Fruits, vegetables, and bladder cancer risk: a systematic review and meta-analysis

Citrus fruit intake and incidence of renal cell carcinoma: A meta-analysis of observational studies

Observational studies on the association between citrus fruit intake and risk of renal cell carcinoma (RCC) have reported inconsistent results. We quantitatively assessed this association by conducting a meta-analysis. PubMed and Embase databases search was conducted including relevant studies published up to January, 2020. We included epidemiological studies that reported relative risks (RRs) or odds ratios (ORs) with 95% confidence intervals (CIs) for the association between citrus fruit intake and RCC risk. A total of eight epidemiological studies consisting of five cohort and three case-control studies were included. The overall analysis showed a significantly reduced risk of RCC for high intake of citrus fruit (OR = 0.84, 95% CI 0.73-0.95). No heterogeneity was detected among the included studies (p = 0.497 for heterogeneity; I2 = 0). There was no significant publication bias by Begg's test (p = 0.266) or Egger's test (P = 0.578). A statistically significant association between citrus fruit intake and RCC was observed in case-control studies (OR = 0.84, 95% CI 0.71-0.98), while no association was observed in cohort studies (OR = 0.84, 95% CI 0.64-1.05). In addition, the dose-response analysis indicated that the RCC risk reduced by 13% (95%CI 1.0%-27%, p = 0.04 for heterogeneity) for each 100 grams per day increment of citrus fruit intake. In summary, our findings suggest an inverse association between citrus fruit intake and RCC incidence.

Adherence to the Diabetes Risk Reduction Diet and Bladder Cancer Risk in the Prostate, Lung, Colorectal, Ovarian (PLCO) Cohort

BACKGROUND

This study aimed to explore the relationship between diabetes risk reduction diet (DRRD) and bladder cancer risk in Prostate, Lung, Colorectal, Ovarian (PLCO) cohort.

METHODS

Data from 99,001 participants in the PLCO Cancer Screening Trial were analyzed using Cox proportional hazards regression models to estimate HRs and 95% confidence intervals (CI) for the association between DRRD score and bladder cancer incidence. Subgroup analyses were conducted to assess whether variables such as age, sex, body mass index, cigarette smoking status, and history of diabetes influenced the observed association. The DRRD score was formulated on the basis of nine nutrient intake indicators derived from the Dietary History Questionnaire.

RESULTS

During the median follow-up of 11.7 years, 761 new bladder cancer cases were identified. Participants with highest DRRD scores exhibited a reduced risk of bladder cancer compared with those in the lowest quartile (unadjusted analysis, HR, 0.65; 95% CI, 0.53-0.82); multivariable adjusted analysis, HR, 0.79; 95% CI, 0.64-0.98; Ptrend = 0.007). A similar risk reduction was seen solely in transitional cell carcinoma (HR, 0.79; 95% CI, 0.64-0.99; P = 0.007). In addition, the significant negative association between DRRD scores and bladder cancer risk persisted even after excluding participants with unique characteristics.

CONCLUSIONS

This large prospective population-based study suggests that adherence to a DRRD may contribute to the prevention of bladder cancer.

IMPACT

The DRRD could potentially mitigate bladder cancer risk, which warrants further validation in diverse populations.

Relationship between Bladder Cancer, Nutritional Supply, and Treatment Strategies: A Comprehensive Review

Bladder cancer (BC) is the predominant neoplasm affecting the urinary system and ranks among the most widespread malignancies globally. The causes of bladder cancer include genetic factors; age; sex; and lifestyle factors, such as imbalanced nutrition, obesity, and metabolic disorders. The lack of proper nutrient intake leads to the development of bladder cancer because insufficient nutrients are consumed to prevent this disease. The purpose of this review was to analyze the nutrients closely linked to the onset and advancement of bladder cancer and to explore the relationship between dietary nutrients and bladder cancer. Particular emphasis was placed on nutrients that are frequently ingested in daily life, including sugar, fat, protein, and others. The focus of this research was to analyze how nutritional intake before and after surgery affects the recovery process of patients who have been diagnosed with bladder cancer. This article seeks to increase awareness among both society and the medical community about the significance of implementing appropriate dietary nutrition to reduce the chances of developing bladder cancer, enhance perioperative care for patients with bladder cancer, and aid in their recuperation.

Food groups and urologic cancers risk: a systematic review and meta-analysis of prospective studies

Background

To assess the association between 12 food groups intake and the risk of urologic cancers.

Methods

We scanned PubMed and Web of Science databases up to April 1st, 2023, and 73 publications met the inclusion criteria in the meta-analysis. We used a random effects model to estimate the summary risk ratios (RRs) and 95% confidence intervals (95% CI).

Results

In the linear dose-response meta-analysis, an inverse association was found between each additional daily 100 g of fruits [RR: 0.89, 95%CI = (0.83, 0.97)], 100 g of vegetables [RR: 0.92, 95%CI = (0.85, 0.99)], 12 g of alcohol [RR: 0.91, 95%CI = (0.88, 0.94)] and 1 cup of coffee [RR: 0.95, 95%CI = (0.83, 0.97)] intake and the risk of renal cell carcinoma. Conversely, each additional daily 100 g of red meat intake was positively associated with renal cell carcinoma [RR: 1.41, 95%CI = (1.03, 2.10)]. Inverse associations were observed between each additional daily 50 g of egg [RR: 0.73, 95%CI = (0.62, 0.87)] and each additional daily 1 cup of tea consumption and bladder cancer risk [RR: 0.97, 95%CI = (0.94, 0.99)]. There were no significant associations for nonlinear dose-response relationships between 12 food groups and urological cancers.

Conclusion

Our meta-analysis strengthens the evidence that appropriate intake of specific food groups, such as fruits, vegetables, alcohol, tea, and coffee, is associated with the risk of renal cell carcinoma or bladder cancer. More studies are required to fill the knowledge gap on the links between various food groups and urologic cancers because the evidence was less credible in this meta-analysis.

Systematic Review Registration

This study was registered on PROSPERO (CRD42022340336).

A review of citrus plants as functional foods and dietary supplements for human health, with an emphasis on meta-analyses, clinical trials, and their chemical composition

Fruits, flowers, leaves, essential oils, hydrosols, and juices of citrus spp. Are utilized to prepare various forms of food products. Along with their nutritional values, in the health industry, different parts of the plants of the citrus genus have been used as supplements or remedies to prevent or control diseases. This review focused on reported meta-analyses and clinical trials on the health benefits of citrus plants as functional foods. Also, chemical compounds of various citrus species were reviewed. The following information sources were used for data collection: Google Scholar, the Web of Science, Scopus, and PubMed. Various keywords, including "citrus AND chemical compounds," "citrus AND phytochemicals," "citrus species," "citrus AND meta-analysis," "nutritional and therapeutical values of citrus spp.," "clinical trials AND citrus," "clinical trials AND Rutaceae," "health benefits of citrus spp.," "citrus edible or non-edible applications," and scientific names of the citrus plants were utilized to collect data for the review. The scientific name and common name of all twenty-eight citrus species, along with any of the above keywords, were also searched in the mentioned databases. Scientific papers and data sources were sought to review and discuss the citrus plant's nutritional and therapeutic importance. Several meta-analyses and clinical trials have reported beneficial effects of citrus spices on a variety of cancer risks, cardiovascular risk factors, neurologic disorders, urinary tract conditions, and gastrointestinal tract conditions. They have shown anxiolytic, antimicrobial, and pain-alleviating effects. Some of them can be helpful in managing obesity and cardiovascular risk factors.

