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Monday, 21 August 2017
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Latest Headlines
'Junk food' may increase cancer risk in 'healthy weight' women - 18 Aug 2017

"Women who eat junk food such as burgers or pizza are increasing their risk of cancer even if they're not overweight, new research has warned," reports the Daily Mail.

The story is based on research from the US looking at the diet of postmenopausal women in the 1990s and then tracking the development of a variety of cancers over about 15 years.

"Junk food" is often defined as food that is rich in calories (energy dense food) but low in nutrients.

Having a diet high in energy dense foods, such as biscuits, chocolate and pizza was found to increase the risk of cancer in these women, specifically in those of a healthy weight, which was defined as having a body mass index (BMI) of between 18.5 and 24.9. This suggests that having a healthy weight does not necessarily protect against cancer risk.

However the connections between diet, lifestyle and cancer outcomes are complex, and while the researchers attempted to adjust their results for other factors, we cannot say with certainty that energy dense foods increase your cancer risk.

The analysis was limited to postmenopausal women and did not consider drink intake, such as sugary drinks and alcohol, which can also be high in calories.

Still, having a healthy, balanced diet will help you get all the nutrients you need and may reduce your risk of developing cancer.

Read more about cancer prevention.


Where did the story come from?

The study was carried out by researchers from the Mel and Enid Zuckerman College of Public Health, the University of Arizona, the University of Iowa, Purdue University, Albert Einstein College of Medicine, Kaiser Permanente Center for Health Research, Harbor-UCLA Medical Center and the University of California, all in the US.

The research was funded by the National Cancer Institute of the National Institutes of Health and The University of Arizona Collaboratory for Metabolic Disease Prevention and Treatment. The Women's Health Initiative (WHI) from which data was sourced is funded by the National Heart, Lung, and Blood Institute; National Institutes of Health; and US Department of Health and Human Services.

The study was published in the peer-reviewed Journal of the Academy of Nutrition and Dietetics.

The UK media's reporting of this US study was generally accurate, although it could have been more explicit about the fact that all women in the study were postmenopausal, meaning the results might not be applicable to all populations.


What kind of research was this?

This was a prospective cohort study, meaning it looked at a large number of women over a number of years, with the aim of finding out if consuming energy dense foods increases the risk of cancer.

Cohort studies such as this are good at looking at trends in large numbers of people over time but cannot on their own prove cause and effect unless the links are strong and consistent.

It cannot be proven from this research that having an energy dense diet will result in increased risk of cancer.


What did the research involve?

The researchers took data from 92,295 women participating in the Women's Health Initiative (WHI) study in the US, a longitudinal study involving healthy, postmenopausal women recruited between 1995-1998 who were between 50 and 79 years old.

The association between an energy dense diet and cancer was investigated over an average 14.6 year follow up period.

The researchers excluded women who had a history of cancer, and those with a lack of dietary data, missing BMI data, or who reported consuming fewer than 600 calories or more than 5,000 calories per day.

Diet was assessed by self-report at the start of the study using a food frequency questionnaire designed to estimate energy, nutrients and food weight.

Dietary energy density (DED) was calculated by dividing the daily energy intake (in kilocalories) from foods (but not drinks) by the portion size reported and corresponding weight in grams of these foods, as per the WHI database.

Cancer assessment at the start of the study was by self-report by participating women and then by self-report on a biannual basis at follow up, with the results also checked against medical records.

Obesity-related cancers were the outcome of interest and were defined using the American Institute of Cancer Research report of diet, physical activity, and cancer. Common obesity-related cancers include breast, colorectal and kidney cancers.

Analysis took into account potentially confounding variables, including:

  • age
  • ethnicity
  • neighbourhood socioeconomic status
  • smoking history
  • physical activity
  • disease history
  • weight change pattern in adulthood
  • alcohol
  • hormone use and use of disease-related medications

BMI and waist circumference were also measured.


What were the basic results?

The total number of women with cancer over the follow up period was 9,565. This included:

  • 5,565 cases of breast cancer
  • 1,639 cases of colorectal cancer
  • 662 cases of ovarian cancer
  • 955 cases of endometrial cancer
  • 347 cases of renal cancer
  • 461 cases of gallbladder cancer
  • 485 cases of oesophageal cancer 
  • 620 cases of pancreatic cancer

Among 28 analyses across two models the risk of any obesity-related cancer was 10% higher in one analysis for the women consuming the highest energy dense diet compared with the lowest (subhazard ratio (sHR) 1.10, 95% confidence interval [CI] 1.03 to 1.20).

