Operationalising World Cancer Research Fund/American Institute for Cancer Research Cancer Prevention Recommendations Using an Index Score

ISBNPA 3-6 June 2015

Giota Mitrou PhD MSc Head of Research Funding & Science External Relations

World Cancer Research Fund International - exhibition stand #11

Outline

World Cancer Research Fund (WCRF) network

WCRF/AICR Cancer prevention recommendations & subrecommendations

WCRF/AICR score & variation across studies

Main challenges

Conclusions

The World Cancer Research Fund Network

WCRF/AICR Cancer prevention recommendations

The Panel emphasises the importance of not smoking

WCRF/AICR sub-recommendations

WCRF/AICR sub-recommendations

WCRF/AICR score In last four years there has been increased interest in

investigating adherence to the WCRF/AICR recommendations in relation to health outcomes

A scoring system has been developed to assess the degree of adherence to the WCRF/AICR recommendations

Study Methodology(Total Score/no. of recommendations)

Outcome(High vs. low adherence)

EPICRomaguera et al., 2012

(Europe)7 points /6 +1 special recommendation (breastfeeding) in women

6 points/6 recommendations in menTotal cancer risk: 18%

IOWAInoue-Choi et al, 2013

(US)8 points (only sugary drinks, +F & V/Fibre) /7 recommendations

(+sodium)Mortality in female elderly cancer

survivors: 33%

EPICVergnaud et al., 2013

(Europe)

7 points /6 +1 special recommendation (breastfeeding) in women6 points/6 recommendations in men

Mortality: 34%Cancer specific mortally: 20%

VITAL StudyHastert et al., 2013

(US)

6 points/6 recommendations (no sodium, +energy density and

sugary drinks, +wholegrain/legumes (plant foods)Post menopausal breast cancer risk:

60%

PCaPArab et al., 2013

(US)

9 points (+energy density/sugary drinks, +F & V/fibre) /7 recommendations (+sodium)

Prostate cancer aggressiveness: low vs. high adherence 38%

VITAL StudyHastert et al., 2014

(US)

6 points/6 recommendations (no sodium, +energy density and

sugary drinks, +wholegrain/legumes (plant foods)Cancer specific mortality:

61%

Studies of WCRF/AICR score

Study Methodology(Total Score/no. of recommendations)

Outcome(High vs. low adherence)

ProtecT trial(Er_V et al., 2014)

(UK)

6 points/6 recommendations (no sodium) Prostate cancer specific dietary index (calcium, tomato/tomato

products + selenium)

Prostate cancer risk: no association, but prostate cancer specific dietary index

18%

Canadian National Breast Screening Study

Catsburg et al., 2014(Canada)

7 points/7 recommendations (+sodium, + F&V and unprocessed grains and legumes, +energy density and sugary drinks)

Breast cancer risk: 21%

CAMA StudyFanidi et al., 2015

(Mexico)

7 points /6 +1 special recommendation (breastfeeding) in women Breast cancer risk: No association but exclusion of BMI 32%

EPICRomaguera et al., 2015

(Europe)7 points /6 +1 special recommendation (breastfeeding) in women

6 points/6 recommendations in men

Mortality: 21% Colorectal cancer specific mortality:

30%

EpiGEICAM sudy Castelló et al., 2015

(Spain)9 points /8 recommendations (+sodium, supplements) + 1

special recommendation (breastfeeding)

Breast cancer risk: low vs. high adherence 3-fold

Framingham Offspring Cohort study

Makarem et al., 2015(US)

7 points/7 recommendations (+salt preserved foods and processed foods with salt, + F&V and refined starchy foods,

+energy density and sugary drinksObesity related cancer risk: no

association

Studies of WCRF/AICR score

Example 1.WCRF/AICR Score in EPIC (I)

Recommendation 1 0.5 0

BODY MASS INDEX (BMI)

1-Be as lean as possible without becoming underweight 18.5 ≤ BMI < 25 25 ≤ BMI < 30

BMI ≥ 30or

BMI < 18.5

PHYSICAL ACTIVITY (PA)

2 -Be physically active for at least 30 minutes every day

Manual workor

Vigorous PA > 2 h/wor

Cycling + Sports > 30 m/d

Cycling + Sports 15 - 30 m/d

Cycling + Sports <15 m/d

FOODS THAT PROMOTE WEIGHT GAIN (FWG)

3.1 -Limit consumption of energy-dense foods

ED ≤ 125 kcal/100 g

125 < ED < 275 kcal/100 g ED ≥ 125 kcal/100 g

3.2 -Avoid sugary drinks 0 g/d ≤ 250 g/d > 250 g/d

Average

WCRF/AICR score in EPIC (II)

Recommendation 1 0.5 0

PLANT FOODS (PF)

4.1 –Eat at least 5 servings fruit and vegetables a day ≥400 g/d 200 - <400 g/d <200 g/d

4.2 –Eat unprocessed cereals and pulses

Dietary fibre ≥25 g/d

Dietary fibre 12.5 - <25 g/d

Dietary fibre <12.5 g/d

MEAT CONSUMPTION (MEAT)