Interplay between Cruciferous Vegetables and the Gut Microbiome: A Multi-Omic Approach

Brassica vegetables contain a multitude of bioactive compounds that prevent and suppress cancer and promote health. Evidence suggests that the gut microbiome may be essential in the production of these compounds; however, the relationship between specific microbes and the abundance of metabolites produced during cruciferous vegetable digestion are still unclear. We utilized an ex vivo human fecal incubation model with in vitro digested broccoli sprouts (Broc), Brussels sprouts (Brus), a combination of the two vegetables (Combo), or a negative control (NC) to investigate microbial metabolites of cruciferous vegetables. We conducted untargeted metabolomics on the fecal cultures by LC-MS/MS and completed 16S rRNA gene sequencing. We identified 72 microbial genera in our samples, 29 of which were significantly differentially abundant between treatment groups. A total of 4499 metabolomic features were found to be significantly different between treatment groups (q ≤ 0.05, fold change > 2). Chemical enrichment analysis revealed 45 classes of compounds to be significantly enriched by brassicas, including long-chain fatty acids, coumaric acids, and peptides. Multi-block PLS-DA and a filtering method were used to identify microbe−metabolite interactions. We identified 373 metabolites from brassica, which had strong relationships with microbes, such as members of the family Clostridiaceae and genus Intestinibacter, that may be microbially derived.

Vegetable and fruit intake and the risk of bladder cancer: Japan Public Health Center-based prospective study

BACKGROUND

Vegetable and fruit consumption may have a protective effect against several types of cancer. However, evidence suggesting that increased intake of vegetables and fruits, their subtypes, or the antioxidant nutrients they contain in abundance decreases the risk of bladder cancer is limited.

METHODS

This study included 80,952 participants from the Japan Public Health Center-based Prospective Study, who responded to a food frequency questionnaire in a 5-year follow-up survey in 1995-1998 and were followed up until December 2015 to investigate the associations between intake of vegetables and fruits, their subtypes, or the antioxidant nutrients and bladder cancer risk using Cox proportional hazards regression models.

RESULTS

Within 1,287,514 person-years of follow-up, 401 bladder cancer cases (307 men and 94 women) were diagnosed. No association was found between intake of total vegetable and fruit, total vegetable, total fruit, subtypes of vegetables and fruits, or antioxidant nutrients and bladder cancer risk in both men and women, even in the analyses conducted among men stratified by smoking status.

CONCLUSIONS

In this population, the consumption of vegetables and fruits was not associated with the risk of bladder cancer.

Clinical Potential of Fruit in Bladder Cancer Prevention and Treatment

Bladder cancer (BC) is the most common tumor of the urinary system in the world. Moreover, despite using anticancer therapies, BC is also characterized by a high recurrence risk. Among numerous risk factors, cigarette smoking, occupational exposure to certain aromatic compounds, and genetic factors contribute most strongly to BC development. However, the epidemiological data to date suggests that diet quality may influence some carcinogenic factors of BC and, therefore, might have a preventative effect. Adequate consumption of selected fruits with scientifically proven properties, including pomegranates and cranberries, can significantly reduce the risk of developing BC, even in those at risk. Therefore, in this article, we aim to elucidate, using available literature, the role of fruits, including pomegranates, cranberries, citrus fruits, cactus pears, and apples, in BC prevention and treatment. Previous data indicate the role of compounds in the above-mentioned fruits in the modulation of the signaling pathways, including cell proliferation, cell growth, cell survival, and cell death.

Angioprevention of Urologic Cancers by Plant-Derived Foods

The number of cancer cases worldwide keeps growing unstoppably, despite the undeniable advances achieved by basic research and clinical practice. Urologic tumors, including some as prevalent as prostate, bladder or kidney tumors, are no exceptions to this rule. Moreover, the fact that many of these tumors are detected in early stages lengthens the duration of their treatment, with a significant increase in health care costs. In this scenario, prevention offers the most cost-effective long-term strategy for the global control of these diseases. Although specialized diets are not the only way to decrease the chances to develop cancer, epidemiological evidence support the role of certain plant-derived foods in the prevention of urologic cancer. In many cases, these plants are rich in antiangiogenic phytochemicals, which could be responsible for their protective or angiopreventive properties. Angiogenesis inhibition may contribute to slow down the progression of the tumor at very different stages and, for this reason, angiopreventive strategies could be implemented at different levels of chemoprevention, depending on the targeted population. In this review, epidemiological evidence supporting the role of certain plant-derived foods in urologic cancer prevention are presented, with particular emphasis on their content in bioactive phytochemicals that could be used in the angioprevention of cancer.

Dietary patterns and risk of bladder cancer: a systematic review and meta-analysis

BACKGROUND

Several studies have investigated the relationship between dietary patterns and the risk of bladder cancer (BC) in different regions including Europe, the United States, and Asia, with no conclusive evidence. A meta-analysis was undertaken to integrate the most recent information on the relationship between a data-driven Western diet (WD), the Mediterranean diet (MD), and dietary-inflammatory-index (DII) and the risk of BC.

METHOD

We looked for published research into the relationship between dietary patterns and the incidence of BC in the PubMed/Medline, Cochrane Library, Web of Science, and Scopus databases up until February 2021. Using a multivariate random-effects model, we compared the highest and lowest categories of WD, MD and DII patterns and provided the relative risk (RR) or odds ratios (OR) and 95 percent confidence intervals (CIs) for the relevant relationships.

RESULTS

The analysis comprised 12 papers that were found to be suitable after scanning the databases. Both case-control (OR 0.73, 95% CI: 0.52, 0.94; I2 = 49.9%, n = 2) and cohort studies (RR 0.93, 95% CI: 0.88, 0.97; I2 = 63%, n = 4) found a substantial inverse association between MD and BC. In addition, although cohort studies (RR 1.53, 95% CI 1.37, 1.70; I2 = 0%, n = 2) showed a direct association between WD and BC, case-control studies (OR 1.33, 95% CI 0.81, 1.88; I2 = 68.5%, n = 2) did not. In cohort studies, we found no significant association between DII and BC (RR 1.02, 95% CI 0.93, 1.12; I2 = 38.5%, n = 2). In case-control studies, however, a strong direct association between DII and BC was discovered (RR 2.04, 95% CI 1.23, 2.85; I2 = 0%, n = 2).

CONCLUSION

The current meta-analysis showed that MD and WD have protective and detrimental effects on BC risk, respectively. No significant association between DII and the risk of BC was observed. More research is still needed to confirm the findings. Additional study is warranted to better understand the etiological mechanisms underlying how different dietary patterns affect BC.

TRIAL REGISTRATION

Protocol registration number: CRD42020155353. Database for protocol registration: The international prospective register of systematic reviews database (PROSPERO). Data of registration: August 2020.

Impact of achievement and change in achievement of lifestyle recommendations in middle-age on risk of the most common potentially preventable cancers

This study aimed to assess the association between achievement, and within-person change in achievement, of lifestyle recommendations in middle-age and incidence of the most common potentially preventable cancers. We used data from 44,572 participants from the Swedish Västerbotten Intervention Programme who had attended at least two health checks 9-11 years apart. We assessed the association between the mean number of healthy lifestyle recommendations achieved (lifestyle score), and change in lifestyle score between the health checks, and risk of one or more of the eight most common potentially preventable cancers using Cox regression. Participants were followed-up for 11.0 (SD 4.9) years. A higher mean lifestyle score was associated with a lower hazard of cancer in men (HR 0.81 (95%CI 0.74-0.90) per unit increase) and women (HR 0.90 (0.84-0.96)). There was no evidence of a linear association between change in lifestyle score and risk (HR 0.93 (0.85-1.03) and HR 1.004 (0.94-1.07) per unit change for men and women respectively). When comparing those with an increase in lifestyle score of ≥2 with those who improved less or declined in achievement the HR was 0.74 (0.54-1.00) and 1.02 (0.84-1.24) for men and women respectively. These findings support the inclusion of lifestyle recommendations in cancer prevention guidelines. They further suggest that interventions to change health behaviours in middle-age may reduce risk of the most common preventable cancers in men, but this association was not observed in women. Strategies to encourage healthy lifestyles earlier in the life course may be more effective.

