Dietary fiber, vegetables, and colon cancer: critical review and meta-analyses of the epidemiologic evidence

The effect of soy isoflavones on the development of intestinal neoplasia in ApcMin mouse

Data from epidemiological studies suggest that isoflavones in soy may have a protective effect on the development of colon cancer in humans. Therefore, we have investigated whether soy isoflavones will inhibit intestinal tumour development in Apc(Min) mice. The mice were fed a Western-type high risk diet (high fat, low fibre and calcium) containing two different isolates of soy protein as a protein source. For the control and test groups this resulted in the administration of about 16 and 475 mg of total isoflavones per kg diet, respectively. As a positive control. a third group of mice was administered a low isoflavone diet supplemented with 300 ppm sulindac. No significant differences in the incidence, multiplicity, size and distribution of intestinal tumours were observed between Min mice fed low and high isoflavone-containing diets. However, a clear reduction in the number of small intestinal tumours was observed for the sulindac diet. Thus, in contrast to epidemiological studies, our results demonstrate that high amounts of soy isoflavones present in a Western-type high risk diet do not protect against intestinal tumour development in a relevant animal model such as the Min mice.

Functional food science and gastrointestinal physiology and function

The gut is an obvious target for the development of functional foods, acting as it does as the interface between diet and the metabolic events which sustain life. The key processes in digestive physiology which can be regulated by modifying diet are satiety, the rate and extent of macronutrient breakdown and absorption from the small bowel, sterol metabolism, the colonic microflora, fermentation, mucosal function and bowel habit, and the gut immune system. The intestinal microflora is the main focus of many current functional foods. Probiotics are foods which contain live bacteria which are beneficial to health whilst prebiotics, such as certain non-digestible oligosaccharides which selectively stimulate the growth of bifidobacteria in the colon, are already on the market. Their claimed benefits are to alleviate lactose maldigestion, increase resistance to invasion by pathogenic species of bacteria in the gut, stimulate the immune system and possibly protect against cancer. There are very few reports of well-designed human intervention studies with prebiotics as yet. Certain probiotic species have been shown to shorten the duration of rotavirus diarrhoea in children but much more work is needed on the mechanism of immunomodulation and of competitive exclusion and microflora modification. The development of functional foods for the gut is in its infancy and will be successful only if more fundamental research is done on digestive physiology, the gut microflora, immune system and mucosal function.

p21(WAF1) is required for butyrate-mediated growth inhibition of human colon cancer cells

A diet high in fiber is associated with a decreased incidence and growth of colon cancers. Butyrate, a four-carbon short-chain fatty acid product of fiber fermentation within the colon, appears to mediate these salutary effects. We sought to determine the molecular mechanism by which butyrate mediates growth inhibition of colonic cancer cells and thereby to elucidate the molecular link between a high-fiber diet and the arrest of colon carcinogenesis. We show that concomitant with growth arrest, butyrate induces p21 mRNA expression in an immediate-early fashion, through transactivation of a promoter cis-element(s) located within 1.4 kb of the transcriptional start site, independent of p53 binding. Studies using the specific histone hyperacetylating agent, trichostatin A, and histone deacetylase 1 indicate that growth arrest and p21 induction occur through a mechanism involving histone hyperacetylation. We show the critical importance of p21 in butyrate-mediated growth arrest by first confirming that stable overexpression of the p21 gene is able to cause growth arrest in the human colon carcinoma cell line, HT-29. Furthermore, using p21-deleted HCT116 human colon carcinoma cells, we provide convincing evidence that p21 is required for growth arrest to occur in response to histone hyperacetylation, but not for serum starvation nor postconfluent growth. Thus, p21 appears to be a critical effector of butyrate-induced growth arrest in colonic cancer cells, and may be an important molecular link between a high-fiber diet and the prevention of colon carcinogenesis.

Diet, nutrients, and gastrointestinal cancer

Tobacco and alcohol use are strong risk factors for cancer of the upper gastrointestinal tract. Saturated fat and red meat intake also appear to increase the risk of colorectal cancer. The strongest and most consistent dietary protective factors for gastrointestinal cancer are vegetables and fruits. Some micronutrients show beneficial effects, but the degree of protection is less than that observed from whole plant foods. Substantial decreases in the morbidity and mortality from gastrointestinal cancer could occur with more widespread adoption of dietary guidelines designed for cancer prevention.

A diet containing chickpeas and wheat offers less protection against colon tumors than a casein and wheat diet in dimethylhydrazine-treated rats

We examined the influence of extruded chickpeas and wheat relative to casein and wheat in a dimethylhydrazine (DMH)-induced colon tumor study in male Sprague-Dawley rats. The three diets, based on a modified AIN76 rodent diet with fat present at 10 g/100 g dry matter (DM), were as follows: casein with wheat starch (Cas/S) as control, casein with wheat (Cas/W) and chickpeas with wheat (CP/W). All diets were fed from 5 wk of age throughout the 28-wk study. At 28 wk, there was a significantly lower incidence of large intestinal tumors in rats fed Cas/W relative to those fed CP/W ( 11 vs. 56%, chi-square test, P = 0.018). The colonic tumor burden (tumors/tumor-bearing animal) was not different in Cas/W-fed and CP/W-fed rats (1 vs. 1.7), but the tumor mass index was significantly lower in the former group (0.22 vs. 1.21, P = 0.026). Rats fed the CP/W diet had significantly lower plasma cholesterol concentration (P < 0.01) than rats fed the other two diets. The cecal contents of rats fed the CP/W diet had significantly greater relative weights (46%, P < 0.05) than those of the Cas/W-fed rats; this was associated with higher concentrations of all short-chain fatty acids. Fecal analyses showed significantly (P < 0.05) higher concentrations of total fat (54%), total steroids (83%) and secondary bile acids (179%) in the CP/W-fed rats relative those fed Cas/W. There were higher concentrations of nitrogen in the feces of CP/W rats relative to the Cas/W-fed rats (84%, P < 0.05), associated with greater fecal weights (67%, P < 0.05). Although wheat and its fibers have been shown to be protective against DMH-induced cancers in rats, this was not the case in this study in which chickpeas (45 g/100 g diet) provided the protein and were an important source of soluble fiber. Elevated fat, secondary bile acid concentrations and/or nitrogenous compounds could be responsible for the increased colon tumorigenesis seen and may reflect a legume effect.

