Adherence to a Mediterranean diet and risk of gastric adenocarcinoma within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort study123

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Background: The Mediterranean dietary pattern is believed to protect against cancer, although evidence from cohort studies that have examined particular cancer sites is limited.

Objective: We aimed to explore the association between adherence to a relative Mediterranean diet (rMED) and incident gastric adenocarcinoma (GC) within the European Prospective Investigation into Cancer and Nutrition study.

Design: The study included 485,044 subjects (144,577 men) aged 35–70 y from 10 European countries. At recruitment, dietary and lifestyle information was collected. An 18-unit rMED score, incorporating 9 key components of the Mediterranean diet, was used to estimate rMED adherence. The association between rMED and GC with respect to anatomic location (cardia and noncardia) and histologic types (diffuse and intestinal) was investigated. A calibration study in a subsample was used to control for dietary measurement error.

Results: After a mean follow-up of 8.9 y, 449 validated incident GC cases were identified and used in the analysis. After stratification by center and age and adjustment for recognized cancer risk factors, high compared with low rMED adherence was associated with a significant reduction in GC risk (hazard ratio: 0.67; 95% CI: 0.47, 0.94). A 1-unit increase in the rMED score was associated with a decreased risk of GC of 5% (95% CI: 0.91, 0.99). There was no evidence of heterogeneity between different anatomic locations or histologic types. The calibrated results showed similar trends (overall hazard ratio for GC: 0.93; 95% CI: 0.89, 0.99).

Conclusion: Greater adherence to an rMED is associated with a significant reduction in the risk of incident GC.

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1

From the Unit of Nutrition Environment and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology, Idibell, Barcelona, Spain (GB, AA, LL, PJ, and CAG); the National Institute for Public Health and the Environment, Bilthoven, Netherlands (HBB-d-M); the Molecular and Nutritional Epidemiology Unit, CSPO–Scientific Institute of Tuscany, Florence, Italy (DP); the German Institute of Human Nutrition, Potsdam-Rehbücke, Germany (HB); the Institute of Molecular Pathology and Immunology of the University of Porto and Medical Faculty/HS João, Porto, Portugal (FC); the Department of Preventive & Predictive Medicine, Nutritional Epidemiology Unit, National Institute of Tumori, Milan, Italy (VK); the University of Torino, Torino, Italy (CS); the Cancer Registry, Azienda Ospedaliera “Civile M.P. Arezzo”, Ragusa, Italy (RT); the Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy (SP); the Department of Human Pathology and Oncology, University of Florence, Florence, Italy (GN); the Department of Surgery, Malmö University Hospital, Sweden, (JM and SR); the Department of Nutritional Research, University of Umeå, Umeå, Sweden (IJ); the Department of Medical Biosciences, University of Umeå, Umeå, Sweden (RS); the Andalusian School of Public Health, Granada, Spain, and CIBER de Epidemiología y Salud Pública, Spain (M-JS); the Department of Public Health of Guipuzkoa, San Sebastian, Spain (MD); the Public Health Institute of Navarra, Pamplona, Spain (AB); the Epidemiology Department, Health Council of Murcia, and CIBER de Epidemiología y Salud Pública, Murcia, Spain (CN); the Public Health and Health Planning Directorate, Asturias, Spain (JRQ); the Cancer Epidemiology Unit, University of Oxford, Oxford, United Kingdom (NEA and TJK); the MRC Dunn Human Nutrition Unit, & MRC Centre for Nutritional Epidemiology in Cancer Prevention and Survival and the Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom (SB); the Division of Clinical Epidemiology, Deutsches Krebsforschungszentrum, Heidelberg, Germany (RK); the Department of Clinical Epidemiology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark (KO and MJ); the Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark (AO and A Tjønneland); the Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, Netherlands (PHMP and MEN); the National Institute for Public Health and the Environment, Bilthoven, Netherlands (MCO); INSERM, Institut Gustave Roussy, Villejuif, France (FC-C SM, and M-CB-R); the Department of Hygiene and Epidemiology, University of Athens Medical School, Greece and Hellenic Health Foundation Athens, Greece (A Trichopoulou and PL); the Department of Epidemiology, Harvard School of Public Health, Boston, MA (DT); the Institute of Community Medicine, University of Tromso, Tromso, Norway (EL); the International Agency for Research on Cancer, Lyon, France (EC PB, and MJ); and the Faculty of Medicine, Division of Epidemiology, Public Health and Primary Care, Imperial College London, London, United Kingdom (ER DR, and TM).

2

Supported by the European Commission FP5 project (QLG1-CT-2001-01049). The EPIC study was funded by “Europe Against Cancer” Programme of the European Commission (SANCO); ISCIII of the Spanish Ministry of Health (RETICC DR06/0020); Ligue contre le Cancer (France); Société 3M (France); Mutuelle Générale de l’Education Nationale; Institut National de la Santé et de la Recherche Médicale (INSERM); German Cancer Aid; German Cancer Research Center; German Federal Ministry of Education and Research; Danish Cancer Society; Health Research Fund (FIS) of the Spanish Ministry of Health (RTICCC; C03/10); the participating regional governments and institutions of Spain; Cancer Research United Kingdom; Medical Research Council, United Kingdom; the Stroke Association, United Kingdom; British Heart Foundation; Department of Health, United Kingdom; Food Standards Agency, United Kingdom; the Wellcome Trust, United Kingdom; Greek Ministry of Health; Stavros Niarchos Foundation; Hellenic Health Foundation; Italian Association for Research on Cancer; Dutch Ministry of Health, Welfare and Sports; Dutch Ministry of Health; Dutch Prevention Funds; LK Research Funds; Dutch Zorg Onderzoek Nederland; World Cancer Research Fund; Swedish Cancer Society; Swedish Scientific Council; Regional Government of Skane, Sweden; Norwegian Cancer Society. Some authors are partners of ECNIS, a network of excellence of the EC (6FP contract 513943).

3

Address correspondence to CA González, Unit of Nutrition Environment and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology, Idibell, Barcelona, Spain. E-mail: [email protected].