Primary and Secondary Prevention of Diverticular Disease

Size: px

Start display at page:

Download "Primary and Secondary Prevention of Diverticular Disease"

Amberly Sherman
6 years ago
Views:

1 Primary and Secondary Prevention of Diverticular Disease Walid.H. Aldoori Wyeth Consumer Healthcare Inc. CANADA Falk Symposium Diverticular Disease: Emerging Evidence in a Common Condition Munich, June 17-18,2005

2 Outline Introduction Health Professionals Follow-Up Study Dietary Factors Non-Dietary Factors Gaps in our knowledge Can we reduce the risk of Diverticular Disease?

3 Introduction Diverticular disease (DD)is one of the most common disorders of the colon in Western societies. It is suggested that lifestyle factors can explain the increase in the prevalence of DD. Identifying these factors is important in the prevention of DD and/or the complications of DD.

Burkitt and Painter s Dietary Fiber Hypothesis Three decades have passed since this hypothesis was widely publicized Several studies have investigated dietary and

4 Burkitt and Painter s Dietary Fiber Hypothesis Three decades have passed since this hypothesis was widely publicized Several studies have investigated dietary and non-dietary factors and the risk of DD Almost all the studies were either case-control studies which are more prone to bias or did not control for potential confounding variables

Health Professionals Follow-up Study (HPFS) To minimize the potential of bias, dietary and non-dietary factors were investigated prospectively among 51,529 health professional US men participating in

5 Health Professionals Follow-up Study (HPFS) To minimize the potential of bias, dietary and non-dietary factors were investigated prospectively among 51,529 health professional US men participating in an ongoing cohort study The study began in 1986 when cohort members completed a dietary questionnaire and provided other relevant information Follow-up questionnaires every two years and dietary questionnaires every four years

Health Professionals Follow-up Study 47,678 Men 40-75 Years Old 382 cases

6 Health Professionals Follow-up Study 47,678 Men Years Old 382 cases Baseline Questionnaire and FFQ FUQ FUQ FUQ Follow-up Time

7 Identification of DD Cases After four years of follow-up, 503 newly diagnosed cases of DD were identified Of the 503 new cases, 382 were classified as symptomatic ( pain, change of bowel habits, or bleeding) To reduce the possibility of detection bias, the symptomatic cases were used as our primary end point In 96 percent of the cases, the diverticula were located in the left colon

8 TABLE 1: Relative Risk of DD by quintiles of total dietary fiber, crude fiber, and by dietary fiber from fruits, vegetables and cereals Variable 1 2 Quintile P Value for Trend* Total Dietary Fiber (median g/d) Cases RR (95% CI) 0.76 (0.57-3) 0.73 ( ) 0.78 (0.58-5) 0.51 ( ) (0.58-7) 0.77 (0.57-5) 0.87 ( ) 0.58 ( ) 0.01 Total Crude Fiber (median g/d) Cases RR (95% CI) 0.78 (0.58-6) 0.72 ( ) 0.71 ( ) 0.48 ( ) < ( ) 0.76 (0.57-2) 0.78 (0.57-6) 0.54 ( ) 0.01 Fruit Fiber (median g/d) Cases RR (95% CI) 3 ( ) 0.85 ( ) 0.54 ( ) 0.62 ( ) < ( ) 0.90 ( ) 0.60 ( ) 0.61 ( ) <

9 TABLE 1: Relative Risk of DD by quintiles of total dietary fiber, crude fiber, and by dietary fiber from fruits, vegetables and cereals Variable 1 2 Quintile P Value for Trend* Vegetable Fiber (median g/d) Cases RR (95% CI) 0.93 ( ) 0.98 ( ) 0.90 ( ) 0.55 ( ) ( ) ( ) 0.87 ( ) 0.59 ( ) Cereal Fiber (median g/d) Cases RR (95% CI) 1.21 ( ) 1.10 ( ) 0.85 ( ) 9 ( ) ( ) 8 ( ) 0.87 ( ) 6 ( ) 0.72 *Test for trend was calculated by using the median intake of nutrients in each quintile as a continuous variable in a multiple logistic regression. Adjusted for age and total energy. Adjusted for age, physical activity, and energy-adjusted total fat. ( Modified from Aldoori WH, et al. Am J Clin Nutr 1994;60: )

