Association between Dietary Energy Density and Obesity-Associated Cancer: Results from the Women’s Health Initiative

Published:August 17, 2017DOI:



      Dietary energy density (DED) is the ratio of energy (kilocalories or kilojoules) intake to food weight (grams) and is a measure of diet quality. Consumption of foods high in DED has been associated with weight gain in adults.


      To investigate the association between baseline DED and incident obesity-associated cancers in the Women’s Health Initiative.


      Prospective cohort study of clinical trial and observational study participants.


      Postmenopausal women aged 50 to 79 years (N=92,295) enrolled in the observational study or the calcium and vitamin D trial and hormone replacement therapy trials of the Women’s Health Initiative.

      Main outcome measures

      Incident, medical record-adjudicated, obesity-related cancers during follow-up. Exposure variable was DED (kilocalories per gram for the total diet) from self-reported dietary intake at baseline using a food frequency questionnaire.

      Statistical analyses

      The associations between DED and each incident cancer, or any obesity-related cancer, were examined using competing-risks regression models, with death as a competing risk. Body mass index-stratified models were generated to investigate body mass index as a potential modifying factor.


      DED was associated with higher body mass index (28.9±6.0 vs 26.3±4.9) and waist circumference (89.3±14.2 vs 82.4±12.4 cm) for DED quintiles 5 vs 1, respectively. DED was associated with a 10% increased risk of any obesity-related cancer (subhazard ratioQ5 vs Q1: 1.1, 95% CI 1.03 to 1.2; P=0.004). This increased risk appeared limited to women who were normal weight at enrollment.


      Higher DED may be a contributing factor for obesity-related cancers, especially among normal-weight postmenopausal women and, as such, could serve as a modifiable behavior for dietary interventions to reduce obesity-associated cancer risk.


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      C. A. Thomson is a professor, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson.


      T. E. Crane is an assistant professor, College of Nursing, The University of Arizona, Tucson.


      D. O. Garcia is an assistant professor, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson.


      B. C. Wertheim is a data analyst/statistician, University of Arizona Cancer Center, The University of Arizona, Tucson.


      M. Hingle is an assistant professor, Department of Nutritional Sciences, College of Agriculture & Life Sciences, The University of Arizona, Tucson.


      L. Snetselaar is a professor and associate provost, College of Public Health, The University of Iowa, Iowa City.


      M. Datta is an assistant professor and director, Coordinated Program in Dietetics, Department of Nutrition Science, Purdue University, West Lafayette, IN.


      T. Rohan is a professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.


      E. LeBlanc is an endocrinologist, Kaiser Permanente Center for Health Research, Portland, OR.


      R. T. Chlebowski is chief and professor in residence, Medical Oncology/Hematology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA.


      L. Qi is an associate professor, Department of Public Health Sciences, The University of California, Davis.