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PAPER Obesity and Overweight in Relation to Organ-Specific Cancer Mortality in London (UK): Findings from the Original Whitehall Study

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PAPER Obesity and Overweight in Relation to Organ-Specific Cancer Mortality in London (UK): Findings from the Original Whitehall Study International Journal of Obesity (2005) 29, 1267–1274 & 2005 Nature Publishing Group All rights reserved 0307-0565/05 $30.00 www.nature.com/ijo PAPER Obesity and overweight in relation to organ-specific cancer mortality in London (UK): findings from the original Whitehall study GD Batty1,2*, MJ Shipley3, RJ Jarrett4, E Breeze3, MG Marmot3 and G Davey Smith5 1MRC Social and Public Health Sciences Unit, University of Glasgow, 4 Lilybank Gardens, Glasgow, UK; 2Department of Psychology, University of Edinburgh, UK; 3Department of Epidemiology and Public Health, University College London, London, UK; 4Bishopsthorpe Road, London, UK; and 5Department of Social Medicine, University of Bristol, Bristol, UK OBJECTIVE: To examine the relation of obesity and overweight with organ-specific cancer mortality. METHODS: In the Whitehall prospective cohort study of London-based government employees, 18 403 middle-age men participated in a medical examination between 1967 and 1970. Subjects were followed up for cause-specific mortality for up to 35 y (median: interquartile range (25th–75th centile); 28.1 y: 18.6–33.8). RESULTS: There were over 3000 cancer deaths in this cohort. There was a raised risk of mortality from carcinoma of the rectum, bladder, colon, and liver, and for lymphoma in obese or overweight men following adjustment for range of covariates, which included socioeconomic position and physical activity. These relationships held after exclusion of deaths occurring in the first 20 y of follow-up. CONCLUSION: Avoidance of obesity and overweight in adult life may reduce the risk of developing some cancers. International Journal of Obesity (2005) 29, 1267–1274. doi:10.1038/sj.ijo.0803020; published online 28 June 2005 Keywords: overweight; cancer; Whitehall; cohort study Introduction women), endometrium, kidney, colon (strongest in men), Although elevated rates of cancer mortality in individuals oesophagus and pancreas.3,4 However, studies examining the with higher body weight were first documented almost a influence of obesity and overweight on other malignan- century ago,1 most attention has focused on the role of ciesFprostate, liver, stomach, bladder, lymphoma and obesity in the aetiology of coronary heart disease (CHD). In leukaemiaFreveal inconclusive findings.3–5 These discre- large-scale prospective studies, findings are generally con- pant results may be explained by variability in definition of sistent: a positive association is apparent such that obese and obesity and overweight across reports, so complicating overweight persons, as indexed by their body mass index comparison; and a failure to adjust for important covariates, (BMI), experience a higher risk of CHD than their leaner such as socioeconomic position6 and physical activity.7 counterparts.2 This relation may be largely ascribed to Additionally, in cohort studies, the presence of subclinical mediation via the established CHD risk indicators of blood malignancy at baseline may lead to low body weight. It is pressure, blood lipids and glucose tolerance.2 likely, therefore, that the positive obesity/overweight–cancer In the last two decades, the cohort studies on which these gradient seen for some sites would, in fact, be steeper if observations are based have matured, so accumulating deaths occurring in the early years of follow-up were sufficient events to allow investigators to examine the link excluded from analyses. However, the few extant prospective between obesity and some organ-specific cancers. There is a cohort studies have a sufficiently high number of cancer consensus that obesity and overweight are associated with cases with which to examine this issue of reverse causality. an increased risk of cancer of the breast (in postmenopausal In the Whitehall study, over 18 000 middle-aged London- based government employees participated in a medical examinationinthelate1960s,whichincludedanassessment *Correspondence: Dr GD Batty, MRC Social and Public Health Sciences of their BMI and a range of covariate data.8 In an extended Unit, University of Glasgow, 4 Lilybank Gardens, Glasgow G12 8RZE, UK. (maximum 35 y) mortality surveillance of this cohort, there E-mail: [email protected] Received 4 August 2004; revised 7 January 2005; accepted 16 March 2005; have been over 3000 cancer deaths, enabling us to address published online 28 June 2005 these issues of data scarcity and methodological shortcomings. Obesity, overweight and cancer GD Batty et al 1268 In earlier (r15y)follow-upsofthiscohort,raisedrisksoftotal 140–208; ICD9: 140–209; ICD10: C00–C97)Freferred to as mortality,9,10 cardiovascular