Modulation of dietary fat-enhanced colorectal carcinogenesis in N-methyl-N'-nitro-N-nitrosoguanidine-treated rats by a vegetables-fruit mixture

The modulation of a vegetables-fruit mixture on N-methyl-N'-nitro-N-nitrosoguanidine (MNNG)-induced colorectal carcinogenesis was studied in rats maintained on a low- or a high-fat diet. For this purpose, 120 rats received a semisynthetic diet without (Groups A and C) or with a vegetables-fruit mixture (19.5% wt/wt, Groups B and D) for 35 weeks. Diets of Group A and B contained 20 (low) energy percent (20e%) fat, whereas diets of Groups C and D contained 40e% (high) fat. Between Weeks 4 and 9 the animals were given weekly intrarectal instillations of 6 mg MNNG/kg body wt. The colorectal adenocarcinoma incidences showed a significant decrease in animals fed high-fat diets with a vegetables-fruit mixture compared with animals fed a high-fat diet alone. Furthermore, without a vegetables-fruit mixture, diets high in fat caused a significant increase in adenocarcinoma incidence compared with diets low in fat. Although not significant, the adenoma incidences tended to be lower in animals fed a vegetables-fruit mixture than in animals maintained on a diet without this mixture. The results demonstrate that a vegetables-fruit mixture has a significant inhibitory potency on the development of colorectal tumors induced by MNNG in rats fed diets high in fat.

Prospective study of diet and female colorectal cancer: the New York University Women's Health Study

The relation between diet and female colorectal cancer was analyzed in a prospective study of 14,727 women aged 34-65 years, who were enrolled at mammographic screening clinics in New York and Florida from 1985 to 1991. They were followed through the end of 1994 (average 7.1 yrs) by a combination of direct contact through mail and telephone and record linkages with regional tumor registries, resulting in 100 incident cases of colorectal cancer. There was no overall positive or inverse association of colorectal cancer risk with intakes of total calories, total or subclasses of fat, carbohydrate, or dietary fiber, whereas there was an inverse association with total protein. Among major food groups, there was a progressive decline in risk of colorectal cancer with increasing intake of fish and shellfish (relative risk for 4th vs. 1st quartile = 0.49, 95% confidence interval = 0.27-0.89). A similar inverse association was also observed for consumption of dairy products, and this association was explained mainly by calcium, not by other nutrients, such as fat or protein. The results of the present study indicated that certain dietary components of fish or dairy products may protect against colorectal cancer, whereas the relations with red meat or total fat remained unclear.

Nutritional factors and colon carcinoma: a case-control study involving French Canadians in Montréal, Quebec, Canada

BACKGROUND

In a population-based case-control study of colon carcinoma and nutrition involving the francophone community in Greater Montreal, a total of 402 cases (200 males and 202 females) and 668 controls (239 males and 429 females) were interviewed.

METHODS

Cases from 1989-1993 were identified through the admission offices of 5 major francophone teaching hospitals in Montreal and were ages 35-79 years. Controls matched by age, place of residence, and language were selected by a modified random digit dialing method. Information on dietary intake was collected with a quantitative food frequency questionnaire.

RESULTS

No associations were evident between colon carcinoma and total energy, protein, or carbohydrate consumption, whereas a suggestive inverse association was found with total fat intake, with an odds ratio (OR) of 0.78 (P = 0.0637), and with saturated fat intake as well (OR = 0.71, P = 0.0893). A strongly significant inverse association was found with dietary fiber (OR = 0.50, P = 0.0018). The strongest inverse association concerning fiber was found with fiber from vegetable sources (OR = 0.57, P = 0.0096), and a suggestive (although nonsignificant) inverse association (OR = 0.74, P = 0.0687) was found with fiber from fruits. Calcium was inversely associated with risk (OR = 0.69, P = 0.0411), as was dietary intake of vitamin A (OR = 0.67, P = 0.0162), retinol, (OR = 0.069, P = 0.0409), vitamin E (OR = 0.53, P = 0.0028), and alphatocopherol (OR = 0.63, P = 0.0256). Although there was no association demonstrated between dietary beta-carotene intake and risk, a suggestive (although nonsignificant) inverse association with intake of other types of carotene was observed (OR = 0.76, P = 0.0740). No association was found between intake of other nutrients investigated in this study and risk of colon carcinoma.

CONCLUSIONS

There is strong evidence from epidemiologic studies that high intake of fat and meat are risk factors for colorectal carcinoma in humans, whereas high intake of vegetable and fruit are inversely associated with risk of colon carcinoma. The findings from this study are in agreement with this observation.

Inhibition by wheat bran cereals of the development of aberrant crypt foci and colon tumours

As variation in both type of fibre and its physical properties can influence physiological effects, the effects of different dietary levels (1, 4, 8%, w/w) of unprocessed wheat bran (WB) were compared with those of two of its processed commercial formulations used in breakfast cereals, on the formation of aberrant crypt foci (ACF) and colon tumours in Fischer 344 rats following azoxymethane (AOM) administration. All diets were high in fat (20 g/100 g) and low in calcium (0.2%, w/w). The rats were fed the experimental diets for 2 wk before receiving two sc injections of AOM (15 mg/kg body weight/wk). 8 wk following the first injection of AOM, five rats per group were killed and the formation of ACF was measured. 23 wk following the first injection of AOM, 12 rats per group were killed and the colon tumour incidence in different dietary groups was measured. The results showed that increasing the dietary concentration of fibre from 1 to 8% (w/w), using all the wheat bran formulations, significantly reduced the number of ACF per rat. None of the diets showed any significant effect on the normal growth of rats. No statistically significant differences were observed between the protective properties of WB and the two commercial formulations under investigation in terms of the reduction of the number of ACF, or in terms of the reduction of the colon adenocarcinoma incidence. The results suggest that wheat bran and its two commercial formulations can offer protection against colon cancer even when they are consumed with a high-fat/low-calcium diet. The addition of any of these formulations of wheat bran fibre is likely to be equally effective in the prevention of colon cancer in human populations that habitually consume high-fat/low-fibre Western-style diets.

A diet rich in fat and poor in dietary fiber increases the in vitro formation of reactive oxygen species in human feces

Production of reactive oxygen species in the lumen of the colon, a process that is influenced by nutritional factors, may be important in the etiology of colorectal cancer. Because research on humans in support of this hypothesis is lacking, the objective of this study was to measure the effect of different dietary compositions on the in vitro oxygen radical production in human feces. Over a period of 12 d, seven healthy subjects received a diet rich in fat (50%) and meat and poor in dietary fiber. After a period of 1 wk, they received a vegetarian diet poor in fat (20%) and rich in dietary fiber. At the end of each study period, feces were collected and analyzed for in vitro oxygen radical production with dimethylsulfoxide as the free radical scavenger. The mean hydroxyl radical production was 13 times greater in feces of subjects when they consumed the diet rich in fat and poor in dietary fiber [52.7 +/- 29.5 micromol/(g feces x h)] than when they consumed the diet poor in fat and rich in dietary fiber [3.9 +/- 3.9 micromol/(g feces x h); P < 0.05]. This difference was associated with a 42% higher fecal iron concentration when they consumed the first diet (7.0 +/- 19.2 micromol/g feces) than when they consumed the second (4.9 +/- 1.9 micromol/g feces; P < 0.05). The results of this study confirm that diets high in fat and meat and low in fiber markedly increase the potential for hydroxyl radical formation in the feces, which in turn may contribute to an enhanced risk of colorectal cancer.