  • After accounting for confounders, energy dense diets were not significantly associated with each individual cancer type.
  • When breaking down into BMI subgroups, only women of a normal weight (BMI < 25) had a positive association between energy dense diets and obesity-related cancer. Those in the highest three quintiles for energy dense diets had a 10%, 18% and 12% increased risk of obesity-related cancer for quintiles 3, 4 and 5 (sHR trend 1.2, significance not reported).
  • Higher energy dense diets were associated with higher BMI (29.0 ± 6.0 versus 26.3 ±4.9 for quintile 5 versus 1).


How did the researchers interpret the results?

The researchers concluded that "among normal-weight women, higher Dietary Energy Density may be a contributing factor for obesity-related cancers. Importantly, Dietary Energy Density is a modifiable risk factor. Nutrition interventions targeting energy density as well as other diet-related cancer preventive approaches are warranted to reduce cancer burden among postmenopausal women."



Energy dense diets appear to be associated with a 10% increased risk of obesity-related cancer in those eating the top 205 high density food types.

A sub analysis of postmenopausal women of normal, overweight or obese weight at the start of the study showed a link specifically in those of a normal weight and a weaker link in those who were overweight or obese.

The authors suggest these findings mean weight management alone might not protect against obesity-related cancer if women have a high energy dense diet.

Although this was a longitudinal study involving a large sample of women, it has some limitations:

  • Food intake was self-reported and so might not accurately represent what women were truly eating as there is a tendency to under-report in such questionnaires.
  • There are a range of other factors that might have contributed to the increased risk of cancer that were not accounted for in analysis, such as whether the participants were employed, the type of employment, home life and social factors, levels of activity, as well as consumption of energy dense drinks (which were not considered in the food questionnaire).
  • Women consuming lower amounts of energy dense food tended to have a lower BMI, engage in more physical activity and consume less alcohol and tobacco, indicating that healthy behaviours cluster together and are hard to unpick.
  • Research was limited to postmenopausal women aged 50 to 79 in the US so might be less relevant to women of other ages or women in the UK where food types and eating trends might differ.

Eating a lot of energy dense foods is not recommended as part of a healthy lifestyle as it increases the risk of becoming overweight due to the high number of calories these foods contain.

To cut down on energy dense foods, aim for balanced diet and try these healthy food swaps.

Links To The Headlines

Junk food is still a cancer risk even if you're not fat: Energy-dense meals can raise the risk of suffering certain types of the disease by 10%. Mail Online, August 17 2017

Women who regularly eat junk food increase their risk of cancer by ten per cent - even if they are SLIM. Daily Mirror, August 17 2017

Links To Science

Thomson CA, Crane TE, Garcia DO, et al. Association between Dietary Energy Density and Obesity-Associated Cancer: Results from the Women's Health Initiative. Journal of the Academy of Nutrition and Dietetics. Published online August 17 2017

People who regularly groom their pubic hair at risk of injuries - 17 Aug 2017

"A quarter of Americans are injured and hospitalized by tidying up 'down there'," the Mail Online reports.

The headline is prompted by a survey which asked 7,570 adults about pubic hair removal and "grooming" (such as waxing). The researchers found that removing all pubic hair, and frequent hair removal, were most likely to cause injuries.

Pubic hair removal has become more common in recent years. This could be due to the mistaken assumption that grooming is more hygienic (as we discussed in 2016). Some commentators have also cited the influence of pornography, where shaved genitals are the norm.

The researchers found 66.5% of men and 85.3% of women who responded to their survey had removed or groomed pubic hair at some point in their lives. However, it's not as dangerous as the Mail Online headline suggests – while 25.6% of people reported at least one injury, these were almost all minor and only 1.4% reported injury that required medical attention.

Cuts, burns, rashes and infections were the main problems. Waxing seemed to cause fewer injuries than shaving, although researchers say more study is needed before it can be recommended as a safer option.

