Predictors of oropharyngeal cancer survival in Europe.

OBJECTIVES: HPV16-positive oropharyngeal cancer (OPC) patients experience better outcomes compared to HPV16-negative patients. Currently, strategies for treatment de-escalation are based on HPV status, smoking history and disease stage. However, the appropriate cut-point for smoking and the role of other non-clinical factors in OPC survival remains uncertain. MATERIALS AND METHODS: We examined factors associated with OPC outcome in 321 patients recruited in a large European multi-center study. Seropositivity for HPV16 E6 was used as a marker of HPV16 positive cancer. Hazard ratios (HR) and confidence intervals (CI) were estimated using Cox proportional models adjusted for potential confounders. RESULTS: Overall 5-year survival following OPC diagnosis was 50%. HPV16-positive OPC cases were at significantly lower risk of death (aHR = 0.51, 95% CI: 0.32-0.80). A significant effect on OPC survival was apparent for female sex (aHR 0.50: 95% CI: 0.29-0.85) and being underweight at diagnosis (aHR: 2.41, 95% CI: 1.38-4.21). A 10 pack year smoking history was not associated with overall survival. Higher stage at diagnosis appeared as the only factor significantly associated with OPC recurrence (aHR: 4.88, 95% CI: 2.12-11.21). CONCLUSION: This study confirms that HPV16 status is an independent prognostic factor for OPC survival while female sex lowers risk of death and being underweight at diagnosis increases the risk of death. Smoking was not an independent predictor of OPC survival.

Expression of estrogen receptors in non-malignant mammary tissue modifies the association between insulin-like growth factor 1 and breast cancer risk.

BACKGROUND: Several studies have reported that the insulin-like growth factor 1 (IGF-1) is positively associated with estrogen receptor-positive [ER(+)] breast cancer risk, whereas there is little or no association with respect to ER(-) breast cancer. All comparisons of ER(+) breast cancer cases, however, have been made versus healthy controls, for whom there is no information about the ER expression in their mammary gland. PATIENTS AND METHODS: In the context of a case-control investigation conducted in Athens, Greece, we studied 102 women with incident ERα(+) breast cancer and compared their IGF-1 blood levels with those of 178 ERα(+) and 83 ERα(-) women with benign breast disease (BBD) who underwent biopsies in the context of their standard medical care. Data were analysed using multiple logistic regression and controlling for potential confounding variables. RESULTS: ERα(+) breast cancer patients had higher IGF-1 levels compared with women with BBD [odds ratio (OR) 1.36, 95% confidence interval (CI): 0.95-1.94, per 1 standard deviation (SD) increase in IGF-1 levels]. When ERα status of women with BBD was taken into account, the difference in IGF-1 levels between ERα(+) breast cancer patients and women with BBD was clearly driven by the comparison with BBD women who were ERα(+) (OR = 1.95, 95% CI: 1.31-2.89 per 1 SD increase in IGF-1 levels), whereas there was essentially no association with IGF-1 levels when ERα(+) breast cancer patients were compared with ERα(-) BBD women. These contrasts were particularly evident among post/peri-menopausal women. CONCLUSIONS: We found evidence in support of an interaction of IGF-1 with the expression of ERα in the non-malignant mammary tissue in the context of breast cancer pathogenesis. This is in line with previous evidence suggesting that IGF-1 increases the risk of ER(+) breast cancer.

A comparison of hormonal profiles between breast cancer and benign breast disease: a case-control study.