Overview of the epidemiology of colorectal cancer

INTRODUCTION

The epidemiology of colorectal cancer has generated more interest recently, because recent developments in genetics, molecular biology, and genetic epidemiology have increased our understanding of the role of genes in the etiology of colorectal cancer. Interactions between genetic susceptibility and environmental factors in the etiology of cancer may be easier to define.

EPIDEMIOLOGY

Colorectal cancer is common in the Western world and is rare in developing countries. A sharp increase is seen in Eastern Europe and Japan.

ETIOLOGY

Molecular genetics has shown that accumulation of genetic changes is important in the development of colorectal cancer. Mutations in at least four to five genes are required for the formation of a malignant tumor. Environmental mutagenic factors may determine which susceptible individuals grow carcinomas. Environmental risk factors for colorectal cancer are found in a western diet, rich in fat, meat, and animal protein and low in fiber, fruit, and vegetables. The complex interrelations between food components make it difficult to define the precise role of specific food factors.

PREVENTION

Conclusive evidence of the effectiveness of primary prevention of colorectal cancer via dietary measures or nonsteroidal anti-inflammatory drugs is lacking. Secondary prevention by interrupting the adenoma carcinoma sequence is an actual possibility, its effectiveness, however, needs to be determined. Molecular genetics holds a promise for identifying populations at high risk for colorectal cancer, therefore, targeting the screening to make it more cost-effective.

Dietary fat influences on polyp phenotype in multiple intestinal neoplasia mice

Significant differences in colon cancer incidence worldwide have led to the hypothesis that this variation can be explained largely by environmental, notably dietary influences. Although a positive correlation between dietary fat intake and incidence is suggested from some human epidemiological and rodent carcinogenesis studies, a direct association remains contentious. Using a spontaneous mouse tumor model of multiple intestinal neoplasia, we demonstrate that there is a generalized increase in tumor counts, in both the large and small bowel with higher dietary fat [standard (3%) fat versus high (15%) fat diet (mean +/- SD) 1.59 +/- 1.46 vs. 3.85 +/- 2.37 P < 0.001 and 21.36 +/- 7.4 vs. 31.3 +/- 9.7, respectively, P < 0.001]. Increasing dietary fat also increases polyp size in the small bowel. These changes appear independent of total calorific intake as assessed by body weights. Halving the crude fiber intake together with an increase in dietary fat from 3% to 10% did not have as marked an effect on tumor counts as an increase of fat alone to 15%, which also decreased survival (P < 0.05). These results demonstrate that increasing dietary fat intake from weaning can have a significant adverse effect on polyp numbers in mice genetically predisposed to intestinal tumor development. A further understanding of the biology of this interaction may provide novel strategies aimed at both colonic polyp prevention and treatment.

Worksite cancer screening and nutrition intervention for high-risk auto workers: design and baseline findings of the Next Step Trial

BACKGROUND

This article describes the design and baseline findings of The Next Step Trial, a health promotion intervention targeting automobile industry employees at increased colorectal cancer risk. The intervention encouraged colorectal cancer screening participation and adoption of low-fat, high-fiber diets.

METHODS

Twenty-eight worksites (n = 5,042) were randomized to control (a company-sponsored screening program) or intervention (an enhanced screening program including a personalized educational booklet and motivational telephone call and diet-change program including nutrition classes, self-help materials, and computer-generated personalized feedback). Outcomes included screening compliance and fat and fiber intake.

RESULTS

Pretrial data indicated targeted employees were predominantly older, well educated, married, Caucasian men. Sixty-one percent (SE = 2) participated in the screening program in the preceding 2 years, and 24% (SE = 1) reported a history of colorectal polyps or cancer. Fifty-eight percent of the cohort responded to the baseline questionnaire; respondents were older and more educated; more were married, retired, and Caucasian than nonrespondents. Mean dietary intakes were 36.9% energy from fat (SE = 0.21), 8.8 g fiber/1000 kcal (SE = 0.07), and 3.4 servings of fruits and vegetables per day (SE = 0.04).

CONCLUSIONS

Baseline data show moderate screening participation and dietary intakes that did not meet guidelines; hence intervention efforts were warranted. Data from this trial will support a rigorous test of whether this high-risk employee population is responsive to targeted health promotion, early cancer detection, and prevention interventions.

Compliance with the Australian Dietary Guidelines in the early 1990's: have population-based health promotion programs been effective?

In an attempt to change the dietary behaviours of the population (and reduce the incidence of diet-related disease), governments and health authorities in Australia have developed Dietary Guidelines. These guidelines have been communicated to the wider society through a range of channels, such as health promotion programs and education campaigns. Studies conducted during the 1980's suggested that up to 30 percent of the population were engaging in food-related behaviours consistent with dietary guideline recommendations, although the extent of compliance varied by population sub-group (eg women and high socioeconomic groups were more likely to comply). More recent research has suggested that compliance with some of the guideline recommendations has increased, although disparities between population sub-groups remain. The aim of this present study is to determine the extent of compliance with the Australian Dietary Guidelines in the early 1990's, and thereby (indirectly) assess the degree to which health promotion efforts have affected the dietary behaviours of the population. The study is based on a representative sample (n = 403, 80.6% response rate) of Brisbane city. Overall, it was estimated that between 40 and 60 percent of the population were regularly engaging in food behaviours consistent with guideline recommendations. This rate of compliance, however, differed markedly depending on the type of behaviour being examined, and it varied significantly (albeit modestly) across different population sub-groups. It is concluded that health promotion has influenced the population's dietary behaviours, although traditional beliefs and attitudes also inform our food behaviours to a considerable extent.

