Operationalising World Cancer Research Fund/American Institute for Cancer Research Cancer Prevention Recommendations Using an Index Score ISBNPA 3-6 June 2015 Giota Mitrou PhD MSc Head of Research Funding & Science External Relations World Cancer Research Fund International

1. Operationalising World Cancer Research
Fund/American Institute for Cancer Research
Cancer Prevention Recommendations Using an
Index Score
ISBNPA 3-6 June 2015
Giota Mitrou PhD MSc
Head of Research Funding & Science External Relations
World Cancer Research Fund International - exhibition stand #11

2. Outline
 World Cancer Research Fund (WCRF) network
 WCRF/AICR Cancer prevention recommendations &
subrecommendations
 WCRF/AICR score & variation across studies
 Main challenges
 Conclusions

3. The World Cancer Research Fund Network

4. WCRF/AICR Cancer prevention
recommendations
The Panel
emphasises the
importance of not
smoking

5. WCRF/AICR sub-recommendations

6. WCRF/AICR sub-recommendations

7. WCRF/AICR score
 In last four years there has been increased interest in
investigating adherence to the WCRF/AICR
recommendations in relation to health outcomes
 A scoring system has been developed to assess the degree
of adherence to the WCRF/AICR recommendations

8. Study Methodology
(Total Score/no. of recommendations)
Outcome
(High vs. low adherence)
EPIC
Romaguera et al., 2012
(Europe)
7 points /6 +1 special recommendation (breastfeeding) in women
6 points/6 recommendations in men
Total cancer risk:  18%
IOWA
Inoue-Choi et al, 2013
(US)
8 points (only sugary drinks, +F & V/Fibre) /7 recommendations
(+sodium)
Mortality in female elderly cancer
survivors:  33%
EPIC
Vergnaud et al., 2013
(Europe)
7 points /6 +1 special recommendation (breastfeeding) in women
6 points/6 recommendations in men
Mortality:  34%
Cancer specific mortally:  20%
VITAL Study
Hastert et al., 2013
(US)
6 points/6 recommendations (no sodium, +energy density and
sugary drinks, +wholegrain/legumes (plant foods)
Post menopausal breast cancer risk:
 60%
PCaP
Arab et al., 2013
(US)
9 points (+energy density/sugary drinks, +F & V/fibre) /7
recommendations (+sodium)
Prostate cancer aggressiveness: low vs.
high adherence  38%
VITAL Study
Hastert et al., 2014
(US)
6 points/6 recommendations (no sodium, +energy density and
sugary drinks, +wholegrain/legumes (plant foods)
Cancer specific mortality:
 61%
Studies of WCRF/AICR score

9. Study Methodology
(Total Score/no. of recommendations)
Outcome
(High vs. low adherence)
ProtecT trial
(Er_V et al., 2014)
(UK)
6 points/6 recommendations (no sodium)
Prostate cancer specific dietary index (calcium, tomato/tomato
products + selenium)
Prostate cancer risk: no association, but
prostate cancer specific dietary index 
18%
Canadian National Breast
Screening Study
Catsburg et al., 2014
(Canada)
7 points/7 recommendations (+sodium, + F&V and unprocessed
grains and legumes, +energy density and sugary drinks)
Breast cancer risk:  21%
CAMA Study
Fanidi et al., 2015
(Mexico)
7 points /6 +1 special recommendation (breastfeeding) in women Breast cancer risk: No association but
exclusion of BMI  32%
EPIC
Romaguera et al., 2015
(Europe)
7 points /6 +1 special recommendation (breastfeeding) in women
6 points/6 recommendations in men
Mortality: 21% 
Colorectal cancer specific mortality: 
30%
EpiGEICAM sudy
Castelló et al., 2015
(Spain)
9 points /8 recommendations (+sodium, supplements) + 1
special recommendation (breastfeeding)
Breast cancer risk: low vs. high
adherence  3-fold
Framingham Offspring
Cohort study
Makarem et al., 2015
(US)
7 points/7 recommendations (+salt preserved foods and
processed foods with salt, + F&V and refined starchy foods,
+energy density and sugary drinks
Obesity related cancer risk: no
association
Studies of WCRF/AICR score

10. Example 1.
WCRF/AICR Score in EPIC (I)
Recommendation 1 0.5 0
BODY MASS INDEX (BMI)
1-Be as lean as possible
without becoming underweight 18.5 ≤ BMI < 25 25 ≤ BMI < 30
BMI ≥ 30
or
BMI < 18.5
PHYSICAL ACTIVITY (PA)
2 -Be physically active for at
least 30 minutes every day
Manual work
or
Vigorous PA > 2 h/w
or
Cycling + Sports
> 30 m/d
Cycling + Sports
15 - 30 m/d
Cycling + Sports
<15 m/d
FOODS THAT PROMOTE WEIGHT GAIN (FWG)
3.1 -Limit consumption of
energy-dense foods
ED ≤ 125
kcal/100 g
125 < ED < 275 kcal/100 g ED ≥ 125
kcal/100 g
3.2 -Avoid sugary drinks 0 g/d ≤ 250 g/d > 250 g/d
Average