BACKGROUND: Benign breast disease (BBD), particularly proliferative BBD, is an established breast cancer risk factor. However, there has been no systematic attempt to compare the hormonal profiles of the two conditions. In a case-control investigation in Athens, Greece, we compared levels of estrogens, testosterone and insulin-like growth factor-1 (IGF-1), as well as their principal binding proteins, between breast cancer patients, women with BBD by histological type (proliferative and nonproliferative) and women with no breast pathology. PATIENTS AND METHODS: We studied 466 women with incident breast cancer, 704 women with BBD and 244 healthy women. We used multiple regression to compare log-transformed serum hormone levels of breast cancer patients with those of healthy women and women with BBD by histological type (proliferative and nonproliferative BBD). RESULTS: The hormonal profile of breast cancer in our study was in line with the generally accepted hormonal profile of this disease, as reported from large cohort studies. Compared with healthy women, breast cancer patients tended to have higher levels of steroid hormones. The evidence was strong for estrone (difference 21.5%, P < 0.001), weaker for testosterone (difference 15.8%, P = 0.07) and weaker still for estradiol (difference 12.0%, P = 0.18). Also compared with healthy women, breast cancer patients had barely higher levels of IGF-1 (difference 2.0%, P = 0.51), but had significantly lower levels of IGF binding protein 3 (IGFBP-3) (difference -6.7%, P = 0.001). Compared with women with BBD, breast cancer patients had nonstatistically significantly lower levels of steroid hormones, but they had higher levels of IGF-1 [difference 5.5%, 95% confidence interval (CI) 0.7% to 10.6%] and lower levels of IGFBP-3 (difference -3.7%, 95% CI -6.7% to -0.7%). Differences were more pronounced when breast cancer patients were contrasted to women with proliferative BBD. CONCLUSIONS: Our findings suggest that high levels of IGF-1 may be an important factor toward the evolution of BBD to breast cancer.

The hormonal profile of benign breast disease.

BACKGROUND: Limited information exists about the endocrine milieu of benign breast disease (BBD), a documented breast cancer risk factor. We compared blood levels of estrogens, testosterone and insulin-like growth factor-1 (IGF-1) between BBD patients by histological type and women without breast pathology. METHODS: We studied 578 BBD patients and 178 healthy women in Athens, Greece, who provided blood samples, and completed interviewer-administered questionnaires. RESULTS: Of the BBD patients, 254 had non-proliferative disease, 268 proliferative disease without atypia and 56 atypical hyperplasia. Comparing BBD patients with healthy women, the per cent differences (and 95% confidence intervals) for blood hormones, among pre-menopausal and peri/post-menopausal women, respectively, were: 22.4% (-4.0%, 56.1%) and 32.0% (5.6%, 65.1%) for estradiol; 26.2% (10.1%, 44.8%) and 30.9% (16.8%, 46.6%) for estrone; 19.5% (3.1%, 38.4%) and 16.5% (-5.0%, 42.9%) for testosterone; and -5.2% (-13.8%, 4.4%) and -12.1% (-19.8%, -3.6%) for IGF-1. Steroid hormones tended to be higher in proliferative compared with non-proliferative BBD. CONCLUSIONS: Circulating steroid hormones tend to be higher among women with BBD than women with no breast pathology and higher in proliferative than non-proliferative disease; these patterns are more evident among peri/post-menopausal women. In peri/post-menopausal women IGF-1 was lower among women with BBD compared with healthy women.

Role of medical history and medication use in the aetiology of upper aerodigestive tract cancers in Europe: the ARCAGE study.

BACKGROUND: The study aimed to investigate the role of medical history (skin warts, Candida albicans, herpetic lesions, heartburn, regurgitation) and medication use (for heartburn; for regurgitation; aspirin) in the aetiology of upper aerodigestive tract (UADT) cancer. METHODS: A multicentre (10 European countries) case-control study [Alcohol-Related CAncers and GEnetic susceptibility (ARCAGE) project]. RESULTS: There were 1779 cases of UADT cancer and 1993 controls. History of warts or C. albicans infection was associated with a reduced risk [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.68-0.94 and OR 0.73, 95% CI 0.60-0.89, respectively] but there was no association with herpetic lesions, heartburn, regurgitation or medication for related symptoms. Regurgitation was associated with an increased risk for cancer of the oesophagus (OR 1.47, 95% CI 0.98-2.21). Regular aspirin use was not associated with risk of UADT cancer overall but was associated with a reduced risk for cancer of oesophagus (OR 0.51, 95% CI 0.28-0.96), hypopharynx (OR 0.53, 95% CI 0.28-1.02) and larynx (OR 0.74, 95% CI 0.54-1.01). CONCLUSIONS: A history of some infections appears to be a marker for decreased risk of UADT cancer. The role of medical history and medication use varied by UADT subsites with aspirin use associated with a decreased risk of oesophageal cancer and suggestive of a decreased risk of hypopharyngeal and laryngeal cancers.