Global, regional and national burden of bladder cancer and its attributable risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease study 2019

Introduction

The current study determined the level and trends associated with the incidence, death and disability rates for bladder cancer and its attributable risk factors in 204 countries and territories, from 1990 to 2019, by age, sex and sociodemographic index (SDI; a composite measure of sociodemographic factors).

Methods

Various data sources from different countries, including vital registration and cancer registries were used to generate estimates. Mortality data and incidence data transformed to mortality estimates using the mortality to incidence ratio (MIR) were used in a cause of death ensemble model to estimate mortality. Mortality estimates were divided by the MIR to produce incidence estimates. Prevalence was calculated using incidence and MIR-based survival estimates. Age-specific mortality and standardised life expectancy were used to estimate years of life lost (YLLs). Prevalence was multiplied by disability weights to estimate years lived with disability (YLDs), while disability-adjusted life years (DALYs) are the sum of the YLLs and YLDs. All estimates were presented as counts and age-standardised rates per 100 000 population.

Results

Globally, there were 524 000 bladder cancer incident cases (95% uncertainty interval 476 000 to 569 000) and 229 000 bladder cancer deaths (211 000 to 243 000) in 2019. Age-standardised death rate decreased by 15.7% (8.6 to 21.0), during the period 1990–2019. Bladder cancer accounted for 4.39 million (4.09 to 4.70) DALYs in 2019, and the age-standardised DALY rate decreased significantly by 18.6% (11.2 to 24.3) during the period 1990–2019. In 2019, Monaco had the highest age-standardised incidence rate (31.9 cases (23.3 to 56.9) per 100 000), while Lebanon had the highest age-standardised death rate (10.4 (8.1 to 13.7)). Cabo Verde had the highest increase in age-standardised incidence (284.2% (214.1 to 362.8)) and death rates (190.3% (139.3 to 251.1)) between 1990 and 2019. In 2019, the global age-standardised incidence and death rates were higher among males than females, across all age groups and peaked in the 95+ age group. Globally, 36.8% (28.5 to 44.0) of bladder cancer DALYs were attributable to smoking, more so in males than females (43.7% (34.0 to 51.8) vs 15.2% (10.9 to 19.4)). In addition, 9.1% (1.9 to 19.6) of the DALYs were attributable to elevated fasting plasma glucose (FPG) (males 9.3% (1.6 to 20.9); females 8.4% (1.6 to 19.1)).

Conclusions

There was considerable variation in the burden of bladder cancer between countries during the period 1990–2019. Although there was a clear global decrease in the age-standardised death, and DALY rates, some countries experienced an increase in these rates. National policy makers should learn from these differences, and allocate resources for preventative measures, based on their country-specific estimates. In addition, smoking and elevated FPG play an important role in the burden of bladder cancer and need to be addressed with prevention programmes.

Consumption of Fruits, Vegetables and Bladder Cancer Risk: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

We examined the association between fruit/vegetable consumption and bladder cancer (BC) risk in a systematic review and meta-analysis of prospective cohort studies stratifying results by gender, smoking status and geographical region. Eligible studies were sought in MEDLINE and EMBASE up to April 20, 2020. Random-effects (DerSimonian-Laird) models were implemented for the calculation of pooled relative risks (RRs) and 95% confidence intervals (CI). Fifteen eligible studies were identified (1,993,881 subjects, 11,097 BC cases). Vegetable consumption (pooled RR = 0.95, 95% CI: 0.87-1.04, n = 10) as well as combined fruit/vegetable consumption was not associated with BC risk. Regarding fruit intake, the overall protective trend did not reach significance (pooled RR = 0.91, 95%CI: 0.81-1.02, n = 11); we found however a significant association in East Asians. A trend toward a protective association with citrus fruit consumption was also noted (pooled RR = 0.83, 95%CI: 0.69-1.01, n = 6), once again with a significant effect in East Asians. Moreover, no association was found regarding the subgroups of leafy vegetables, dark green vegetables, and berries. Single studies pointed to a reduced BC risk in never smoking males consuming cruciferous vegetables and East Asians consuming yellow vegetables. In conclusion, our study reveals possible protective effects; larger studies are needed to investigate the emerging trends.

Metabolic Fate of Dietary Glucosinolates and Their Metabolites: A Role for the Microbiome

Robust evidence shows that phytochemicals from cruciferous vegetables, like broccoli, are associated with numerous health benefits. The anti-cancer properties of these foods are attributed to bioactive isothiocyanates (ITCs) and indoles, phytochemicals generated from biological precursor compounds called glucosinolates. ITCs, and particularly sulforaphane (SFN), are of intense interest as they block the initiation, and suppress the progression of cancer, through genetic and epigenetic mechanisms. The efficacy of these compounds is well-demonstrated in cell culture and animal models, however, high levels of inter-individual variation in absorption and excretion of ITCs is a significant barrier to the use of dietary glucosinolates to prevent and treat disease. The source of inter-individual ITC variation has yet to be fully elucidated and the gut microbiome may play a key role. This review highlights evidence that the gut microbiome influences the metabolic fate and activity of ITCs. Human feeding trials have shown inter-individual variations in gut microbiome composition coincides with variations in ITC absorption and excretion, and some bacteria produce ITCs from glucosinolates. Additionally, consumption of cruciferous vegetables can alter the composition of the gut microbiome and shift the physiochemical environment of the gut lumen, influencing the production of phytochemicals. Microbiome and diet induced changes to ITC metabolism may lead to the decrease of cancer fighting phytochemicals such as SFN and increase the production of biologically inert ones like SFN-nitrile. We conclude by offering perspective on the use of novel “omics” technologies to elucidate the interplay of the gut microbiome and ITC formation.

Consumption of cruciferous vegetables and the risk of bladder cancer in a prospective US cohort: data from the NIH-AARP diet and health study

BACKGROUND

Abundant pre-clinical data suggest that consumption of cruciferous vegetables might protect against bladder cancer. While small-scale clinical evidence supports this hypothesis, population-level data is lacking. We tested the hypothesis that consumption of cruciferous vegetables is associated with a lower risk of bladder cancer in a large population-based study.

METHODS

We investigated the association between dietary consumption of cruciferous vegetables and the risk of bladder cancer in the NIH-American Association of Retired Persons (AARP) Diet and Health Study. Diet at baseline was collected with self-administered food-frequency questionnaires. Bladder cancer diagnoses were identified through linkage with state cancer registries. Hazard ratio (HR) and 95% confidence intervals (CI) were estimated with Cox proportional hazards models.

RESULTS

Our analysis included 515,628 individuals. Higher intake of cruciferous vegetables, both overall and when stratified by variety (broccoli vs. brussels sprouts vs. cauliflower), were not associated with bladder cancer risk for men or women. A history of smoking did not affect the results.

CONCLUSIONS

Our study shows no association between dietary consumption of cruciferous vegetables and incident bladder cancer.

Vegetable intake and the risk of bladder cancer in the BLadder Cancer Epidemiology and Nutritional Determinants (BLEND) international study

BACKGROUND

Although a potential inverse association between vegetable intake and bladder cancer risk has been reported, epidemiological evidence is inconsistent. This research aimed to elucidate the association between vegetable intake and bladder cancer risk by conducting a pooled analysis of data from prospective cohort studies.

METHODS

Vegetable intake in relation to bladder cancer risk was examined by pooling individual-level data from 13 cohort studies, comprising 3203 cases among a total of 555,685 participants. Pooled multivariate hazard ratios (HRs), with corresponding 95% confidence intervals (CIs), were estimated using Cox proportional hazards regression models stratified by cohort for intakes of total vegetable, vegetable subtypes (i.e. non-starchy, starchy, green leafy and cruciferous vegetables) and individual vegetable types. In addition, a diet diversity score was used to assess the association of the varied types of vegetable intake on bladder cancer risk.

