Digital Food Frequency Questionnaire Assessing Adherence to the Norwegian Food-Based Dietary Guidelines and Other National Lifestyle Recommendations: Instrument Validation Study

BACKGROUND

Valid assessment tools are needed when investigating adherence to national dietary and lifestyle guidelines.

OBJECTIVE

The relative validity of the new digital food frequency questionnaire, the DIGIKOST-FFQ, against 7-day weighed food records and activity sensors was investigated.

METHODS

In total, 77 participants were included in the validation study and completed the DIGIKOST-FFQ and the weighed food record, and of these, 56 (73%) also used the activity sensors. The DIGIKOST-FFQ estimates the intake of foods according to the Norwegian food-based dietary guidelines (FBDGs) in addition to lifestyle factors.

RESULTS

At the group level, the DIGIKOST-FFQ showed good validity in estimating intakes according to the Norwegian FBDG. The median differences were small and well below portion sizes for all foods except "water" (median difference 230 g/day). The DIGIKOST-FFQ was able to rank individual intakes for all foods (r=0.2-0.7). However, ranking estimates of vegetable intakes should be interpreted with caution. Between 69% and 88% of the participants were classified into the same or adjacent quartile for foods and between 71% and 82% for different activity intensities. The Bland-Altman plots showed acceptable agreements between DIGIKOST-FFQ and the reference methods. The absolute amount of time in "moderate to vigorous intensity" was underestimated with the DIGIKOST-FFQ. However, estimated time in "moderate to vigorous intensity," "vigorous intensity," and "sedentary time" showed acceptable correlations and good agreement between the methods. The DIGIKOST-FFQ was able to identify adherence to the Norwegian FBDG and physical activity recommendations.

CONCLUSIONS

The DIGIKOST-FFQ gave valid estimates of dietary intakes and was able to identify individuals with different degrees of adherence to the Norwegian FBDG and physical activity recommendations. Moderate physical activity was underreported, water was overreported, and vegetables showed poor correlation, which are important to consider when interpreting the data. Good agreement was observed between the methods in estimating dietary intakes and time in "moderate to vigorous physical activity," "sedentary time," and "sleep."

Development and validation of a risk prediction model for post-polypectomy colorectal cancer in the USA: a prospective cohort study

Background

Effective risk stratification tools for post-polypectomy colorectal cancer (PPCRC) are lacking. We aimed to develop an effective risk stratification tool for the prediction of PPCRC in three large population-based cohorts and to validate the tool in a clinical cohort.

Methods

Leveraging the integrated endoscopic, histopathologic and epidemiologic data in three U.S population-based cohorts of health professional (the Nurses' Health Study (NHS) I, II and Health Professionals Follow-up Study (HPFS)), we developed a risk score to predict incident PPCRC among 26,741 patients with a polypectomy between 1986 and 2017. We validated the PPCRC score in the Mass General Brigham (MGB) Colonoscopy Cohort (Boston, Massachusetts, U.S) of 76,603 patients with a polypectomy between 2007 and 2018. In all four cohorts, we collected detailed data on patients' demographics, endoscopic history, polyp features, and lifestyle factors at polypectomy. The outcome, incidence of PPCRC, was assessed by biennial follow-up questionnaires in the NHS/HPFS cohorts, and through linkage to the Massachusetts Cancer Registry in the MGB cohort. In all four cohorts, individuals who were diagnosed with CRC or died before baseline or within six months after baseline were excluded. We used Cox regression to calculate the hazard ratio (HR), 95% confidence interval (CI) and assessed the discrimination using C-statistics and reclassification using the Net Reclassification Improvement (NRI).

Findings

During a median follow-up of 12.8 years (interquartile range (IQR): 9.3, 16.7) and 5.1 years (IQR: 2.7, 7.8) in the NHS/HPFS and MGB cohorts, we documented 220 and 241 PPCRC cases, respectively. We identified a PPCRC risk score based on 11 predictors. In the validation cohort, the PPCRC risk score showed a strong association with PPCRC risk (HR for high vs. low, 3.55, 95% CI, 2.59-4.88) and demonstrated a C-statistic (95% CI) of 0.75 (0.70-0.79), and was discriminatory even within the low- and high-risk polyp groups (C-statistic, 0.73 and 0.71, respectively) defined by the current colonoscopy surveillance recommendations, leading to a NRI of 45% (95% CI, 36-54%) for patients with PPCRC.