Maternal and cord blood hormone levels in the United States and China and the intrauterine origin of breast cancer.

BACKGROUND: Breast cancer is less common in China than in the United States and perinatal characteristics predict breast cancer risk in the offspring. We determined levels of pregnancy hormones in Boston and Shanghai to identify those possibly involved in the intrauterine origin of breast cancer. PARTICIPANTS AND METHODS: We compared maternal and cord blood levels of estradiol, estriol, testosterone, progesterone, prolactin, insulin-like growth factors (IGF) 1 and 2, insulin-like growth factor-binding protein 3, adiponectin and sex hormone-binding globulin (SHBG) in 241 Caucasian and 295 Chinese women. RESULTS: In both centers, hormone levels at the 16th were predictive of those at the 27th gestational week, but there was little correlation between maternal and cord blood levels. In cord blood, we found significantly (P < 0.01) higher levels of estradiol (44.2%), testosterone (54.5%), IGF-2 (22.7%) and strikingly SHBG (104.6%) in Shanghai women, whereas the opposite was true for IGF-1 (-36.8%). CONCLUSIONS: Taking into account the current understanding of the plausible biological role of the examined endocrine factors, those likely to be involved in the intrauterine origin of breast cancer are SHBG and IGF-2, with higher cord blood levels among Chinese, and IGF-1, with higher cord blood levels among Caucasian women.

Life course social mobility and risk of upper aerodigestive tract cancer in men.

The aim of this study was to explore associations between social mobility and tumours of the upper aero-digestive tract (UADT), focussing on life-course transitions in social prestige (SP) based on occupational history. 1,796 cases diagnosed between 1993 and 2005 in ten European countries were compared with 1585 controls. SP was classified by the Standard International Occupational Prestige Scale (SIOPS) based on job histories. SIOPS was categorised in high (H), medium (M) and low (L). Time weighted average achieved and transitions between SP with nine trajectories: H --> H, H --> M, H --> L, M --> H, M --> M, M --> L, L --> H, L --> M and L --> L were analysed. Odds ratios (ORs) and 95%-confidence intervals [95%-CIs] were estimated with logistic regression models including age, consumption of fruits/vegetables, study centre, smoking and alcohol consumption. The adjusted OR for the lowest versus the highest of three categories (time weighted average of SP) was 1.28 [1.04-1.56]. The distance of SP widened between cases and controls during working life. The downward trajectory H --> L gave an OR of 1.71 [0.75-3.87] as compared to H --> H. Subjects with M --> M and L --> L trajectories ORs were also elevated relative to subjects with H --> H trajectories. The association between SP and UADT is not fully explained by confounding factors. Downward social trajectory during the life course may be an independent risk factor for UADT cancers.

[A study of eating attitudes in Nutrition and Dietetics senior students].

The aim of the study was to investigate eating attitudes and related factors in a sample of senior female students of Harokopeion University, Nutrition and Dietetics Department (ND). The group of ND students was compared to a relative sample of female senior students of Technological Institute of Athens, Health Visitor's School (HV). Sixty five ND and 60 HV female senior students were approached af ter lectures. From the 55 ND and the 46 HV students that were eligible to be included in the study, 44 ND and 37 HV students agreed to participate. Ten ND and 14 HV students were excluded because they were either older than 25 years or suffering from a chronic physical or mental disorder. Eleven ND and 9 HV students refused to participate mainly because the did not wanted to be weighted by the researchers. Eating Attitudes Test (EAT-26), and two questionnaires for demographic, clinical and nutritional data were administered to all participants. Also each student was asked to pinpoint on a set of 12 male and female figures the figure that was more likely to represent their own body as well as their ideal female and male body. The ND group scored lower in the mean EAT-26 total score (p=0.03) and oral control subscale (p=0.01) than the HV group. EAT-26 score in the ND group correlated positively with self figure (Kendall's tau-b=0.2, p=0.04) and body dissatisfaction (Kendall's tau-b=0.3, p=0.01). The difference between the ideal female figure and the self figure was used as an indication of body dissatisfaction. Logistic regression analysis showed that avoidance of dinner (OR= 0.7, sig=0.03), choosing leaner ideal women figure (OR= 2.1, sig=0.03) and larger self image (OR=0.5, sig=0.001) were the three factors that could predict high EAT-26 total scores (EAT-26 ≥20) in the group of senior female students from both university departments. In conclusion, Nutrition and Dietetics senior female students showed less disordered eating attitudes than senior female Health Visitor's students. Furthermore, the estimation of the ideal female body figure as compared to the perception of the participant's own body figure was significantly related to disordered eating attitudes in the total sample of female university students.

