Changes in Overall Diet Quality in Relation to Survival in Postmenopausal Women with Breast Cancer: Results from the Women’s Health Initiative



      Lifestyle factors are important for cancer survival. However, empirical evidence regarding the effects of dietary changes on mortality in breast cancer survivors is sparse.


      The objective was to examine the associations of changes in overall diet quality, indicated by the Healthy Eating Index (HEI)-2010 score, with mortality in breast cancer survivors.


      This was a prospective cohort study from September 1993 through September 30, 2015.


      This study included 2,295 postmenopausal women who were diagnosed with invasive breast cancer and completed a food frequency questionnaire both before and after the diagnosis of breast cancer in the Women’s Health Initiative.

      Main outcome measures

      The HEI-2010 score (maximum score of 100) was calculated based on consumption of 12 dietary components. The outcomes were mortality from all causes, breast cancer, and causes other than breast cancer.

      Statistical analyses performed

      Multivariable Cox proportional hazards models were used to estimate adjusted hazard ratios of mortality from all causes, breast cancer, and other causes.


      Over 12 years of follow-up, 763 deaths occurred. Compared with women with relatively stable diet quality (±14.9% change in HEI-2010 score), women who decreased diet quality (≥15% decrease in HEI-2010 score) had a higher risk of death from breast cancer (adjusted hazard ratio 1.66, 95% CI 1.09 to 2.52). Increased diet quality (≥15% increase in HEI-2010 score) was not significantly associated with lower risk of death. These associations persisted after additional adjustment for change in body mass index.


