Towards refining World Cancer Research Fund/American Institute for Cancer Research cancer prevention recommendations for red and processed meat intake: insights from Alberta's Tomorrow Project cohort.

Current cancer prevention recommendations advise limiting red meat intake to <500 g/week and avoiding consumption of processed meat, but do not differentiate the source of processed meat. We examined the associations of processed meat derived from red v. non-red meats with cancer risk in a prospective cohort of 26 218 adults who reported dietary intake using the Canadian Diet History Questionnaire. Incidence of cancer was obtained through data linkage with Alberta Cancer Registry with median follow-up of 13·3 (interquartile range (IQR) 5·1) years. Multivariable Cox proportional hazards regression models were adjusted for covariates and stratified by age and sex. The median consumption (g/week) of red meat, processed meat from red meat and processed meat from non-red meat was 267·9 (IQR 269·9), 53·6 (IQR 83·3) and 11·9 (IQR 31·8), respectively. High intakes (4th Quartile) of processed meat from red meat were associated with increased risk of gastrointestinal cancer adjusted hazard ratio (AHR): 1·68 (95 % CI 1·09, 2·57) and colorectal cancers AHR: 1·90 (95 % CI 1·12, 3·22), respectively, in women. No statistically significant associations were observed for intakes of red meat or processed meat from non-red meat. Results suggest that the carcinogenic effect associated with processed meat intake may be limited to processed meat derived from red meats. The findings provide preliminary evidence towards refining cancer prevention recommendations for red and processed meat intake.

The effect of different methods to identify, and scenarios used to address energy intake misestimation on dietary patterns derived by cluster analysis.

BACKGROUND: All self-reported dietary intake data are characterized by measurement error, and validation studies indicate that the estimation of energy intake (EI) is particularly affected. METHODS: Using self-reported food frequency and physical activity data from Alberta's Tomorrow Project participants (n = 9847 men 16,241 women), we compared the revised-Goldberg and the predicted total energy expenditure methods in their ability to identify misreporters of EI. We also compared dietary patterns derived by k-means clustering under different scenarios where misreporters are included in the cluster analysis (Inclusion); excluded prior to completing the cluster analysis (ExBefore); excluded after completing the cluster analysis (ExAfter); and finally, excluded before the cluster analysis but added to the ExBefore cluster solution using the nearest neighbor method (InclusionNN). RESULTS: The predicted total energy expenditure method identified a significantly higher proportion of participants as EI misreporters compared to the revised-Goldberg method (50% vs. 47%, p < 0.0001). k-means cluster analysis identified 3 dietary patterns: Healthy, Meats/Pizza and Sweets/Dairy. Among both men and women, participants assigned to dietary patterns changed substantially between ExBefore and ExAfter and also between the Inclusion and InclusionNN scenarios (Hubert and Arabie's adjusted Rand Index, Kappa and Cramer's V statistics < 0.8). CONCLUSIONS: Different scenarios used to account for EI misreporters influenced cluster analysis and hence the composition of the dietary patterns. Continued efforts are needed to explore and validate methods and their ability to identify and mitigate the impact of EI misestimation in nutritional epidemiology.

Administering a combination of online dietary assessment tools, the Automated Self-Administered 24-Hour Dietary Assessment Tool, and Diet History Questionnaire II, in a cohort of adults in Alberta's Tomorrow Project.

BACKGROUND: Evidence suggests that combining tools that gather short- and long-term dietary data may be the optimal approach for the assessment of diet-disease associations in epidemiologic studies. Online technology can reduce the associated burdens for researchers and participants, but feasibility must be demonstrated in real-world settings before wide-scale implementation. OBJECTIVE: The objective of this study was to determine the feasibility and acceptability of combining web-based tools (the Automated Self-Administered 24-hour Dietary Assessment Tool [ASA24-2016] and the past-year Diet History Questionnaire II [DHQ-II]) in a subset of participants in Alberta's Tomorrow Project, a prospective cohort. DESIGN: For this feasibility study, invitations were mailed to 550 randomly selected individuals enrolled in Alberta's Tomorrow Project. Consented participants (n = 331) were asked to complete a brief sociodemographic and health questionnaire, four ASA24-2016 recalls, the DHQ-II, and an evaluation survey. PARTICIPANTS/SETTING: The study was conducted from March 2016 to December 2016 in Alberta, Canada. The majority of participants, mean age (SD) = 57.4 (9.8) years, were women (70.7%), urban residents (85.5%), and nonsmokers (95.7%). MAIN OUTCOME MEASURES: Primary outcomes were number of ASA24-2016 recalls completed, response rate of DHQ-II completion, and time to complete each assessment. STATISTICAL ANALYSES: The Wilcoxon signed rank sum test was used to assess differences in completion time. RESULTS: One-third (n = 102) of consenting participants did not complete any ASA24-2016 recalls. The primary reason to withdraw from the feasibility study was a lack of time. Among consenting participants, 51.9% (n = 172), 41.1% (n = 136), and 36.5% (n = 121) completed at least two ASA24-2016 recalls, the DHQ-II, and at least two ASA24-2016 recalls plus the DHQ-II, respectively. Median (25th to 75th percentile) completion times for participants who completed all recalls were 39 minutes (25 to 53 minutes) for the first ASA24-2016 recall and 60 minutes (40 to 90 minutes) for the DHQ-II. CONCLUSIONS: Findings indicate combining multiple ASA24-2016 recalls and the DHQ-II is feasible in this subset of Alberta's Tomorrow Project participants. However, optimal response rates may be contingent on providing participant support. Completion may also be sensitive to timing and frequency of recall administration.

