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Fruit and vegetable intake and risk of cancer: a prospective cohort study^1,2,3

¹ From the Yale School of Public Health, New Haven, CT (SMG); the Nutritional Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (YP, NDF, and AS); the Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany (MFL); the Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD (ECD, JR, and AFS); and AARP, Washington, DC (AH).

² Supported by the Intramural Research Program of the National Cancer Institute, National Institutes of Health, Bethesda, MD.

³ Address reprint requests and correspondence to A Subar, 6130 Executive Boulevard, MSC 7344, EPN 4005, Bethesda, MD 20892-7344. E-mail: subara{at}mail.nih.gov.

	ABSTRACT

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Background: There is probable evidence that some types of fruit and vegetables provide protection against many cancers.

Objective: We hypothesized that fruit and vegetable intakes are inversely related to the incidence of total cancers among women and men aged >50 y.

Design: We performed a prospective study among the cohort of the National Institutes of Health–AARP Diet and Health Study. We merged the MyPyramid Equivalents Database (version 1.0) with food-frequency-questionnaire data to calculate cup equivalents for fruit and vegetables. From 1995 to 2003, we identified 15,792 and 35,071 cancer cases in 195,229 women and 288,109 men, respectively. We used Cox proportional hazards models to estimate multivariate relative risks (RRs) and 95% CIs associated with the highest compared with the lowest quintile (Q) of fruit and vegetable intakes.

Results: Fruit intake was not associated with the risk of total cancer among women (RR_{Q5 vs Q1} = 0.99; 95% CI: 0.94, 1.05; P trend = 0.059) or men (RR_{Q5 vs Q1} = 0.98; 95% CI: 0.95, 1.02; P for trend = 0.17). Vegetable intake was not associated with risk of total cancer among women (RR_{Q5 vs Q1} = 1.04; 95% CI: 0.98, 1.09; P for trend = 0.084), but was associated with a significant decrease in risk in men (RR_{Q5 vs Q1} = 0.94; 95% CI: 0.91, 0.97; P trend = 0.004). This significant finding among men was no longer evident when we limited the analysis to men who never smoked (RR_{Q5 vs Q1} = 0.97; 95% CI: 0.91, 1.04; P for trend = 0.474).

Conclusions: Intake of fruit and vegetables was generally unrelated to total cancer incidence in this cohort. Residual confounding by smoking is a likely explanation for the observed inverse association with vegetable intake among men.

	INTRODUCTION

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The 20-fold variation in risk of many cancers across geographic regions suggests that environmental factors, such as diet, might be important in the respective etiologies of cancers (1). On the basis of international variation, time trends, and epidemiologic research, it has been estimated that 30% of cancer could be explained by diet (2) and that fruit and vegetable intake could potentially prevent 5–12% of cancers (3).

Fruit and vegetables are rich sources of nutrients (eg, fiber, vitamins, carotenoids, and phytochemicals) that have anticarcinogenic properties. These nutrients and bioactive compounds have antioxidant and antiproliferative activities, modulate steroid hormone concentrations and metabolism, and stimulate the immune system and synthesis and methylation of DNA (4).

The 2007 report Food, Nutrition, Physical Activity and the Prevention of Cancer: A Global Perspective by the World Cancer Research Fund and American Institute for Cancer Research indicated a probable protective role for fruit, vegetables, and their constituents against cancers of the esophagus, head and neck, stomach, lung, colorectum, pancreas, and prostate (5). However, no associations with specific cancer sites were found to be "convincing," which indicated the need for further research (5). We sought to investigate the association of fruit and vegetable intake and cancer incidence in a very large prospective cohort of men and women aged >50 y with a wide range of intakes. Given the probable evidence for many of the leading sites of cancer incidence, we hypothesized that fruit, vegetable, and fruit and vegetable intakes are inversely related to the incidence of total cancers.

	SUBJECTS AND METHODS

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Subjects
The National Institutes of Health (NIH)–AARP Diet and Health Study was initiated in 1995–1996 with the mailing of a self-administered questionnaire to 3.5 million AARP members aged 50–71 y from 6 US states (California, Florida, Louisiana, New Jersey, North Carolina, and Pennsylvania) and 2 metropolitan areas (Atlanta, GA, and Detroit, MI). The design was reported previously (6), but a brief description follows.

