Annals of Oncology Advance Access originally published online on October 25, 2005
Annals of Oncology 2006 17(2):341-345; doi:10.1093/annonc/mdj051
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© 2005 European Society for Medical Oncology
Consumption of sweet foods and breast cancer risk in Italy
1 Istituto di Ricerche Farmacologiche ‘Mario Negri’, Milan, Italy; 2 Centro di Riferimento Oncologico, Aviano (Pordenone), Italy; 3 International Agency for Research on Cancer, Lyon, France; 4 Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy; 5 Istituto Tumori ‘Fondazione Pascale’, Naples, Italy; 6 Istituto di Statistica Medica e Biometria, Università degli Studi di Milano, Milan, Italy
* Correspondence to: Dr A. Tavani, Istituto di Ricerche Farmacologiche ‘Mario Negri’, Via Eritrea 62, 20157 Milan, Italy. Tel: +39-02-39014-460; Fax: +39-02-39001-916; E-mail: tavani{at}marionegri.it
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Abstract |
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Background: The relation between the intake of sugar and sweets and the risk of breast cancer has been considered in ecological, prospective and case–control studies, but the results are unclear. We analyzed such a relation in a case–control study conducted between 1991 and 1994 in Italy.
Patients and methods: Cases were 2569 women with histologically confirmed incident breast cancer and controls were 2588 women admitted to hospital for acute, non-neoplastic, non-hormone-related conditions. Information on diet was based on an interviewer-administered questionnaire tested for reproducibility and validity. The odds ratios (OR) and 95% confidence intervals (CI) were computed by multiple logistic regression equations.
Results: Compared with women with the lowest tertile of intake, women in the highest tertile of intake of desserts (including biscuits, brioches, cakes, puffs and ice-cream) and sugars (including sugar, honey, jam, marmalade and chocolate) had multivariate ORs of 1.19 (95% CI 1.02–1.39) and 1.19 (95% CI 1.02–1.38), respectively. The results were similar in strata of age, body mass index, total energy intake and other covariates.
Conclusions: We found a direct association between breast cancer risk and consumption of sweet foods with high glycemic index and load, which increase insulin and insulin growth factors.
Key words: breast cancer, case–control study, risk factors, sweets, sugar
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introduction |
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TopAbstractintroductionpatients and methodsresultsdiscussionReferences |
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The influence of sugar and sweets on the risk of breast cancer has been considered in several ecological, prospective and case–control studies, but the results are unclear. Among 20 ecological studies, 10 found a positive correlation between sugar or sweet intakes and incidence or mortality from breast cancer. The correlations were more consistent in international studies than in within-country analyses [1
].
An increased breast cancer risk with cake intake was found in a prospective study from Norway [2], whereas no relation with sweets was found in another cohort study conducted among Japanese women living in Hawaii [3]. Some case–control studies found elevated risks with sweetened beverages [4], or with intake of sweet foods [5–8], although the excess risk was generally small. In two case–control studies, one Canadian [5] and one Spanish [7], elevated risks were found for the highest intake of sweets (odds ratio, OR, 1.5 and 2.3, respectively). In a French case–control study, desserts and chocolate were directly associated with breast cancer risk [6]. A population-based case–control study on American women younger than 45 years found a significant increase of breast cancer risk with sweet items (OR 1.3 for the highest intake), in the absence of a relation with several other foods, calories, macronutrients or types of fats [9]. However, other studies found no consistent relation between breast cancer risk and intake of sugar [4, 10–14], mono or disaccarides [15, 16], or sweet foods [4, 10, 17–20].
The inconsistent results of epidemiological studies may depend on chance or bias or different approaches to data analysis and interpretation, but they may also reflect heterogeneity in components of sweet foods (i.e. cereals, sugars and fats), or recipes in various populations, or different correlates of sweet food intake.
Using data from an Italian case–control study on diet and breast cancer [21], we found that sweet foods were directly associated with breast cancer risk. In order to elucidate better the issue of the relationship between sweet foods and breast cancer risk, we analyzed in detail the potential role of various types of sweets and of selected covariates in a uniquely large dataset.
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patients and methods |
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Data were derived from a case–control study of breast cancer conducted between June 1991 and April 1994 in six Italian areas: greater Milan; the province of Pordenone; the urban area of Genoa; the province of Forlì, in northern Italy; the province of Latina in central Italy; and the urban area of Naples in southern Italy [21
]. Cases were 2569 women with incident, histologically confirmed breast cancer (median age 55 years, range 23–74 years) and controls were 2588 women (median age 56 years, range 20–74 years) with no history of cancer admitted to the same hospitals for acute, non-neoplastic, non-gynaecological conditions, unrelated to hormonal or digestive tract diseases or to long-term modification of diet. Among controls 22% had traumas, 33% other orthopaedic diseases, 15% acute surgical condition, 18% eye diseases and 12% other miscellaneous diseases. On average, less than 4% of cases and controls who were approached for interview refused to participate.