Low carbohydrate-high protein diet and mortality in a cohort of Swedish women.

OBJECTIVE: The long-term health consequences of diets used for weight control are not established. We have evaluated the association of the frequently recommended low carbohydrate diets - usually characterized by concomitant increase in protein intake - with long-term mortality. DESIGN: The Women's Lifestyle and Health cohort study initiated in Sweden during 1991-1992, with a 12-year almost complete follow up. SETTING: The Uppsala Health Care Region. SUBJECTS: 42,237 women, 30-49 years old at baseline, volunteers from a random sample, who completed an extensive questionnaire and were traced through linkages to national registries until 2003. MAIN OUTCOME MEASURES: We evaluated the association of mortality with: decreasing carbohydrate intake (in deciles); increasing protein intake (in deciles) and an additive combination of these variables (low carbohydrate-high protein score from 2 to 20), in Cox models controlling for energy intake, saturated fat intake and several nondietary covariates. RESULTS: Decreasing carbohydrate or increasing protein intake by one decile were associated with increase in total mortality by 6% (95% CI: 0-12%) and 2% (95% CI: -1 to 5%), respectively. For cardiovascular mortality, amongst women 40-49 years old at enrolment, the corresponding increases were, respectively, 13% (95% CI: -4 to 32%) and 16% (95% CI: 5-29%), with the additive score being even more predictive. CONCLUSIONS: A diet characterized by low carbohydrate and high protein intake was associated with increased total and particularly cardiovascular mortality amongst women. Vigilance with respect to long-term adherence to such weight control regimes is advisable.

Flavonoid classes and risk of peripheral arterial occlusive disease: a case-control study in Greece.

OBJECTIVE: To assess the relation between specific flavonoid classes and peripheral arterial occlusive disease (PAOD), an important manifestation of atherosclerosis. DESIGN: Using data from a case-control study conducted in Greece in 1980 on the nutritional epidemiology of PAOD, we have exploited recently published databases on the content of foods in specific flavonoid classes to assess the relation between intake of these compounds and PAOD. SETTING: A major teaching hospital in Athens, Greece. SUBJECTS: Cases were 100 patients with PAOD and controls 100 patients with minor surgical conditions admitted to the same hospital. INTERVENTIONS: No interventions. All cases and controls were interviewed in the hospital wards, and a 110-food item semiquantitative food frequency questionnaire was administered by the same interviewer. RESULTS: Flavonols, flavones and perhaps flavan-3-ols were inversely associated with PAOD risk, the odds ratios (and 95% confidence intervals) for increments equal to the corresponding standard deviations being 0.41 (0.20-0.86), 0.56 (0.32-0.96) and 0.53 (0.26-1.05), respectively. Total flavonoids were also significantly inversely associated with PAOD. CONCLUSIONS: On the basis of these results, the biological properties of flavonoids and evidence concerning their relation to other manifestations of atherosclerosis, we conclude that dietary intake of specific classes of flavonoids, as well as total flavonoids, may have a protective effect against PAOD. SPONSORSHIP: This study was partially supported by a grant to Harvard University by the Samourkas Foundation.

Intake of specific flavonoid classes and coronary heart disease--a case-control study in Greece.