Butyrate alters activity of specific cAMP-receptor proteins in a transgenic mouse colonic cell line

There is great interest in utilizing butyrate as a chemotherapeutic agent. To elucidate its mechanism of action, the effect of butyrate on cAMP receptor protein kinase (PKA) activity in young adult mouse colon (YAMC) cells isolated from transgenic mice bearing a temperature sensitive mutation of the SV40 large T antigen gene was investigated. Conditionally immortalized cultures were plated at the permissive temperature (33 degrees C) or growth arrested by incubation at the nonpermissive temperature (39 degrees C). In addition, cells were incubated at 33 degrees C with or without 1 mmol/L butyrate for 24 h. Butyrate treatment reduced cell proliferation by 28% and enhanced apoptosis by 350% compared with cultures not exposed to butyrate. The PKA type I/II isozyme activity ratio was lower (P < 0.05) in cells incubated with butyrate. The relative level of PKA I isozyme was higher in proliferating cells at 33 degrees C (63% of total PKA), while the relative level of PKA II was higher in nonproliferating cells undergoing apoptosis at 39 degrees C (59% of total PKA). Neither incubation conditions (33 vs. 39 degrees C) nor butyrate treatment altered total PKA activity. When YAMC cells were incubated with 8-CI-cAMP, an activator of PKA II, growth was markedly inhibited in cells at both temperatures. Consistent with in vitro data, increased PKA I isozyme levels were associated with dysregulated growth in vivo. Specifically, the relative level of PKA I isozyme was three- to fivefold higher in rat colonic tumors compared with normal nontransformed colonic mucosa. These data indicate that the biological effects of butyrate on colonocyte proliferation and apoptosis are associated with changes in PKA isozyme-dependent signal transduction, and the YAMC cell line is a relevant model to examine the molecular mechanisms by which dietary-derived factors affect relative cancer risk.

Epidemiology and risk factors for colorectal cancer

The striking geographic differences in colorectal cancer incidence and the changes in disease risk among immigrants suggest an important environmental component to colorectal cancer risk. Table 1 lists risk factors for colorectal cancer. The categories in the table are somewhat arbitrary but are designed to provide an overall semiquantitative summary of the current epidemiologic literature. Certain of the most important risk factors (e.g., age, family history) cannot be modified. Individuals at high risk might benefit from surveillance. Dietary factors appear to be among the most important determinants of colorectal cancer risk. Diet helps to explain geographic variation in disease. A diet that is high in red meat and saturated fat appears to increase risk. Vegetables, fruits, fiber, folate, and calcium may be protective. Obesity, particularly abdominal obesity, and tall stature may be risk factors. Physical activity has been repeatedly shown to reduce the risk of colorectal cancer. Postmenopausal hormone replacement therapy may also be protective. Exciting new data suggest a significantly lower risk of colorectal cancer in regular users of aspirin and NSAIDs. It is important to recognize that the use of these drugs can have adverse as well as beneficial effects, and the appropriate dose and timing are not known. Enough information is available to make recommendations to lower the risk of colorectal cancer. Reducing red meat and fat consumption; increasing fruits, vegetables, and grains; avoiding obesity; and adopting a regular program of physical activity reduce the risk of colorectal cancer. Fortunately, these modifications also decrease the risk of cardiovascular disease, an even more important cause of mortality in Western societies.

Substrates available for colonic fermentation from oat, barley and wheat bread diets. A study in ileostomy subjects

Nutrients not absorbed in the small bowel will form substrates for microbial growth in the colon which may have implication for the development of colon cancer. The aim of the present study was to investigate whether fibre-rich oat and barley diets increase the excretion of energy-supplying nutrients from the small bowel compared with a low-fibre wheat diet, and whether a possible increase could be related to the beta-glucan content. Nine ileostomy subjects were served four types of bread together with a low-fibre basal diet (12 g dietary fibre/d). The breads were based on either wheat flour (W diet, 7 g dietary fibre/d), oat bran (OB diet, 29 g dietary fibre/d), the same amount of oat bran with addition of beta-glucanase (EC 3.2.1.4) (OBE diet, 19 g dietary fibre/d) or a fibre-rich barley fraction (B diet, 35 g dietary fibre/d). An increased ileal excretion of starch was observed with the barley diet but no effect of the oat beta-glucan on starch recovery was found. The NSP + Klason lignin in the ileostomy effluents accounted only for 24, 31, 24 and 35% of the gross energy excretion in the W, OB, OBE and B diet periods respectively. A large part of the dry weight and energy (30, 21, 28 and 27%, in the W, OB, OBE and B diets respectively) in the effluents could not be identified as fat, protein, total starch or NSP + Klason lignin. This unidentified part was probably made up of oligosaccharides, endogenous losses and nutrient complexes. Methods for identifying and analysing these components should be developed and their role as substrates for colonic fermentation and colon cancer development ought to be investigated.

Vegetables, fruit, and cancer prevention: a review

In this review of the scientific literature on the relationship between vegetable and fruit consumption and risk of cancer, results from 206 human epidemiologic studies and 22 animal studies are summarized. The evidence for a protective effect of greater vegetable and fruit consumption is consistent for cancers of the stomach, esophagus, lung, oral cavity and pharynx, endometrium, pancreas, and colon. The types of vegetables or fruit that most often appear to be protective against cancer are raw vegetables, followed by allium vegetables, carrots, green vegetables, cruciferous vegetables, and tomatoes. Substances present in vegetables and fruit that may help protect against cancer, and their mechanisms, are also briefly reviewed; these include dithiolthiones, isothiocyanates, indole-3-carbinol, allium compounds, isoflavones, protease inhibitors, saponins, phytosterols, inositol hexaphosphate, vitamin C, D-limonene, lutein, folic acid, beta carotene, lycopene, selenium, vitamin E, flavonoids, and dietary fiber. Current US vegetable and fruit intake, which averages about 3.4 servings per day, is discussed, as are possible noncancer-related effects of increased vegetable and fruit consumption, including benefits against cardiovascular disease, diabetes, stroke, obesity, diverticulosis, and cataracts. Suggestions for dietitians to use in counseling persons toward increasing vegetable and fruit intake are presented.

Nutrition chemoprevention of gastrointestinal cancers: a critical review

Various strategies utilizing specific dietary factors have been investigated for their ability to modulate the development of several cancers of the gastrointestinal tract. The effects of fat, red meat, fiber, fruits and vegetables, and alcohol on colorectal carcinogenesis have been reasonably well defined. Folate, selenium, and omega-3 fatty acids are rapidly emerging as important agents in nutrition chemoprevention, while the role of antioxidant vitamins and calcium is less certain. Although recent intervention studies from China have suggested a protective role of certain vitamins and minerals for esophageal and gastric cancers, further data from prospective randomized intervention studies are needed. Until more firm data are available, the dietary recommendations provided by the American Cancer Society and the National Cancer Institute are appropriate guidelines.