5 -Limit consumption of red meats and avoid processed meats

Red + Processed meats <500 g/d

andProcessed meat

<3 g/d

Red + Processed meats <500 g/d

andProcessed meat

3 - <50 g/d

Red + Processed meats ≥500 g/dand/or

Processed meat ≥50 g/d

ALCOHOL INTAKE (ALC)

6 -Limit alcoholic drinks to 2 for men and 1 for women a day

Ethanol≤ 20 g/d men

≤ 10 g/d women

Ethanol>20-30 g/d men

>10-20 g/d women

Ethanol>30 g/d men

>20 g/d women

7 -Limit consumption of salty foods

Insufficient data available

Average

WCRF/AICR Score in EPIC (III)

Recommendation 1 0.5 0

8 -Don´t use supplements to protect against cancer Not applicable

BREAST FEEDING (BF)

9 -Breastfeed exclusively for up to 6 months

Cumulative BF ≥ 6 months

Cumulative BF >0 - <6 months

Cumulative BF 0 months

10 -Cancer survivors should follow the recommendations Not applicable

Score RangeScore Range: 0 – 6 points in Men

0 – 7 points in Women

Association between the WCRF/AICR score and total cancer risk

Men Women

Cox regression model stratified by centre and age, and adjusted by energy intake, level of school, smoking status, presence of chronic diseases at baseline, ever use of contraceptive pills, ever use of HRT, age at first menarche, age at first pregnancy, and menopausal status

P for trend <0.0001 P for trend <0.0001

Romaguera D et al, AJCN 2012

Association between the WCRF/AICR score and total mortality

Men Women

Cox regression model stratified by centre and age, and adjusted by level of school, smoking status, smoke intensity, and menopausal status

P for trend <0.0001 P for trend <0.0001

Vergnaud AC et al, AJCN 2013

Example 2.WCRF/AICR score in VITAL study (I)

Recommendation Met Not met

BODY MASS INDEX (BMI)

1-Be as lean as possible within the normal range of body weight

18.5 ≤ BMI < 25 BMI ≥ 25or

BMI < 18.5

PHYSICAL ACTIVITY (PA)

2 -Be physically active as part of everyday life

≥30 minutes p/d moderate/fast walking and/or moderate/strenuous activity on at least 5 d/wk in at least 7 of the past 10yrs

<30 minutes p/d or <5 d/wk or <7 of the previous 10yrs of moderate/fast

walking of moderate/strenuous activity

FOODS THAT PROMOTE WEIGHT GAIN (FWG)

3 -Limit consumption of energy dense foods; avoid sugary drinks

ED ≤ 125 kcal/100 g & <1 sugary drink/w

ED ≥125 kcal/100 g & ≥1 sugary drink/w

PLANT FOODS (PF)

4 -Eat mostly foods of plant origin ≥5 servings of FV & ≥1 serving of wholegrains and/or legumes/d

<5 servings of FV and/or <1 serving of wholegrains and/or legumes/d

MEAT CONSUMPTION (MEAT)

5 -Limit intake of red meat and avoid processed meat

<18 oz red meat and/or processed meat/w

≥18 oz red meat and/or processed meat/w

Recommendation Met Not met

ALCOHOL CONSUMPTION (ALC)

6 -Limit alcohol drinks ≤1 drink/d for women, ≤2 drinks/d men >1 drink/d for women, >2 drinks/d men

PRESERVATION, PROCESSING AND PREPARATION

7 -Limit consumption of salty foods; avoid mouldy grains or legumes

Not operationalised

SUPPLEMENT INTAKE

8 - Aim to meet nutritional needs through diet alone

Not operationalised

WCRF/AICR score in VITAL study (II)

Score RangeScore Range: 0 – 6 points in Men & Women

Hastert et al, Cancer Causes Control 2014

WCRF/AICR score of high vs. low adherence Cancer specific mortality

EPIC vs. VITAL

*Adjusted for multivariate analysis

WCRF/AICR score dependent on the available data

Inclusion of subrecommendations or not in score construction and variation of interpretation of recommendations and subrecommendations eg BMI vs. Waist Circumference for body fatness, physical activity indices vs metric values; use of categorical vs continuous variables for certain recommendations

Some dietary exposures might not be common in particular diets e.g. moldy legumes/cereals, salt preserved foods etc.

Use of special recommendations eg. breastfeeding and dietary supplements depends on research question and data availability

Variation in scoring eg inclusion of 0.5 points for partially meeting a recommendation; use of tertile and media cutoffs to operationalise recommendations

Assumes each component is equally important and additively related to health, however top 3 WCRF/AICR recommendations may need to be weighted differently when studying cancer as an outcome?

Methodological challenges in dietary assessment and data collection based on self reported dietary intake might lead to misclassification of whether an individual meets the recommendation

Main challenges

Conclusions

In almost all studies so far adherence to the WCRF/AICR recommendations has shown inverse associations with health outcomes

Dependent on WCRF/AICR recommendations for cancer prevention but other NCDs were considered when developing recommendations, hence not only specific to cancer

Subjectivity introduced in interpretation of WCRF/AICR recommendations and subrecomendations but easily reproducible and fairly comparable

For further information

@wcrfint

facebook.com/wcrfint

www.wcrf.org

Giota Mitrou PhD MSc Head of Research Funding & Science External Relations

World Cancer Research Fund International - exhibition stand #11

g.mitrou@wcrf.org