Previous research has shown that removal of pubic hair can also make sexually transmitted infections (STIs) such as HPV more likely.

The most effective method of reducing your risk of catching an STI is to always used a condom during sex, including oral and anal sex.


Where did the story come from?

The study was carried out by researchers from the University of California, the University of Texas Dell Medical School and the Washington University School of Medicine, all in the US. It was funded by the Alafi Foundation, the Hellman Foundation and the National Institute of Diabetes and Digestive and Kidney Diseases.

It was published in the peer-reviewed medical journal JAMA Dermatology.

The Guardian carried a balanced and accurate report of the study. In contrast, the Mail Online's reporting was muddled, misleading and sensationalised. For example, the website states: "A quarter of groomers have suffered severe injuries," although the injuries were mostly minor.

The Mail also inaccurately reported that "more than a third of people surveyed by government health researchers" said they'd had five or more injuries – although this figure applies to only one third of the 25% of people injured, not one third of people questioned. The report also includes findings from other studies as if they were part of the new study which could further mislead the reader. 


What kind of research was this?

This was a cross sectional study, using a web-based survey targeted at US adults aged 18 to 65. The researchers contacted more than 10,000 adults in a "nationally representative" sample.

This type of study can give a snapshot view of what people are prepared to say in a survey about their grooming habits. However, it can't guarantee people answer truthfully.

Also, this methodology leaves any results open to accusations of selection bias. People who take the time to complete the survey may not be representative of the general public.


What did the research involve?

Researchers randomly recruited people to take the survey through sampling of the US postal service database. An email request was sent out in January 2014 asking people to take part in the online survey.

The survey asked questions about people's grooming habits, experience, injuries and infections.

To ensure people weren't excluded because of lack of internet or computer access, those without access were provided with internet facilities to complete the questionnaire.

Participants also received a small points-based incentive equivalent to one dollar.

The results were analysed to find out the extent and nature of the problem, and to identify factors that seemed to increase the risk of injury.


What were the basic results?

Almost half of the people contacted declined to take part in the survey. Of the 52.5% of people (7,570) who did take part:

  • 66.5% of men said they had groomed their pubic hair, and 23.7% said they'd been injured while doing it
  • 85.3% of women had groomed their public hair and 27.1% had been injured

The most common problems were:

  • cuts (61.2%)
  • burns (23.0%)
  • rash (12.2%)
  • infection (9.3%)

This may reflect the types of hair removal methods used. Shaving with a non-electric razor was the most common method (47.5%) followed by electric razor (26.9%), scissors (18.4%) and waxing (2.6%).

For women, those who reported waxing as their main method of hair removal were less likely to have repeated frequent injuries (adjusted odds ratio (AOR) 0.11, 95% confidence interval [CI] 0.03 to 0.43). For men (who were less likely to wax) the type of hair removal method made no difference to injury rate.

Women and men who removed all pubic hair regularly (more than 10 times per year) were more likely to report having an injury (women: AOR 2.21, 95% CI 1.53 to 3.19; men: AOR 1.97, 95% CI 1.28 to 3.01).

The position adopted while grooming made some difference to the severity of injury. People were more likely to get an injury that needed medical attention if they carried out hair removal lying on their back (perhaps because they could not see what they were doing) or if other people were carrying out the hair removal.


How did the researchers interpret the results?

The researchers said their research showed that "pubic hair grooming is a widespread practice" and so "injury prevention efforts are necessary". They said their study "may contribute to the development of clinical guidelines or recommendations for safe pubic hair removal."



Pubic hair removal is now common practice, and this study suggests it is not without risk. It seems sensible to find out more about how it can be done safely, with minimal risk of injury.

However, while the study provides useful information about peoples' experiences of pubic hair removal and injury (at least in the US), it doesn't tell us which is the safest method.

Although waxing was linked to fewer repeated injuries among women, previous studies suggest it can be harmful if done incorrectly, leading to severe injury or infection.

Similarly, although frequent removal of all pubic hair is linked to higher risk of injury, we don't know why this is. It may simply be that doing anything regularly means you have more opportunities to make a mistake.

The research has some limitations. It's notable that almost half of people contacted didn't take the survey. It may be that the people who refused to do the survey were less likely to carry out pubic hair grooming or removal, or are more likely to be embarrassed at the thought of answering questions about it.