Co-consumption of Vegetables and Fruit, Whole Grains, and Fiber Reduces the Cancer Risk of Red and Processed Meat in a Large Prospective Cohort of Adults from Alberta's Tomorrow Project.

We examined whether co-consumption of red and processed meat with key foods items and food constituents recommended for cancer prevention (vegetables and fruit, whole grains, and fiber) mitigates cancer incidence. In a prospective cohort of 26,218 adults aged 35-69 years at baseline, dietary intake was collected through 124-item past-year food frequency questionnaire. Incidence of all-cause and 15 cancers previously linked to red and processed meat intake was obtained through data linkage with a cancer registry (average follow-up 13.5 years). Competing risk Cox Proportional Hazard models estimated cancer risk and Accelerated Failure Time models estimated time-to-cancer occurrence for different combinations of intake levels while considering mortality from vital statistics and established confounders. Co-consumption of low vegetables and fruit intake with high processed meat was associated with higher incidence of all-cause and 15 cancers (men: HR = 1.85, 1.91; women: HR = 1.44, 1.49) and accelerated time-to-cancer occurrence (men: 6.5 and 7.1 years and women: 5.6 and 6.3 years, respectively), compared to high vegetables and fruit with low processed meat intake. Less pronounced and less consistent associations were observed for whole grains and fiber and for red meat. The findings provide initial evidence toward refining existing cancer prevention recommendations to optimize the intake and combination of foods in the general adult population.

Strategies to Address Misestimation of Energy Intake Based on Self-Report Dietary Consumption in Examining Associations Between Dietary Patterns and Cancer Risk.

The objective of this study was to determine the influence of strategies of handling misestimation of energy intake (EI) on observed associations between dietary patterns and cancer risk. Data from Alberta's Tomorrow Project participants (n = 9,847 men and 16,241 women) were linked to the Alberta Cancer Registry. The revised-Goldberg method was used to characterize EI misestimation. Four strategies assessed the influence of EI misestimation: Retaining individuals with EI misestimation in the cluster analysis (Inclusion), excluding before (ExBefore) or after cluster analysis (ExAfter), or reassigning into ExBefore clusters using the nearest neighbor method (InclusionNN). Misestimation of EI affected approximately 50% of participants. Cluster analysis identified three patterns: Healthy, Meats/Pizza and Sweets/Dairy. Cox proportional hazard regression models assessed associations between the risk of cancer and dietary patterns. Among men, no significant associations (based on an often-used threshold of p < 0.05) between dietary patterns and cancer risk were observed. In women, significant associations were observed between the Sweets/Dairy and Meats/Pizza patterns and all cancer risk in the ExBefore (HR (95% CI): 1.28 (1.04-1.58)) and InclusionNN (HR (95% CI): 1.14 (1.00-1.30)), respectively. Thus, strategies to address misestimation of EI can influence associations between dietary patterns and disease outcomes. Identifying optimal approaches for addressing EI misestimation, for example, by leveraging biomarker-based studies could improve our ability to characterize diet-disease associations.

The Comparative Reliability and Feasibility of the Past-Year Canadian Diet History Questionnaire II: Comparison of the Paper and Web Versions.

Advances in technology-enabled dietary assessment include the advent of web-based food frequency questionnaires, which may reduce costs and researcher burden but may introduce new challenges related to internet connectivity and computer literacy. The purpose of this study was to evaluate the intra- and inter-version reliability, feasibility and acceptability of the paper and web Canadian Diet History Questionnaire II (CDHQ-II) in a sub-sample of 648 adults (aged 39-81 years) recruited from Alberta's Tomorrow Project. Participants were randomly assigned to one of two groups: (1) paper, web, paper; or (2) web, paper, web over a six-week period. With few exceptions, no statistically significant differences in mean nutrient intake were found in the intra- and inter-version reliability analyses. The majority of participants indicated future willingness to complete the CDHQ-II online, and 59% indicated a preference for the web over the paper version. Findings indicate that, in this population of adults drawn from an existing cohort, the CDHQ-II may be administered in paper or web modalities (increasing flexibility for questionnaire delivery), and the nutrient estimates obtained with either version are comparable. We recommend that other studies explore the feasibility and reliability of different modes of administration of dietary assessment instruments prior to widespread implementation.

