Level of Dietary Adherence to WCRF/AICR

Recommendations among 75,131 Adventist

Health Study-2 Participants

Lap T. Le, DrPH(s)

Loma Linda University School of Public Health

Acknowledgements

» Karen Jaceldo, DrPH» Rawiwan Sirirat, MPH, RD

Objectives

» Rationales: WCRF/AIRC Index, AHS-2 cohort» Aims of study» Methods: Operationalization of WCRF/AIRC Index

» Results» Discussion» Conclusion

Rationale: WCRF/IACR » Most common chronic diseases, including cancers are preventable through modifiable risk factors.

Rationale: WCRF/AICR

» The relationship between modifiable risk factors and the major chronic diseases of lifestyle, including cancer is complex and intricate, and therefore requires a comprehensive approach to assess risk behaviors which encompass diets, physical activity, and other intermediate risk factors.

Rationale: Significance to Public Health

» The need to explore alternative measurements to assess and effectively prescribe overall dietary and lifestyle behavior recommendations to the public for cancer prevention is warranted.

WCRF / AICR» World Cancer Research Fund & American Institute of Cancer Research (WCRF/AICR) issued 8 recommendations (+2 special recommendations) for cancer prevention.~ Diet ~ Alcohol consumption~ Physical activity~ Weight management

WCRF/AICR Index-Based Recommendations1. Body fatness. Be as lean as possible without becoming underweight.

2. Physical activity. Be physically active as part of your everyday life.

3. Foods and drinks that promote weight gain. Limit consumption of energy-dense foods; avoid sugary drinks.

4. Plant foods. Eat mostly foods of plant origin.

5. Animal foods. Limit intake of red meat and avoid processed meat.

6. Alcoholic drinks. Limit alcoholic drinks.

7. Preservation, processing, preparation. Limit consumption of salt. Avoid moldy cereals (grains) or pulses (legumes).

8. Dietary Supplements. Aim to meet nutritional needs through diet alone.

9. Breastfeeding. Aim to breastfeed infants exclusively up to six months and continue with complementary feeding thereafter.

10. Cancer survivors.* All cancer survivors to receive nutritional care from an appropriately trained professional.

Rationale: WCRF/AICR» Popular dietary index scores only dietary components

» Characterized at the level of nutrients, individual foods, food groups, and 5 dietary patterns (non-veg, semi-, pesco-, lacto-ovo, and vegan)

» WCRF/AICR Index assesses both diets and lifestyle components (+ special recommendations)~ Allows AHS-2 to generate a composite index score to

assess both dietary and lifestyle behaviors.

Why focus on AHS-2 cohort?» Large cohort of ~96,000 Adventists in North America, with

unique & wide range of dietary patterns~35% male; 65% female~48% non-veg, 5% semi-, 10% pesco-, 29% lacto-ovo, and

8% vegan.

» Relatively small percentage of alcohol consumption and cigarette smoking.

» Dietary, lifestyle, and breastfeeding variables.

Aims of Study» To assess the degree of dietary adherence to the WCRF/AICR recommendations among the Adventist Health Study-2 (AHS-2) population.

» Compare the WCRF/AICR scores among vegetarians and non-vegetarians.

Methods» Constructed from the operationalization of multiple dietary and lifestyle components, using data from AHS-2 comprehensive questionnaires including: ~Quantitative FFQ ~Lifestyle assessment questionnaires

» SAS 9.4 was used.

EXAMPLE:WCRF/AICR

recommendationsPersonal

Recommendations Operationalization for

AHS-2 Cohort Score

3) Foods and drinks that promote weight gain. Limit consumption of energy-dense foods; avoid sugary drinks.

3a) Consume energy-dense foods sparingly

Consumed energy dense food less than 150 kcals per 100 grams per day

1

Consumed energy dense food more than 150 but less than 225 kcals per 100 grams per day

0.5

Consumed energy dense food more than 225 kcals per grams per day

0

3b) Avoid sugary drinks

Consumed sugary drinks equal to zero gram per day

1

Consumed sugary drinks greater than zero but less than 250 grams per day

0.5

Consumed sugary drinks greater than 250 grams per day

0

3c) Consume fast foods sparingly, if at all

Never or rarely consumed fast food or consumed 1-3 times per month

1

Consumed fast food 1-3 per month or once a week

0.5

Consumed fast food 4 times or more per week

0

Methods» Computed WCRF/AICR composite scores

~Total score = ∑ score of each individual recommendations

» Higher scores indicate greater concordance with recommendations.~ 0 = poor diet/lifestyle quality~16 = high diet/lifestyle quality (for AHS-2)

» Assumption of WCRF/AICR: Each major recommendation should contribute equally to the total composite score.

