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


  • K. Aleksandrova
  • T. Pischon
  • M. Jenab
  • H. Bueno-de-Mesquita
  • V. Fedirko
  • T. Norat
  • D. Romaguera
  • S. Knüppel
  • M.C. Boutron-Ruault
  • L. Dossus
  • L. Dartois
  • R. Kaaks
  • K. Li
  • A. Tjønneland
  • K. Overvad
  • J. Quirós
  • G. Buckland
  • M. Sánchez
  • M. Dorronsoro
  • M.D. Chirlaque
  • A. Barricarte
  • K.T. Khaw
  • N.J. Wareham
  • K.E. Bradbury
  • A. Trichopoulou
  • P. Lagiou
  • D. Trichopoulos
  • D. Palli
  • V. Krogh
  • R. Tumino
  • A. Naccarati
  • S. Panico
  • P.D. Siersema
  • P. Peeters
  • I. Ljuslinder
  • I. Johansson
  • U. Ericson
  • B. Ohlsson
  • E. Weiderpass
  • G. Skeie
  • K. Borch
  • S. Rinaldi
  • I. Romieu
  • J. Kong
  • M.J. Gunter
  • H.A. Ward
  • E. Riboli
  • H. Boeing


  • BMC Medicine


  • BMC Med 12 (1): 168


  • 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.