Of the 566,402 respondents (339,669 men and 226,733 women) who filled out the survey in satisfactory detail and consented to be in the study, we excluded those who indicated that they were proxies for the intended respondents (n = 15,760), had a prevalent cancer other than nonmelanoma skin cancer at baseline (n = 51,193), had self-reported end-stage renal disease at baseline (n = 997), and had a cancer cause of death record and no cancer registry record (n = 3,876). We further excluded individuals who reported extreme intakes (>2 times the interquartile range of sex-specific Box-Cox log-transformed intakes) of total energy (n = 4382) and of fruit and vegetables (continuous and nutrient densities) (n = 6,856) to account for erroneous overreporting and underreporting of foods. After these primary exclusions, the analytic cohort consisted of 288,109 men and 195,229 women. For the analyses of cancers of the ovary and uterus, we excluded women who had self-reported bilateral oophorectomy (n = 52,499) or hysterectomy (n = 95,857) at baseline, respectively.

Cancer ascertainment
Cases were identified through probabilistic linkage with 8 states and 3 additional state cancer registry databases, certified by the North American Association of Central Cancer Registries as being 90% complete within 2 y of cancer occurrence (6). We recently expanded our cancer registry ascertainment area by 3 states (Texas, Arizona, and Nevada) to capture cancer cases occurring among participants who moved to those states during follow-up. The case ascertainment method used in the study detected 90% of all cancer cases in our cohort (7).

We counted as incident cancer cases only those who were both invasive and the first malignancy diagnosed during the follow-up period (through 31 December 2003). Cancers were defined on the basis of criteria from the Surveillance Epidemiology and End Results Program and the International Classification of Diseases for Oncology (8). For reasons of statistical power, only cancers with >50 cases in a sex-combined cohort were considered in site-specific analyses.

Dietary assessment
At baseline, dietary intakes were assessed with a self-administered 124-item food-frequency questionnaire (FFQ), which was an earlier grid-based version of the diet history questionnaire developed at the National Cancer Institute. Participants reported their usual frequency of intake and portion size over the past 12 mo according to 3 predefined categories of portion size and 10 predefined frequency categories ranging from "never" to "6 times/d" for beverages and from "never" to "2 times/d" for foods. The food items, portion sizes, and nutrient database for this FFQ were constructed by using Subar et al's (9) method from the US Department of Agriculture 1994–1996 Continuing Survey of Food Intake by Individuals. We merged the MyPyramid Equivalents Database (MPED) version 1.0 (10) with the FFQ data to calculate cup equivalents for fruit and vegetables (1 cup = 237 mL). We excluded white potatoes from the vegetable group. In general, a cup equivalent is 1 cup of raw or cooked fruit or vegetable, 1 cup of 100% juice, 2 cups of raw leafy greens, or 0.5 cup of dried fruit.

The FFQ used in the study was evaluated in a calibration study by using 2 nonconsecutive 24-h dietary recalls in 2053 participants (11). When the 26 nutrient constituents examined in the FFQ were adjusted for reported energy intake, estimated correlations with intake in the reference method ranged from 0.36 to 0.70 for women and from 0.40 to 0.76 for men (11). Estimated correlations of fruit and vegetable intake between the FFQ and the reference method were 0.61 for women and 0.72 for men (11). We also collected information on demographic characteristics, medical history, and lifestyle characteristics at baseline.

Statistical analysis
Multivariate relative risks (RRs) and 2-sided 95% CIs were estimated with Cox proportional hazards models using the SAS PROC PHREG procedure (version 9.1.3; SAS Institute, Cary, NC). Person-years of follow-up time were calculated from the date of the baseline questionnaire until the date of a cancer diagnosis, death, move out of the registry areas, or end of follow-up, whichever came first. The proportional hazards assumption was evaluated by modeling an interaction term of time with total fruit and vegetable intake, and no significant deviations were found. The relative risks of all and site-specific cancers were estimated according to sex-specific quintiles of intake of fruit or vegetable cup equivalents/1000 kcal. The test for linear trend across categories of fruit and vegetable intakes was performed by assigning participants the median value of their categories, creating a continuous variable from those values, and entering that variable in a regression model.

Multivariate models were adjusted for age, race-ethnicity (non-Hispanic white, non-Hispanic black, and others), education (less than high school, high school graduate, some college, and college graduate or post graduate), marital status (married or unmarried), body mass index (in kg/m²; <18.5, 18.5 to <25, 25 to <30, 30 to <35, or 35), family history of any cancer (yes or no), physical activity (never or rarely, 1–3 times/mo, or 1–2, 3–4, or 5 times/wk), smoking (never, 20 cigarettes/d in the past, >20 cigarettes/d in the past, currently 20 cigarettes/d, and currently >20 cigarettes/d), alcohol consumption (0, <5, 5 to <15, 15 to <30, or 30 g/d), menopausal hormone therapy (never, past, or current) (MHT), and total energy intake. To adjust for energy intake, we used the nutrient density method. We divided fruit and vegetable intake by total energy intake (per 1000 kcal) and also included total energy from all dietary sources in the models. Models for fruit intake also were adjusted for vegetable intake, and models for vegetable intake were adjusted for fruit intake. For categorical variables, an indicator variable for missing responses in each covariate was created, if applicable.