Because the research relies on people's own reporting of their experience, we don't know how accurate it is. People may be too embarrassed to give truthful answers, may forget minor injuries, or people who suffer major injuries may be more likely to respond to the survey. All of these things could skew the results.

While people may choose to remove their pubic hair for cosmetic reasons, there are no medical benefits to the practice, and it could increase your risk of contracting a sexually transmitted infection, as we reported on last year.

Links To The Headlines

The dangers of pubic hair grooming: A QUARTER of Americans are injured and hospitalized by tidying up 'down there' - and this study reveals the nation's stupidest techniques. Mail Online, August 16 2017

Wax on, wax ouch: pubic grooming has a high injury rate, survey reveals. The Guardian, August 16 2017

Links To Science

Truesdale MD, Osterberg EC, Gaither TW. Prevalence of Pubic Hair Grooming–Related Injuries and Identification of High-Risk Individuals in the United States. JAMA Dermatology. Published online August 16 2017

'Alternative cancer therapies' may increase your risk of death - 16 Aug 2017

"Cancer patients who use alternative medicine more than twice as likely to die," is the stark message from The Independent. Researchers found that people who chose alternative medicine instead of conventional cancer treatments were much less likely to survive for at least five years.

Conventional treatments included surgery, radiotherapychemotherapy or hormone treatments. The research only applies to people who choose not to have conventional treatments.

Overall, 78% of people having conventional treatment for cancer survived at least five years, compared to only 55% of people having alternative treatment alone. The difference was biggest for breast cancer, where people who chose alternative therapies were more than five times as likely to die within five years as those who chose conventional treatments.

Because this is an observational study, we don't know if other factors might have affected people's survival chances, as well as treatment choice. However, treatment choice seems the most likely explanation.

There are reports that some people find complementary treatments of benefit during cancer treatments. For example, some people have said that acupuncture helped them cope better with the side effects of chemotherapy.

But importantly, the emphasis is very much on the "complementary" and not on the "alternative". Ignoring medical advice on the treatment choices that potentially offer the most benefit could prove fatal.


Where did the story come from?

The study was carried out by researchers from Yale School of Medicine. No funding information was provided. Two of the four researchers had received previous grants from companies involved in conventional cancer treatments, and one received research funding from the organisation 21st Century Oncology.

The study was published in the peer-reviewed Journal of the National Cancer Institute as a "brief communication", meaning not all the study data was published. Some additional data is published online.

Most of the UK media ran reasonably accurate and balanced stories. Several – notably the Mail Online and The Sun – speculated on the types of alternative therapy people might have been using.

For example, the Mail said: "Breast cancer patients are 5.68 times more at risk if they opt for homeopathy." However, the researchers did not record the alternative therapies used, so we don't know whether homeopathy was one of them.

The Mail also refers to "herbs, botanicals, diets or energy crystals." While these are sometimes promoted as alternative treatments for cancer, again, we don't know which of them were used by people in this study.


What kind of research was this?

This was an observational case control study. This means researchers identified people with cancer who chose to use alternative therapies (cases) and compared their outcomes with those of people with cancer who chose conventional treatments (controls).

The controls were matched as far as possible with each case based on age, sex, demographics and type of cancer. Observational studies can show trends and links between factors (in this case between type of treatment and length of survival after cancer diagnosis) but cannot prove that one causes the other.


What did the research involve?

Researchers used data from the US National Cancer Database to identify patients with breast, lung, colorectal or prostate cancer, who opted not to receive conventional cancer therapies, but were recorded as having had "other-unproven cancer treatments administered by non-medical personnel."

These patients were matched with two patients with the same type of cancer, who were similar in other ways, but had opted for conventional treatment. Researchers then looked to see how many people lived for at least five years, comparing those who chose alternative therapies with those who chose conventional cancer treatments.

Researchers only included people who had cancer that had not yet spread from the initial site. This type of cancer is usually treatable by conventional treatments They also excluded people with stage 4 (advanced) cancer, those whose treatment was intended to be palliative rather than curative, and people whose treatment was unknown.

Researchers found 281 people who matched the criteria and who had opted for alternative therapy only. Of these, 280 were matched to 560 people with the same cancer, who chose conventional cancer treatments.