TABLE 2: Relative Risk of DD by quintiles of soluble and insoluble fiber components Variable 1 2 Quintile 3 4 5 P Value for Trend Soluble Fiber ( g/d) 4.10 5.10 5.90 9.90 8.60 RR (95% CI) 3 (0.75-1.

10 TABLE 2: Relative Risk of DD by quintiles of soluble and insoluble fiber components Variable 1 2 Quintile P Value for Trend Soluble Fiber ( g/d) RR (95% CI) 3 ( ) 0 ( ) 0.83 ( ) 0.82 ( ) ( ) 4 ( ) 0.91 ( ) 0.90 ( ) 0.40 Insoluble Fiber (g/d) RR (95% CI) 0.89 ( ) 0.78 (0.57-7) 0.80 ( ) 0.55 ( ) ( ) 0.80 ( ) 0.87 ( ) 0.63 ( ) 0.02 Adjusted for age and total energy. Adjusted for age, physical activity, and energy-adjusted total fat. (Aldoori WH, et al. J Nutr 1998;128: )

TABLE 3: Relative Risk of DD by quintiles of hemicellulose, cellulose, and lignin intake Variable 1 2 Quintile 3 4 5 P Value for Trend Hemicellulose (g/d) 4.40 6.00 7.30 8.90 11.70 RR (95% CI) 1.

11 TABLE 3: Relative Risk of DD by quintiles of hemicellulose, cellulose, and lignin intake Variable 1 2 Quintile P Value for Trend Hemicellulose (g/d) RR (95% CI) 1.27 ( ) 0.77 (0.55-7) 0.78 (0.56-9) 0.78 (0.56-8) ( ) 0.79 ( ) 0.84 ( ) 0.88 ( ) 0.11 Cellulose (g/d) RR (95% CI) 0.75 (0.55-3) 0.71 ( ) 0.78 (0.57-6) 0.47 ( ) (0.56-5) 0.74 (0.54-1) 0.83 ( ) 0.52 ( ) Lignin (g/d) RR (95% CI) 0.82 ( ) 0.87 ( ) 0.65 ( ) 0.53 ( ) ( ) 0.89 ( ) 0.71 (0.51-0) 0.62 ( ) Adjusted for age and total energy. Adjusted for age, physical activity, and energy-adjusted total fat. (Aldoori WH, et al. J Nutr 1998;128: )

12 Fig. 1: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Red Meat Intake Relative Risk Low (<17) Medium (17-28) High (29+) 1.90 High (>116.6) Medium ( ) Low (<28.5) RED MEAT INTAKE (g/d) DIETARY FIBRE INTAKE (g/d) *Adjusted for age and total energy. (Aldoori WH, et al. Am J Clin Nutr 1994; 60: )

13 TABLE 4: Relative Risk of DD by quintiles of total fat and specific dietary fats Fats 1 2 Quintile P for Trend* Total Fat (median g/d) Cases RR (95% CI) 1.27 ( ) 1.57 ( ) 1.25 ( ) 1.71 (-2.37) ( ) 1.40 (-1.98) 9 ( ) 1.38 ( ) 0.20 Animal Fat (median g/d) Cases RR (95% CI) 1.66 ( ) 1.39 ( ) 1.57 ( ) 1.43 (2-2.01) (8-2.10) 1.20 ( ) 1.27 ( ) 8 ( ) 0.80 Vegetable Fat (median g/d) Cases RR (95% CI) 6 ( ) 1.28 ( ) 6 ( ) 1.28 ( ) ( ) 1.30 ( ) 8 ( ) 1.32 ( ) 0.10

