Amit Bhaniani

Television Viewing and Incident Cardiovascular Disease: Prospective Associations and Mediation Analysis in the EPIC Norfolk Study

Background Although television viewing time is detrimentally associated with intermediate cardiovascular risk factors, the relationship with incident total (i.e. combined fatal and non-fatal) cardiovascular disease (CVD), non-fatal CVD and coronary heart disease is largely unknown. This study examined whether television viewing time is associated with these three outcomes, independently of physical activity energy expenditure and other confounding variables. Methodology/Principal Findings A population-based cohort of 12,608 men and women (aged 61.4±9.0), free from stroke, myocardial infarction and cancer at baseline in 1998–2000 were followed up until 2007 (6.9±1.9 years). Participants self-reported education, smoking, alcohol use, antihypertensive, lipid lowering and antidepressant medication, disease history, total energy intake, sleep duration, physical activity and television viewing. BMI, waist circumference, blood pressure, triglycerides, HDL cholesterol and glycated haemoglobin (HbA1c) were measured by standardized procedures; a clustered metabolic risk score was constructed. Every one hour/day increase in television viewing was associated with an increased hazard for total (HR = 1.06, 95%CI = 1.03–1.08; 2,620 cases), non-fatal CVD (HR = 1.06, 95%CI = 1.03–1.09; 2,134 cases), and coronary heart disease (HR = 1.08, 95%CI = 1.03–1.13; 940 cases), independent of gender, age, education, smoking, alcohol, medication, diabetes status, CVD family history, sleep duration and physical activity energy expenditure. Energy intake, BMI, waist circumference, blood pressure, triglycerides, HDL cholesterol, HbA1c and the clustered metabolic risk score only partially mediated these associations. Conclusions These results indicate that the most prevalent leisure time (sedentary) behaviour, television viewing, independently contributes to increased CVD risk. Recommendations on reducing television viewing time should be considered.

Intakes and sources of soya foods and isoflavones in a UK population cohort study (EPIC-Norfolk).

Background:It has been suggested that the consumption of a diet rich in phytoestrogens might protect against a variety of diseases common in Western societies. However, there are little available data on the food sources or distribution of intake in the UK diet.Objective:To estimate the average intake and range of soya foods and isoflavones in a population-based cohort and to provide data on isoflavone consumption by food group.Subjects:Men and women (11 843) from the Norfolk arm of the European Prospective Investigation into Cancer and Nutrition (EPIC).Methods:Dietary daidzein and genistein intakes were obtained from 7-day food diaries, completed by participants between 1993 and 1998 and calculated from an in-house food composition database. Energy and anthropometric measurements were also carried out.Results:Average daily isoflavone intakes for both men and women were less than 1 mg (interquartile range (IQR) men: 0.39–0.82 mg; women: 0.30–0.64 mg). However, in soya-consumers, average daily intakes were higher: 8.6 mg in women (IQR: 2.28–10.72 mg) and 7.5 mg in men (IQR: 2.22–9.17 mg). In both men and women, bread and bread rolls made the highest contribution to isoflavone intake – 62.5 and 53.0%, respectively. In soya-consuming men and women, vegetable dishes and milks were the main contributors – 25.0 and 38.5% in men and 38.5% and 26.0% in women, respectively.Conclusions:Isoflavone intake is low in the UK but may be an underestimate due to soya added to commercial products. Future analyses of the isoflavone and lignan content of basic ingredient foods and commercial items commonly consumed in the UK diet will enable more accurate estimates of phytoestrogen intake to be made. The ability to estimate isoflavone intake in Western populations more accurately will enable investigations to be conducted into the suggested beneficial effects of phytoestrogens on health.