RESULTS

The association between vegetable intake and bladder cancer risk differed by sex (P-interaction = 0.011) and smoking status (P-interaction = 0.038); therefore, analyses were stratified by sex and smoking status. With adjustment of age, sex, smoking, energy intake, ethnicity and other potential dietary factors, we found that higher intake of total and non-starchy vegetables were inversely associated with the risk of bladder cancer among women (comparing the highest with lowest intake tertile: HR = 0.79, 95% CI = 0.64-0.98, P = 0.037 for trend, HR per 1 SD increment = 0.89, 95% CI = 0.81-0.99; HR = 0.78, 95% CI = 0.63-0.97, P = 0.034 for trend, HR per 1 SD increment = 0.88, 95% CI = 0.79-0.98, respectively). However, no evidence of association was observed among men, and the intake of vegetable was not found to be associated with bladder cancer when stratified by smoking status. Moreover, we found no evidence of association for diet diversity with bladder cancer risk.

CONCLUSION

Higher intakes of total and non-starchy vegetable are associated with reduced risk of bladder cancer for women. Further studies are needed to clarify whether these results reflect causal processes and potential underlying mechanisms.

Vegetable and Fruit Consumption and Prognosis Among Cancer Survivors: A Systematic Review and Meta-Analysis of Cohort Studies

The number of cancer survivors is growing rapidly worldwide, especially long-term survivors. Although a healthy diet with a high vegetable and fruit consumption is a key factor in primary cancer prevention, there is a lack of specific dietary recommendations for cancer survivors, except in the case of breast cancer [World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) report]. We have therefore carried out a systematic review and meta-analysis of cohort studies reporting on the associations between vegetable and fruit intake with cancer recurrence and mortality and all-cause mortality in cancer patients. After a comprehensive search of PubMed and Scopus databases, the results of 28 selected articles were analyzed. A high vegetable intake before diagnosis was inversely associated with overall mortality in survivors of head and neck (HR: 0.75; 95% CI: 0.65, 0.87) and ovarian cancer (HR: 0.78; 95% CI: 0.66, 0.91). In ovarian cancer patients, prediagnosis fruit intake was also inversely associated with all-cause mortality (HR: 0.82; 95% CI: 0.70, 0.96). The evidence was insufficient for survivors of other cancers, although these associations generally tended to be protective. Therefore, more studies are needed to clarify the association between vegetable and fruit consumption and the prognosis of these different types of cancer. To date, the general recommendation to consume ≥5 servings of vegetables and fruit per day (∼400 g/d) could underestimate the needs of cancer survivors, particularly those with ovarian tumors, in which the recommendation could increase to ∼600 g/d (i.e., 300 g/d of vegetables and 300 g/d of fruit).

A data mining approach to investigate food groups related to incidence of bladder cancer in the BLadder cancer Epidemiology and Nutritional Determinants International Study

At present, analysis of diet and bladder cancer (BC) is mostly based on the intake of individual foods. The examination of food combinations provides a scope to deal with the complexity and unpredictability of the diet and aims to overcome the limitations of the study of nutrients and foods in isolation. This article aims to demonstrate the usability of supervised data mining methods to extract the food groups related to BC. In order to derive key food groups associated with BC risk, we applied the data mining technique C5.0 with 10-fold cross-validation in the BLadder cancer Epidemiology and Nutritional Determinants study, including data from eighteen case-control and one nested case-cohort study, compromising 8320 BC cases out of 31 551 participants. Dietary data, on the eleven main food groups of the Eurocode 2 Core classification codebook, and relevant non-diet data (i.e. sex, age and smoking status) were available. Primarily, five key food groups were extracted; in order of importance, beverages (non-milk); grains and grain products; vegetables and vegetable products; fats, oils and their products; meats and meat products were associated with BC risk. Since these food groups are corresponded with previously proposed BC-related dietary factors, data mining seems to be a promising technique in the field of nutritional epidemiology and deserves further examination.

Potential of food intake biomarkers in nutrition research

The influence of dietary habits on health/disease is well-established. Accurate dietary assessment is essential to understand metabolic pathways/processes involved in this relationship. In recent years, biomarker discovery has become a major area of interest for improving dietary assessment. Well-established nutrient intake biomarkers exist; however, there is growing interest in identifying and using biomarkers for more accurate and objective measurements of food intake. Metabolomics has emerged as a key tool used for biomarker discovery, employing techniques such as NMR spectroscopy, or MS. To date, a number of putatively identified biomarkers were discovered for foods including meat, cruciferous vegetables and legumes. However, many of the results are associations only and lack the desired validation including dose-response studies. Food intake biomarkers can be employed to classify individuals into consumers/non-consumers of specific foods, or into dietary patterns. Food intake biomarkers can also play a role in correcting self-reported measurement error, thus improving dietary intake estimates. Quantification of food intake was previously performed for citrus (proline betaine), chicken (guanidoacetate) and grape (tartaric acid) intake. However, this area still requires more investigation and expansion to a range of foods. The present review will assess the current literature of identified specific food intake biomarkers, their validation and the variety of biomarker uses. Addressing the utility of biomarkers and highlighting gaps in this area is important to advance the field in the context of nutrition research.

Metabolomic-Based Approach to Identify Biomarkers of Apple Intake

SCOPE

There is an increased interest in developing biomarkers of food intake to address some of the limitations associated with self-reported data. The objective is to identify biomarkers of apple intake, examine dose-response relationships, and agreement with self-reported data.

METHODS AND RESULTS

Metabolomic data from three studies are examined: an acute intervention, a short-term intervention, and a free-living cohort study. Fasting and postprandial urine samples are collected for analysis by ¹ H-NMR and liquid chromatography-mass spectrometry (LC-MS). Calibration curves are developed to determine apple intake and classify individuals into categories of intake. Multivariate analysis of data reveals that levels of multiple metabolites increase significantly post-apple consumption, compared to the control food-broccoli. In the dose-response study, urinary xylose, epicatechin sulfate, and 2,6-dimethyl-2-(2-hydroxyethyl)-3,4-dihydro-2H-1-benzopyran increase as apple intake increases. Urinary xylose concentrations in a free-living cohort perform poorly at an individual level but are capable of ranking individuals in categories of intake.

CONCLUSION

Urinary xylose exhibits a dose-response relationship with apple intake and performs well as a ranking biomarker in the population study. Other potential biomarkers are identified and future work will combine these with xylose in a biomarker panel which may allow for a more objective determination of individual intake.

Molecular Mechanisms of the Anti-Cancer Effects of Isothiocyanates from Cruciferous Vegetables in Bladder Cancer

Bladder cancer (BC) is a representative of urological cancer with a high recurrence and metastasis potential. Currently, cisplatin-based chemotherapy and immune checkpoint inhibitors are used as standard therapy in patients with advanced/metastatic BC. However, these therapies often show severe adverse events, and prolongation of survival is unsatisfactory. Therefore, a treatment strategy using natural compounds is of great interest. In this review, we focused on the anti-cancer effects of isothiocyanates (ITCs) derived from cruciferous vegetables, which are widely cultivated and consumed in many regions worldwide. Specifically, we discuss the anti-cancer effects of four ITC compounds—allyl isothiocyanate, benzyl isothiocyanate, sulforaphane, and phenethyl isothiocyanate—in BC; the molecular mechanisms underlying their anti-cancer effects; current trends and future direction of ITC-based treatment strategies; and the carcinogenic potential of ITCs. We also discuss the advantages and limitations of each ITC in BC treatment, furthering the consideration of ITCs in treatment strategies and for improving the prognosis of patients with BC.