Alberta's Tomorrow Project: adherence to cancer prevention recommendations pertaining to diet, physical activity and body size.

OBJECTIVE: To explore cross-sectional adherence to cancer prevention recommendations by adults enrolled in a prospective cohort in Alberta, Canada. DESIGN: Questionnaire data were used to construct a composite cancer prevention adherence score for each participant, based on selected personal recommendations published by the World Cancer Research Fund/American Institute for Cancer Research (2007). Data were self-reported on health and lifestyle, past-year physical activity and past-year FFQ. The scores accounted for physical activity, dietary supplement use, body size, and intakes of alcohol, fruit, vegetables and red meat. Tobacco exposure was also included. Scores ranged from 0 (least adherent) to 7 (most adherent). SETTING: Alberta's Tomorrow Project; a research platform based on a prospective cohort. SUBJECTS: Adult men and women (n 24 988) aged 35-69 years recruited by random digit dialling and enrolled in Alberta's Tomorrow Project between 2001 and 2009. RESULTS: Of the cohort, 14 % achieved adherence scores ≥5 and 60 % had scores ≤3. Overall adherence scores were higher in women (mean (sd): 3·4 (1·1)) than in men (3·0 (1·2)). The extent of overall adherence was also associated with level of education, employment status, annual household income, personal history of chronic disease, family history of chronic disease and age. CONCLUSIONS: Reported adherence to selected personal recommendations for cancer prevention was low in this cohort of adults. In the short to medium term, these results suggest that more work is required to identify behaviours to target with cancer prevention strategies at a population level. Future work will explore the associations between adherence scores and cancer risk in this cohort.

Using national dietary intake data to evaluate and adapt the US Diet History Questionnaire: the stepwise tailoring of an FFQ for Canadian use.

OBJECTIVE: To evaluate the Canadian Diet History Questionnaire I (C-DHQ I) food list and to adapt the US DHQ II for Canada using Canadian dietary survey data. DESIGN: Twenty-four-hour dietary recalls reported by adults in a national Canadian survey were analysed to create a food list corresponding to C-DHQ I food questions. The percentage contribution of the food list to the total survey intake of seventeen nutrients was used as the criterion to evaluate the suitability of the C-DHQ I to capture food intake in Canadian populations. The data were also analysed to identify foods and to modify portion sizes for the C-DHQ II. SETTING: The Canadian Community Health Survey (CCHS) - Cycle 2.2 Nutrition (2004). SUBJECTS: Adults (n 20 159) who completed 24 h dietary recalls during in-person interviews. RESULTS: Four thousand five hundred and thirty-three foods and recipes were grouped into 268 Food Groups, of which 212 corresponded to questions on the C-DHQ I. Nutrient intakes captured by the C-DHQ I ranged from 79 % for fat to 100 % for alcohol. For the new C-DHQ II, some food questions were retained from the original US DHQ II while others were added based on foods reported in CCHS and foods available on the Canadian market since 2004. Of 153 questions, 143 were associated with portion sizes of which fifty-three were modified from US values. Sex-specific nutrient profiles for the C-DHQ II nutrient database were derived using CCHS data. CONCLUSIONS: The C-DHQ I and II are designed to optimize the capture of foods consumed by Canadian populations.

Leisure-Time Physical Activity Does not Attenuate the Association Between Occupational Sedentary Behavior and Obesity: Results From Alberta's Tomorrow Project.

BACKGROUND: Sedentary behavior has been proposed as a risk factor for obesity that is distinct from physical inactivity. This study aimed to examine the association between occupational sedentary behavior and obesity, and to determine if this association is independent of leisure-time physical activity (LTPA). METHODS: Fully employed participants enrolled between 2001 and 2008 to Alberta's Tomorrow Project, a prospective cohort study in Alberta, Canada, were studied (n = 12,409). Associations between occupational sedentary behavior and waist circumference (WC), waist-to-hip ratio (WHR), and body mass index (BMI) were examined using multiple binary and multinomial logistic regressions. RESULTS: In men, a positive association was observed between daily occupational sedentary hours and WC, WHR, BMI, and with high risk profiles that incorporated both BMI and WC (P < .01). Controlling for vigorous-intensity LTPA in all models strengthened associations between sedentary behavior and measures of obesity. In contrast, inverse associations were observed for occupational sedentary hours and WHR for women (P < .05). CONCLUSIONS: In fully employed men, occupational sedentary behavior was positively associated with obesity risk that was not attenuated by physical activity. In women, an increase in obesity risk was not observed with sedentary behavior. Gender differences in the health effects of sedentary behavior require further study.