Modulation of gene expression in subjects at risk for colorectal cancer by the chemopreventive dithiolethione oltipraz

Prolonged exposure to mutagenic substances is strongly associated with an individual's risk of developing colorectal cancer. Clinical investigation of oltipraz as a chemopreventive agent is supported by its induction of the expression of detoxication enzymes in various tissues, and its protective activity against the formation of chemically induced colorectal tumors in animals. The goals of the present study were: to determine if oltipraz could induce detoxicating gene expression in human tissues; to identify effective non-toxic doses for more extensive clinical testing; and to establish a relationship between effects in the colon mucosa and those in a more readily available tissue, the peripheral mononuclear cell. 24 evaluable patients at high risk for colorectal cancer were treated in a dose-finding study with oltipraz 125, 250, 500, or 1,000 mg/m2 as a single oral dose. Biochemical analysis of sequential blood samples and colon mucosal biopsies revealed increases in glutathione transferase activity at the lower dose levels. These effects were not observed at the higher doses. More pronounced changes were observed in detoxicating enzyme gene expression in both tissues at all doses. Peripheral mononuclear cell and colon mRNA content for gamma-glutamylcysteine synthetase (gamma-GCS) and DT-diaphorase increased after dosing to reach a peak on day 2-4 after treatment, and declined to baseline in the subsequent 7-10 d. The extent of induction of gene expression in colon mucosa reached a peak of 5.75-fold for gamma-GCS, and a peak of 4.14-fold for DT-diaphorase at 250 mg/m2 ; higher doses were not more effective. Levels of gamma-GCS and DT-diaphorase correlated closely (P < or = 0.001) between peripheral mononuclear cells and colon mucosa both at baseline and at peak. These findings demonstrate that the administration of minimally toxic agents at low doses may modulate the expression of detoxicating genes in the tissues of individuals at high risk for cancer. Furthermore, peripheral mononuclear cells may be used as a noninvasive surrogate endpoint biomarker for the transcriptional response of normal colon mucosa to drug administration.

Antimutagenic activity of alkylresorcinols from cereal grains

Alkylresorcinols, natural amphiphilic compounds commonly found in cereal grains, markedly decreased mutagenic activity of four standard mutagens examined in the Ames test. The effect was the strongest in the case of indirect-acting mutagens, benzo[a]pyrene and 2-aminofluorene. In the case of direct-acting mutagens, daunorubicin and methyl methanesulfonate, the diminution of the mutagenic activity by the alkylresorcinols was smaller but still noticeable. In the Sister Chromatid Exchanges test (SCEs) with cultured in vitro human blood-derived lymphocytes, a significant decrease of SCEs frequency induced by benzo[a]pyrene was observed in the presence of alkylresorcinols. These preliminary results seem to be important in the aspect of possible antimutagenic and anticarcinogenic potency of alkylresorcinols found in cereal grains.

The effect of calcium and vitamin supplements on the incidence and recurrence of colorectal adenomatous polyps

BACKGROUND

Recent attention has focused on calcium and certain vitamins as potential protective agents against colorectal neoplasia.

METHODS

Two case-control studies were conducted on patients who underwent colonoscopy between 1986 and 1988, comparing 297 patients with newly diagnosed adenomas with 505 controls (without current or prior history of neoplasia), and 198 patients with recurrent adenomas with 347 recurrent controls (with no current neoplasia, but with a history of polypectomy). Subjects were interviewed regarding their regular usage of supplementation with vitamins A, C, D, and E, or with calcium, multivitamins, or any vitamin supplements.

RESULTS

No consistent associations were observed with the use of any of these supplements.

CONCLUSIONS

More studies are necessary to confirm these findings. It may be necessary to develop other chemopreventive agents, such as aspirin, for colorectal neoplasia.

Fecal short-chain fatty acids associated with inflammation in cotton-top tamarin model for idiopathic colitis

This study measured fecal levels of short-chain fatty acids (SCFAs) relative to the severity of colitis in the cotton-top tamarin model of colitis and colon cancer. Severity of colitis was classified as mild, moderate, or severe by subjective scoring of colonic mucosal biopsies and quantification of inflammatory cell infiltrates in the lamina propria. SCFAs were determined by gas chromatography of SCFAs extracted from fresh feces. Tamarins with moderate or severe colitis had significantly reduced levels of fecal SCFAs. The percent dry matter of feces declined significantly in moderate and severe colitis, while total dry matter output per day increased, indicating that moderate and severe colitis in tamarins was associated with diarrhea and increased fecal water loss. In conclusion, this study found colitis in the tamarin model was associated with decreased fecal SCFA levels and progressive inflammation in a pattern similar to human colitis.

Nutritional issues in cancer management

The objective of this article was to investigate the relationship between nutrition and cancer, as it relates to the initiation, promotion, and treatment of tumor growth. English-language studies published in the last 25 years were retrieved using MEDLINE, bibliographies, and consultation with experts. MEDLINE search terms included "cancer", "malnutrition," and "nutritional support." In vitro and in vivo controlled studies addressing the impact of nutritional factors on cancer prevention and treatment were selected. Approximately 30% of cancers in the Western countries are diet-related. The presence of malignancy affects patients' nutritional status negatively, leading to increased morbidity and mortality. Standard nutritional support (both enteral and parenteral) is not always effective in significantly improving outcome in malnourished cancer patients, due to characteristic changes in host metabolism. Preliminary studies suggest that newer nutritional-pharmacologic agents may be beneficial in counteracting the derangement of host metabolism, and consequently in ameliorating cancer patients' nutritional status and outcome of malnourishment. This review suggests that dietary manipulations and nutritional-pharmacologic therapy might be highly effective adjuncts in controlling the symptoms of patients with neoplastic disease.

Dietary intake and the risk of malignant mesothelioma

A high consumption of fruit and vegetables reduces the risk of several types of cancer. There is little information on the association between dietary intake and mesothelioma. A hospital-based case-control study of 94 men and women with malignant mesothelioma and 64 control patients without cancer was conducted to determine the odds associated with consumption of carotenoid-containing fruits and vegetables. After statistical adjustment for occupational asbestos exposure, the odds ratio was 0.2 [95% confidence interval (CI) 0.1-0.8] for carrot consumption and 0.5 (95% CI 0.2-1.4) for tomato consumption. However, the frequency of consuming other foods that have a high vitamin A or carotenoid content was not associated with a decreased risk of cancer. These results provide some justification for the hypothesis that provitamin A or beta-carotene may decrease the risk of mesothelioma. The body mass index was unrelated to the risk of mesothelioma.