Interpretation

We developed and validated a risk stratification model for PPCRC that may be useful to guide tailored colonoscopy surveillance. Further work is needed to determine the optimal surveillance interval and test the added value of other predictors of PPCRC beyond those included in the current study, along with implementation studies.

Funding

US National Institutes of Health, the American Cancer Society, the South-Eastern Norway Regional Health Authority, the Deutsche Forschungsgemeinschaft.

Associations of the 2018 World Cancer Research Fund/American Institute of Cancer Research (WCRF/AICR) cancer prevention recommendations with stages of colorectal carcinogenesis

BACKGROUND

While adherence to cancer prevention recommendations is linked to lower risk of colorectal cancer (CRC), few have studied associations across the entire spectrum of colorectal carcinogenesis. Here, we studied the relationship of the standardized 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Score for cancer prevention recommendations with detection of colorectal lesions in a screening setting. As a secondary objective, we examined to what extent the recommendations were being followed in an external cohort of CRC patients.

METHODS

Adherence to the seven-point 2018 WCRF/AICR Score was measured in screening participants receiving a positive fecal immunochemical test and in CRC patients participating in an intervention study. Dietary intake, body fatness and physical activity were assessed using self-administered questionnaires. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for screen-detected lesions.

RESULTS

Of 1486 screening participants, 548 were free from adenomas, 524 had non-advanced adenomas, 349 had advanced lesions and 65 had CRC. Adherence to the 2018 WCRF/AICR Score was inversely associated with advanced lesions; OR 0.82 (95% CI 0.71, 0.94) per score point, but not with CRC. Of the seven individual components included in the score, alcohol, and BMI seemed to be the most influential. Of the 430 CRC patients included in the external cohort, the greatest potential for lifestyle improvement was seen for the recommendations concerning alcohol and red and processed meat, where 10% and 2% fully adhered, respectively.

CONCLUSIONS

Adherence to the 2018 WCRF/AICR Score was associated with lower probability of screen-detected advanced precancerous lesions, but not CRC. Although some components of the score seemed to be more influential than others (i.e., alcohol and BMI), taking a holistic approach to cancer prevention is likely the best way to prevent the occurrence of precancerous colorectal lesions.

Endoscopic Screening and Risk of Colorectal Cancer according to Type 2 Diabetes Status

Current recommendations for colorectal cancer screening have not accounted for type 2 diabetes (T2D) status. It remains unknown whether the colorectal cancer-preventive benefit of endoscopic screening and the recommended age for screening initiation differ by T2D. Among 166,307 women (Nurses' Health Study I and II, 1988-2017) and 42,875 men (Health Professionals Follow-up Study, 1988-2016), endoscopic screening and T2D diagnosis were biennially updated. We calculated endoscopic screening-associated hazard ratios (HR) and absolute risk reductions (ARR) for colorectal cancer incidence and mortality according to T2D, and age-specific colorectal cancer incidence according to T2D. During a median of 26 years of follow-up, we documented 3,457 colorectal cancer cases and 1,129 colorectal cancer deaths. Endoscopic screening was associated with a similar HR of colorectal cancer incidence in the T2D and non-T2D groups (P-multiplicative interaction = 0.57). In contrast, the endoscopic screening-associated ARR for colorectal cancer incidence was higher in the T2D group (2.36%; 95% CI, 1.55%-3.13%) than in the non-T2D group (1.73%; 95% CI, 1.29%-2.16%; P-additive interaction = 0.01). Individuals without T2D attained a 10-year cumulative risk of 0.35% at the benchmark age of 45 years, whereas those with T2D reached this threshold risk level at the age of 36 years. Similar results were observed for colorectal cancer mortality. In conclusion, the absolute benefit of endoscopic screening for colorectal cancer prevention may be substantially higher for individuals with T2D compared with those without T2D. Although T2D is comparatively rare prior to the fifth decade of life, the rising incidence of young-onset T2D and heightened colorectal cancer risk associated with T2D support the consideration of earlier endoscopic screening in individuals with T2D.

