Association of Physical Activity and Sedentary Behavior with Colorectal Cancer Risk in Moroccan Adults: A Large-Scale, Population-Based Case-Control Study.

BACKGROUND: Physical activity has been associated with a lower risk of colorectal cancer in studies mainly conducted in high-income countries, while sedentary behavior has been suggested to increase CRC risk. In this study, we aimed to investigate the role of physical activity and sedentary behavior on CRC risk in the Moroccan population. METHODS: A case-control study was conducted involving 1516 case-control pairs, matched on age, sex and center in five university hospital centers. A structured questionnaire was used to collect information on socio-demographics, lifestyle habits, family history of CRC, and non-steroidal anti-inflammatory drug (NSAID) use. Information on physical activity and sedentary behavior were collected by the Global Physical Activity Questionnaire (GPAQ). For each activity (work, household, and recreational activities), a metabolic equivalent (MET) was calculated using GPAQ recommendations. Conditional logistic regression models were used to assess the association between physical activity, sedentary behavior and the risk of overall CRC, colon cancer, and rectal cancer taking into account other CRC risk factors. RESULTS: High level of physical activity was associated with lower risk of rectal cancer, colon cancer, and overall CRC, the adjusted odds ratios (ORa) for the highest versus the lowest level of activity were 0.67 (95% CI: 0.54-0.82), 0.77 (95% CI: 0.62-0.96), and 0.72 (95% CI: 0.62-0.83), respectively. In contrast, sedentary behavior was positively associated with rectal cancer risk (ORa=1.19, 95% CI: 1.01-1.40), but was unrelated to colon cancer risk (ORa=1.02, 95% CI: 0.87-1.20). CONCLUSION: We found an inverse association between physical activity and CRC risk in the Moroccan population, and a positive association between sedentary behavior and rectal cancer risk. Considering that one-third of the total population studied had a sedentary lifestyle, these results may be used to improve strategies of public health suitable for Moroccan population.

Food processing groups and colorectal cancer risk in Morocco: evidence from a nationally representative case-control study.

OBJECTIVE: The aim of this study was to investigate the association between the consumption of foods and drinks from different food processing categories using the NOVA classification and CRC risk among Moroccan adults. METHODS: 1453 cases and 1453 matched controls aged at least 18 years and recruited from the 5 greater Moroccan regions were interviewed by trained investigators about their habitual diet using a standardized food frequency questionnaire (FFQ). Foods were categorized according to their degree of processing by the NOVA classification. Intakes of each food processing group were categorized into tertiles based on the distribution of controls with the lowest tertile considered as the reference category. Multivariable conditional logistic regression models were used to assess the association between each group and CRC risk (Odds Ratio (OR) and 95% Confidence Intervals (CI)), taking relevant confounders into account. RESULTS: High consumption of unprocessed or minimally processed foods (NOVA group 1) was significantly inversely (OR = 0.82, 95%CI = 0.72-0.93), while high consumption of ultra-processed foods and drink products (NOVA group 4) was significantly positively (OR = 1.40, 95% CI = 1.22-1.61) associated with CRC risk as compared to the lowest intake group. These results were similar for colon and rectum sub-sites. CONCLUSION: This is the first study to evaluate the association between the NOVA classification groups and CRC risk in an African country. Our results suggest that the consumption of ultra-processed foods and drink products may be associated with an increased risk of developing CRC, but longitudinal studies are needed to confirm these results.

Dietary Fat Intake and KRAS Mutations in Colorectal Cancer in a Moroccan Population.

Epidemiologic data support an association between diet and mutations in the Kirsten-ras (KRAS) gene involved in colorectal cancer (CRC) development. This study aimed to explore the associations between fat intake and KRAS mutations in codons 12 and 13 in cases of CRC in the Moroccan population. A multicenter case-series study nested in a large-scale Moroccan CRC case-control study was conducted. Among all CRC cases recruited, 151 specimens were available for the DNA mutation analysis. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (Cis) for KRAS mutation status according to the fat intake variables. A KRAS mutation was detected in the CRC tumor of 34.4% of the patients among whom 65.4% had a single mutation at codon 12 and 34.6% had a single mutation at codon 13. Compared to low levels of consumption, a positive association was observed between high polyunsaturated fatty acids (PUFA) consumption (>16.9 g/day) and prevalence of KRAS mutations (OR = 2.15, 95% CI = 1.01-4.59). No statistically significant associations were observed for total fat, monounsaturated fatty acids, saturated fatty acids and KRAS mutations. The results of this study suggest that PUFA may be relevant in the etiology of CRC, possibly through the generation of G > A transitions at the KRAS oncogene. Further studies are needed to verify and explain this finding.