Plant Foods, Antioxidant Biomarkers, and the Risk of Cardiovascular Disease, Cancer, and Mortality: A Review of the Evidence

Although a high intake of plant foods such as fruits, vegetables, whole grains, nuts, and legumes has been recommended for chronic disease prevention, it has been unclear what is the optimal amount of intake of these foods and whether specific subtypes are particularly beneficial. The evidence from several recently published meta-analyses on plant foods and antioxidants and various health outcomes is reviewed as well as more recently published studies. In meta-analyses of prospective studies, inverse associations were observed between intake of fruits, vegetables, whole grains, and nuts and the risk of coronary artery disease, stroke, cardiovascular disease overall, total cancer, and all-cause mortality. The strongest reductions in risk were observed at an intake of 800 g/d for fruits and vegetables, 225 g/d for whole grains, and 15-20 g/d for nuts, respectively. Whole-grain and nut consumption was also inversely associated with mortality from respiratory disease, infections, and diabetes. Stronger and more linear inverse associations were observed between blood concentrations of antioxidants (vitamin C, carotenoids, vitamin E) and cardiovascular disease, cancer, and all-cause mortality than for dietary intake. Most studies that have since been published have been consistent with these results; however, further studies are needed on subtypes of plant foods and less common causes of death. These results strongly support dietary recommendations to increase intake of plant foods, and suggest optimal intakes for chronic disease prevention may be ∼800 g/d for intakes of fruits and vegetables, 225 g/d for whole grains, and 15-20 g/d for nuts. Diets high in plant foods could potentially prevent several million premature deaths each year if adopted globally.

Food consumption, meat cooking methods and diet diversity and the risk of bladder cancer

BACKGROUND

Since food metabolites are eliminated by the urinary tract, several studies have investigated the association between diet and bladder cancer risk. Recently, the World Cancer Research Fund International/American Institute for Cancer Research (WCRF/AICR) suggested a potential beneficial effect of some foods (mainly vegetables, fruit, and milk) in the development of bladder cancer. We investigated the association between food groups and bladder cancer risk, seeking insights into food diversity as well as meat cooking methods.

METHODS

Data were derived from an Italian multicentre case-control study, conducted between 2003 and 2014, including 690 bladder cancer cases and 665 frequency-matched controls. Odds ratios (ORs) and the corresponding 95% confidence intervals (95%CIs) for various dietary aspects were estimated by unconditional logistic regression models adjusted for energy intake and the major known risk factors for bladder cancer.

RESULTS

Comparing the highest versus the lowest quartiles, consumption of vegetables (OR = 0.62; 95%CI: 0.44-0.88) and milk/yogurt (OR = 0.62; 95%CI: 0.44-0.87) reduced the risk of bladder cancer. Conversely, consumption of meat increased bladder cancer risk with an OR of 1.57 (95%CI: 1.07-2.31), particularly when the meat was stewed (OR = 1.47; 95%CI: 1.03-2.09) or roasted (OR = 1.41; 95%CI: 1.00-1.99). There was a suggestion that a diversified diet reduced the risk of bladder cancer, but this was not significant.

CONCLUSIONS

Our study consolidates the role of diet in bladder cancer aetiology, showing a reduced risk for vegetable and milk/yogurt consumption and an increased risk for meat consumption, especially when the meat is stewed or roasted.

Bladder cancer: overview and disease management. Part 1: non-muscle-invasive bladder cancer

Part 1 of this two-part article provides an overview of bladder cancer and discusses its management. Since publication of a previous article entitled 'Understanding the role of smoking in the aetiology of bladder cancer' ( Anderson, 2009 ), the author has received many requests for an update. This article provides an overview of bladder cancer and its current management practices, underlining the continued role of smoking as the predominant risk factor in the disease's development. The management of bladder cancer is governed by specific guidelines. Management of non-muscle-invasive cancers, including surgical intervention with transurethral resection, and intravesical therapy using chemotherapy and immunotherapy agents, is discussed. Cystectomy (removal of the bladder), is sometimes necessary. Treatments are effective in reducing tumour recurrence, but the effects of the risks and side-effects on the individual's quality of life can be significant. The prevalence of bladder cancer, and the nature of its management make this cancer one of the most expensive for the NHS to treat. The effectiveness of health promotional strategies in increasing peoples' awareness of their risk of developing the disease, and in enabling them to change long-term health behaviours is discussed. The role of the multidisciplinary team is explored, along with that of the uro-oncology cancer nurse specialist. Part 2 will consider the management of muscle-invasive and metastatic bladder cancer.

Fruit and vegetable consumption and health outcomes: an umbrella review of observational studies

The aim of this study was to provide a comprehensive evaluation of current evidence on fruit and vegetable consumption and health outcomes. A systematic search for quantitative syntheses was performed. Several criteria, including study design, dose-response relationship, heterogeneity and agreement of results over time, and identification of potential confounding factors, were used to assess the level of evidence. The strongest (probable) evidence was found for cardiovascular disease protection; possible evidence for decreased risk of colon cancer, depression and pancreatic diseases was found for fruit intake; and colon and rectal cancer, hip fracture, stroke, depression and pancreatic diseases was found for vegetable intake. Suggestive and rather limited associations with other outcomes have been found. Evidence of potential confounding by sex and geographical localisation has been reported. Despite findings are consistent enough for hypothesising causation (at least for cardiovascular-related outcomes), further studies are needed to clarify the role of potential confounding factors.

An inverse association between the Mediterranean diet and bladder cancer risk: a pooled analysis of 13 cohort studies

Purpose

The role of diet in bladder carcinogenesis has yet to be established. To date most studies have investigated dietary components individually, rather than as dietary patterns, which may provide stronger evidence for any influence of diet on bladder carcinogenesis. The Mediterranean diet has been associated with many health benefits, but few studies have investigated its association with bladder cancer risk.

Methods

We investigated the potential association between the Mediterranean diet score (MDS) and risk of developing bladder cancer by pooling 13 prospective cohort studies included in the BLadder cancer Epidemiology and Nutritional Determinants (BLEND) study and applying a Cox regression analysis.

Results

Dietary data from 646,222 study participants, including 3639 incident bladder cancer cases, were analysed. We observed an inverse association between Mediterranean diet and bladder cancer risk (HR_high 0.85 [95% CI 0.77, 0.93]). When stratifying the results on non-muscle-invasive or muscle-invasive disease or sex the association remained similar and the HR estimate was consistently below 1.00 both for medium and high adherence to the Mediterranean diet. A consistent association was observed when disregarding fat or alcohol intake.

Conclusion

We found evidence that adherence to the Mediterranean diet was associated with reduced risk of developing bladder cancer, suggesting a positive effect of the diet as a whole and not just one component.

The Associations of Fruit and Vegetable Intakes with Burden of Diseases: A Systematic Review of Meta-Analyses

BACKGROUND

Low fruit and vegetable intakes are recognized risk factors for noncommunicable diseases. This systematic review summarizes published meta-analyses of global burden of diseases attributable to low fruit and vegetable intakes, and the best relative risk estimates.

METHODS

A published novel assessment process combining Cochrane Review measures, Assessing the Methodological Quality of Systematic Reviews checklist, and Newcastle-Ottawa Quality Assessment Scale was employed.

RESULTS

Sixty-four reports investigating 98 risk-disease pairs were included in the systematic review. Fifty-six pairs from 39 reports were assessed as statistically significant, involving 29 burden of diseases. Dose responses were identified for 31 negative and two positive associations. High against low intake relative risks were identified for 22 negative and one positive association. The highest identified linear dose response for each 100 g/day increase in fruit intakes was 0.56 (95% CI 0.42 to 0.74) for esophageal cancer, followed by 0.72 (95% CI 0.59 to 0.87) for mouth, pharynx, and larynx cancer; nonlinear dose response for the first 100 g/day of fruit intakes were 0.86 (95% CI 0.84 to 0.88) for stroke, followed by 0.89 (95% CI 0.88 to 0.90) for all-cause mortality. The highest identified linear dose response for each 100 g/day increase in vegetable intakes was 0.88 (95% CI 0.80 to 0.95) for renal cell cancer, followed by 0.89 (95% CI 0.84 to 0.95) for non-Hodgkin lymphoma; nonlinear dose responses for the first 100 g/day of vegetable intake were 0.86 (95% CI 0.84 to 0.89) for coronary heart disease, followed by 0.87 (95% CI 0.84 to 0.90) for all-cause mortality. For nonlinear associations, clear increases in protective associations were observed with the first 200 g/day of intakes, whereas little further increase or even decrease in protective associations were reported beyond 300 g/day intakes. Canned fruit intakes were positively associated with all-cause and cardiovascular disease mortality, and pickled vegetable intakes were positively associated with stomach cancer.