PREVENTION RELEVANCE

The endoscopic screening-associated ARRs for colorectal cancer incidence and mortality were higher for individuals with T2D than those without T2D. Endoscopic screening confers a greater benefit for colorectal cancer prevention among T2D individuals, who may also benefit from an earlier screening than the current recommendation.

Abstract PR002: Development and validation of a risk prediction model for post-polypectomy colorectal cancer in 4 prospective US cohorts

Background: Individuals with polypectomy are still at higher risk of developing colorectal cancer than general population and are thus recommended to undergo colonoscopy surveillance for timely detection and prevention of subsequent colorectal cancer. The current clinical guidelines regarding the interval of surveillance are based on weak evidence. There is substantial overuse of surveillance colonoscopy in low-risk individuals and underuse in high-risk individuals. Effective risk stratification tools for post-polypectomy colorectal cancer (PPCRC) are lacking. Methods: Leveraging the integrated endoscopic, histopathologic and epidemiologic data in 3 population-based cohorts (Nurses’ Health Study (NHS) I, II and Health Professionals Follow-up Study (HPFS)), we developed a risk score to predict incident PPCRC among 26,744 patients with a polypectomy between 1986 and 2017. We validated the risk score in the Mass General Brigham (MGB) colonoscopy cohort of 76,603 individuals with a polypectomy between 2005 and 2017. In the MGB cohort, we used the validated natural language processing algorithms to extract detailed histopathologic data and merged them with the endoscopic and other clinical data from the electronic health record systems. The detailed protocol for the cohort development has been published (PMID: 33590405). We used Cox regression to calculate the hazard ratios (HRs) and assessed the discrimination using C-statistics and reclassification using the Net Reclassification Improvement (NRI). Results: During a median follow-up of 12.8 (IQR: 9.3, 16.7) and 5.1 (IQR: 2.7, 7.8) years in the NHS I, II/HPFS and MGB colonoscopy cohorts, we documented 220 and 241 PPCRC cases, respectively. We identified a PPCRC risk score based on 11 predictors. In the validation cohort, the risk score showed a strong association with higher risk of PPCRC (HR for high vs. low, 3.55, 95% CI, 2.59-4.88) and demonstrated a C-statistic (95% CI) of 0.75 (0.70-0.79), and was discriminatory even within the low- and high-risk polyp groups of patients (C-statistic, 0.73 and 0.71, respectively) defined by the current colonoscopy surveillance guidelines, leading to a NRI of 45% for PPCRC patients. Conclusion: We developed and validated a risk stratification model for PPCRC that can be used to guide tailored colonoscopy surveillance.

Citation Format: Markus Dines Knudsen, Liang Wang, Kai Wang, Georgios Polychronidis, Paula Berstad, Kana Wu, Xiaosheng He, Dong Hang, Zhe Fang, Shuji Ogino, Andrew T. Chan, Edward L. Giovannucci, Molin Wang, Mingyang Song. Development and validation of a risk prediction model for post-polypectomy colorectal cancer in 4 prospective US cohorts [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer; 2022 Oct 1-4; Portland, OR. Philadelphia (PA): AACR; Cancer Res 2022;82(23 Suppl_1):Abstract nr PR002.

A Short Digital Food Frequency Questionnaire (DIGIKOST-FFQ) Assessing Dietary Intake and Other Lifestyle Factors Among Norwegians: Qualitative Evaluation With Focus Group Interviews and Usability Testing

Background

In-person dietary counseling and interventions have shown promising results in changing habits toward healthier lifestyles, but they are costly to implement in large populations. Developing digital tools to assess individual dietary intake and lifestyle with integrated personalized feedback systems may help overcome this challenge. We developed a short digital food frequency questionnaire, known as the DIGIKOST-FFQ, to assess diet and other lifestyle factors based on the Norwegian Food-Based Dietary Guidelines. The DIGIKOST-FFQ includes a personalized feedback system, the DIGIKOST report, that benchmarks diet and lifestyle habits. We used qualitative focus group interviews and usability tests to test the feasibility and usability of the DIGIKOST application.