Association between obesity and chronic obstructive pulmonary disease in Moroccan adults: Evidence from the BOLD study.

OBJECTIVE: The Moroccan cross-sectional study aimed to investigate obesity in association to chronic obstructive pulmonary disease in Fez city. METHODS: A cross-sectional survey was carried out in Moroccan adults. Anthropometric and spirometry measurements were performed using standardized guidelines. RESULTS: Among the 744 participants, 53.9% of were women, with a mean age of 55.27 years (SD = 10.29). Nearly all women declared themselves to be never smokers, while 21% of men were current smokers. Overall, chronic obstructive pulmonary disease prevalence decreased with body mass index (p = 0.01) and waist circumference (p < 0.001). The same trends were also observed in women. The adjusted regression analysis showed a significant independent association between chronic obstructive pulmonary disease and decreasing overweight (ORa: 0.66; CI95% (0.40-0.98)), obesity (ORa: 0.66 CI95%: (0.36-0.89)), and a decreasing waist circumference-abdominal obesity (ORa: 0.58 CI95%: (0.34-0.99)) in the whole population. The same association remains significant in women for overweight (ORa: 0.18 CI95%: (0.06-0.54)) and for waist circumference-abdominal obesity (ORa: 0.40 CI95%: (0.19-0.85)). All these associations disappeared for men. CONCLUSION: Chronic obstructive pulmonary disease decreases with the increase in body mass index and waist circumference. The effect of waist circumference on the chronic obstructive pulmonary disease was greater among women, regardless of the tobacco factor. A multicenter study would help to confirm the accuracy of these findings in a larger sample of the Moroccan population. Developed lifestyle programs in patients with chronic obstructive pulmonary disease should be considered.

Extended healthy lifestyle index and colorectal cancer risk in the Moroccan population.

PURPOSE: Little is known about the combined effect of different lifestyle factors on CRC incidence among populations living in developing countries. In this study, we sought to create an Extended Healthy Lifestyle Index (EHLI) and to investigate its association with CRC risk in the Moroccan population. METHODS: A large case-control study including 1516 cases and 1516 controls, matched on age, sex and center were recruited in 5 Moroccan university hospital centers between 2009 and 2017. EHLI scores, including 9 modifiable factors (smoking, alcohol consumption, physical activity intensity, BMI, fruit and vegetables consumption, drinks that promote weight gain, red and processed meat, relatively unprocessed cereals and/or pulses, and dairy products consumption) were assigned to lifestyle information derived from the participants. We assessed the score based on the answers on each of the nine lifestyle components as unhealthy/un-compliant (0 point), healthy/compliant (1 point) and 0.5 for partial compliance to the recommendation. Conditional logistic regression models were used to assess the association between the EHLI and CRC risk and to estimate multivariate ORs and their 95% confidence intervals (CIs). All potential confounder variables were considered. RESULTS: After adjusting for potential confounding factors, a significant decrease in the risk of overall CRC was observed when comparing the highest EHLI category with the lowest index category (0.39, 95% CI: 0.33-0.47). These results did not differ by colon or rectum subsite. CONCLUSION: Combined healthy lifestyle factors are associated with a significantly lower incidence of CRC in Moroccan populations. Prevention strategies should consider targeting of multiple lifestyle factors.

Meat and colorectal cancer in Middle Eastern and North African countries: update of literature review.

