An EPIC undertaking

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An EPIC undertaking Lessons for vegetarians and
vegans from the EPIC-Oxford study Paul
Appleby September 2008
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• The European Prospective Investigation into
  Cancer and Nutrition (EPIC)
• Largest ever cohort study of diet and health
• 520,000 participants in 10 European countries
• Coordinated at the International Agency for
  Cancer Research (IARC, part of WHO)
• Investigating the relationships between diet,
  lifestyle and environmental factors and the
  incidence of cancer and other chronic diseases

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EPIC 520,000 men and women in 10 countries
Tromsø Umeå Malmö Aarhus Copenhagen Oxf
ord Cambridge Potsdam Heidelberg Utrecht Bi
lthoven Paris (nationwide) Turin Milan Flo
rence Naples Ragusa Oviedo San
Sebastian Pamplona Murcia Granada Athens
(nationwide)
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• EPIC-Oxford
• Recruitment 1993-1999 throughout the UK
• Aim to recruit as many vegetarians as possible
  through GPs for the general public, by post for
  vegetarians
• Participants
• 65,500 diet group, basic characteristics
• 57,500 lifestyle and food frequency questionnaire
  (FFQ)
• 31,000 first 7-day food diary (1993-99)
• 19,200 blood sample (1993-98)
• 38,000 first follow-up questionnaire (2000-03)
• 31,600 second follow-up questionnaire (2007-08)
• 14,000 second 7-day food diary (2007-08)

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Diet groups For many analyses EPIC-Oxford
participants have been divided into one of 4 diet
groups. Group Men Women Total Meat eaters
7,800 26,100 33,900 (52) Fish eaters 1,700
8,400 10,100 (15) Vegetarians
4,200 14,700 18,900 (29) Vegans 900
1,700 2,600 ( 4) Total 14,600 50,900 65,500
(Numbers rounded to the nearest 100)
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• Main findings from EPIC-Oxford to date
• lifestyle characteristics and nutrient intakes
• diet and body mass index / weight gain
• hypertension and blood pressure
• hormones and diet
• diet and fracture risk
• diet and cancer incidence
• diet and mortality
• miscellaneous