Objective

We aimed to explore attitudes, perceptions, and challenges in completing the DIGIKOST-FFQ. We also investigated perceptions and understanding of the personalized feedback in the DIGIKOST report and the technical flow and usability of the DIGIKOST-FFQ and the DIGIKOST report.

Methods

Healthy individuals and cancer survivors were invited to participate in the focus group interviews. The transcripts were analyzed using thematic analysis. Another group of healthy individuals completed the usability testing, which was administered individually by a moderator and 2 observers. The results were analyzed based on predefined assignments and discussion with the participants about the interpretation of the DIGIKOST report and technical flow of the DIGIKOST-FFQ.

Results

A total of 20 individuals participated in the focus group interviews, divided into 3 groups of healthy individuals and 3 groups of cancer survivors. Each group consisted of 3 to 4 individuals. Five main themes were investigated: (1) completion time (on average 19.1, SD 8.3, minutes, an acceptable duration), (2) layout (participants reported the DIGIKOST-FFQ was easy to navigate and had clear questions but presented challenges in reporting dietary intake, sedentary time, and physical activity in the last year), (3) questions (the introductory questions on habitual intake worked well), (4) pictures (the pictures were very helpful, but some portion sizes were difficult to differentiate and adding weight in grams would have been helpful), and (5) motivation (users were motivated to obtain personalized feedback). Four individuals participated in the usability testing. The results showed that the users could seamlessly log in, give consent, fill in the DIGIKOST-FFQ, and receive, print, and read the DIGIKOST report. However, parts of the report were perceived as difficult to interpret.

Conclusions

The DIGIKOST-FFQ was overall well received by participants, who found it feasible to use; however, some adjustments with regard to reporting dietary intake and lifestyle habits were suggested. The DIGIKOST report with personalized feedback was the main motivation to complete the questionnaire. The results from the usability testing revealed a need for adjustments and updates to make the report easier to read.

Changes in Lifestyle Factors After Endoscopic Screening: A Prospective Study in the United States

BACKGROUND

Endoscopic screening and adherence to a healthy lifestyle are major avenues for colorectal cancer (CRC) prevention. We investigated changes in lifestyles after endoscopic screening.

METHODS

We drew data from 76,303 pairs of time- and age-matched individuals who had and had not, respectively, reported first time endoscopic screening, in the 3 cohorts (Nurses' Health Study I and II and the Health Professionals Follow-up Study). Detailed information was collected every 2-4 years on endoscopy screening, 12 lifestyle factors (including smoking, physical activity, regular use of aspirin/nonsteroidal anti-inflammatory drugs, body weight, and 8 dietary factors), and adherence to a healthy lifestyle based on a score defined by 5 major lifestyle factors (smoking, alcohol, body weight, physical activity, and diet). We assessed changes in lifestyle from pre- to post-screening periods for the matched pairs. We also conducted subgroup analysis according to screening findings (negative, low- and high-risk polyps, and CRC).

RESULTS

Endoscopic screening was associated with higher prevalence of adherence to a healthy lifestyle (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04-1.16). The association strengthened with the severity of the screening findings, with an OR of 1.09 (95% CI, 1.03-1.15) for negative screening, 1.19 (95% CI, 1.07-1.33) for low-risk polyps, 1.42 (95% CI, 1.14-1.77) for high-risk polyps, and 1.55 (95% CI, 1.17-2.05) for CRC. The individual lifestyle factors and diet showed modest change.

CONCLUSIONS

Endoscopic screening was associated with a modest improvement in healthy lifestyles, particularly in individuals with more severe endoscopic findings. Further efforts of integrating lifestyle medicine into the screening setting are needed, to better leverage the teachable moment in improving CRC prevention.

Lifestyle predictors for inconsistent participation to fecal based colorectal cancer screening

BACKGROUND

Consistent participation in colorectal cancer (CRC) screening with repeated fecal immunochemical test (FIT) is important for the success of the screening program. We investigated whether lifestyle risk factors for CRC were related to inconsistent participation in up to four rounds of FIT-screening.