Centrally trained interviewers conducted interviews in hospital for both cases and controls using a structured questionnaire, including information on socio-demographic factors, anthropometric variables, smoking, alcohol and other lifestyle habits, physical activity, a problem-oriented medical history and history of breast cancer in first-degree relatives. Information on diet referred to the previous 2 years and was based on a food frequency questionnaire, including 78 foods or food groups or complex recipes, plus questions aimed at assessing fat intake and general dietary habits. The questionnaire was tested for validity [22] and reproducibility [23]. Subjects were asked to indicate their average weekly consumption of single food items or recipes; intakes lower than once a week, but at least once per month were coded as 0.5 per week. Sweet items were grouped into two food groups: desserts and sugars. ‘Desserts’ was created using six food items of the questionnaire and included biscuits, brioches, croissants, puffs, cream cakes, cream puffs, sponge cakes, panettone, fruit or jam tarts, ice cream and cooked fruit (half portion). ‘Sugars’ was created using three food items of the questionnaire and included sugar, honey, jam, marmalade and chocolate. Desserts and sugars were categorized into approximate tertiles based on the distribution of controls. To compute energy intake, Italian food composition databases were used, appropriately checked and supplemented with other published data and information from the manufacturers [24].
ORs and 95% confidence intervals (CI) were estimated by multiple logistic regression models fitted by the method of maximum likelihood [25]. Regression equations included terms for quinquennia of age, study center, year of interview, education, body mass index (BMI), total energy intake, parity, menopausal status and family history of breast cancer in first-degree relatives.
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results |
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The distribution of 2569 cases of breast cancer and 2588 controls according to frequency of sweet food consumption is shown in Table 1. Among food items, compared with the lowest level of intake, a direct association was found for the highest level of consumption of biscuits (OR 1.19), sugar (OR 1.23) and chocolate (OR 1.19). No association was found for the other sweet food items considered. Sweet items were grouped into two groups: desserts and sugars. For dessert intake the ORs of breast cancer were 1.11 for the second and 1.19 for the third tertile, compared with the lowest tertile. For sugars, the corresponding ORs were 1.22 and 1.19. Trends in risk were significant for both desserts and sugars.
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Table 2 considers the intake of desserts and sugars across strata of age at diagnosis, body mass index (BMI), total energy, total alcohol intake, physical activity at work, parity and family history of breast cancer. No heterogeneity across any strata was found either for desserts or for sugars, all ORs being above unity in the highest level of intake.
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discussion |
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TopAbstractintroductionpatients and methodsresultsdiscussionReferences |
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In this study, sweet consumption was directly associated to breast cancer risk. The risk was consistently elevated in strata of age (also an indicator of menopausal status), BMI, total calorie intake, alcohol, physical activity and family history of breast cancer.
Our results are in agreement with some epidemiological studies that have considered the issue of sweets, including studies from the USA [9], Canada [5] and Spain [7].
We also found that women in the highest decile of consumption of cakes and desserts and refined sugars had higher breast cancer risk [26], suggesting that sweet foods are among the features of a high-risk dietary pattern. In the Swedish Mammography Screening Cohort, based on a factor analysis, sweets were also included in the definition of unfavorable Western dietary pattern [27]. Moreover, sweet foods were rich in several nutrients potentially involved in the aetiology of breast cancer, such as refined carbohydrates and saturated fats [28–33]. It is difficult to completely allow for these in the analyses, because reciprocal allowance of various foods and nutrients is hampered by problems of collinearity [34]. Alternatively, consumption of sweet foods may reduce intake of foods with favourable influence on the risk of breast cancer, such as vegetables [21], fibers [35], olive oil [36, 37], or n-3 polyunsaturated fatty acids [38]. A frequent consumption of sugars or foods with a high glycemic index may lead to insulin resistance, and a direct association between glycemic index or glycemic load and breast cancer risk has been suggested [30, 39, 40]. This may cause an increase of insulin-related growth factors (IGF), which are promoters of breast carcinogenesis [41–44]. Insulin also stimulates ovarian steroid secretion, including estrogens and androgens, which have been related to excess breast cancer risk [45, 46]. Desserts are also rich in trans-fatty acids, which have been related to unfavourable health effects [47], as well as in saturated fatty acids, which have been associated with breast cancer risk in a pooled analysis of cohort studies [31, 48].
Furthermore, the association between sweets and breast cancer risk can be related to reduced diversity of diet for favourable foods [21], or greater meal frequency [49], which again may interfere with the insulin-related pathways of breast carcinogenesis [9]. Finally, it has been shown that calorie restriction has a favourable impact on breast cancer risk [50]. Consequently, although we allowed for energy intake in the analyses, some residual excess risk due to high calorie intake in women with frequent sweet consumption is possible.
Only patients admitted to hospital for acute, non hormone-related conditions were included in the control group, whereas patients with admission diagnosis related to major changes in diet and other lifestyle factors were excluded. Among the strengths of this study, are its large size, and the satisfactory reproducibility and validity of the questionnaire [22, 23]. Furthermore, interviews were conducted in the same setting for cases and controls, cases and controls were drawn from the same catchment areas and participation rate was almost complete.
In relative terms, the excess risk associated with highest sweet consumption is moderate, but most dietary correlates in breast cancer show similar modest associations [21, 28, 31, 51]. However, if real, the excess risk for frequent sweet consumption may account for 12% of breast cancer cases in this Italian population [52, 53] and, therefore, is far from negligible on a public health level [54].
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Acknowledgements |
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The study was supported by the Italian Association for Research on Cancer (AIRC), Milan, Italy, the Italian League against Cancer, and the Italian Ministry of Education (COFIN 2003).
Received for publication June 29, 2005. Revision received September 9, 2005. Accepted for publication September 21, 2005.
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