11. WCRF/AICR score in EPIC (II)
Recommendation 1 0.5 0
PLANT FOODS (PF)
4.1 –Eat at least 5 servings
fruit and vegetables a day ≥400 g/d 200 - <400 g/d <200 g/d
4.2 –Eat unprocessed cereals
and pulses
Dietary fibre
≥25 g/d
Dietary fibre
12.5 - <25 g/d
Dietary fibre
<12.5 g/d
MEAT CONSUMPTION (MEAT)
5 -Limit consumption of red
meats and avoid processed
meats
Red + Processed meats
<500 g/d
and
Processed meat
<3 g/d
Red + Processed meats
<500 g/d
and
Processed meat
3 - <50 g/d
Red + Processed meats
≥500 g/d
and/or
Processed meat
≥50 g/d
ALCOHOL INTAKE (ALC)
6 -Limit alcoholic drinks to 2
for men and 1 for women a day
Ethanol
≤ 20 g/d men
≤ 10 g/d women
Ethanol
>20-30 g/d men
>10-20 g/d women
Ethanol
>30 g/d men
>20 g/d women
7 -Limit consumption of salty
foods
Insufficient data available
Average

12. WCRF/AICR Score in EPIC (III)
Recommendation 1 0.5 0
8 -Don´t use supplements to
protect against cancer Not applicable
BREAST FEEDING (BF)
9 -Breastfeed exclusively for up
to 6 months
Cumulative BF
≥ 6 months
Cumulative BF
>0 - <6 months
Cumulative BF
0 months
10 -Cancer survivors should
follow the recommendations Not applicable
Score RangeScore Range:
0 – 6 points in Men
0 – 7 points in Women

13. Association between the WCRF/AICR score and
total cancer risk
Men Women
Cox regression model stratified by centre and age, and adjusted by energy intake, level of school, smoking
status, presence of chronic diseases at baseline, ever use of contraceptive pills, ever use of HRT, age at first
menarche, age at first pregnancy, and menopausal status
P for trend <0.0001 P for trend <0.0001
Romaguera D et al, AJCN 2012

14. Association between the WCRF/AICR score
and total mortality
Men Women
Cox regression model stratified by centre and age, and adjusted by level of school, smoking status, smoke
intensity, and menopausal status
P for trend <0.0001 P for trend <0.0001
Vergnaud AC et al, AJCN 2013

15. Example 2.
WCRF/AICR score in VITAL study (I)
Recommendation Met Not met
BODY MASS INDEX (BMI)
1-Be as lean as possible within the
normal range of body weight
18.5 ≤ BMI < 25 BMI ≥ 25
or
BMI < 18.5
PHYSICAL ACTIVITY (PA)
2 -Be physically active as part of
everyday life
≥30 minutes p/d moderate/fast walking
and/or moderate/strenuous activity on at
least 5 d/wk in at least 7 of the past 10yrs
<30 minutes p/d or <5 d/wk or <7 of
the previous 10yrs of moderate/fast
walking of moderate/strenuous
activity
FOODS THAT PROMOTE WEIGHT GAIN (FWG)
3 -Limit consumption of energy
dense foods; avoid sugary drinks
ED ≤ 125
kcal/100 g & <1 sugary drink/w
ED ≥125
kcal/100 g & ≥1 sugary drink/w
PLANT FOODS (PF)
4 -Eat mostly foods of plant origin ≥5 servings of FV & ≥1 serving of
wholegrains and/or legumes/d
<5 servings of FV and/or <1 serving
of wholegrains and/or legumes/d
MEAT CONSUMPTION (MEAT)
5 -Limit intake of red meat and
avoid processed meat
<18 oz red meat and/or processed
meat/w
≥18 oz red meat and/or processed
meat/w

16. Recommendation Met Not met
ALCOHOL CONSUMPTION (ALC)
6 -Limit alcohol drinks ≤1 drink/d for women, ≤2 drinks/d men >1 drink/d for women, >2 drinks/d
men
PRESERVATION, PROCESSING AND PREPARATION
7 -Limit consumption of salty
foods; avoid mouldy grains or
legumes
Not operationalised
SUPPLEMENT INTAKE
8 - Aim to meet nutritional needs
through diet alone
Not operationalised
WCRF/AICR score in VITAL study (II)
Score RangeScore Range:
0 – 6 points in Men & Women
Hastert et al, Cancer Causes Control 2014

17. WCRF/AICR score of high vs. low adherence
Cancer specific mortality
EPIC vs. VITAL
*Adjusted for multivariate analysis

18.  WCRF/AICR score dependent on the available data
 Inclusion of subrecommendations or not in score construction and variation of interpretation of
recommendations and subrecommendations eg BMI vs. Waist Circumference for body fatness,
physical activity indices vs metric values; use of categorical vs continuous variables for certain
recommendations
 Some dietary exposures might not be common in particular diets e.g. moldy legumes/cereals,
salt preserved foods etc.
 Use of special recommendations eg. breastfeeding and dietary supplements depends on
research question and data availability
 Variation in scoring eg inclusion of 0.5 points for partially meeting a recommendation; use of
tertile and media cutoffs to operationalise recommendations
 Assumes each component is equally important and additively related to health, however top 3
WCRF/AICR recommendations may need to be weighted differently when studying cancer as
an outcome?
 Methodological challenges in dietary assessment and data collection based on self reported
dietary intake might lead to misclassification of whether an individual meets the
recommendation
Main challenges

19. Conclusions
 In almost all studies so far adherence to the WCRF/AICR
recommendations has shown inverse associations with
health outcomes
 Dependent on WCRF/AICR recommendations for cancer
prevention but other NCDs were considered when
developing recommendations, hence not only specific to
cancer
 Subjectivity introduced in interpretation of WCRF/AICR
recommendations and subrecomendations but easily
reproducible and fairly comparable

20. For further information
@wcrfint
facebook.com/wcrfint
www.wcrf.or
g
Giota Mitrou PhD MSc
Head of Research Funding & Science External Relations
World Cancer Research Fund International - exhibition stand #11
g.mitrou@wcrf.org