58
Department of Research, Cancer Registry of Norway, Oslo, Norway. Elisabete.Weiderpass.Vainio@ki.se.
59
Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. Elisabete.Weiderpass.Vainio@ki.se.
60
Samfundet Folkhälsan, Helsinki, Finland. Elisabete.Weiderpass.Vainio@ki.se.
61
Department of Community Medicine, Faculty of Health Sciences, University of Tromso, The Arctic University of Norway, Tromsø, Norway. guri.skeie@uit.no.
62
Department of Community Medicine, Faculty of Health Sciences, University of Tromso, The Arctic University of Norway, Tromsø, Norway. kristin.benjaminsen.borch@uit.no.
63
International Agency for Research on Cancer (IARC-WHO), Lyon, France. rinaldi@iarc.fr.
64
International Agency for Research on Cancer (IARC-WHO), Lyon, France. romieui@iarc.fr.
65
International Agency for Research on Cancer (IARC-WHO), Lyon, France. KongJ@fellows.iarc.fr.
66
Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK. m.gunter@imperial.ac.uk.
67
Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK. heather.ward@imperial.ac.uk.
68
Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK. e.riboli@imperial.ac.uk.
69
Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany. boeing@dife.de.

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.

PMID:
25319089
PMCID:
PMC4192278
DOI:
10.1186/s12916-014-0168-4
[Indexed for MEDLINE]
Free PMC Article

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