CONCLUSIONS

This systematic review supports existing recommendations for fruit and vegetable intakes. Current comparative risk assessments might significantly underestimate the protective associations of fruit and vegetable intakes.

Benefits of Community Gardening Activity in Obesity Intervention: Findings from F.E.A.T. Programme

This study determines the beneficial effect of community gardening activity in obesity intervention among overweight and obese adults in semi-urban area. The study was one of the activities in Arus Perdana Research Grant for obesity intervention, The Fit, Eat, Active and Training (F.E.A.T) programme. The study employs a pre-post quasi experimental design assigned into intervention (n=31) and control (n=30) group respectively. The intervention group followed a series of activities for 12 weeks of intervention. In one of the activities, subjects received a nutrition counselling session with nutritionist on daily vegetables intake, while agriculture officers demonstrated the procedure of producing fertilizers from household waste and vegetable gardening techniques. The subjects were divided into groups which planted their own vegetables at the space around community hall and in the pot during the intervention period. There was significant difference (p<0.05) for vegetable intake after 12-week intervention, when 1.8 ± 0.7 serving size for the intervention group is compared to 0.7 ± 0.5 serving size for the control group. The results reported noteworthy reductions (p<0.05) in body weight with -3.5% reduction for the intervention group which was involved in gardening as compared to -0.4% reduction for the control group. Moreover, BMI reductions were observed to be -4.1% and -0.9% and waist circumference reductions were -9.9% and -4.0% for intervention group and control group respectively. In conclusion, the community gardening program is fund to be a successful activity in improving daily vegetable intake, as well as reducing the BMI and waist circumference among obese adults in semi-urban community.

Epidemiology of Bladder Cancer: A Systematic Review and Contemporary Update of Risk Factors in 2018

CONTEXT

Bladder cancer (BC) is a significant health problem, and understanding the risk factors for this disease could improve prevention and early detection.

OBJECTIVE

To provide a systematic review and summary of novel developments in epidemiology and risk factors for BC.

EVIDENCE ACQUISITION

A systematic review of original articles was performed by two pairs of reviewers (M.G.C., I.J., F.E., and K.P.) using PubMed/Medline in December 2017, updated in April 2018. To address our primary objective of reporting contemporary studies, we restricted our search to include studies from the last 5yr. We subdivided our review according to specific risk factors (PICO [Population Intervention Comparator Outcome]).

EVIDENCE SYNTHESIS

Our search found 2191 articles, of which 279 full-text manuscripts were included. We separated our manuscripts by the specific risk factor they addressed (PICO). According to GLOBOCAN estimates, there were 430000 new BC cases and 165000 deaths worldwide in 2012. Tobacco smoking and occupational exposure to carcinogens remain the factors with the highest attributable risk. The literature was limited by heterogeneity of data.

CONCLUSIONS

Evidence is emerging regarding gene-environment interactions, particularly for tobacco and occupational exposures. In some populations, incidence rates are declining, which may reflect a decrease in smoking. Standardisation of reporting may help improve epidemiologic evaluation of risk.

PATIENT SUMMARY

Bladder cancer is common worldwide, and the main risk factors are tobacco smoking and exposure to certain chemicals in the working and general environments. There is ongoing research to identify and reduce risk factors, as well as to understand the impact of genetics on bladder cancer risk.

Dietary intake and blood concentrations of antioxidants and the risk of cardiovascular disease, total cancer, and all-cause mortality: a systematic review and dose-response meta-analysis of prospective studies

Background

High dietary intake or blood concentrations (as biomarkers of dietary intake) of vitamin C, carotenoids, and vitamin E have been associated with reduced risk of cardiovascular disease, cancer, and mortality, but these associations have not been systematically assessed.

Objective

We conducted a systematic review and meta-analysis of prospective studies of dietary intake and blood concentrations of vitamin C, carotenoids, and vitamin E in relation to these outcomes.

Design

We searched PubMed and Embase up to 14 February 2018. Summary RRs and 95% CIs were calculated with the use of random-effects models.

Results

Sixty-nine prospective studies (99 publications) were included. The summary RR per 100-mg/d increment of dietary vitamin C intake was 0.88 (95% CI: 0.79, 0.98, I2 = 65%, n = 11) for coronary heart disease, 0.92 (95% CI: 0.87, 0.98, I2 = 68%, n = 12) for stroke, 0.89 (95% CI: 0.85, 0.94, I2 = 27%, n = 10) for cardiovascular disease, 0.93 (95% CI: 0.87, 0.99, I2 = 46%, n = 8) for total cancer, and 0.89 (95% CI: 0.85, 0.94, I2 = 80%, n = 14) for all-cause mortality. Corresponding RRs per 50-μmol/L increase in blood concentrations of vitamin C were 0.74 (95% CI: 0.65, 0.83, I2 = 0%, n = 4), 0.70 (95% CI: 0.61, 0.81, I2 = 0%, n = 4), 0.76 (95% CI: 0.65, 0.87, I2 = 56%, n = 6), 0.74 (95% CI: 0.66, 0.82, I2 = 0%, n = 5), and 0.72 (95% CI: 0.66, 0.79, I2 = 0%, n = 8). Dietary intake and/or blood concentrations of carotenoids (total, β-carotene, α-carotene, β-cryptoxanthin, lycopene) and α-tocopherol, but not dietary vitamin E, were similarly inversely associated with coronary heart disease, stroke, cardiovascular disease, cancer, and/or all-cause mortality.

Conclusions

Higher dietary intake and/or blood concentrations of vitamin C, carotenoids, and α-tocopherol (as markers of fruit and vegetable intake) were associated with reduced risk of cardiovascular disease, total cancer, and all-cause mortality. These results support recommendations to increase fruit and vegetable intake, but not antioxidant supplement use, for chronic disease prevention.

Leitzmann M, Brenner*2 H, Mons*2 U. Cancers Due to Excess Weight, Low Physical Activity, and Unhealthy Diet

BACKGROUND

Excess weight, low physical activity, low intakes of dietary fiber, fruits, and vegetables, and high meat and salt intake increase cancer risk.

METHODS

Numbers and proportions (population-attributable fractions, PAF) of incident cancer cases in Germany in 2018 attributable to these factors were estimated by sex and age groups for ages 35 to 84 years using population projections, national cancer incidence and exposure data, and published risk estimates.

RESULTS

Estimated numbers (percentages) of attributable cancers were 30 567 (7%) for excess weight, 27 081 (6%) for low physical activity, 14 474 (3%) for low dietary fiber intake, 9447 (2%) for low fruit and vegetable consumption, 9454 (2%) and 1687 (0.4%) for processed meat and high red meat consumption, respectively, and 1204 (0.3%) for high salt intake. Excess weight substantially contributed to endometrial, renal, and liver cancer (PAF = 24 to 35%). Low physical activity contributed to endometrial, renal, and lung cancer (PAF = 15 to 19%), and dietary factors mainly contributed to colorectal, breast, and lung cancer (PAF = 9 to 16%).

CONCLUSION

A considerable proportion of cancer cases are attributable to excess weight, physical inactivity, and unhealthy dietary habits. Major prevention efforts are needed to reduce the cancer incidence attributable to these avoidable factors.