In multivariate models for bladder, esophageal, head and neck, pancreatic, lung, and total cancer, we used a more detailed cigarette smoking variable that incorporated smoking status (never, former, or current), time since quitting smoking (10 y ago, 5–9 y ago, 1–4 y ago, within the past year, or current smoker), and smoking dose (1–10 cigarettes/d, 11–20 cigarettes/d, 21–30 cigarettes/d, 31–40 cigarettes/d, 41–60 cigarettes/d, 60 cigarettes/d, or missing) to better control for smoking. In the lung and total cancer analyses, because of the potential for residual confounding by smoking, we chose to additionally exclude cases with missing smoking information (12). For all statistically significant associations found, we ran additional analyses that were restricted to never smokers. The proportion of never-smokers was 29% for men and 44% for women.

	RESULTS

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Descriptive characteristics of the study population by sex and quintiles of fruit and vegetable intakes are provided in Table 1. All comparisons were statistically significant at P < 0.001. For both fruit intake and vegetable intake, as compared with the lowest quintile (Q1), women and men in the highest quintile (Q5) of intake were older, more educated, more likely to exercise 5 times/wk, and less likely to be current smokers or have a BMI > 25. For both exposures, compared with those in Q1, women in Q5 were more likely to be receiving MHT and to have a family history of cancer and were less likely to be married and white. However, men in Q5 were less likely to have family history of cancer and were more likely to be married and white.

Among men, fruit intake was associated with a significantly lower risk of pancreatic cancer (RR_{Q5 vs Q1} = 0.73; 95% CI: 0.57, 0.95). Also among men, vegetable intake was associated with a significantly decreased risk of colorectal cancer (RR_{Q5 vs Q1} = 0.84; 95% CI: 0.75, 0.93) and lung cancer (RR_{Q5 vs. Q1} = 0.87; 95% CI: 0.78, 0.98) and a significantly increased risk of advanced prostate cancer (RR_{Q5 vs Q1} = 1.10; 95% CI: 1.01, 1.38) and thyroid cancer (RR_{Q5 vs Q1} = 1.95; 95% CI: 1.16, 3.28).

When we restricted the analysis to never-smokers, the inverse relation between vegetable intake and total cancer among men was attenuated and no longer statistically significant (RR_{Q5 vs Q1} = 0.97; 95% CI: 0.91, 1.04; P for trend = 0.474), as were all of the aforementioned significant findings, except for the association between vegetable intake and thyroid cancer in men (data not shown).

	DISCUSSION

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Our results do not support an association between the intake of fruit and vegetables and the incidence of total cancer in men or women. When we restricted the analyses of significant findings to those who had never smoked, the only association we found was between vegetable intake and thyroid cancer in men. Our restricted results may have partly changed because of the small number of cancer cases in nonsmokers, but residual confounding by cigarette smoking is a likely explanation for these associations. It is also possible that the biological effects of fruit and vegetable intake are different among smokers, given their exposure to tobacco carcinogens (13). With regard to endometrial cancer, the association was also not present in women who had never received MHT, which suggests that the positive association may be explained by residual confounding by smoking and MHT.

The association between vegetable intake and thyroid cancer among men may have been a chance finding. A well-cited animal study showed a positive relation between administered goitrogens and thyroid tumor promotion. A recent review of evidence from case-control and cohort studies on vegetables and thyroid cancer indicated a slightly inverse (although nonsignificant) relation (14). Future research is warranted.

We found some associations for only one sex. It is possible that the biology of how fruit or vegetable intakes affect cancer incidence may differ by sex because of hormonal, genetic, and metabolic factors. Alternatively, there may have been exposure misclassification differences between women and men because of differential reporting. Power was also low for several cancer sites in women.

Our study strengths include having 500,000 participants, >50,000 cancer cases, 3,320,418 person-years of follow up (mean = 6.9 y), and a wide range of fruit and vegetable intakes. Additionally, this is the first prospective cohort study to report results consistent with the most current US Department of Agriculture classification of fruit and vegetable cup equivalents. We used the MPED to calculate cup equivalents for fruit and vegetables rather than servings. These cup equivalents align with the 2005 Dietary Guidelines for Americans (15), which include recommendations based on common household measures rather than servings. The MPED replaced the Pyramid Servings Database in October 2006. The results per servings per day were similar (data not shown).