OBJECTIVE: Dietary intake of flavonoids has been reported to protect against coronary heart disease (CHD) risk, but associations of specific classes of flavonoids with CHD have not been adequately studied. DESIGN: Hospital-based case-control study relying on interviewer administered questionnaires. SETTING: Cardiology Department of the University of Athens Medical School in the Hippokrateion General Hospital (1990-1991). SUBJECTS: Cases were 329 patients with electrocardiographically confirmed first coronary infarct or a first positive coronary arteriogram, or both (participation fraction 93%). Controls were 570 patients admitted to the same hospital for minor conditions unrelated to nutrition (participation fraction 95%). All cases and controls were interviewed in the hospital wards by experienced interviewers, and a 110-item food frequency questionnaire was administered. RESULTS: There was statistically significant evidence (P approximately 0.03) for an inverse association between intake of flavan-3-ols and CHD risk, an increase of about 21 mg per day corresponding to a 24% decrease in CHD risk. The inverse association between flavan-3-ols and CHD risk was largely accounted for by the intake of wine and to a lesser extent tea. For none of the other flavonoid classes was there statistically significant evidence of an association. CONCLUSION: Flavan-3-ols, which are largely found in wine and tea, are inversely associated with, and may be protective against, coronary heart disease.

Flavonoids, vitamin C and adenocarcinoma of the stomach.

OBJECTIVE: To examine the role of six flavonoid classes (flavanones, flavan-3-ols, flavonols, flavones, anthocyanidins and isoflavones) and vitamin C in the aetiology of stomach cancer. METHODS: Case-control study undertaken in Greece in the 1980s. Dietary information was obtained from 110 patients with incident stomach adenocarcinoma and 100 control patients. Flavonoid estimates were based on the recently released database of the US Department of Agriculture. RESULTS: In models including sociodemographic variables, energy intake, vegetables, fruits and, alternatively, vitamin C the six flavonoid classes, only flavanones and vegetables remained significantly inversely associated with stomach cancer risk. The odds ratio (95% confidence intervals) per one standard deviation increase of intake of flavanones was 0.55 (0.31-0.96) whereas for vitamin C it was 1.05 (0.46-2.41). When fruits and vegetables were not adjusted for, both vitamin C and several flavonoid categories were inversely associated with stomach cancer risk, but these associations could be attributed to other compounds in these foods. CONCLUSIONS: Among the major flavonoid classes studied, only flavanone intake is inversely associated with stomach cancer risk and could account for the apparent protective effect of fruit intake against this form of cancer. Additional factors, however, are likely to be involved in the consistent protection conveyed by vegetables.

Flavonoid intake and breast cancer risk: a case--control study in Greece.

Flavonoids have been investigated for possible inverse associations with various chronic degenerative diseases, but there are no epidemiologic data concerning a possible association between several of the main flavonoid categories and breast cancer risk. We have applied recently published data on the flavonoid content of several foods and beverages on dietary information collected in the context of a large case-control study of 820 women with breast cancer and 1548 control women, conducted in Greece. We found a strong, statistically significant inverse association of flavone intake with breast cancer. The odds ratio for an increment equal to one standard deviation of daily flavone intake (i.e. 0.5 mg day(-1)) was 0.87, with 95% confidence interval 0.77-0.97. The association persisted after controlling for fruit and vegetable consumption, or for other flavonoid intake. This inverse association is compatible with and may explain the reported inverse association of breast cancer with consumption of vegetables, particularly leafy vegetables. After controlling for dietary confounding, there was no association of breast cancer risk with flavanones, flavan-3-ols, flavonols, anthocyanidins or isoflavones.

Consumption of dairy products in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort: data from 35 955 24-hour dietary recalls in 10 European countries.