METHOD

We included data from 3,051 individuals who participated in up to four FIT-screening rounds and returned a lifestyle questionnaire. Using logistic regression analyses, we estimated associations between smoking habits, body mass index (BMI), physical activity, alcohol consumption, diet and a healthy lifestyle score (from least favorable 0 to most favorable 5), and inconsistent participation (i.e. not participating in all rounds of eligible FIT screening invitations).

RESULTS

Altogether 721 (24%) individuals were categorized as inconsistent participants Current smoking and BMI ≥30 kg/m² were associated with inconsistent participation; odds ratios (ORs) and 95% confidence intervals (CIs) were 1.54 (1.21-2.95) and 1.54 (1.20-1.97), respectively. A significant trend towards inconsistent participation by a lower healthy lifestyle score was observed (p < 0.05).

CONCLUSIONS

Lifestyle behaviors were associated with inconsistent participation in FIT-screening. Initiatives aimed at increasing participation rates among those with the unhealthiest lifestyle have a potential to improve the efficiency of screening.

Public Awareness and Perceptions of Colorectal Cancer Prevention: a Cross-Sectional Survey

We aimed to investigate awareness of colorectal cancer (CRC) lifestyle risk factors, willingness to participate in CRC screening, and preferences concerning channels for information on CRC prevention in the general population, including the target age of the upcoming Norwegian national CRC screening program. The present study was a cross-sectional online survey of adults aged 39 to 55 years registered as Kantar Web Panel respondents in Norway. The survey included demographic characteristics, multiple choice knowledge questions of lifestyle risk factors for CRC, attitudes towards CRC screening, and preferred channels for receiving information on CRC prevention. Of 4375 participants invited, 2007 (46%) answered the survey. The average number of correctly identified lifestyle risk factors for CRC was 7.3 of ten. Women were significantly more likely than men, and those with university or college education more likely than those with lower education to correctly identify at least eight risk factors (odds ratio, OR = 1.53, 95% confidence interval, CI 1.25-1.87, and OR = 1.51, 95% CI 1.23-1.86, respectively). The number of correctly identified risk factors was positively associated with willingness to participate in CRC screening (P for trend < 0.001). The national public work force and the Norwegian Cancer Society were selected by 76% and 69% of the participants, respectively, to be trustworthy sources of information on CRC prevention. Awareness of CRC risk factors was associated with willingness to participate in CRC screening. The national public work force and Cancer Society can be generally accepted sources of CRC preventive information.

Improving Cancer Preventive Behaviors: A Randomized Trial of Tailored Lifestyle Feedback in Colorectal Cancer Screening

BACKGROUND

Cancer screening provides an opportunity to increase awareness of cancer-preventive lifestyle behaviors such as nonsmoking, physical activity, low alcohol consumption, and a healthy diet. We tested the effect of standardized, individually tailored written feedback (TF), and a standard leaflet (SL) on 1-year lifestyle behaviors in a colorectal cancer screening setting.

METHODS

A total of 3,642 men and women aged 50-74 years invited to sigmoidoscopy screening were randomly assigned to: (i) TF; (ii) SL for cancer-preventive lifestyle behaviors; or (iii) control. Participants were mailed two self-reported lifestyle questionnaires (LSQ) 1 year apart. The TF intervention was based on the prescreening LSQ answers. We analyzed differences [with 95% confidence intervals (CI)] by comparing prescreening to 1-year follow-up of single cancer-preventive factors and the number of cancer-preventive lifestyle behaviors (range 0-4) between the groups by multivariable logistic regression and analysis of covariance (ANCOVA).

RESULTS

A total of 1,054 screening participants without neoplastic findings (29% of those invited to screening) were included in this study. Participants in the TF group increased their number of cancer-preventive lifestyle behaviors significantly compared with those in the control group by 0.11 (95% CI, 0.02 to 0.19). Overweight/obese individuals in the TF group had a -0.84 kg (95% CI, -1.47 to -0.22) larger reduction in body weight compared with the control group.

CONCLUSIONS

TF at sigmoidoscopy screening led to small improvements in cancer-preventive behaviors.

IMPACT

Colorectal cancer screening is a suitable setting for increasing awareness of cancer-preventive behavior.