Studies on the role of specific dietary fibres in protection against colorectal cancer

Although dietary fibre is generally thought to protect against the development of colorectal cancer, some of the results of animal and epidemiological studies are equivocal. We believe that this may be because the term dietary fibre covers a range of complex materials and some may protect but others may not. Dietary fibre is mainly composed of plant cell walls which vary in composition and properties according cell type and plant species. In addition to polysaccharides, the walls of some plant cell types contain the hydrophobic polymers lignin or suberin. Two groups of mechanisms have been proposed for the way dietary fibres may protect against colorectal cancer: those in which the dietary fibre may act directly and those in which the dietary fibre may have an indirect effect as a consequence of it being degraded by colonic bacterial enzymes and the products fermented. Direct mechanisms include the adsorption of carcinogens onto undegraded dietary fibres which pass out of the intestinal tract in the faeces. we have shown that different types of plant cell walls adsorbed a range of carcinogens, including heterocyclic aromatic amines, to different extents. Cell walls that contained lignin or suberin adsorbed hydrophobic carcinogens particularly well. Furthermore, the presence of lignin, and probably suberin, in the walls makes them resistant to degradation in the colon. Wheat bran, which is a good source of dietary fibre, contains some cell types with lignified walls. We used Fischer-344 rats to test the ability of wheat bran to protect against the formation of aberrant crypts (which are considered to be precursors to colon cancer) caused by the heterocyclic aromatic amine, 2-amino-3-methylimidazo[4,5-f]quinoline (IQ). Our results indicate that wheat bran protects and probably does so by a direct mechanism.

Folate and alcohol intakes: related or independent roles in the adenoma-carcinoma sequence?

Epidemiologic studies have suggested that high alcohol and low folate intakes might be jointly associated with colorectal tumors via DNA metabolism. We investigated this hypothesis in a case-control study comparing small adenoma (< 10 mm, n = 154), large adenoma (n = 208), and polyp-free (n = 426) subjects, recruited after colonoscopy, and cancer cases (n = 171) with population controls (n = 309). Odds ratios for the fifth vs. the first quintile of intake (OR5) were as follows: Folate intake was related to the risk of small and large adenomas compared with polyp-free subjects [OR5 = 0.5, 95% confidence interval (CI) 0.3-1.0; OR5 = 0.5, 95% CI 0.3-1.0, respectively], whereas alcohol was related to risk of large adenomas (OR5 = 4.1, 95% CI 2.1-8.1), but not of small adenomas (OR5 = 1.2, 95% CI 0.7-2.2). In large adenomas, there was some interaction between alcohol and folate, with a stronger protective effect of folate with high alcohol intake and a stronger risk with alcohol with low folate intake. For cancer patients compared with general population controls, neither alcohol (OR5 = 1.6, 95% CI 0.8-3.0) nor folates (OR5 = 1.0, 95% CI 0.5-2.0) were related to risk. Our data support the hypothesis that folate intake might be mostly beneficial to prevent adenoma formation but might have an additional protective effect against adenoma growth associated with alcohol.

Prostaglandin synthesis in human cancer cells: influence of fatty acids and butyrate

Previous research has suggested that prostaglandins (PGs) may play a role in the development of colon cancer since tumor cells produce more PGs than normal cells. However, the exact mechanism by which PGs play a role in the development of cancer is not known. In addition, factors that influence PG synthesis are not known since they are complicated by the presence of homeostatic mechanisms. To avoid the homeostatic mechanisms, the present research was designed to examine factors that may influence PG synthesis in an in vitro system, i.e., a tissue culture. We have chosen two human colon cancer cell lines that differ in their ability to metabolize long-chain fatty acids (LCFAs), LS174T cells and HT-29 cells. We examined the effect of LCFAs on their membrane fatty acid composition, growth, and ability to release the main PGs (PGE2 and PGI). The LCFAs used were those most common in the colonic lumen [18:0, 18:2 (n-6), and 18:3 (n-3)]. In addition, we examined the effect of butyrate on the above mentioned parameters. Butyrate is produced in the colon through fermentation of dietary fibers. The data obtained suggest that although both of these tumor cell lines are of human colonic origin, they differ in their response to LCFAs and butyrate in some of the characteristics studied, such as growth, composition of membranes, and the relationship between membrane FA composition and PG synthesis. Polyunsaturated fatty acid supplementation stimulated the growth of HT-29 cells but not of LS174T cells when compared with growth in media supplemented with 18:0.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of bile acids in colorectal carcinogenesis

Dietary factors are considered important environmental risk determinants for colorectal cancer development. Epidemiological studies have shown that a high fat (or meat) intake is associated positively and a high starch, fibre (non-starch polysaccharide), vegetable and fruit intake negatively with colorectal cancer incidence. One mechanism by which these effects are possibly exerted is through the metabolism of secondary bile acids. Secondary bile acids are formed after enzymatic deconjugation and dehydroxylation of primary bile acids in the large bowel by anaerobic bacteria. It has been shown that these compounds can have tumour-promoting capacities in animal experiments. In epidemiological studies, colonic cancer risk is related to the faecal bile acid concentration. In serum and bile of patients with colonic adenomas, more deoxycholic acid was detected than in healthy controls. Secondary bile acids are toxic to several cell systems at physiological concentrations. The exact mechanism by which these amphiphilic molecules exert their action is not well understood. It might act through membrane damage, intracellular mitochondrial action or genotoxic effects. So far the evidence that bile acids are involved in colonic carcinogenesis is largely circumstantial. It is, however, well accepted that environmental factors, such as dietary habits influence genetic susceptibility. Bile acids could play a promoting role in this process.

Heat shock protein 70 and HLA-DR molecules tissue expression. Prognostic implications in colorectal cancer

PURPOSE

The expression of 70,000-Da heat shock protein (HSP 70) and HLA-DR molecules on cancer cells influences immunologic mechanisms that may be of some prognostic significance. The purpose of this study was to examine the relationship among immunohistochemical HSP 70, HLA-DR expression, and clinicopathologic tumor variables, as well as patient survival in a series of 128 colorectal carcinomas.

METHOD

A three-step immunoperoxidase staining technique was undertaken for detection of both markers.

RESULTS

Of the examined carcinomas 77.3 percent were HSP 70-positive and 74.2 percent were HLA-DR-positive. Increased HSP 70-positive expression correlated significantly with low differentiation (P < 0.05), showed a tendency to characterize advanced stages of disease, and was clearly associated with worse overall survival (P < 0.05). The highest rate of HLA-DR positivity was demonstrated in early stages and was significantly associated with more favorable prognosis (P < 0.001). HSP 70-positive/HLA-DR-negative patients had worse overall survival compared with the rest (P < 0.001).

CONCLUSIONS

The resulting opposite effects on prognosis of examined markers seem to be related to different pathophysiologic functional roles on tumor immunology.