14 TABLE 4: Relative Risk of DD by quintiles of total fat and specific dietary fats Fats 1 2 Quintile P for Trend* Saturated Fatty Acids (median g/d) Cases RR (95% CI) (4-2.02) 1.30 ( ) ( ) 1.34 ( ) (8-2.13) 1.27 ( ) ( ) 1.22 ( ) Monounsaturated Fatty Acids (median g/d) Cases RR (95% CI) 1.26 ( ) 1.45 (4-2.01) 1.41 (1-1.97) 1.53 ( ) ( ) 1.29 ( ) 1.19 ( ) 1.24 ( ) 0.26 Polyunsaturated Fatty Acids (median g/d) Cases RR (95% CI) 1.14 ( ) 0.95 ( ) 1.14 ( ) 1.25 ( ) ( ) 0.95 ( ) 1.14 ( ) 1.28 ( ) 0.16

TABLE 4: Relative Risk of DD by quintiles of total fat and specific dietary fats Fats 1 2 Quintile 3 4 5 P for Trend* Omega-3 Fatty Acids (median g/d) <0.1 0.1 0.2 0.3 0.

15 TABLE 4: Relative Risk of DD by quintiles of total fat and specific dietary fats Fats 1 2 Quintile P for Trend* Omega-3 Fatty Acids (median g/d) < Cases RR (95% CI) 8 ( ) 1.17 ( ) 0.92 ( ) 0.86 ( ) ( ) 1.25 ( ) 2 ( ) 0.97 ( ) 0.38 Trans Fatty Acids (median g/d) Cases RR (95% CI) 1.28 ( ) 1.73 ( ) 1.70 ( ) 1.49 (6-2.09) ( ) 1.52 ( ) 1.46 (3-2.07) 1.29 ( ) 0.25 *Test for trend was calculated by using the median intake of nutrients in each quintile as a continuous variable in a multiple logistic regression. Adjusted for age and total energy. Adjusted for age, energy-adjusted dietary fiber and physical activity. (Aldoori WH, et al. Am J Clin Nutr 1994;60: )

16 Fig. 2: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Total Fat Intake Relative Risk Low (<17) Medium (17-28) 1.62 High (+29) High (>81.1) Medium (47-81) Low (<47) (g/d) TOTAL FAT INTAKE (g/d) TOTAL FIBRE INTAKE (g/d) *Adjusted for age and total energy. (Aldoori WH, et al. Am J Clin Nutr 1994; 60: )

17 TABLE 5: Relative Risk of DD according to alcohol intake Alcohol Personyears Observed cases Relative risk (95% CI) Age adjusted Multivariate* None 44, Reference Reference g/day 51, ( ) 1.30 ( ) g/day 31, ( ) 1.38 ( ) g/day 20, ( ) 1.13 ( ) g/day 25, ( ) 1.16 ( ) , ( ) (P value for trend =0.15) 1.36 ( ) (P value for trend =0.37) *Adjusted for age, energy-adjusted dietary fiber and energy-adjusted total fat. Test for trend was calculated by using the median alcohol intake in each category as continuous in a multiple logistic regression. (Aldoori WH, et al. Ann Epidemiol 1995;5: )

18 TABLE 6: Relative Risk of DD by levels of total caffeine, coffee, tea, and decaffeinated coffee Variable Personyears Observed cases* Relative risk (95% CI) Age adjusted Multivariate** CAFFEINE (median mg/day) 6.0 mg/day 37, Reference Reference 82 mg/day 37, (1-1.94) 1.34 ( ) 165 mg/day 37, ( ) 1.14 ( ) 355 mg/day 37, ( ) 1.26 ( ) 615 mg/day 37, ( ) 1.11 ( ) (P value for trend =0.25) (P value for trend =0.98) *Number of cases do not always add up to 382, because of missing information for specific beverages. ** Adjusted for age, energy-adjusted dietary fiber and energy-adjusted total fat. Test for trend was calculated by using the median intake specific beverages in each category as continuous in a multiple logistic regression. (Aldoori WH, et al. Ann Epidemiol 1995;5: )