To our knowledge only 3 other cohorts have examined the relation between fruit and vegetable intake and total cancer incidence. A pooled analysis of the Health Professionals Follow-Up Study and the Nurses' Health Study (16) as well as the Japanese Public Health Center Based Prospective Study (17) found no evidence of an association. The Greek European Prospective Investigation into Cancer Cohort Study (18) found an inverse association between total fruit and vegetable intake and total cancer incidence, but the sample size (10,582 men; 15,031 women) and total number of cancer cases (men: 421 cases; women: 430 cases) were much smaller than in other cohorts reporting null results.

Similar to other cohorts, the participants in our study who ate more fruit and vegetables also exercised more, drank less alcohol, and had lower BMIs (19). Also, in general, nonsmokers had higher average median intakes of fruit and vegetables than did nonsmokers. When multiple dietary variables were measured with error (and potentially correlated with one another), the effect on the risk estimate of main dietary exposure is unclear (20). Therefore, it is also possible that measurement error obscured associations between fruit, vegetables, and cancer in this study.

Fruit and vegetables are among the most widely studied dietary risk factors for cancer. On the basis of previous research and reviews conducted in the 1980s, the National Cancer Institute began an intensive campaign in 1991 known as the 5 A Day for Better Health Program (now known as Fruits & Veggies–More Matters and run by the Centers for Disease Control and Prevention), the purpose of which is to increase fruit and vegetable consumption with the goal of preventing cancer and other chronic diseases (21). Although fruit and vegetable intake should be encouraged for many reasons related to overall health, energy balance, and nutritional requirements, our data do not provide support regarding the cancer preventative properties of fruit and vegetables as a group.

In this large US prospective cohort study, we observed no association between fruit and vegetable intake and total cancer incidence. However, on the basis of animal studies, human case control and cohort studies, and randomized controlled trials, there is likely no harm associated with the consumption of fruit and vegetables (22) and their consumption may prevent cardiovascular disease (16). Additionally, the consumption of nutrient-dense, high-fiber foods is important for meeting nutrient requirements, in weight-loss programs, and in maintaining energy balance. Future studies of dietary patterns may complement single food group analyses of fruit and vegetables in understanding the role that diet plays in cancer prevention (23). Indeed, analyses in this cohort and in others that have investigated dietary patterns rich in fruit and vegetables have found reduced risks of colorectal cancer (24–26) and mortality, including death from cardiovascular disease and all cancers (27).

	ACKNOWLEDGMENTS

 
We are indebted to the participants in the NIH-AARP Diet and Health Study for their outstanding cooperation. Cancer incidence data from the Atlanta metropolitan area were collected by the Georgia Center for Cancer Statistics, Department of Epidemiology, Rollins School of Public Health, Emory University. Cancer incidence data from California were collected by the California Department of Health Services, Cancer Surveillance Section. Cancer incidence data from the Detroit metropolitan area were collected by the Michigan Cancer Surveillance Program, Community Health Administration, State of Michigan. The Florida cancer incidence data used in this report were collected by the Florida Cancer Data System under contract to the Department of Health (DOH). The views expressed are those of the authors and do not reflect those of the contraction on DOH. Cancer incidence data from Louisiana were collected by the Louisiana Tumor Registry, Louisiana State University Medical Center in New Orleans. Cancer incidence data from New Jersey were collected by the New Jersey State Cancer Registry, Cancer Epidemiology Services, New Jersey State Department of Health and Senior Services. Cancer incidence data from North Carolina were collected by the North Carolina Central Cancer Registry. Cancer incidence data from Pennsylvania were supplied by the Division of Health Statistics and Research, Pennsylvania Department of Health, Harrisburg, PA. The Pennsylvania Department of Health specifically disclaims responsibility for any analyses interpretation or conclusions.

The authors' responsibilities were as follows—SAM: analyzed and interpreted the data; drafted, reviewed, and revised the manuscript; and approved the final version of the manuscript. YP, MFL, JR, and NDF: analyzed and interpreted the data, reviewed and revised the manuscript, and approved the final version of the manuscript. ECD: reviewed and revised the manuscript, assisted with the tables, and approved the final version of the manuscript; and AS, AH, and AFS: helped with the conception and design of the study, acquired the data, analyzed and interpreted the data, reviewed and revised the manuscript, and approved the final version of the manuscript. No conflicts of interest were declared.

	REFERENCES

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This Article Abstract Full Text (PDF) All Versions of this Article: 89/1/347    most recent ajcn.2008.26722v1 Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Citation Map Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by George, S. M Articles by Subar, A. F Search for Related Content PubMed PubMed Citation Articles by George, S. M Articles by Subar, A. F Agricola Articles by George, S. M Articles by Subar, A. F