The causes and prevention of cancer

Epidemiological evidence indicates that avoidance of smoking, increased consumption of fruits and vegetables, and control of infections will have a major effect on reducing rates of cancer. Other factors include avoidance of intense sun exposure, increases in physical activity, and reduction of alcohol consumption and possibly red meat. A substantial reduction in breast cancer is likely to require modification of sex hormone levels, and development of practical methods for doing so is a high research priority. Resolution of the potential protective roles of specific antioxidants and other constituents of fruits and vegetables deserves major attention. Mechanistic studies of carcinogenesis indicate an important role of endogenous oxidative damage to DNA that is balanced by elaborate defense and repair processes. Also key is the rate of cell division, which is influenced by hormones, growth, cytotoxicity, and inflammation, as this determines the probability of converting DNA lesions to mutations. These mechanisms may underlie many epidemiologic observations.

Clinical characteristics of metachronous colorectal tumors

A cancer-registry-based study was conducted to investigate the survival patterns associated with metachronous colorectal tumors and to compare the survival of patients with single and metachronous colorectal tumors. The study included all 1,396 White patients with metachronous colorectal tumors diagnosed among 143,283 patients with primary colorectal tumors reported between 1973-1986 to the SEER program. The influence on survival of age at diagnosis, site of tumor and stage was evaluated by means of multivariate survival analysis, using Cox Proportional Hazards Models. Metachronous tumors developed more often following left-colon tumors. Stage distribution of the second tumors was better than that of single 47% of the second tumors were discovered in regionally-advanced or distant-metastatic stages. Survival from the second tumor diagnosed in the rectum was worse than that of a single tumor in the same stage and site. Only the stage of the second tumor was found to influence survival from metachronous tumors. The relatively high rate of diagnosis of advanced second colorectal tumors may reflect either improper follow-up after the diagnosis of the first tumor, or more aggressive biological characteristics of the second tumors.

The effects of dietary fiber from Lagenaria scineraria (yugao-melon) on colonic carcinogenesis in mice

BACKGROUND

The increasing trend of colon cancer in Japan is attributed to changes in dietary habits, that is, increased amounts of fat and decreased amounts of fiber in the diet. The effects of Japanese dietary fiber from Lagenaria scineraria (yugao-melon) on colonic carcinogenesis in mice were examined.

METHODS

Eighteen ICR mice in each group were fed with either a basal diet or a diet containing 5%, 10%, or 20% of yugao powder for 35 weeks. All the mice received a weekly intraperitoneal injection of 1,2-dimethylhydrazine (DMH), 10 mg/kg body weight for 10 weeks. The effects of yugao powder on the mucosal and luminal variables involved in colonic carcinogenesis were then compared with those of wheat bran in the mice without any carcinogen treatment.

RESULTS

The incidence of colon tumors (adenocarcinomas) was lower in the yugao powder diet groups than in the basal diet group at week 35 (24% vs. 50%, P < 0.05). The bile acid concentration in the colon was reduced in all the fiber diet groups except for the 5% yugao powder diet group. The colonic luminal pH acidified as yugao powder contents also increased in the yugao powder diet groups. The findings on the colonic short chain fatty acids, microflora, and mucosal fatty acids and ornithine decarboxylase activity were all inconsistent with a tendency to either develop or to inhibit carcinogenesis in both the fiber diet groups.

CONCLUSIONS

Dietary fiber from yugao-melon suppressed DMH-induced colonic carcinogenesis in mice by lowering the bile acid concentration and pH in the colon. The results of the luminal and mucosal variables examined also suggested that the mechanisms of action of yugao powder against colonic carcinogenesis differed from those of wheat brain.

Insulin and colon cancer

Some factors related to Westernization or industrialization increase risk of colon cancer. It is believed widely that this increase in risk is related to the direct effects of dietary fat and fiber in the colonic lumen. However, the fat and fiber hypotheses, at least as originally formulated, do not explain adequately many emerging findings from recent epidemiologic studies. An alternative hypothesis, that hyperinsulinemia promotes colon carcinogenesis, is presented here. Insulin is an important growth factor of colonic epithelial cells and is a mitogen of tumor cell growth in vitro. Epidemiologic evidence supporting the insulin/colon-cancer hypothesis is largely indirect and based on the similarity of factors which produce elevated insulin levels with those related to colon cancer risk. Specifically, obesity--particularly central obesity, physical inactivity, and possibly a low dietary polyunsaturated fat to saturated fat ratio--are major determinants of insulin resistance and hyperinsulinemia, and appear related to colon cancer risk. Moreover, a diet high in refined carbohydrates and low in water-soluble fiber, which is associated with an increased risk of colon cancer, causes rapid intestinal absorption of glucose into the blood leading to postprandial hyperinsulinemia. The combination of insulin resistance and high glycemic load produces particularly high insulin levels. Thus, hyperinsulinemia may explain why obesity, physical inactivity, and a diet low in fruits and vegetables and high in red meat and extensively processed foods, all common in the West, increase colon cancer risk.

Colorectal cancer risk factors: a case-control study in Bangkok

A case-control study for colorectal cancer risk factors was conducted in Bangkok, Thailand. A total of 279 incident cases of colorectal cancer were individually matched by sex, age and same hospital to 279 hospital controls with other cancers except gastrointestinal cancer. Each subject was interviewed with regard to bowel pattern information, family history, past history of illness and dietary information. The major findings were elevated risk for those with a history of bowel polyps (OR = 14.69, 95%CI = 2.01-301.46), parent's history of colon cancer (OR = 4.00, 95%CI = 1.39-12.43), anal abscess (OR = 3.78, 95%CI = 0.97-17.24), chronic colitis (OR = 3.61, 95%CI = 1.67-8.00), chronic hemorrhoid (OR = 3.13, 95%CI = 2.03-4.86) and the frequency of stools every three days or more (OR = 2.16, 95%CI = 1.17-4.01). The results also indicated an increased risk for dietary factors; bacon (OR = 12.49, 95%CI = 1.68-269.1) and butter (OR = 2.68, 95%CI = 1.29-5.68). There was a protective effect provided by banana (OR = 0.54, 95%CI = 0.37-0.79) and papaya (OR = 0.58, 95%CI = 0.40-0.84) for colorectal cancer. In unconditional logistic regression analysis, bacon showed the highest risk for colorectal cancer (OR = 8.82, 95%CI = 1.03-75.57), instead of bowel polyps (OR = 4.50, 95%CI = 0.48-42.59). The data suggest that nitrite-treated meat increases colorectal cancer risk while dietary fiber decreases colorectal cancer risk.