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Selected lifestyle characteristics Women Characte
ristic Meat Fish Veg Vegan Median
age 48 39 35 32 Current smoker
() 11 8 8 10 University degree
() 35 47 44 45 Married () 71 63 61 51 Men Cha
racteristic Meat Fish Veg Vegan Median
age 51 42 39 35 Current smoker
() 10 10 9 8 University degree
() 50 61 55 49 Married () 77 69 66 50
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Mean daily nutrient intakes for
women Nutrient Meat Fish Veg Vgn DRV Energy
(MJ) 8.02 7.75 7.60 6.97 8.10 Carbohydrate (
E) 48.3 51.2 52.9 56.1 47 Protein (
E) 17.3 14.9 13.8 13.5 14.7 Total fat (
E) 31.5 30.7 30.4 27.8 33 Saturated fat (
E) 10.4 9.3 9.3 5.1 10 PUFA ( E)
5.2 5.4 5.3 7.2 6 Dietary fibre (g
NSP) 18.9 21.6 21.8 26.4 18 Folate
(µg) 321 346 350 412 200 Vitamin B12
(µg) 7.0 4.9 2.5 0.5 1.5 Calcium
(mg) 989 1021 1012 582 700 Iron
(mg) 12.6 12.8 12.6 14.1 14.8
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Mean daily nutrient intakes for
men Nutrient Meat Fish Veg Vgn DRV Energy
(MJ) 9.18 8.90 8.78 8.01 10.6 Carbohydrate (
E) 46.9 49.8 51.2 54.9 47 Protein (
E) 16.0 13.9 13.1 12.9 14.7 Total fat (
E) 31.9 31.1 31.1 28.2 33 Saturated fat (
E) 10.7 9.4 9.4 5.0 10 PUFA ( E)
5.2 5.6 5.7 7.5 6 Dietary fibre (g
NSP) 18.7 22.1 22.7 27.7 18 Folate
(µg) 329 358 367 431 200 Vitamin B12
(µg) 7.3 5.0 2.6 0.4 1.5 Calcium
(mg) 1057 1081 1087 610 700 Iron
(mg) 13.4 14.0 13.9 15.3 8.7
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Men
Women
Davey et al, Public Health Nutrition 2003 6
259-268
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Mean annual weight gain (grams) during 5 years of
follow-up by diet group
Diet group Men Women Meat eater 406 423 Fish
eater 377 338 Vegetarian 386 392 Vegan 284
303 Reverted1 468 433 Converted2 242
301 Means are adjusted for age at
recruitment, smoking, physical activity, marital
status, current paid job, age left school, and
age at menarche in women. / denotes
significantly lower mean weight gain compared
with meat eaters at the Plt0.05 / Plt0.001
significance level. 1 denotes subjects who
changed their diet to include more animal foods
during follow-up. 2 denotes subjects who changed
their diet to include fewer animal foods during
follow-up.
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Prevalence of self-reported hypertension by diet
group Women ( with self-reported
hypertension) Adjusted for Meat Fish Veg Vegan P
Age alone 12.1 9.6 8.9 7.7 lt0.001 Age
BMI 10.6 9.7 8.7 8.3 0.07 Men ( with
self-reported hypertension) Adjusted
for Meat Fish Veg Vegan P Age alone 15.0 9.8 9.8
5.8 lt0.001 Age BMI 12.9 9.3 9.5 6.1 0.01
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Mean systolic blood pressure by diet
group Women Adjusted for Meat Fish Veg Vegan P A
ge alone 120.1 119.0 120.0 117.6 lt0.005 Age
BMI 119.7 119.4 120.2 118.4 0.08 everything 1
19.4 119.4 120.3 119.5 0.21 Men Adjusted
for Meat Fish Veg Vegan P Age alone 126.6 125.3
125.5 122.4 lt0.005 Age BMI 126.0 125.4 125.8 1
23.5 0.18 everything 125.0 125.7 126.2 125.2
0.66 - age, BMI, non-dietary factors, nutrient
intakes
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Self-reported fracture risk by diet group in
EPIC-Oxford
Diet group IRR (95 CI)1 IRR (95 CI)2 Meat
eaters 1.00 (reference) 1.00 (reference) Fish
eaters 1.01 (0.88-1.17) 1.05 (0.90-1.21) Vegetari
ans 1.00 (0.89-1.13) 1.02 (0.90-1.15) Vegans 1.3
0 (1.02-1.66) 1.00 (0.69-1.44) 1 Fracture
incidence rate ratio compared with meat eaters
among all participants, adjusted for age, sex and
various non-dietary factors 2 As above, but
restricted to participants consuming at least 525
mg/day calcium
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Cancer in vegetarians incidence rate ratios for
vegetarians compared to non-vegetarians
All results adjusted for age, sex, smoking and
study, as applicable Key at al Am J Clin Nutr
1999, and unpublished 2008.
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EPIC-Oxford standardized mortality ratios as
percentages, compared to UK national rates, among
all participants aged below 90 with known diet
group
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Mortality in EPIC-Oxford deaths before age 90
among participants with no prior IHD, stroke or
cancer
Adjusted for age, sex and smoking
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• Miscellaneous findings
• higher frequency of bowel movements among
  vegetarians and vegans
• compared with people who become vegetarian when
  adult, life-long vegetarians do not differ in
  adult height, weight, BMI or age at menarche in
  women

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• Selected Publications
• Allen NE, Appleby PN, Davey GK, Key TJ. Hormones
  and diet low insulin-like growth factor-I but
  normal bioavailable androgens in vegan men.
  British Journal of Cancer 2000 83 95-97.
• Appleby PN, Davey GK, Key TJ. Hypertension and
  blood pressure among meat eaters, fish eaters,
  vegetarians and vegans in EPIC-Oxford. Public
  Health Nutrition 2002 5 645-654.
• Davey GK, Spencer EA, Appleby PN, Allen NE, Knox
  KH, Key TJ. EPIC-Oxford lifestyle
  characteristics and nutrient intakes in a cohort
  of 33883 meat-eaters and 31546 non meat-eaters in
  the UK. Public Health Nutrition 2003 6 259-268.
• Spencer EA, Appleby PN, Davey GK, Key TJ. Diet
  and body mass index in 38000 EPIC-Oxford
  meat-eaters, fish-eaters, vegetarians and vegans.
  International Journal of Obesity 2003 27
  728-734.
• Key TJ, Appleby PN, Davey GK, Allen NE, Spencer
  EA, Travis RC. Mortality in British vegetarians
  review and preliminary results from EPIC-Oxford.
  American Journal of Clinical Nutrition 2003 78
  533S-538S.
• Appleby P, Roddam A, Allen E, Key T. Comparative
  fracture risk in vegetarians and non-vegetarians
  in EPIC-Oxford. European Journal of Clinical
  Nutrition 2007 611400-1406.

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Further information and acknowledgements EPIC-Oxf
ord website www.epic-oxford.org Thanks are
owing to all participants in EPIC-Oxford, and to
Professor Tim Key and colleagues past and present
at the Cancer Epidemiology Unit, Oxford
University. EPIC-Oxford is supported by Cancer
Research UK, the Medical Research Council, and
the European Community.