BACKGROUND: This review discusses the findings from epidemiological studies that have examined the possible role of meat and colorectal cancer (CRC) risk in Middle Eastern and North African (MENA) countries. METHODS: We conducted a literature search in the PubMed, Clinical Trials, Google Scholar, Science Direct, and Cochrane databases for observational studies that investigated the association between meat and CRC risk in adults from the MENA region. RESULTS: Eleven studies were included in this review. For red meat overall, significant associations were found. Regarding beef meat intake, the study included found controversial results with OR = 0.18 (95% CI 0.03-0.09). A positive association was observed between chicken and CRC risk, at OR = 2.52 (95% CI 1.33-4.77) to OR = 4.00 (95% CI 1.53-10.41) to OR = 15.32 (95% CI 3.28-71.45). A significant association was observed between processed meat intake and CRC risk, OR = 9.08 (95% CI 1.02-80.58). CONCLUSION: This is the first literature review which illustrated the association between meat consumption and CRC risk in MENA region. We concluded that these studies included in this review have been controversial and not sufficient to establish a clear relationship between CRC and meat consumption in the MENA region. Further studies are necessary to be carried out in this region, with a larger sample size and submit to rigorous criteria. This review will help researchers to improve the quality of future studies about the association between CRC and nutritional diet in general and meat in particular.

Behavioral, Nutritional, and Genetic Risk Factors of Colorectal Cancers in Morocco: Protocol for a Multicenter Case-Control Study.

BACKGROUND: Colorectal cancer (CRC) has been reported as the third most commonly diagnosed cancer worldwide and is currently considered as a major public health concern. A peak increase in incidence has been noted in economically transitioning countries like Morocco where industrialization started shifting from a traditional lifestyle and diet toward a more westernized diet and lifestyle. OBJECTIVE: This paper aims to present the protocol of a large-scale Moroccan case-control study that aims at investigating associations of diet, other lifestyle factors, and genetic traits with CRC risk in Morocco. METHODS: A case-control study was conducted between 2009 and 2017, including 3032 case-control pairs (1516 cases and 1516 controls) matched on sex, age, and center in 5 major public health hospitals in Morocco. Questionnaires on sociodemographic data, lifestyle, family history of CRC, and nonsteroidal anti-inflammatory drugs (NSAIDs) were completed by trained investigators during face-to-face interviews. In addition, participants completed a semiquantitative food-frequency questionnaire, developed to assess food intake in the Moroccan population. Information regarding genetic factors was recorded for cases, and paraffin blocks (with embedded tumor tissues) are available in 3 collaborating hospitals. Conditional logistic regression analysis is planned to assess associations between diet and CRC risk. Binary logistic regression is considered to predict associations between mutations and nutritional risk factors including only CRC case series. RESULTS: Altogether, 2966 cases-control pairs (1483 cases and 1483 controls) were considered eligible and included in this study. Both cases and controls did not differ significantly with respect to age (P=.36), sex (P=.51), center (P>.99), marital status (P=.30), and NSAID use (P=.08). However, participants in the control group were significantly more likely to have a high income level and live in urban areas and to have a high level of education than cases. CONCLUSIONS: This is the first study investigating potential risk factors of CRC such as lifestyle, diet, and genetic factors, originating from a southern Mediterranean country with low but increasing CRC prevalence. Identified risk factors allow the establishment of evidence-based preventive actions regarding nutrition and other lifestyle habits adapted to the Moroccan context. In brief, this study will promote cancer research and prevention in Morocco. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/13998.

Consumption of meat, traditional and modern processed meat and colorectal cancer risk among the Moroccan population: A large-scale case-control study.

The current study aimed to investigate the relationship between red and white meat subtypes, processed meat (divided into traditional "Khlii, Kaddid" and industrially processed meat) and colorectal cancer (CRC) risk, considering CRC subsites, in Moroccan adults. A case-control study was conducted including 2,906 matched case-control pairs recruited from the five largest university hospitals in Morocco. Dietary data were collected through a validated Food Frequency Questionnaire (FFQ). Multivariable odds ratios (OR) and 95% confidence intervals (CI), for the association of CRC risk with meat consumption (high vs. low intake), were estimated using conditional logistic regression models, adjusted for relevant confounding variables. Overall, consumption of red meat was positively associated with colon cancer and CRC risk (OR = 1.23, 95% CI = 1.05-1.44; OR = 1.14, 95% CI = 1.02-1.27), respectively. In contrast, no significant association was observed between the consumption of red meat and rectal cancer risk (OR = 1.05, 95% = 0.90-1.23). Interestingly, while processed meat from industrial processes was positively associated with colon cancer, rectal cancer and CRC (OR = 1.61, 95% CI = 1.27-2.04; OR = 1.73, 95% CI = 1.34-2.23; OR = 1.67, 95% CI = 1.41-1.98), processed meat prepared using traditional methods was inversely associated with colon cancer and CRC risk (OR = 0.74, 95% CI = 0.57-0.98; OR = 0.77, 95% CI = 0.64-0.93), respectively. Furthermore, positive associations were observed between poultry intake and colon cancer risk among men (OR = 1.27, 95% CI = 1.01-1.59). Our study showed similar associations between the consumption of red meat and CRC risk in Morocco as in developed countries, while inverse associations were found for traditionally processed meat products. This is the first study to investigate the differential effects of traditional vs. westernized processed meat products in a developing country. Other studies are needed to confirm these findings and to understand the physiological pathways underlying these associations.

