Article open access publication

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

BMC Medicine, Springer Nature, ISSN 1741-7015

Volume 12, 1, 2014

DOI:10.1186/s12916-014-0168-4, Dimensions: pub.1015961217, PMC: PMC4192278, PMID: 25319089,



  1. (1) German Institute of Human Nutrition, grid.418213.d
  2. (2) Max Delbrück Center for Molecular Medicine, grid.419491.0
  3. (3) International Agency For Research On Cancer, grid.17703.32
  4. (4) National Institute for Public Health and the Environment, grid.31147.30
  5. (5) University Medical Center Utrecht, grid.7692.a
  6. (6) Imperial College London, grid.7445.2
  7. (7) Emory University, grid.189967.8
  8. (8) Hospital Universitario Son Espases, grid.411164.7
  9. (9) Institute of Health Carlos III, grid.413448.e
  10. (10) Centre for research in epidemiology and population health, grid.463845.8
  11. (11) IGR, F-94805, Villejuif, France
  12. (12) University of Paris-Sud, grid.5842.b
  13. (13) German Cancer Research Center, grid.7497.d
  14. (14) Danish Cancer Society, grid.417390.8
  15. (15) Aarhus University, grid.7048.b, AU
  16. (16) Public Health Directorate, Asturias, Spain
  17. (17) Catalan Institute of Oncology, grid.418701.b
  18. (18) Andalusian School of Public Health, grid.413740.5
  19. (19) Public Health Division of Gipuzkoa, Basque Regional Health Department, Epidemiology and Health Information, San Sebastian, Spain
  20. (20) Department of Epidemiology, Murcia Regional Health Authority, Murcia, Spain
  21. (21) Instituto de Salud Pública de Navarra, grid.419126.9
  22. (22) University of Cambridge, grid.5335.0
  23. (23) Institute of Metabolic Science, grid.470900.a
  24. (24) University of Oxford, grid.4991.5
  25. (25) Hellenic Health Foundation, grid.424637.0
  26. (26) Academy of Athens, grid.417593.d
  27. (27) National and Kapodistrian University of Athens, grid.5216.0
  28. (28) Harvard University, grid.38142.3c
  29. (29) Istituto per lo Studio e la Prevenzione Oncologica, grid.417623.5
  30. (30) Fondazione IRCCS Istituto Nazionale dei Tumori, grid.417893.0
  31. (31) Cancer Registry and Histopathology Unit, “M.P.Arezzo” Hospital, Ragusa, Italy
  32. (32) Human Genetics Foundation, grid.428948.b
  33. (33) University of Naples Federico II, grid.4691.a
  34. (34) Umeå University, grid.12650.30
  35. (35) Lund University, grid.4514.4
  36. (36) Department of Clinical Sciences, Division of Internal Medicine, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
  37. (37) Cancer Registry of Norway, grid.418941.1
  38. (38) Folkhälsans Forskningscentrum, grid.428673.c
  39. (39) Karolinska Institute, grid.4714.6
  40. (40) The Arctic University of Norway, grid.10919.30


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.


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