Differences in intake of specific food plants by Polynesians may explain their lower incidence of colorectal cancer compared with Europeans in New Zealand

Epidemiological studies have implicated obesity; high intakes of alcohol, fat, and energy; and low intakes of food plants as risk factors for colorectal cancer. In New Zealand, Polynesians (including Maoris and people from several Pacific Islands) are more likely to be overweight and have higher intakes of fat and energy than Europeans, and they are likely to have similar total intakes of food plants. Yet, in New Zealand, Polynesians have a significantly lower incidence of colorectal cancer than the Europeans. It is possible that the difference in incidence of colorectal cancer is due to differences in consumption of specific food plants by Polynesians and Europeans in New Zealand. Here we have compared the consumption of specific food plants by 429 Maoris, 643 Pacific Islanders, and 4,451 Europeans in paid employment in New Zealand. Of the 51 food plants eaten by New Zealanders, 6 were eaten significantly more frequently and 17 significantly less frequently by the two Polynesian groups than by Europeans. The quantity of any protective chemical components (or other as yet unknown protective factors) in food plants is likely to be related to their botanical classification. Differences in the intake of specific food plants may at least partly explain differences in the incidence of colorectal cancer between Polynesians and Europeans.

Influence of starch fermentation on bile acid metabolism by colonic bacteria

Secondary bile acids (BA) may be involved in the pathogenesis of colorectal cancer. In vivo, starch malabsorption has been shown to reduce fecal excretion of secondary BA. The present in vitro study was performed to investigate the effect of starch fermentation on BA metabolism by colonic bacteria. Fecal samples of healthy volunteers were incubated in anaerobic batch cultures for 48 hours with the primary bile acids cholic (0.6 g/l) and chenodeoxycholic acid (0.4 g/l). Media were starch free or enriched with starch (10 g/l). The pH was controlled and held at 6 or 7. In the starch-free incubations, secondary BA were rapidly formed, and degradation of primary to secondary BA was complete within 24 hours. The formation of secondary BA was partially inhibited by the addition of starch to the media. This effect was stronger at pH 6 than at pH 7. Starch was rapidly and completely fermented. In conclusion, this study showed that formation of secondary BA by fecal bacteria is inhibited when starch is simultaneously fermented, an effect that is mainly, but not completely, explained by reduction of pH.

Food choices of whites, blacks, and Hispanics: data from the 1987 National Health Interview Survey

Dietary guidelines posit an association between diet and cancer. Different cancer mortality rates among whites, blacks, and Hispanics may be related to differences in diet. Food frequency data from the 1987 National Health Interview Survey on 20,143 adults were used to estimate the percentage of adults, by gender and race/ethnicity, who consume some 59 foods six or more times per year, median number of servings for consumers, and frequency of consumption of skin on poultry and fat on red meat. On the basis of percent consumption of these foods, women appear to have a more diverse diet than men. Women eat more fruits and vegetables, less meat, and fewer high-fat foods and drink fewer alcoholic beverages. Whites eat a more varied diet than blacks and Hispanics; blacks eat more fried and high-fat food; consumption of high-fat foods is lowest among Hispanics. Public health messages, especially those aimed at cancer prevention, should be targeted at increasing the overall consumption of fruits and vegetables, decreasing consumption of high-fat foods, especially among white and black men, and increasing consumption of those healthful foods already consumed by particular race/ethnicity groups.

New directions in dietary studies in cancer: the National Cancer Institute

Through an orderly sequence incorporating epidemiologic and laboratory research, human clinical/metabolic studies, and clinical intervention trials, the NCI develops and maintains cancer prevention and control programs that are directed toward the overall goal to reduce cancer incidence, morbidity, and mortality. Epidemiologic studies have shown correlations between consumption of numerous dietary constituents and cancer risk. Results of in vitro and animal studies have reinforced many of these epidemiologic associations and data from clinical/metabolic studies are being used to evaluate the relevance of these associations in humans. Although much remains to be learned about the influence of specific dietary constituents and dietary patterns on cancer risk, it is clear that diet can have a significant impact in cancer prevention and control. Investigations on the cellular and molecular effects of dietary constituents, as well as their metabolic and physiologic effects should provide better insight on the mechanisms of action of these dietary constituents. There also is a need to develop biomarkers of dietary intake that could be used to monitor compliance in intervention studies, as well as biomarkers as clinical trial endpoints that can be used to predict the emergence and progression of cancer. Working with other agencies and the private sector, the NCI will continue to design and implement information programs that translate the knowledge gained from these diet and cancer prevention studies to help Americans adopt dietary patterns that may reduce cancer risk. Continued emphasis will be placed on intervention programs targeted toward high-risk and underserved segments of the U.S. population in an effort to reduce the high incidence of cancers in these groups.

Dietary factors and risk of colon cancer

The incidence rates of colon cancer are high in North America and northern Europe, lower in southern Europe, and much lower in Asia and Africa. It is widely believed that environmental factors, particularly dietary patterns, account for most of this marked variation in rates. Over the past decade, a large number of case-control and cohort studies have added a substantial body of evidence regarding our understanding of the causes of colon cancer. Although the data are not entirely consistent, several important risk factors have emerged. The epidemiological evidence that physical inactivity or excess energy intake relative to requirements increases risk of this malignancy is quite strong. Intake of red meat appears to increase risk, but protein-rich sources other than red meat probably do not elevate risk and may even reduce the occurrence of colon cancer. Dietary fat, at least that from sources other than red meat, does not appear to increase risk appreciably. High consumption of vegetables and fruits and the avoidance of highly refined sugar containing foods are likely to reduce risk of colon cancer, although the responsible constituents remain unclear. Alcohol intake may enhance risk of cancers of the distal colorectum, although the evidence is not entirely consistent. The influence of alcohol may be particularly strong when combined with a diet low in methionine and folate, suggesting that the effect of alcohol may be through antagonism of methyl-group metabolism. The combined effect of these dietary factors, as well as modifiable non-dietary factors such as cigarette smoking, suggest that the majority of cases of colon cancer are preventable.

The Nambour Skin Cancer and Actinic Eye Disease Prevention Trial: design and baseline characteristics of participants

The Nambour Skin Cancer and Actinic Eye Disease Prevention Trial (the Nambour Trial) is a field trial conducted in an unselected adult population in Australia. Using a randomized 2 x 2 factorial design, the principal aim is to evaluate whether regular use of high-protection sunscreen and/or dietary supplementation with beta-carotene (30 mg daily) can alter the incidence rates of basal cell carcinomas and squamous cell carcinomas of the skin over a minimum follow-up time of 4.5 years. Changes in the incidence of solar keratoses and actinic eye disease and the rate of photoaging after intervention will also be investigated. In 1992, 1626 participants between the ages of 25 and 75 years were enrolled, all of whom had been randomly selected from residents of the southeastern Queensland township of Nambour for an earlier skin cancer prevalence survey. This paper describes the background to the trial and its design, with respect to evaluation of effects on actinic skin disease, and documents the baseline characteristics of participants recruited into the Nambour Trial.