Baseline characteristics and number of incident cancers in the EPIC-NL cohort according to tertiles of adherence to the Healthy Diet Indicator (HDI).

1<p>HDI (range 0–7 points) included 7 components: saturated fatty acids, polyunsaturated fatty acids, cholesterol, protein, fibre, fruits and vegetables and free sugars.</p>2<p>HDI tertiles: T1: <3 points; T2∶3 points; T3: >3 points.</p

Multivariable hazards ratios (HRs) and 95% CIs of cancer according to tertiles of adherence to the Healthy Diet Indicator (HDI) in the EPIC-NL cohort.

1<p>All models were stratified by sex and cohort, and adjusted for age at baseline, body mass index, smoking status, education, physical activity, energy intake without energy from alcohol, and alcohol intake.</p>2<p>Models in women were additionally adjusted for menopausal status.</p>3<p>Smoking-related cancer included cancer of the lung, kidney, upper aero-digestive tract, stomach, pancreas, bladder, liver, and colorectal.</p>4<p>Alcohol-related cancer included cancer of the upper aero-digestive tract, breast, liver, and colorectal.</p>5<p>P for trend values were calculated using two-sided test for linear trend, treating the HDI categories as a continuous variable.</p

HR and 95% CI for overall cancer associated with increments in the components of the Healthy Diet Indicator (men and women combined).

1<p>The increment is a rounded number close to the s.d. of the component.</p>2<p>All models were stratified cohort, and adjusted for sex, age at baseline, body mass index, smoking status, education, physical activity, energy intake without energy from alcohol, and alcohol intake.</p>3<p>(en%) refers to the percentage of total energy intake excluding alcohol.</p><p>Abbreviations: s.d., standard deviation, m, milligrams, g, grams, en%, energy percentage, HR, hazard ratio, CI, confidence interval.</p

Composition of the Healthy Diet Indicator¹ (HDI) used in analyses of cancer, based on the WHO's dietary guidelines for the prevention of chronic diseases.

1<p>HDI range was 0–7 points. Tertiles of adherence to the HDI was; T1: <3 points, T2∶3 points, T3: >3 points.</p>2<p>(en%) refers to the percentage of total energy intake excluding alcohol.</p><p>Abbreviations: mg, milligrams, g, grams, en%, energy percentage.</p

Example of DALY calculation for a deceased participant.

<p>Abbreviations: YLD, Years Lost due to Disability; YLL, Years of Life Lost; DALY, Disability-Adjusted Life Year. The disability weights are 0.20 for Diabetes and 1 for death.</p

Years Lost due to Disease (YLD), Years of Life Lost (YLL) and Disability-Adjusted Life Years (DALYs) of all EPIC-NL participants (N = 33,507).

<p>Abbreviations: YD, Years with Disability; DW, Disability Weight; YLD, Years Lost due to Disease; YLL, Years of Life Lost; CHD, Coronary Heart Disease; CVA, Cerebrovascular Accident; COPD, Chronic Obstructive Pulmonary Disease; IBD, Inflammatory Bowel Disease.</p>a<p>Years lost per disease presented only using life expectancy at time of death or if alive at end of follow-up (method 4), total DALYs are shown for the other life expectancy methods.</p>b<p>Non-fatal incidence cases.</p>c<p>Primary or secondary cause of death due to disease.</p>d<p>Participants with DALYs.</p>e<p>DALYs have been calculated for each specific cancer type but were aggregated for this table.</p

Association between Lifestyle Factors and Quality-Adjusted Life Years in the EPIC-NL Cohort

<div><p>The aim of our study was to relate four modifiable lifestyle factors (smoking status, body mass index, physical activity and diet) to health expectancy, using quality-adjusted life years (QALYs) in a prospective cohort study. Data of the prospective EPIC-NL study were used, including 33,066 healthy men and women aged 20–70 years at baseline (1993–7), followed until 31-12-2007 for occurrence of disease and death. Smoking status, body mass index, physical activity and adherence to a Mediterranean-style diet (excluding alcohol) were investigated separately and combined into a healthy lifestyle score, ranging from 0 to 4. QALYs were used as summary measure of healthy life expectancy, combining a person's life expectancy with a weight for quality of life when having a chronic disease. For lifestyle factors analyzed separately the number of years living longer in good health varied from 0.12 year to 0.84 year, after adjusting for covariates. A combination of the four lifestyle factors was positively associated with higher QALYs (P-trend <0.0001). A healthy lifestyle score of 4 compared to a score of 0 was associated with almost a 2 years longer life in good health (1.75 QALYs [95% CI 1.37, 2.14]).</p></div

Exposure to Famine at a Young Age and Unhealthy Lifestyle Behavior Later in Life

<div><p>Background</p><p>A healthy diet is important for normal growth and development. Exposure to undernutrition during important developmental periods such as childhood and adolescence can have effects later in life. Inhabitants of the west of the Netherlands were exposed to severe undernutrition during the famine in the last winter of the second World War (1944–1945).</p><p>Objective</p><p>We investigated if exposure of women to the Dutch famine during childhood and adolescence was associated with an unhealthy lifestyle later in life.</p><p>Design</p><p>We studied 7,525 women from the Prospect-EPIC cohort, recruited in 1993–97 and aged 0–18 years during the Dutch famine. An individual famine score was calculated based on self-reported information about experience of hunger and weight loss. We investigated the association between famine exposure in early life and four lifestyle factors in adulthood: smoking, alcohol consumption, physical activity level and a Mediterranean-style diet.</p><p>Results</p><p>Of the 7,525 included women, 46% were unexposed, 38% moderately exposed and 16% severely exposed to the Dutch famine. Moderately and severely exposed women were more often former or current smokers compared to women that did not suffer from the famine: adjusted prevalence ratio 1.10 (95% CI: 1.05; 1.14) and 1.18 (1.12; 1.25), respectively. They also smoked more pack years than unexposed women. Severely exposed women were more often physically inactive than unexposed women, adjusted prevalence ratio 1.32 (1.06; 1.64). Results did not differ between exposure age categories (0–9 and 10–17 years). We found no associations of famine exposure with alcohol consumption and no dose-dependent relations with diet.</p><p>Conclusions</p><p>Exposure to famine early in female life may be associated with higher prevalence of smoking and physical inactivity later in life, but not with unhealthy diet and alcohol consumption.</p></div

Example of DALY calculation for a participant still alive at truncation of follow-up.

<p>Abbreviations: CVA, Cerebrovascular Accident; YLD, Years Lost due to Disability; YLL, Years of Life Lost; DALY, Disability-Adjusted Life Year. The disability weights are as follows; 0.20 for Diabetes, 0.61 for CVA and 1 for death.</p

Sensitivity analysis for the relationship of smoking status with Disability-Adjusted Life Years (DALYs) in 33,507 EPIC-NL participants^a.

<p>Abbreviations: CHD, Coronary Heart Disease; CVA, Cerebrovascular Accident; COPD, Chronic.</p><p>Obstructive Pulmonary Disease; IBD, Inflammatory Bowel Disease.</p>a<p>DALYs in this table are calculated using life expectancy calculated at time of death or if alive at end of follow-up (method 4).</p>b<p>Models adjusted for age, sex and BMI, physical activity, education, ethanol and energy intake.</p>c<p>DALYs have been calculated for each specific cancer type but were aggregated for this table.</p