      Among women with breast cancer, decreased diet quality after breast cancer diagnosis was associated with higher risk of death from breast cancer.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Harbeck N.
        • Gnant M.
        Breast cancer.
        Lancet. 2017; 389: 1134-1150
        • Siegel R.L.
        • Miller K.D.
        • Jemal A.
        Cancer Statistics, 2017.
        CA Cancer J Clin. 2017; 67: 7-30
        • Schemper M.
        The relative importance of prognostic factors in studies of survival.
        Stat Med. 1993; 12: 2377-2382
        • Schwingshackl L.
        • Hoffmann G.
        Diet quality as assessed by the Healthy Eating Index, the Alternate Healthy Eating Index, the Dietary Approaches to Stop Hypertension Score, and health outcomes: a systematic review and meta-analysis of cohort studies.
        J Acad Nutr Diet. 2015; 115: 780-800
        • Sotos-Prieto M.
        • Bhupathiraju S.N.
        • Mattei J.
        • et al.
        Association of changes in diet quality with total and cause-specific mortality.
        N Engl J Med. 2017; 377: 143-153
        • Izano M.A.
        • Fung T.T.
        • Chiuve S.S.
        • Hu F.B.
        • Holmes M.D.
        Are diet quality scores after breast cancer diagnosis associated with improved breast cancer survival?.
        Nutr Cancer. 2013; 65: 820-826
        • Kim E.H.J.
        • Willett W.C.
        • Fung T.
        • Rosner B.
        • Holmes M.D.
        Diet quality indices and postmenopausal breast cancer survival.
        Nutr Cancer. 2011; 63: 381-388
        • George S.M.
        • Ballard-Barbash R.
        • Shikany J.M.
        • et al.
        Better postdiagnosis diet quality is associated with reduced risk of death among postmenopausal women with invasive breast cancer in the Women’s Health Initiative.
        Cancer Epidemiol Biomarkers Prev. 2014; 23: 575-583
        • George S.M.
        • Irwin M.L.
        • Smith A.W.
        • et al.
        Postdiagnosis diet quality, the combination of diet quality and recreational physical activity, and prognosis after early-stage breast cancer.
        Cancer Causes Control. 2011; 22: 589-598
        • McCullough M.L.
        • Gapstur S.M.
        • Shah R.
        • et al.
        Pre- and postdiagnostic diet in relation to mortality among breast cancer survivors in the CPS-II Nutrition Cohort.
        Cancer Cause Control. 2016; 27: 1303-1314
        • Fang S.Y.
        • Lee K.T.
        “From Patient to Survivor”: Women’s experience with breast cancer after 5 years.
        Cancer Nurs. 2016; 39: E40-E48
        • Thomson C.A.
        • Flatt S.W.
        • Rock C.L.
        • Ritenbaugh C.
        • Newman V.
        • Pierce J.P.
        Increased fruit, vegetable and fiber intake and lower fat intake reported among women previously treated for invasive breast cancer.
        J Am Diet Assoc. 2002; 102: 801-808
        • Harnack L.
        • Block G.
        • Subar A.
        • Lane S.
        • Brand R.
        Association of cancer prevention-related nutrition knowledge, beliefs, and attitudes to cancer prevention dietary behavior.
        J Am Diet Assoc. 1997; 97: 957-965
        • Guenther P.M.
        • Casavale K.O.
        • Reedy J.
        • et al.
        Update of the Healthy Eating Index: HEI-2010.
        J Acad Nutr Diet. 2013; 113: 569-580
      1. Design of the Women’s Health Initiative clinical trial and observational study. The Women’s Health Initiative Study Group.
        Control Clin Trials. 1998; 19: 61-109
        • Ritenbaugh C.
        • Patterson R.E.
        • Chlebowski R.T.
        • et al.
        The Women’s Health Initiative Dietary Modification trial: overview and baseline characteristics of participants.
        Ann Epidemiol. 2003; 13: S87-S97
        • Patterson R.E.
        • Kristal A.R.
        • Tinker L.F.
        • Carter R.A.
        • Bolton M.P.
        • Agurs-Collins T.
        Measurement characteristics of the Women’s Health Initiative food frequency questionnaire.
        Ann Epidemiol. 1999; 9: 178-187
        • Block G.
        • Hartman A.M.
        • Dresser C.M.
        • Carroll M.D.
        • Gannon J.
        • Gardner L.
        A data-based approach to diet questionnaire design and testing.
        Am J Epidemiol. 1986; 124: 453-469
        • Willett W.C.
        • Sampson L.
        • Browne M.L.
        • et al.
        The use of a self-administered questionnaire to assess diet four years in the past.
        Am J Epidemiol. 1988; 127: 188-199
        • Rimm E.B.
        • Giovannucci E.L.
        • Stampfer M.J.
        • Colditz G.A.
        • Litin L.B.
        • Willett W.C.
        Reproducibility and validity of an expanded self-administered semiquantitative food frequency questionnaire among male health-professionals.
        Am J Epidemiol. 1992; 135: 1114-1126
        • Schakel S.F.
        • Sievert Y.A.
        • Buzzard I.M.
        Sources of data for developing and maintaining a nutrient database.
        J Am Diet Assoc. 1988; 88: 1268-1271
      2. The University of Minnesota Nutrition Coordinating Center. The University of Minnesota Nutrition Coordinating Center (NCC) Food and Nutrient Database 2016. Accessed May 8, 2018.

      3. The University of Minnesota Nutrition Coordinating Center. Nutrition Data System for Research. Accessed May 8, 2018.

      4. US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US Government Printing Office; 2011.

        • Johnson-Kozlow M.
        • Rock C.L.
        • Gilpin E.A.
        • Hollenbach K.A.
        • Pierce J.P.
        Validation of the WHI brief physical activity questionnaire among women diagnosed with breast cancer.
        Am J Health Behav. 2007; 31: 193-202
        • Anderson G.L.
        • Manson J.
        • Wallace R.
        • et al.
        Implementation of the Women’s Health Initiative study design.
        Ann Epidemiol. 2003; 13: S5-S17
      5. US Department of Health and Human Services PHS, National Institutes of Health. SEER Program: comparative staging guide for cancer. Version 1.1. Washington, DC: NIH Publication; 1993:93-3640.

        • Hammond M.E.
        • Hayes D.F.
        • Dowsett M.
        • et al.
        American Society of Clinical Oncology/College Of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer.
        J Clin Oncol. 2010; 28: 2784-2795
        • Demark-Wahnefried W.
        • Platz E.A.
        • Ligibel J.A.
        • et al.
        The role of obesity in cancer survival and recurrence.
        Cancer Epidemiol Biomarkers Prev. 2012; 21: 1244-1259
      6. Statistical Analysis Software [computer program]. 9.4 ed. Cary: NC: SAS Institute; 2013.