Food sources of plant sterols in the EPIC Norfolk population

Objective:To investigate the intake of plant sterols and identify major dietary sources of plant sterols in the British diet.Subjects:A total of 24 798 men and women recruited during 1993–1997, participating in the European Prospective Investigation into Cancer (EPIC-Norfolk).Interventions:A database of the plant sterol (campesterol, β-sitosterol, stigmasterol, campestanol and β-sitostanol) content in foods, based on gas-liquid chromatography (GLC) analyses, was linked to nutritional intake data from food frequency questionnaires in the EPIC-Norfolk population.Results:The mean (s.d.) intake of total plant sterols was 300 (108) mg/d for men and 293 (100) mg/d for women. Bread and other cereals, vegetables and added fats were the three major food sources of plant sterols representing 18.6 (8.9), 18.4 (8.5) and 17.3 (10.4)% of the total plant sterol intake respectively. Women had a higher plant sterol density than men (36.4 vs 32.8 mg/1000 kJ, P<0.001) and in relation to energy intake higher intakes of plant sterols from vegetables, bread and other cereals, added fats, fruits and mixed dishes (all P<0.001), whilst men had higher intakes of plant sterols from cakes, scones and chocolate, potatoes (all P<0.001) and other foods (P<0.01).Conclusions:The intake of plant sterols in UK, mainly from bread, cereals, fats and vegetables, is much higher than previously reported but comparable to recent European studies.

A new tool for converting food frequency questionnaire data into nutrient and food group values: FETA research methods and availability

Objectives To describe the research methods for the development of a new open source, cross-platform tool which processes data from the European Prospective Investigation into Cancer and Nutrition Norfolk Food Frequency Questionnaire (EPIC-Norfolk FFQ). A further aim was to compare nutrient and food group values derived from the current tool (FETA, FFQ EPIC Tool for Analysis) with the previously validated but less accessible tool, CAFÉ (Compositional Analyses from Frequency Estimates). The effect of text matching on intake data was also investigated. Design Cross-sectional analysis of a prospective cohort study—EPIC-Norfolk. Setting East England population (city of Norwich and its surrounding small towns and rural areas). Participants Complete FFQ data from 11 250 men and 13 602 women (mean age 59 years; range 40–79 years). Outcome measures Nutrient and food group intakes derived from FETA and CAFÉ analyses of EPIC-Norfolk FFQ data. Results Nutrient outputs from FETA and CAFÉ were similar; mean (SD) energy intake from FETA was 9222 kJ (2633) in men, 8113 kJ (2296) in women, compared with CAFÉ intakes of 9175 kJ (2630) in men, 8091 kJ (2298) in women. The majority of differences resulted in one or less quintile change (98.7%). Only mean daily fruit and vegetable food group intakes were higher in women than in men (278 vs 212 and 284 vs 255 g, respectively). Quintile changes were evident for all nutrients, with the exception of alcohol, when text matching was not executed; however, only the cereals food group was affected. Conclusions FETA produces similar nutrient and food group values to the previously validated CAFÉ but has the advantages of being open source, cross-platform and complete with a data-entry form directly compatible with the software. The tool will facilitate research using the EPIC-Norfolk FFQ, and can be customised for different study populations.

Phytoestrogen Exposure Is Associated with Circulating Sex Hormone Levels in Postmenopausal Women and Interact with ESR1 and NR1I2 Gene Variants