Lifestyle predictors for non-participation and outcome in the second round of faecal immunochemical test in colorectal cancer screening

BACKGROUND

To reduce colorectal cancer (CRC) mortality through population-based screening programmes using faecal tests, it is important that individuals continue to participate in the repeated rounds of screening. We aimed to identify lifestyle predictors for discontinuation of faecal immunochemical test (FIT) screening after the first round, as well as lifestyle predictors for colorectal neoplasia detected in the second-round FIT screening.

METHODS

In this longitudinal study, we invited 6959 individuals aged 50-74 years from south-east Norway for a first round of FIT screening and to complete a self-reported lifestyle questionnaire on demographic factors, body mass index (BMI, kg m-2), smoking habits, physical activity, consumption of alcohol and dietary items. Two years later, we estimated the associations between these factors, non-participation and screening results in the second round of FIT screening using adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Of the 3114 responders to the questionnaire who completed the first-round FIT and who were invited to participate in second-round FIT screening, 540 (17%) did not participate. The OR and (95% CI) for discontinuation of FIT screening after the first round was 1.61 (1.24-2.10) for current smoking compared with non-smoking; 2.01 (1.25-3.24) for BMI⩾35 kg m-2 compared with BMI 16.9-24.9 kg m-2 and 0.70 (0.52-0.94) for physical activity in the third quartile vs the first. Among participants, smoking, high BMI and high alcohol consumption were associated with an increased odds of detecting colorectal neoplasia (n=107).

CONCLUSIONS

These results may indicate that Norwegian FIT screening participants who discontinue after the first round have lifestyle behaviours associated with increased risk of CRC.

Correlates of irregular family meal patterns among 11-year-old children from the Pro Children study

Background: The importance of family meals to the consumption of healthful food choices has been stated in recent reviews. However, little information is available on barriers that interfere with regular family meal patterns during childhood.

Objective: Describe family meal patterns among 11-year-old children across Europe and identify correlates of irregular family breakfast and dinner consumption.

Design: Cross-sectional survey involving samples of 13,305 children from nine European countries in 2003.

Results: The proportions of children who regularly ate family breakfast and dinner were 62% and 90%, respectively. Correlates of irregular family breakfasts and dinners were less vegetable consumption, and irregular family breakfasts were associated with more television viewing. Social differences in the consumption of family breakfasts were observed.

Discussion: Strengths of this study are the large sample size and validated research method. Limitations are the cross-sectional design and self-reported data.

Conclusion: The majority of 11-year-old children regularly ate breakfast and dinner with their families. Less vegetable consumption and more television viewing were associated with irregular family breakfasts and dinners, respectively. Social differences were observed in the regularity of family breakfasts. Promoting family meals across social class may lead to healthier eating and activity habits, sustainable at the population Level.

Self-reported whole-grain intake and plasma alkylresorcinol concentrations in combination in relation to the incidence of colorectal cancer

Self-reported food frequency questionnaires (FFQs) have occasionally been used to investigate the association between whole-grain intake and the incidence of colorectal cancer, but the results from those studies have been inconsistent. We investigated this association using intakes of whole grains and whole-grain products measured via FFQs and plasma alkylresorcinol concentrations, a biomarker of whole-grain wheat and rye intake, both separately and in combination (Howe's score with ranks). We conducted a nested case-control study in a cohort from a research project on Nordic health and whole-grain consumption (HELGA, 1992-1998). Incidence rate ratios and 95% confidence intervals were calculated using conditional logistic regression. Plasma alkylresorcinol concentrations alone and Howe's score with ranks were inversely associated with the incidence of distal colon cancer when the highest quartile was compared with the lowest (for alkylresorcinol concentrations, incidence rate ratio = 0.34, 95% confidence interval: 0.13, 0.92; for Howe's score with ranks, incidence rate ratio = 0.35, 95% confidence interval: 0.15, 0.86). No association was observed between whole-grain intake and any colorectal cancer (colon, proximal, distal or rectum cancer) when using an FFQ as the measure/exposure variable for whole-grain intake. The results suggest that assessing whole-grain intake using a combination of FFQs and biomarkers slightly increases the precision in estimating the risk of colon or rectal cancer by reducing the impact of misclassification, thereby increasing the statistical power of the study.