OBJECTIVES: To describe and compare the consumption of dairy products in cohorts included in the European Prospective Investigation into Cancer and Nutrition (EPIC). METHODS: Data from single 24-hour dietary recall interviews collected through a highly standardised computer-based program (EPIC-SOFT) in 27 redefined centres in 10 European countries between 1995 and 2000. From a total random sample of 36 900, 22 924 women and 13 031 men were selected after exclusion of subjects under 35 and over 74 years of age. RESULTS: A high total consumption of dairy products was reported in most of the centres in Spain and in the UK cohort sampled from the general population, as well as in the Dutch, Swedish and Danish centres. A somewhat low consumption was reported in the Greek centre and in some of the Italian centres (Ragusa and Turin). In all centres and for both sexes, milk constituted the dairy sub-group with the largest proportion (in grams) of total dairy consumption, followed by yoghurt and other fermented milk products, and cheese. Still, there was a wide range in the contributions of the different dairy sub-groups between centres. The Spanish and Nordic centres generally reported a high consumption of milk, the Swedish and Dutch centres reported a high consumption of yoghurt and other fermented milk products, whereas the highest consumption of cheese was reported in the French centres. CONCLUSION: The results demonstrate both quantitative and qualitative disparities in dairy product consumption among the EPIC centres. This offers a sound starting point for analyses of associations between dairy intake and chronic diseases such as cancer.

Physical activity and energy intake selectively predict the waist-to-hip ratio in men but not in women.

BACKGROUND: The waist-to-hip ratio (WHR) has emerged as an important risk factor for several chronic diseases, but little quantitative information exists about its relation with energy intake and expenditure in men and women. OBJECTIVE: We examined the relative role of energy intake and physical activity as determinants of WHRs in men and women, after adjustment for body mass index (BMI) and other likely confounding factors. DESIGN: In the context of the European Prospective Investigation into Cancer and Nutrition (EPIC), 16433 women and 11520 men aged 30-82 y, apparently healthy and from all over Greece, were examined between 1994 and 1999. Anthropometric measurements were taken, a validated semiquantitative food-frequency questionnaire was administered, and time-weighted occupational and leisure activities were assessed. The WHR was regressed, separately for men and women, on energy intake and energy expenditure after age and BMI were controlled for. RESULTS: Results for women and men differed. In women, neither energy intake nor energy expenditure was associated with the WHR in any way other than that mediated through BMI. In contrast, in men, higher energy intakes and higher energy expenditures were associated significantly, and largely independently of BMI, with higher and lower WHRs, respectively. CONCLUSIONS: Because the WHR is an important predictor of several cardiovascular and other chronic diseases, documentation of a strong effect of physical activity on the WHR selectively in men may provide a partial explanation of how the effect of physical activity is mediated and why physical activity is more effective in men than in women in reducing disease risk.

Testosterone and oestradiol in relation to tobacco smoking, body mass index, energy consumption and nutrient intake among adult men.

There is substantial evidence linking steroid hormones and diet to cancer aetiology. The evidence on lifestyle determinants of steroid hormones, however, is limited. We have conducted a study to identify dietary and other lifestyle predictors of testosterone and oestradiol among adult men. Subjects were 112 healthy Greek men, recruited as controls in a case-control study on the aetiology of liver cancer. Demographic data and detailed histories of smoking habits and alcohol consumption were recorded. Diet was assessed through an interviewer-administered validated food-frequency questionnaire. Serologic measurements of oestradiol, testosterone and sex hormone binding globulin were also conducted. We developed linear regression models to evaluate the associations of smoking and dietary factors with serum testosterone and oestradiol. The results indicate that, among men, both testosterone and oestradiol serum levels decline with age, whereas body mass index may be inversely related with testosterone and positively with oestradiol. The evidence concerning alcohol in relation to these hormones is inconclusive. Emerging evidence concerning smoking suggests positive associations with both hormones in the blood. The principal nutritional findings are a positive association of carbohydrate intake with testosterone levels and a set of inverse associations of vitamins with oestradiol.

Are there age-dependent effects of diet on prostate cancer risk?