In this large cross-sectional study, we investigated the relationship between phytoestrogen exposure and circulating sex hormones and sex hormone-binding globulin (SHBG) levels in 1988 healthy postmenopausal women and their interactions with polymorphisms in genes involved in estrogen signaling. Plasma estradiol, testosterone, androstenedione, estrone, and SHBG were measured. Urinary levels of five isoflavones (daidzein, genistein, glycitein, O-desmethylangolensin, and equol) and two lignans (enterodiol and enterolactone) were measured and used as biomarkers for dietary intakes. Eighteen polymorphisms in ESR1, ESR2, and NR1I2 genes were genotyped. Results showed that lignans were positively associated with plasma SHBG levels (ηp2 = 1.2%; P < 0.001) and negatively associated with plasma testosterone (ηp2 = 0.2%; P = 0.042). Equol was negatively associated with plasma estradiol levels (ηp2 = 0.3%; P = 0.028), whereas O-desmethylangolensin was positively associated with plasma estradiol level (ηp2 = 0.3%; P = 0.010). There were significant phytoestrogen interactions with polymorphisms in ESR1 and NR1I2 genes in affecting estrone levels. We conclude that phytoestrogens modulate sex hormone and SHBG levels in postmenopausal women and interact with gene variants involved in estrogen signaling. Such phytoestrogen-gene interactions may explain the conflicting literature on the hormonal effects of phytoestrogens. (Cancer Epidemiol Biomarkers Prev 2007;16(5):1009–16)

Cohort Profile: A prospective cohort study of objective physical and cognitive capability and visual health in an ageing population of men and women in Norfolk (EPIC-Norfolk 3)

The European Prospective Investigation of Cancer (EPIC) is a 10-country collaborative study in which EPIC-Norfolk is one of the UK centres. EPIC-Norfolk examined 25 639 men and women resident in East Anglia (aged 40–79 years), between 1993 and 1997. The EPIC collaboration was set up to examine the dietary determinants of cancer, but the remit in the EPIC-Norfolk cohort was broadened from the outset to include determinants of other health conditions and chronic diseases. EPIC-Norfolk completed a third round of health examinations (EPIC-Norfolk 3 or 3HC) in December 2011, on 8623 participants in the age range 48–92 years. EPIC-Norfolk focused on objective measures of cognitive function, physical capability and visual health, adapting this existing mid-life cohort to the current need to investigate healthy and independent living for ageing societies. With a wealth of longitudinal data and a biobank (including DNA) collected at up to three separate time points, EPIC-Norfolk offers the unique opportunity to investigate the association of lifestyle and biological factors, including genetic exposures, with a range of health outcomes in middle and later life. Information for data access can be found on the study website, details as given in this cohort profile.

Dietary fat and breast cancer: comparison of results from food diaries and food-frequency questionnaires in the UK Dietary Cohort Consortium

BACKGROUND Epidemiologic studies of dietary fat and breast cancer risk are inconsistent, and it has been suggested that a true relation may have been obscured by the imprecise measurement of fat intake. OBJECTIVE We examined associations of fat with breast cancer risk by using estimates of fat intake from food diaries and food-frequency questionnaires (FFQs) pooled from 4 prospective studies in the United Kingdom. DESIGN A total of 657 cases of breast cancer in premenopausal and postmenopausal women were matched on study, age, and recruitment date with 1911 control subjects. Nutrient intakes were estimated from food diaries and FFQs. Conditional logistic regression was used to estimate ORs for breast cancer associated with total, saturated, monounsaturated, and polyunsaturated fat intakes with adjustment for relevant covariates. RESULTS Neither the food diaries nor the FFQs showed any positive associations between fat intake and overall breast cancer risk. ORs (95% CIs) for the highest compared with lowest quintiles of percentage of energy from total fat were 0.90 (0.66, 1.23) for food diaries and 0.80 (0.59, 1.09) for FFQs. CONCLUSION In this study, breast cancer risk was not associated with fat intake in middle-aged women in the United Kingdom, irrespective of whether diet was measured by food diaries or by FFQs.