Consumption of modern and traditional Moroccan dairy products and colorectal cancer risk: a large case control study.

PURPOSE: The main objective of this study is to describe the association between the consumption of either traditional or modern dairy products or calcium intakes and the risk of colorectal cancer (CRC) in the adult Moroccan population. METHODS: A case-control study was conducted in five Moroccan hospital centers. The study was matched on sex, age (± 5 years) and center. Data were collected using validated food frequency questionnaire (FFQ) taking into account different types of Moroccan dairy products. Conditional logistic regression models were used to assess the association between dairy products consumption, calcium intakes and CRC risk subtypes. In all statistical tests, the significance level was set at 0.05. RESULTS: Among 1453 cases and 1453 matched controls, 50.7% were women and 49.3% were men. Milk ORb 0.84, 95% CI 0.74-0.96 and yogurt ORb 0.74, 95% CI 0.64-0.86 were inversely associated with CRC risk. Similar inverse associations were observed for traditional dairy products namely Lben ORb 0.77, 95% CI 0.67-0.88, Raib ORb 0.86, 95% CI 0.76-0.96 and Jben ORb 0.77, 95% CI 0.67-0.88. The dairy calcium intake was inversely associated to CRC overall ORb 0.83, 95% CI 0.74-0.93. CONCLUSIONS: Our study supports previous international evidence and suggests that individuals who have a high intake of either modern or traditional dairy products are at lower risk for CRC. These findings should be further confirmed by longitudinal data and studies investigating potential pathways involved.

Concordance with the World Cancer Research Fund/American Institute for Cancer Research recommendations for cancer prevention and colorectal cancer risk in Morocco: A large, population-based case-control study.

The present study aimed to investigate associations between adherence to the recommendations on cancer prevention from the WCRF/AICR and colorectal cancer (CRC) risk in Morocco. Incident CRC cases (n = 1,516) and controls (n = 1,516) matched on age, sex and center, were recruited between September 2009 and February 2017 at five major hospitals located in Morocco. In-person interviews were conducted to assess habitual diet using a validated Food Frequency Questionnaire, physical activity and anthropometric measurements. Adherence to the WCRF/AIRC Recommendations was ranged from 0 (no adherence) to 6 (maximal adherence) and incorporating six WCRF/AICR components (food groups, physical activity and BMI). Multivariable odd ratios (ORA ) and 95% confidence intervals (CI) were calculated using conditional multivariate logistic regression models, with low adherence as referent, adjusting for potential confounding factors. Compared to those with the lowest adherence score, individuals in the highest WCRF/AICR score category had a statistically significant reduced risk for colon cancer (ORA = 0.63, 95% CI 0.53-0.76); rectal cancer (ORA = 0.52, 95% CI 0.43-0.63) and CRC overall (ORA = 0.58, 95% CI 0.51-0.66). For individual score components, when comparing the lowest with the highest adherence category, CRC risk was significantly lower in the highest adherence category for body fatness (ORA = 0.73; 95% CI 0.62-0.85), physical activity (ORA = 0.70; 95% CI 0.60-0.82), plant foods (ORA = 0.50; 95% CI 0.39-0.63) and red/processed meat (ORA = 0.81; 95% CI 0.71-0.92). Our analysis indicated that greater adherence to the WCRF/AICR recommendations for cancer prevention may lower CRC risk in Morocco.