OBJECTIVES: To examine whether there are age-dependent effects of diet on prostate cancer risk. METHODS: We have postulated that nutritional factors that may affect the risk of initiation would be more likely to be identified among younger patients, whereas those that may affect the risk of progression would be more clearly identifiable among older patients. Study subjects were 320 patients with prostate cancer and 246 controls with no systematic disease, hospitalised in six major hospitals in Athens, Greece. Logistic regression models were fitted separately for men under 70 years and 70 years or older. RESULTS: Polyunsaturated lipids substantially increased the risk among younger subjects, but played little role among older ones (p for interaction 0.21). Cooked tomatoes had a strong protective effect among older persons, but not among younger subjects (p for interaction 0.009). Last, vitamin E was strongly inversely related to prostate cancer risk among younger subjects, but not among older subjects (p for interaction 0.15). CONCLUSIONS: Even a simple straight forward interpretation of the data, i.e., that older cases of prostate cancer have a different dietary risk profile than younger ones, has potentially useful implications.

Body mass index in relation to energy intake and expenditure among adults in Greece.

The empirical evidence concerning the quantitative relations between energy intake and expenditure on the one hand and body mass index (BMI) on the other is inconclusive. We have used a large database of 14,281 individuals, for whom habitual dietary intake and expenditure have been ascertained with adequate methodology, to examine the mutually adjusted associations of these variables with BMI. Study subjects were adult participants in the Greek component of the European Prospective Investigation into Cancer and Nutrition (EPIC) study. After adjustment for age and gender and exclusion of dieting individuals and energy underreporters, an increment of about 500 kcal intake was found to correspond to an increment of about 0.33 kg/m2 of BMI, whereas an increment of about 5 MET-hours of energy expenditure was associated with a decrease of about 0.18 kg/m2 of BMI, where MET is the ratio of the metabolic rate associated with a given activity to the resting metabolic rate. Our results indicate that increasing physical activity is about half as effective as decreasing energy intake in reducing BMI.

Standardization of the 24-hour diet recall calibration method used in the european prospective investigation into cancer and nutrition (EPIC): general concepts and preliminary results.

OBJECTIVES: Despite increasing interest in the concept of calibration in dietary surveys, there is still little experience in the use and standardization of a common reference dietary method, especially in international studies. In this paper, we present the general theoretical framework and the approaches developed to standardize the computer-assisted 24 h diet recall method (EPIC-SOFT) used to collect about 37 000 24-h dietary recall measurements (24-HDR) from the 10 countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). In addition, an analysis of variance was performed to examine the level of standardization of EPIC-SOFT across the 90 interviewers involved in the study. METHODS: The analysis of variance used a random effects model in which mean energy intake per interviewer was used as the dependent variable, while age, body mass index (BMI), energy requirement, week day, season, special diet, special day, physical activity and the EPIC-SOFT version were used as independent variables. The analysis was performed separately for men and women. RESULTS: The results show no statistical difference between interviewers in all countries for men and five out of eight countries for women, after adjustment for physical activity and the EPIC-SOFT program version used, and the exclusion of one interviewer in Germany (for men), and one in Denmark (for women). These results showed an interviewer effect in certain countries and a significant difference between gender, suggesting an underlying respondent's effect due to the higher under-reporting among women that was consistently observed in EPIC. However, the actual difference between interviewer and country mean energy intakes is about 10%. Furthermore, no statistical differences in mean energy intakes were observed across centres from the same country, except in Italy and Germany for men, and France and Spain for women, where the populations were recruited from areas scattered throughout the countries. CONCLUSION: Despite these encouraging results and the efforts to standardize the 24-HDR interview method, conscious or unconscious behaviour of respondents and/or interviewer bias cannot be prevented entirely. Further evaluation of the reliability of EPIC-SOFT measurements will be conducted through validation against independent biological markers (nitrogen, potassium).

Mediterranean diet and coronary heart disease: are antioxidants critical?

There is substantial evidence that several variants of the Mediterranean diet reduce the incidence of coronary heart disease (CHD) and perhaps other chronic conditions. Recently, the final results of the Lyon Diet Heart Study, a randomized secondary prevention trial, indicated that the Mediterranean diet substantially reduces the rate of recurrence after a first myocardial infarction. Data from this study also suggest that the Mediterranean diet protects against CHD through mechanisms that are independent of traditional CHD risk factors. We postulate that the antioxidant properties of several plant foods in the Mediterranean diet may be critical mediators of the beneficial effects of this diet.