19 TABLE 6: Relative Risk of DD by levels of total caffeine, coffee, tea, and decaffeinated coffee Variable Personyears Observed cases* Relative risk (95% CI) Age adjusted Multivariate** COFFEE (cups) Almost never 54, Reference Reference 1-3/month to 1/day 65, ( ) ( ) 2-3/day 42, ( ) 1 ( ) š4-5/day 19, ( ) 0.95 ( ) (P value for trend =0.53) (P value for trend =0.81)

20 TABLE 6: Relative Risk of DD by levels of total caffeine, coffee, tea, and decaffeinated coffee Variable Personyears Observed cases* Relative risk (95% CI) Age adjusted Multivariate** TEA (cups) Almost never 76, Reference Reference 1-3/month to 1/day 65, ( ) 1.14 ( ) 2-3/day 42, (4-2.24) 1.53 (4-2.26) š4-5/day 2, ( ) 4 ( ) (P value for trend =0.09) (P value for trend =0.12)

TABLE 6: Relative Risk of DD by levels of total caffeine, coffee, tea, and decaffeinated coffee Variable Personyears Observed cases* Relative risk (95% CI) Age adjusted Multivariate** DECAFFEINATED

21 TABLE 6: Relative Risk of DD by levels of total caffeine, coffee, tea, and decaffeinated coffee Variable Personyears Observed cases* Relative risk (95% CI) Age adjusted Multivariate** DECAFFEINATED COFFEE (cups) Almost never 84, Reference Reference 1-3/month to 1/day 69, ( ) 1.51 ( ) 2-3/day 20, (0-1.95) 1.56 ( ) š4-5/day 6, ( ) 1.12 ( ) (P value for trend =0.02) (P value for trend =0.17)

TABLE 7: Relative Risk of DD by physical activity, non-vigorous, and vigorous activity levels Variable 1 2 Category 3 4 5 P Value for Trend Total physical activity (median of Total MET) 0.9 4.8 11.

22 TABLE 7: Relative Risk of DD by physical activity, non-vigorous, and vigorous activity levels Variable 1 2 Category P Value for Trend Total physical activity (median of Total MET) RR* (95% CI) 0.89 ( ) 0.67 ( ) 0.68 ( ) 0.57 ( ) ( ) 0.71 ( ) 0.74 (0.54-1) 0.63 ( ) Non-vigorous activity (median of Total MET) RR * (95% CI) 1.13 ( ) 0.78 ( ) 6 ( ) 0.93 ( ) ( ) 0.79 ( ) 9 ( ) 0.93 ( ) 0.65 Vigorous activity (median of Total MET) RR * (95% CI) 0.74 ( ) 0.79 (0.61-3) 0.53 ( ) (0.60-2) 0.88 ( ) 0.60 ( ) 0.01 *Adjusted for age. Test for trend was calculated by using the median Total MET value of exercise in each category as a continuous variable in a multiple logistic regression. Adjusted for age, energy-adjusted dietary fiber and energy-adjusted total fat. Included flight of stairs climbed and walking or hiking outdoors (including walking at golf). 2Included running (10 minutes/mile or faster), jogging (slower than 10 minutes/mile), lap swimming, tennis, squash or racquetball, calisthenics or rowing, bicycling (including stationary machines). Total MET = sum of the average time/week spent in each activity x MET value of each activity. MET value = caloric need/kg body wt/hour during activity caloric need/kg body wt/hour at rest (Aldoori WH, et al. Gut 1995;36: ).