To minimise the effect of confounding factors researchers matched people in the study using these criteria:

  • cancer type
  • age
  • stage of cancer
  • health insurance – in the US people with health insurance tend to receive a better standard of treatment
  • co-morbidities (other illnesses)
  • race
  • year of diagnosis

In addition, when calculating relative chances of surviving five years, the researchers adjusted their figures to account for the effects of medical and demographic factors.


What were the basic results?

Researchers found that people choosing alternative therapies were more likely to be younger, female, have fewer other ailments, a higher cancer stage, a higher income and education level.

Taking all types of cancer together:

  • 78.3% of people having conventional cancer treatment lived at least five years (95% confidence interval [CI] 74.2% to 81.8%)
  • 54.7% of people having alternative therapies lived at least five years (95% CI 47.5% to 61.3%)
  • people were 2.5 times more likely to live for at least five years if they had conventional treatment (hazard ratio [HR] 2.5, 95% CI 1.88 to 3.27)

The type of cancer made a difference, though. This is probably because some cancers can kill quickly without treatment, and treatment is very effective. We can see this in the breast cancer results:

  • 86.6% of people who chose conventional treatment for breast cancer lived at least five years (95% CI 80.7% to 90.7%)
  • 58.1% of people who chose alternative therapies for breast cancer lived at least five years (95% CI 46% to 68.5%)
  • people were 5.68 times more likely to live at least five years if they had conventional treatment for breast cancer (HR 5.68, 95% CI 3.22 to 10.04)

However, for prostate cancer, it made little difference whether people opted for conventional treatment (91.5% lived for at least five years) or alternative treatment (86.2% lived for at least five years).

This is probably because prostate cancer usually grows very slowly in the early stages so few people die.

For the first five to 10 years, there's little difference in those who have conventional treatments and those who have their prostate cancer monitored, with no treatment unless it starts to grow. So, you would not expect to see a difference in a five year study.


How did the researchers interpret the results?

The researchers said: "We found that cancer patients who initially chose treatment with alternative medicine without conventional cancer treatment were more likely to die."

They added: "Improved communication between patients and caregivers, and greater scrutiny of use of alternative medicine for initial treatment of cancer is needed."



The results and conclusions of this study are clear: people who choose conventional treatments for cancer (such as surgery, radiotherapy, chemotherapy and hormone treatments) are likely to live longer than those who choose alternative medicine only.

It's rare for people to choose to ignore conventional treatment completely when faced with a cancer diagnosis. More often, people choose to add complementary therapies to their conventional cancer treatment. This study doesn't apply to people combining conventional and complementary therapies.

There are some limitations to the study to be aware of:

  • As an observational study, it cannot prove that treatment choice (as opposed to other factors) was the sole reason that people who chose conventional treatments lived longer. However, it seems the most likely explanation. The researchers made efforts to balance out other possibly confounding factors. It's also clear from other studies that conventional cancer therapies do work.
  • The study might have misclassified some people who started taking alternative therapies when diagnosed, but switched later to conventional treatments. However, as they would be classified in this study as having taken conventional treatments, this suggests that any switchers would only strengthen the study findings, if they were reclassified as having taken alternative medicine.

People who are diagnosed with cancer and want the best chance of surviving should choose conventional cancer therapies. These give the best chance of helping people with cancer to live longer lives.

Complementary therapies such as acupuncture and tai chi may help some people but they should never take the place of potentially life-saving treatments such as chemotherapy, surgery and radiotherapy.

Links To The Headlines

Cancer patients who use alternative medicine more than twice as likely to die. The Independent, August 15 2017

Cancer patients who rely on herbs, homeopathy or energy crystals over conventional treatment are two-and-a-half times more likely to die within five years of diagnosis. Mail Online, August 15 2017

Cancer patients who shun chemo for alternative therapies ‘are TWICE as likely to die’. The Sun, August 15 2017

Cancer warning: THIS treatment option could double your risk of dying. Daily Express, August 15 2017

Links To Science

Johnson SB, Park HS, Gross CP, Yu JB. Use of Alternative Medicine for Cancer and Its Impact on Survival. Journal of the National Cancer Institute. Published online August 10 2017

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