Dietary intake measurement using 7 d diet diaries in British men and women in the European Prospective Investigation into Cancer-Norfolk study: a focus on methodological issues

The aim of the present study was to describe the energy, nutrient and crude v. disaggregated food intake measured using 7 d diet diaries (7dDD) for the full baseline Norfolk cohort recruited for the European Prospective Investigation into Cancer (EPIC-Norfolk) study, with emphasis on methodological issues. The first data collection took place between 1993 and 1998 in Norfolk, East Anglia (UK). Of the 30,445 men and women, aged 40-79 years, registered with a general practitioner invited to participate in the study, 25,639 came for a health examination and were asked to complete a 7dDD. Data from diaries with data recorded for at least 1 d were obtained for 99% members of the cohort; 10,354 (89·8%) of the men and 12,779 (91·5%) of the women completed the diet diaries for all 7 d. Mean energy intake (EI) was 9·44 (SD 2·22) MJ/d and 7·15 (SD 1·66) MJ/d, respectively. EI remained approximately stable across the days, but there was apparent under-reporting among the participants, especially among those with BMI >25 kg/m². Micronutrient density was higher among women than among men. In conclusion, under-reporting is an issue, but not more so than that found in national surveys. How foods were grouped (crude or disaggregated) made a difference to the estimates obtained, and comparison of intakes showed wide limits of agreement. The choice of variables influences estimates obtained from the food group data; while this may not alter the ranking of individuals within studies, this issue may be relevant when comparing absolute food intakes between studies.

Vitamins, minerals, essential fatty acids and colorectal cancer risk in the United Kingdom Dietary Cohort Consortium

The risk for colorectal cancer may be influenced by the dietary intake of various vitamins, minerals and essential fatty acids. We conducted a pooled analysis of dietary data collected using food diaries in seven prospective studies in the United Kingdom Dietary Cohort Consortium. Five hundred sixty‐five cases of colorectal cancer were matched with 1,951 controls on study centre, age, sex and recruitment date. Dietary intakes of retinol, vitamin A, thiamin, riboflavin, vitamin B6, folate, vitamin B12, vitamin D, calcium, iron, magnesium, potassium, n − 6 fatty acids, n − 3 fatty acids and the ratio of n − 6 to n − 3 fatty acids were estimated and their associations with colorectal cancer examined using conditional logistic regression models, adjusting for exact age, height, weight, energy intake, alcohol intake, fiber intake, smoking, education, social class and physical activity. There were no statistically significant associations between colorectal cancer risk and dietary intake of any of the vitamins, minerals or essential fatty acids examined.

Physical activity and ocular perfusion pressure: the EPIC-Norfolk eye study.

PURPOSE To examine the relationship between physical activity and ocular perfusion pressure (OPP), a consistent risk factor for glaucoma. METHODS The relationship between previous physical activity and current OPP in 5650 participants aged 48 to 90 who attended the first (1993-1997) and third (2006-2010) health check as part of the European Prospective Investigation into Cancer (EPIC)-Norfolk study was examined. Usual combined physical activity at work and leisure was assessed using a validated instrument. Individuals were categorized as inactive, moderately inactive, moderately active, or active. Three IOP measurements were obtained (Ocular Response Analyzer [ORA]; Reichert, Inc., Depew, NY). Mean Goldmann correlated IOP (IOPg) from one eye was used in the analysis. Systolic and diastolic blood pressure (BP) were recorded as the mean of two measurements taken with a sphygmomanometer. Associations between physical activity and low (≤40 mm Hg) mean OPP (2/3 mean arterial pressure - IOP) and low (≤50 mm Hg) diastolic OPP (diastolic BP - IOP) were tested using logistic regression, adjusting for age, sex, body mass index, social class, IOP, and BP. RESULTS Active people had a lower risk of mean OPP ≤ 40 mm Hg and diastolic OPP ≤ 50 mm Hg after adjusting for age, sex, social class, and body mass index (odds ratio, 0.75; 95% confidence interval [CI], 0.60-0.93; P < 0.01) and (odds ratio, 0.73, 95% CI, 0.58-0.93; P = 0.01), respectively. The association between physical activity and perfusion pressure was independent of IOP, but largely mediated through diastolic BP. CONCLUSIONS Lower levels of physical activity were associated with lower OPP. Further research is needed to investigate the potential benefit of increased physical activity as a safe and simple method of modifying glaucoma risk.