        • Saxe G.A.
        • Rock C.L.
        • Wicha M.S.
        • Schottenfeld D.
        Diet and risk for breast cancer recurrence and survival.
        Breast Cancer Res Treat. 1999; 53: 241-253
        • Reedy J.
        • Krebs-Smith S.M.
        • Miller P.E.
        • et al.
        Higher diet quality is associated with decreased risk of all-cause, cardiovascular disease, and cancer mortality among older adults.
        J Nutr. 2014; 144: 881-889
        • George S.M.
        • Ballard-Barbash R.
        • Manson J.E.
        • et al.
        Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women’s Health Initiative Observational Study: evidence to inform national dietary guidance.
        Am J Epidemiol. 2014; 180: 616-625
        • Fulgoni V.L.
        • Dreher M.
        • Davenport A.J.
        Avocado consumption is associated with better diet quality and nutrient intake, and lower metabolic syndrome risk in US adults: results from the National Health and Nutrition Examination Survey (NHANES) 2001-2008.
        Nutr J. 2013; 12
        • Reedy J.
        • Mitrou P.N.
        • Krebs-Smith S.M.
        • et al.
        Index-based dietary patterns and risk of colorectal cancer: the NIH-AARP Diet and Health Study.
        Am J Epidemiol. 2008; 168: 38-48
        • Rathod A.D.
        • Bharadwaj A.S.
        • Badheka A.O.
        • Kizilbash M.
        • Afonso L.
        Healthy Eating Index and mortality in a nationally representative elderly cohort.
        Arch Intern Med. 2012; 172: 275-277
        • Prentice R.L.
        • Pettinger M.
        • Anderson G.L.
        Statistical issues arising in the Women’s Health Initiative.
        Biometrics. 2005; 61 (discussion 911-841): 899-911
        • Smith A.W.
        • Alfano C.M.
        • Reeve B.B.
        • et al.
        Race/ethnicity, physical activity, and quality of life in breast cancer survivors.
        Cancer Epidemiol Biomarkers Prev. 2009; 18: 656-663
        • Ganz P.A.
        A teachable moment for oncologists: Cancer survivors, 10 million strong and growing!.
        J Clin Oncol. 2005; 23: 5458-5460
        • Goodwin P.J.
        • Segal R.J.
        • Vallis M.
        • et al.
        Randomized trial of a telephone-based weight loss intervention in postmenopausal women with breast cancer receiving letrozole: The LISA trial.
        J Clin Oncol. 2014; 32: 2231-2239


      Y. Sun is a postdoctoral research scholar, Department of Epidemiology, College of Public Health, University of Iowa, Iowa City.


      B. Liu is a postdoctoral research scholar, Department of Epidemiology, College of Public Health, University of Iowa, Iowa City.


      L. G. Snetselaar is a professor and chair, Preventive Nutrition Education, Department of Epidemiology, College of Public Health, University of Iowa, Iowa City.


      W. Bao is an assistant professor, Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, and a member, Obesity Research and Education Initiative and the Fraternal Order of Eagles Diabetes Research Center, University of Iowa, Iowa City.


      B. J. Caan is a senior research scientist and director of the early stage scientist program, Division of Research, Kaiser Permanente Northern California, Oakland.


      D. S. Lane is vice chair and a professor, Department of Family, Population and Preventive Medicine; division head, Preventive Medicine and Population Health; and division head, Graduate Medical Education, School of Medicine, Stony Brook University, Stony Brook, NY.


      A. E. Millen is an associate professor, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo.


      M. S. Simon is an oncologist and professor, Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, MI.


      C. A. Thomson is a professor, Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson.


      L. F. Tinker is a nutrition scientist, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA.


      L. V. Van Horn is a professor, associate dean, and chief of nutrition, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.


      M. Z. Vitolins is vice chair and a professor, Department of Epidemiology and Prevention, Wake Forest School of Medicine and Comprehensive Cancer Center at Wake Forest Baptist Health, Winston-Salem, NC.