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

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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.


  • Krasimira Aleksandrova
  • Tobias Pischon
  • Mazda Jenab
  • H. Bas Bueno-de-Mesquita
  • Veronika Fedirko
  • Teresa Norat
  • Dora Romaguera
  • Sven Knueppel
  • Marie-Christine Boutron-Ruault
  • Laure Dossus
  • Laureen Dartois
  • Rudolf Kaaks
  • Kuanrong Li
  • Anne Tjonneland
  • Kim Overvad
  • Jose Ramon Quiros
  • Genevieve Buckland
  • Maria Jose Sanchez
  • Miren Dorronsoro
  • Maria-Dolores Chirlaque
  • Aurelio Barricarte
  • Kay-Tee Khaw
  • Nicholas J. Wareham
  • Kathryn E. Bradbury
  • Antonia Trichopoulou
  • Pagona Lagiou
  • Dimitrios Trichopoulos
  • Domenico Palli
  • Vittorio Krogh
  • Rosario Tumino
  • Alessio Naccarati
  • Salvatore Panico
  • Peter D. Siersema
  • Petra H. M. Peeters
  • Ingrid Ljuslinder
  • Ingegerd Johansson
  • Elisabete Weiderpass
  • Guri Skeie
  • Kristin Benjaminsen Borch
  • Sabina Rinaldi
  • Isabelle Romieu
  • Joyce Kong
  • Marc J. Gunter
  • Heather A. Ward
  • Elio Riboli
  • Heiner Boeing
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Cancer and Oncology
  • Endocrinology and Diabetes


  • lifestyle factors, combined impact, population attributable risks, colorectal cancer, European Prospective Investigation into Cancer and, Nutrition (EPIC)
Original languageEnglish
Article number168
JournalBMC Medicine
Publication statusPublished - 2014
Publication categoryResearch

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