Hours spent and energy expended in physical activity domains: results from the Tomorrow Project cohort in Alberta, Canada.

BACKGROUND: Knowledge of adult activity patterns across domains of physical activity is essential for the planning of population-based strategies that will increase overall energy expenditure and reduce the risk of obesity and related chronic diseases. We describe domain-specific hours of activity and energy expended among participants in a prospective cohort in Alberta, Canada. METHODS: The Past Year Total Physical Activity Questionnaire was completed by 15,591 Tomorrow Project® participants, between 2001 and 2005 detailing physical activity type, duration, frequency and intensity. Domain-specific hours of activity and activity-related energy expenditure, expressed as a percent of total energy expenditure (TEE) (Mean (SD); Median (IQR)) are reported across inactive (<1.4), low active (1.4 to 1.59), active (1.6 to 1.89) and very active (≥ 1.9) Physical Activity Level (PAL = TEE:REE) categories. RESULTS: In very active women and amongst all men except those classified as inactive, activity-related energy expenditure comprised primarily occupational activity. Amongst inactive men and women in active, low active and inactive groups, activity-related energy expenditure from household activity was comparable to, or exceeded that for occupational activity. Leisure-time activity-related energy expenditure decreased with decreasing PAL categories; however, even amongst the most active men and women it accounted for less than 10 percent of TEE. When stratified by employment status, leisure-time activity-related energy expenditure was greatest for retired men [mean (SD): 10.8 (8.5) percent of TEE], compared with those who were fully employed, employed part-time or not employed. Transportation-related activity was negligible across all categories of PAL and employment status. CONCLUSION: For the inactive portion of this population, active non-leisure activities, specifically in the transportation and occupational domains, need to be considered for inclusion in daily routines as a means of increasing population-wide activity levels. Environmental and policy changes to promote active transport and workplace initiatives could increase overall daily energy expenditure through reducing prolonged sitting time.

Exploring statistical approaches to diminish subjectivity of cluster analysis to derive dietary patterns: The Tomorrow Project.

Dietary patterns derived by cluster analysis are commonly reported with little information describing how decisions are made at each step of the analytical process. Using food frequency questionnaire data obtained in 2001-2007 on Albertan men (n = 6,445) and women (n = 10,299) aged 35-69 years, the authors explored the use of statistical approaches to diminish the subjectivity inherent in cluster analysis. Reproducibility of cluster solutions, defined as agreement between 2 cluster assignments, by 3 clustering methods (Ward's minimum variance, flexible beta, K means) was evaluated. Ratios of between- versus within-cluster variances were examined, and health-related variables across clusters in the final solution were described. K means produced cluster solutions with the highest reproducibility. For men, 4 clusters were chosen on the basis of ratios of between- versus within-cluster variances, but for women, 3 clusters were chosen on the basis of interpretability of cluster labels and descriptive statistics. In comparison with those in other clusters, men and women in the "healthy" clusters by greater proportions reported normal body mass index, smaller waist circumference, and lower energy intakes. The authors' approach appeared helpful when choosing the clustering method for both sexes and the optimal number of clusters for men, but additional analyses are required to understand why it performed differently for women.

Prevalence, trend, and sociodemographic association of five modifiable lifestyle risk factors for cancer in Alberta and Canada.

OBJECTIVES: To examine the 12-year trend, in Alberta and Canada, of five modifiable lifestyle risk factors for cancer, and their associations with sociodemographic factors. METHODS: Six surveys collected data from Canadians aged > or =12 years. The prevalence, trends, and sociodemographic association of five lifestyle risk factors (smoking, inactivity, excessive drinking, overweight/obesity, and insufficient fruit/vegetable intake) were examined. RESULTS: Smoking and inactivity decreased significantly: by 5.4% and 2.7% (Alberta men) and 4.9% and 12.1% (Alberta women); by 7.5% and 8.5% (Canada men) and 7.7% and 11.9% (Canada women). Excessive drinking increased significantly: by 3.6% (men) and 0.9% (women), Alberta; by 2.5% (men) and 0.9% (women), Canada. Overweight/obesity significantly increased by 6.0% (Alberta) and 4.1% (Canada) in women. Being female, single, highly educated, or having higher income decreased the likelihood of exposure to multiple lifestyle risk factors; being middle aged, widowed/separated/divorced, or in poor health condition increased the likelihood. CONCLUSIONS: The downward trends for smoking and physical inactivity were in a direction that may help reduce cancer burden. The excessive drinking and overweight/obesity trends did not change in desired direction and deserve attention. The clustering of the lifestyle risk factors in specific social groups provides useful information for future intervention planning.