Results

WCRF/ AICR Mean Scores & Ranges » Results: Parameters Score Range Mean ±SD

Composite score 2–16 9.09 ±1.80 Gender* Male 2–15.5 8.66 ±1.73 Female 2–16 9.33 ±1.79

Race* Black 2–15.5 8.62 ±1.83 Non-Black 2–16 9.19 ±1.77Dietary Patterns* Non-vegetarian 2–15 8.49 ±1.78 Semi-vegetarian 4.5–14.5 9.23 ±1.57 Pesco- 3.4–15 9.63 ±1.63 Lacto-ovo- 3.5–16 9.54 ±1.58 Vegan 4–16 10.4 ±1.55* Statistically significant, p-value <0.05.

Average WCRF/AICR Score for Selected Characteristics among 75,131 AHS-2 Participants

Participant Characteristics Mean SD

Age, yrs

<50 8.97 1.86

50-64 9.14 1.82

>64 9.18 1.69

Educational level

High school or less 8.80 1.83 Trade school, associate degree, or some college 9.04 1.82 College graduates or higher 9.30 1.73

Smoking status

Never 9.22 1.75

Past 8.64 1.84

Current 7.13 1.88

Marital status

Never married 8.68 1.86 First marriage, remarried, Common Law marriage 9.12 1.78

Separated, divorced, widowed 9.14 1.82

Household income, $ per year

Less than 10,000 8.82 1.83

10,000 to 75,000 9.03 1.79

>75,000 to 200,000 9.18 1.77

More than 200,000 9.49 1.78

0

3

6

9

8.59.2

9.6 9.5

10.4

Average WCRF/AICR Scores According to Dietary Patterns among 75,131 Adventist Health Study-2 Participants

Non-veg Semi- Pesco- Lacto-ovo- Vegan

Av

era

ge

WC

RF

/AIC

R S

co

re

Non-black Black0

3

6

9

8.78.2

9.58.8

Average WCRF/AICR Scores According to Gender and Race/Ethnicity among 75,131 Adventist Health Study-2 Participants

Male Female

Race/Ethnicity

Av

era

ge

WC

RF

/AIC

R S

co

re

Black Non-blackMales

0

3

6

9

12

8.18.98.9 9.49.3

9.99.2

9.810.110.7

Average WCRF/AICR Scores by Dietary Patterns According to Race/Ethnicity among 26,510 Male Participants

Non-vegetarian Semi-vegetarian Pesco- Lacto-ovo- Vegan

Race/Ethnicity

Av

era

ge

WC

RF

/AIC

R S

co

re

Black Non-blackFemales

0

3

6

9

12

7.88.38.7

9.38.8

9.48.8

9.49.610.3

Average WCRF/AICR Scores by Dietary Patterns According to Race/Ethnicity among 48,597 Female Participants

Non-vegetarian Semi-vegetarian Pesco- Lacto-ovo- Vegan

Race/Ethnicity

Av

era

ge

WC

RF

/AIC

R S

co

re

Summary» The average composite score is 9.09, ranging from 2 to 16.

» There is a step-wise increase in the average WCRF/AICR score moving toward a plant-based diet.

» Overall, non-black female vegans have better dietary and lifestyle quality than their black non-vegetarian male counterparts, with the average score being higher with increased age, increased level of education, being married, higher household income, and those who never smoked cigarettes.

Discussion» EPIC cohort:

score range 0-6 for males; 0-7 for females~ Difference in operationalization for each

component among different studies~ Not all studies have available data to satisfy all

10 recommendations outlined by the WCRF/AICR.

» Further improvements to better operationalize individual components.

Conclusion

» Data collected from AHS-2 cohort were applicable to 9 out of 10 recommendations~ Applying WCRF/AICR index to this cohort is appropriate

in assessing overall dietary and lifestyle behaviors

» Vegan dietary pattern may be a good surrogate measure for healthy lifestyle

» WCRF/AICR scoring index could be used an exposure variable relating to other outcomes.

Disclosures

» Funding for AHS-2: National Cancer Institute grant 1U01CA152939

Q&A