Cruciferous Vegetables, Isothiocyanates, and Bladder Cancer Prevention

Bladder cancer is a significant health burden due to its high prevalence, risk of mortality, morbidity, and high cost of medical care. Epidemiologic evidence suggests that diets rich in cruciferous vegetables, particularly broccoli, are associated with lower bladder cancer risk. Phytochemicals in cruciferous vegetables, such as glucosinolates, which are enzymatically hydrolyzed to bioactive isothiocyanates, are possible mediators of an anticancer effect. In vitro studies have shown inhibition of bladder cancer cell lines, cell cycle arrest, and induction of apoptosis by these isothiocyanates, in particular sulforaphane and erucin. Although not yet completely understood, many mechanisms of anticancer activity at the steps of cancer initiation, promotion, and progression have been attributed to these isothiocyanates. They target multiple pathways including the adaptive stress response, phase I/II enzyme modulation, pro-growth, pro-survival, pro-inflammatory signaling, angiogenesis, and even epigenetic modulation. Multiple in vivo studies have shown the bioavailability of isothiocyanates and their antitumoral effects. Although human studies are limited, they support oral bioavailability with reasonable plasma and urine concentrations achieved. Overall, both cell and animal studies support a potential role for isothiocyanates in bladder cancer prevention and treatment. Future studies are necessary to examine clinically relevant outcomes and define guidelines on ameliorating the bladder cancer burden.

Food as Pharma? The Case of Glucosinolates

BACKGROUND

Glucosinolates (GLSs) are dietary plant secondary metabolites occurring in the order Brassicales with potential health effects, in particular as anti-carcinogenic compounds. GLSs are converted into a variety of breakdown products (BPs) upon plant tissue damage and by the gut microbiota. GLS biological activity is related to BPs rather than to GLSs themselves.

METHODS

we have reviewed the most recent scientific literature on the metabolic fate and the biological effect of GLSs with particular emphasis on the epidemiological evidence for health effect and evidence from clinical trials. An overview of potential molecular mechanisms underlying GLS biological effect is provided. The potential toxic or anti-nutritional effect has also been discussed.

RESULTS

Epidemiological and human in vivo evidence point towards a potential anti-cancer effect for sulforaphane, indole-3-carbinol and 3,3-diindolylmethane. A number of new human clinical trials are on-going and will likely shed further light on GLS protective effect towards cancer as well as other diseases. BPs biological effect is the results of a plurality of molecular mechanisms acting simultaneously which include modulation of xenobiotic metabolism, modulation of inflammation, regulation of apoptosis, cell cycle arrest, angiogenesis and metastasis and regulation of epigenetic events. BPs have been extensively investigated for their protective effect towards cancer but in recent years the interest also includes other diseases.

CONCLUSION

It appears that certain BPs may protect against and may even represent a therapeutic strategy against several forms of cancer. Whether this latter effect can be achieved through diet or supplements should be investigated more thoroughly.

Potential Mechanisms of Action of Dietary Phytochemicals for Cancer Prevention by Targeting Cellular Signaling Transduction Pathways

Cancer is a severe health problem that significantly undermines life span and quality. Dietary approach helps provide preventive, nontoxic, and economical strategies against cancer. Increased intake of fruits, vegetables, and whole grains are linked to reduced risk of cancer and other chronic diseases. The anticancer activities of plant-based foods are related to the actions of phytochemicals. One potential mechanism of action of anticancer phytochemicals is that they regulate cellular signal transduction pathways and hence affects cancer cell behaviors such as proliferation, apoptosis, and invasion. Recent publications have reported phytochemicals to have anticancer activities through targeting a wide variety of cell signaling pathways at different levels, such as transcriptional or post-transcriptional regulation, protein activation and intercellular messaging. In this review, we discuss major groups of phytochemicals and their regulation on cell signaling transduction against carcinogenesis via key participators, such as Nrf2, CYP450, MAPK, Akt, JAK/STAT, Wnt/β-catenin, p53, NF-κB, and cancer-related miRNAs.

Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies

Background

Questions remain about the strength and shape of the dose-response relationship between fruit and vegetable intake and risk of cardiovascular disease, cancer and mortality, and the effects of specific types of fruit and vegetables. We conducted a systematic review and meta-analysis to clarify these associations.

Methods

PubMed and Embase were searched up to 29 September 2016. Prospective studies of fruit and vegetable intake and cardiovascular disease, total cancer and all-cause mortality were included. Summary relative risks (RRs) were calculated using a random effects model, and the mortality burden globally was estimated; 95 studies (142 publications) were included.

Results

For fruits and vegetables combined, the summary RR per 200 g/day was 0.92 [95% confidence interval (CI): 0.90-0.94, I 2  = 0%, n  = 15] for coronary heart disease, 0.84 (95% CI: 0.76-0.92, I 2  = 73%, n  = 10) for stroke, 0.92 (95% CI: 0.90-0.95, I 2  = 31%, n  = 13) for cardiovascular disease, 0.97 (95% CI: 0.95-0.99, I 2  = 49%, n  = 12) for total cancer and 0.90 (95% CI: 0.87-0.93, I 2  = 83%, n  = 15) for all-cause mortality. Similar associations were observed for fruits and vegetables separately. Reductions in risk were observed up to 800 g/day for all outcomes except cancer (600 g/day). Inverse associations were observed between the intake of apples and pears, citrus fruits, green leafy vegetables, cruciferous vegetables, and salads and cardiovascular disease and all-cause mortality, and between the intake of green-yellow vegetables and cruciferous vegetables and total cancer risk. An estimated 5.6 and 7.8 million premature deaths worldwide in 2013 may be attributable to a fruit and vegetable intake below 500 and 800 g/day, respectively, if the observed associations are causal.

Conclusions

Fruit and vegetable intakes were associated with reduced risk of cardiovascular disease, cancer and all-cause mortality. These results support public health recommendations to increase fruit and vegetable intake for the prevention of cardiovascular disease, cancer, and premature mortality.

[A critical perspective on the global research activity in the field of bladder cancer]

BACKGROUND

Bladder cancer (BC) is one of the most common forms of cancer world-wide. This underestimated disease can cause severe morbidity and mortality in individuals. Increasing awareness can be depicted by the increasing numbers of publications since the 1990s. Hence, it is challenging for a scientist to obtain an overview of the topic. To quantify the global research activity in this field, a scientometric investigation was conducted.

MATERIAL AND METHODS

Using the database Web of Science, the bibliometric data of publications on the topic of BC was acquired for the period 1900-2007. According to the NewQIS protocol, different visualization techniques and scientometric methods were applied.

RESULTS

A total of 19,651 publications were evaluated. The USA takes a leading position in terms of the overall number of publications, institutions, and collaborations. International collaboration on BC has changed considerably in terms of quantity during the past 20 years. The largest number of articles and the highest number of citations regarding BC are found in the Journal of Urology. Thus, it is considered the most prolific journal. Furthermore, the productivity (i. e., publication numbers) of authors and scientific impact (i. e., citation rates) vary greatly.

CONCLUSION

The field of BC continues to progress, whereby the influence of international co-operation on scientific progress is of increasing importance. New evaluation factors/tools have to be established for a more reliable evaluation of scientific work.

The economic burden of inadequate consumption of vegetables and fruit in Canada

Objective

Public health decision makers not only consider health benefits but also economic implications when articulating and issuing lifestyle recommendations. Whereas various estimates exist for the economic burden of physical inactivity, excess body weight and smoking, estimates of the economic burden associated with our diet are rare. In the present study, we estimated the economic burden attributable to the inadequate consumption of vegetables and fruit in Canada.

Design

We accessed the Canadian Community Health Survey to assess the inadequacy in the consumption of vegetables and fruit and published meta-analyses to assemble risk estimates for chronic diseases. Based on these inadequacy and risk estimates, we calculated the population-attributable fraction and avoidable direct and indirect costs to society. Direct costs include those for hospital care, physician services and drugs in 2015.

Results

About 80 % of women and 89 % of men consume inadequate amounts of vegetables and fruit. We estimated this to result in an economic burden of $CAN 3·3 billion per year, of which 30·5 % is direct health-care costs and 69·5 % is indirect costs due to productivity losses. A modest 1 percentage point annual reduction in the prevalence of inadequate vegetables and fruit consumption over the next 20 years would avoid approximately $CAN 10·8 billion, and an increase of one serving of vegetables and fruit per day would avoid approximately $CAN 9·2 billion.