23 Fig. 3: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Physical Activity 2.56 Relative Risk Low (<17) Medium (17-28) *Adjusted for age and total energy. (Aldoori WH, et al. Gut 1995; 36: ) 1.43 High (+29) DIETARY FIBRE INTAKE (g/d) High (>32.5) Low (<) Medium (1-32.5) PHYSICAL ACTIVITY (Total MET)

24 Body Mass Index (BMI) There was a positive association between increasing age adjusted BMI and and the risk of DD This association was attenuated and non significant when we adjusted for other confounding variables Total caloric intake was not associated with risk of DD

25 TABLE 8: Relative Risk of DD by smoking status Variable Personyears Observed cases* Relative risk (95% CI) Age adjusted Multivariate SMOKING STATUS Non-smokers 84, Reference Reference Past smokers 77, ( ) 0.96 ( ) Current smokers (cig/day) 1-14 cig/day 4, ( ) 0.94 ( ) cig/day 5, ( ) 1.28 ( ) 25+ cig/day 5, ( ) 1.25 ( ) (P value for trend =0.05) (P value for trend =0.36) * Numbers of cases do not always add up to 382, because of missing information for smoking. Adjusted for age, energy-adjusted dietary fiber, and energy-adjusted total fat. Test for trend is calculated by using the median number of cigarettes smoked across categories of current smoking in a multiple logistic regression. (Aldoori WH, et al. Ann Epidemiol 1995;5: ).

26 TABLE 9: Relative risk of DD by NSAIDs and acetaminophen use in the HPFS Variable Follow-up Period NSAIDs and acetaminophen Use to to 1992 NSAID Nonusers, Cases/person-years 265 / 122, / 51, 475 Users, Cases/person-years* 45 / 13, / 8, 745 Age-adjusted RR (95% CI) 1.52 ( ) 2.19 ( ) Multivariate RR (95% CI) 1.50 (9-2.06) 2.24 ( ) P Value Acetaminophen Nonusers, Cases/person-years 286 / 128, / 55,314 Users, Cases/person-years* 24 / 7, / 4, 906 Age-adjusted RR (95% CI) 1.40 ( ) 1.82 ( ) Multivariate RR (95% CI) P Value 1.33 ( ) ( ) 0.16 *Participants who reported NSAIDs and acetaminophen use (the follow-up period for1988 was ; for 1988 and 1990, ); nonusers reported no NSAID or acetaminophen use during the specified time periods. Age-adjusted relative risk and 95% CI for users compared with nonusers of NSAID or acetaminophen for each of the specified time periods. Relative risk adjusted for age, physical activity, energy-adjusted dietary fiber and total fat. Does not include aspirin. NSAID indicates nonsteroidal anti-inflammatory drug. (Aldoori WH, et al. Arch Fam Med 1998;7: )

27 TABLE 10: Relative risk of DD for participants whose main symptoms were abdominal pain and change in bowel habits, by NSAIDs and acetaminophen use in the HPFS. Variable Follow-up Period NSAIDs and acetaminophen Use to to 1992 NSAID Nonusers, Cases/person-years 200 / 122, / 51,475 Users, Cases/person-years* 30 / 13, / 8, 745 Age-adjusted RR (95% CI) 1.35 ( ) 2.27 ( ) Multivariate RR (95% CI) 1.33 ( ) 2.32 ( ) P Value Acetaminophen Nonusers, Cases/person-years 216 / 128, / 55,314 Users, Cases/person-years* 14 / 7, / 4, 906 Age-adjusted RR (95% CI) 9 ( ) 1.17 ( ) Multivariate RR (95% CI) P Value 4 ( ) ( ) 0.78 *Participants who reported NSAIDs and acetaminophen use (the follow-up period for1988 was ; for 1988 and 1990, ); nonusers reported no NSAID or acetaminophen use during the specified time periods. Age-adjusted relative risk and 95% CI for users compared with nonusers of NSAID or acetaminophen for each of the specified time periods. Relative risk adjusted for age, physical activity, energy-adjusted dietary fiber and total fat. Does not include aspirin. (Aldoori WH, et al. Arch Fam Med 1998;7: )