disease9,11 and total cancers9 were ‘all-cancers’Fwas divided into individual organs. These reported in overweight and obese groups. In this most recent were: oesophagus (ICD8/9: 150; ICD10: C15); stomach follow-up we examine, for the first time, the link between (ICD8/9: 151; ICD10: C16); colon (ICD8/9: 153; ICD10: obesity and a range of organ-specific malignancies. C18); rectum (ICD8/9: 154; ICD10: C19); liver (ICD8/9: 155– 156; ICD10: C22-C24); pancreas (ICD8/9: 157; ICD10: C25); trachea, bronchus and lung (ICD8/9: 162; ICD10: C33–C34; Materials and methods referred to as ‘lung cancer’); prostate (ICD8/9: 185; ICD10: In the Whitehall study, data were collected on 18 403 non- C61); bladder (ICD8/9: 188; ICD10: C67); kidney (ICD8/9: industrial London-based male government employees aged 189; ICD10: C64–C66, C68); brain (ICD8/9: 191; ICD10: from 40 to 64 y when examined between September 1967 C71); lymphoma (ICD8/9: 200–203; ICD10: C81–C90); and and January 1970, representing a 74% response. This leukaemia (ICD8: 204–207; ICD9: 204–208; ICD 10: C91– involved the completion of a study questionnaire and C95). participation in a medical examination, both of which have been described in detail elsewhere.8 In brief, the question- naire included enquiries regarding civil service employment Data analyses grade (an indicator of socio-economic position),12 smoking A total of 17 347 men identified in the NHSCR had data for habits,13 intermittent claudication,14 angina,15,16 chronic BMI and all potential covariates. The cause of death for 41 of bronchitis,17 marital status,18 physical activity,19 unex- these was unknown and they were excluded from all plained weight loss in the preceding year and the use of analyses. In addition, we excluded 204 men classified as drug therapy for heart problem or high blood pressure.8 underweight (see later explanation) leaving an analytical Forced expiratory volume in one second (FEV1) adjusted for sample of 17 102 men (92.9% of those recruited). In analyses height,20 ischaemia,21 fasting plasma cholesterol,22 post- of baseline characteristics according to the level of obesity challenge 2-h blood glucose,23 blood pressure,24 and triceps and overweight, the prevalence of the former was adjusted skinfold thickness8 were determined using standardised for age (5 y age groups) by the direct standardisation method. protocols. In addition, in a representative sample of the Trends in proportions were tested for statistical significance cohort, 1669 men participated in a dietary survey. This using the Mantel–Haenszel test; for continuous variables, involved the completion of a 3-day semiquantitative record least-squares means were used to present the age-adjusted of all food and drink consumed.25 means, and tests for trend across obesity, overweight and normal weight groups were computed by fitting a linear trend term. In the examination of the relation of dietary Assessment of obesity and overweight characteristics with weight in a subsample of the present Height was measured with the subject wearing shoes and cohort, the distribution of alcohol intake was highly skewed; standing with his back to a measuring rod; readings were therefore, analysis was conducted on the logarithmically 1 8 transformed data after adding 0.5 to all data points to taken to the nearest 2 in. (approximately 12.7 mm) below. Weight was recorded with the subject wearing shoes but with overcome values of zero. 1 Models fitted with a BMI by follow-up time interaction jacket removed; readings were taken to the nearest 2 lb (227 g).8 Following conversion from imperial to metric units, term confirmed that the proportional hazards assumption BMI (weight (kg) divided by height squared (m2)) was was not violated. Thus, hazard ratios and accompanying computed. To facilitate comparability of our findings with confidence intervals were computed for the relation of those from other studies,26–28 we defined underweight obesity/overweight with each mortality outcome using Cox’s 33 (o18.5 to 25.0 kg/m2), normal weight (BMI 18.5 to proportional hazards regression model with follow-up o25.0 kg/m2), overweight (25.0–29.99 kg/m2) and obesity period as the time scale. These models were initially adjusted (Z30.0 kg/m2), according to criteria advanced by the World for age and then for other potential covariates. For the Health Organisation.29 purposes of statistical adjustment, age, triceps skinfold thickness, plasma cholesterol, height-adjusted FEV1 and systolic blood pressure were fitted as continuous variables; Ascertainment of cancer mortality while unexplained weight loss in the last year (two levels), The records of 18 245 men (99.1% of subjects) were traced employment grade (5), marital status (4), blood pressure- and flagged using the procedures of the National Health lowering medication (2), blood glucose levels (3), disease at Service Central Registry (NHSCR) until 31 December 2002.
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