Aleksandrova, KrasimiraPischon, TobiasJenab, MazdaBueno-de-Mesquita, HFedirko, VeronikaNorat, TeresaRomaguera, DoraKnüppel, SvenBoutron-Ruault, Marie-ChristineDossus, LaureDartois, LaureenKaaks, RudolfLi, KuanrongTjønneland, AnneOvervad, KimQuirós, José RamónBuckland, GenevieveSanchez-Perez, Maria-JoseDorronsoro, MirenChirlaque, Maria-DoloresBarricarte, AurelioKhaw, Kay-TeeWareham, Nicholas JBradbury, Kathryn ETrichopoulou, AntoniaLagiou, PagonaTrichopoulos, DimitriosPalli, DomenicoKrogh, VittorioTumino, RosarioNaccarati, AlessioPanico, SalvatoreSiersema, Peter DPeeters, PetraLjuslinder, IngridJohansson, IngegerdEricson, UlrikaOhlsson, BodilWeiderpass, ElisabeteSkeie, GuriBorch, KristinRinaldi, SabinaRomieu, IsabelleKong, JoyceGunter, Marc JWard, Heather ARiboli, ElioBoeing, Heiner2015-09-112015-09-112014-10-10Aleksandrova K, Pischon T, Jenab M, Bueno-de-Mesquita H, Fedirko V, Norat T, et al. Combined impact of healthy lifestyle factors on colorectal cancer: a large European cohort study. BMC Med. 2014; 12(1): 168http://hdl.handle.net/10668/1988JOURNAL ARTICLE;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.enLifestyle factorsCombined impactPopulation attributable risksColorectal cancerEuropean Prospective Investigation into Cancer and Nutrition (EPIC)Neoplasias colorrectalesConsumo de alcoholDietaHábito de fumarMedical Subject Headings::Diseases::Neoplasms::Neoplasms by Site::Digestive System Neoplasms::Gastrointestinal Neoplasms::Intestinal Neoplasms::Colorectal NeoplasmsMedical Subject Headings::Psychiatry and Psychology::Behavior and Behavior Mechanisms::Psychology, Social::Life StyleMedical Subject Headings::Psychiatry and Psychology::Behavior and Behavior Mechanisms::Behavior::Drinking Behavior::Alcohol DrinkingMedical Subject Headings::Phenomena and Processes::Physiological Phenomena::Nutritional Physiological Phenomena::DietMedical Subject Headings::Psychiatry and Psychology::Behavior and Behavior Mechanisms::Behavior::Motor ActivityMedical Subject Headings::Psychiatry and Psychology::Behavior and Behavior Mechanisms::Behavior::Habits::SmokingMedical Subject Headings::Analytical, Diagnostic and Therapeutic Techniques and Equipment::Investigative Techniques::Epidemiologic Methods::Epidemiologic Study Characteristics as Topic::Epidemiologic Studies::Cohort StudiesMedical Subject Headings::Analytical, Diagnostic and Therapeutic Techniques and Equipment::Investigative Techniques::Epidemiologic Methods::Epidemiologic Study Characteristics as Topic::Epidemiologic Studies::Cohort Studies::Longitudinal Studies::Prospective Studiesresearch article25319089open access10.1186/s12916-014-0168-41741-7015PMC4192278