28 TABLE 11: Relative risk of DD for participants whose main symptoms were bleeding, by NSAIDs and acetaminophen use in the HPFS. Variable Follow-up Period NSAIDs and acetaminophen Use to to 1992 NSAID Nonusers, Cases/person-years 28 / 122, / 51,475 Users, Cases/person-years* 7 / 13, / 8, 745 Age-adjusted RR (95% CI) 2.23 ( ) 4.20 ( ) Multivariate RR (95% CI) 2.15 ( ) 4.64 ( ) P Value Acetaminophen Nonusers, Cases/person-years 28 / 128, / 55,314 Users, Cases/person-years* 7 / 7, / 4, 906 Age-adjusted RR (95% CI) 4.11 ( ) ( ) Multivariate RR (95% CI) P Value 3.75 ( ) ( ) *Participants who reported NSAIDs and acetaminophen use (the follow-up period for1988 was ; for 1988 and 1990, ); nonusers reported no NSAID or acetaminophen use during the specified time periods. Age-adjusted relative risk and 95% CI for users compared with nonusers of NSAID or acetaminophen for each of the specified time periods. Relative risk adjusted for age, physical activity, energy-adjusted dietary fiber and total fat. Does not include aspirin. (Aldoori WH, et al. Arch Fam Med 1998;7: )

29 Gaps in our Knowledge Better understanding of the interactions between colonic structures, motility, diet, lifestyle and genetic factors Better understanding why symptoms develop Better understanding whether specific factors are important for the formation of diverticula, and whether different factors contribute to the symptomatic presentation and / or complications

30 Can we reduce the risk of DD? A diet high in fiber mainly from fruits and vegetables and low in total fat and red meat decreases risk of DD Insoluble component of fiber is strongly associated with lower risk of DD. This association was particularly strong for cellulose

Fig. 1: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Red Meat Intake 3.22 3.16 2.53 3.5 2.60 1.73 Relative Risk 3 2.5 2 1.5 1 0.5 0 1.96 1.

31 Fig. 1: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Red Meat Intake Relative Risk Low (<17) Medium (17-28) High (29+) 1.90 High (>116.6) Medium ( ) Low (<28.5) RED MEAT INTAKE (g/d) DIETARY FIBRE INTAKE (g/d) *Adjusted for age and total energy. (Aldoori WH, et al. Am J Clin Nutr 1994; 60: )

Fig. 2: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Total Fat Intake 2.35 1.72 Relative Risk 2.5 2 1.5 1 0.5 0 1.50 1.88 1.26 Low (<17) Medium (17-28) 1.

32 Fig. 2: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Total Fat Intake Relative Risk Low (<17) Medium (17-28) 1.62 High (+29) High (>81.1) Medium (47-81) Low (<47) (g/d) TOTAL FAT INTAKE (g/d) TOTAL FIBRE INTAKE (g/d) *Adjusted for age and total energy. (Aldoori WH, et al. Am J Clin Nutr 1994; 60: )

33 Caffeine, smoking and alcohol do not substantially increase risk of DD, nor does obesity Higher levels of physical activity seem to reduce risk of DD

Fig. 3: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Physical Activity 2.56 Relative Risk 3 2.5 2 1.5 1 0.5 0 0.85 1.81 1.

34 Fig. 3: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Physical Activity 2.56 Relative Risk Low (<17) Medium (17-28) *Adjusted for age and total energy. (Aldoori WH, et al. Gut 1995; 36: ) 1.43 High (+29) DIETARY FIBRE INTAKE (g/d) High (>32.5) Low (<) Medium (1-32.5) PHYSICAL ACTIVITY (Total MET)

35 There is evidence that regular and consistent use of NSAIDs and acetaminophen is associated with complicated DD Most of this positive association was attributable to cases associated with bleeding

36 THANK YOU

Dietary Guidelines for Americans 2005

The DB Brown Research Chair on Obesity from Université Laval presents its Newsletter on Obesity: Dietary Guidelines for Americans 2005 The sixth edition of Dietary Guidelines for Americans was recently