Conclusions

Further investments in the promotion of vegetables and fruit will prevent chronic disease and substantially reduce direct and indirect health-care costs.

Modifiable risk factors for the prevention of bladder cancer: a systematic review of meta-analyses

Each year, 430,000 people are diagnosed with bladder cancer. Due to the high recurrence rate of the disease, primary prevention is paramount. Therefore, we reviewed all meta-analyses on modifiable risk factors of primary bladder cancer. PubMed, Embase and Cochrane database were systematically searched for meta-analyses on modifiable risk factors published between 1995 and 2015. When appropriate, meta-analyses (MA) were combined in meta-meta-analysis (MMA). If not, the most comprehensive MA was selected based on the number of primary studies included. Probability of causation was calculated for individual factors and a subset of lifestyle factors combined. Of 1496 articles identified, 5 were combined in MMA and 21 were most comprehensive on a single risk factor. Statistically significant associations were found for current (RR 3.14) or former (RR 1.83) cigarette smoking, pipe (RR 1.9) or cigar (RR 2.3) smoking, antioxidant supplementation (RR 1.52), obesity (RR 1.10), higher physical activity levels (RR 0.86), higher body levels of selenium (RR 0.61) and vitamin D (RR 0.75), and higher intakes of: processed meat (RR 1.22), vitamin A (RR 0.82), vitamin E (RR 0.82), folate (RR 0.84), fruit (RR 0.77), vegetables (RR 0.83), citrus fruit (RR 0.85), and cruciferous vegetables (RR 0.84). Finally, three occupations with the highest risk were tobacco workers (RR 1.72), dye workers (RR 1.58), and chimney sweeps (RR 1.53). The probability of causation for individual factors ranged from 4 to 68 %. The combined probability of causation was 81.8 %. Modification of lifestyle and occupational exposures can considerably reduce the bladder cancer burden. While smoking remains one of the key risk factors, also several diet-related and occupational factors are very relevant.

Dietary factors associated with bladder cancer

It is biologically plausible for dietary factors to influence bladder cancer risk considering that beneficial as well as harmful components of a diet are excreted through the urinary tract and in direct contact with the epithelium of the bladder. However, studies that investigated the association between dietary factors and bladder cancer (BC) risk have largely reported inconsistent results. The macronutrient intake and risk of BC could have yield inconsistent results across studies because of lack of details on the type, source and the quantities of different dietary fatty acids consumed. There is evidence to suggest that consumption of processed meat may increase BC risk. Dietary carbohydrate intake does not appear to be directly associated with BC risk. Even though a large number of studies have investigated the association between fruit/vegetable consumption/micronutrients in those and BC risk, they have yielded inconsistent results. Gender-specific subgroup analysis, details of how fruits and vegetables are consumed (raw vs. cooked), adequate control for smoking status/aggressiveness of the cancer and consideration of genetic make-up may clarify these inconsistent results. There is no strong evidence to suggest that supplementation with any common micronutrient is effective in reducing BC risk. These limitations in published research however do not totally eclipse the observation that a diet rich in fruits and vegetables and low in processed meat along with especially smoking cessation may convey some protective effects against BC risk.

Comparison of methods of extracting information for meta-analysis of observational studies in nutritional epidemiology

OBJECTIVES

A common method for conducting a quantitative systematic review (QSR) for observational studies related to nutritional epidemiology is the "highest versus lowest intake" method (HLM), in which only the information concerning the effect size (ES) of the highest category of a food item is collected on the basis of its lowest category. However, in the interval collapsing method (ICM), a method suggested to enable a maximum utilization of all available information, the ES information is collected by collapsing all categories into a single category. This study aimed to compare the ES and summary effect size (SES) between the HLM and ICM.

METHODS

A QSR for evaluating the citrus fruit intake and risk of pancreatic cancer and calculating the SES by using the HLM was selected. The ES and SES were estimated by performing a meta-analysis using the fixed-effect model. The directionality and statistical significance of the ES and SES were used as criteria for determining the concordance between the HLM and ICM outcomes.

RESULTS

No significant differences were observed in the directionality of SES extracted by using the HLM or ICM. The application of the ICM, which uses a broader information base, yielded more-consistent ES and SES, and narrower confidence intervals than the HLM.

CONCLUSIONS

The ICM is advantageous over the HLM owing to its higher statistical accuracy in extracting information for QSR on nutritional epidemiology. The application of the ICM should hence be recommended for future studies.

Increasing vegetable intakes: rationale and systematic review of published interventions

Purpose

While the health benefits of a high fruit and vegetable consumption are well known and considerable work has attempted to improve intakes, increasing evidence also recognises a distinction between fruit and vegetables, both in their impacts on health and in consumption patterns. Increasing work suggests health benefits from a high consumption specifically of vegetables, yet intakes remain low, and barriers to increasing intakes are prevalent making intervention difficult. A systematic review was undertaken to identify from the published literature all studies reporting an intervention to increase intakes of vegetables as a distinct food group.

Methods

Databases—PubMed, PsychInfo and Medline—were searched over all years of records until April 2015 using pre-specified terms.

Results

Our searches identified 77 studies, detailing 140 interventions, of which 133 (81 %) interventions were conducted in children. Interventions aimed to use or change hedonic factors, such as taste, liking and familiarity (n = 72), use or change environmental factors (n = 39), use or change cognitive factors (n = 19), or a combination of strategies (n = 10). Increased vegetable acceptance, selection and/or consumption were reported to some degree in 116 (83 %) interventions, but the majority of effects seem small and inconsistent.

Conclusions

Greater percent success is currently found from environmental, educational and multi-component interventions, but publication bias is likely, and long-term effects and cost-effectiveness are rarely considered. A focus on long-term benefits and sustained behaviour change is required. Certain population groups are also noticeably absent from the current list of tried interventions.

Fruits and vegetables intake and risk of bladder cancer: a PRISMA-compliant systematic review and dose-response meta-analysis of prospective cohort studies

Clinical practice recommends eating ≥2.5 cups of fruits and vegetables (FVs) each day for cancer prevention, in which the evidence from epidemiological studies for the association between FVs intake and bladder cancer (BC) prevention is inconsistent.We searched the PubMed, Embase, and Willy online Library for relevant studies published up to September 27, 2014. Prospective cohort studies investigated FVs intake, and the risk of BC with ≥3 categories of exposure was included. A dose-response meta-analysis was carried out to evaluate the association between FVs intake and risk of BC.Fourteen cohorts with 17 studies including 9447 cases were identified. No evidence of nonlinear association was examined between FVs intake and risk of BC. The summarized relevant risk (RR) of every 0.2 serving increment a day was 1.00 (95%CI: 0.99, 1.00; P = 0.17; I = 41.7%; n = 14) for total fruits; 0.99 (95%CI: 0.96, 1.01; P = 0.28; I = 37.0%; n = 13) for total vegetables; and 0.99 (95%CI: 0.97, 1.01; P = 0.24; I = 57.5%; n = 8) for both FVs. In further analysis, we observed inverse association between every 0.2 serving increment of green leafy vegetables intake a day and risk of BC (RR = 0.98, 95%CI: 0.96, 0.99; I = 0.0%; P < 0.01; Power = 0.76; n = 6), but neither for cruciferous vegetables (RR = 0.97, 95%CI: 0.93, 1.01; P = 0.19; I = 55.8%; n = 8) nor for citrus (RR = 1.00, 95%CI: 1.00, 1.00; P = 0.83; I = 0.0%; n = 7). Subgroup analysis showed consistent results.Little evidence supports a beneficial effect for total fruits, vegetables, both FVs, and citrus intake against bladder cancer. Green leafy vegetables may help prevent bladder cancer.