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Global Cancer Burden Attributable to Dietary Risks: Trends,
Regional Disparities, and Future Projections (1990-2050)
Jinghao Liang1, #, Yijian Lin2, #, Zishan Huang3, #, Jingchun Ni2, Hongmiao Lin4,
Yiwen Cai2, Jihao Qi2, Liangyi Yao2, Luoyao Yang3,Dianhan Lin5,Zhihua Guo1,
Weiqiang Yin1,*, Jianxing He 1,*
1Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou
Medical University, State Key Laboratory of Respiratory Disease & National Clinical Research
Center for Respiratory Disease, Guangzhou, China
2Second Clinical Medical College, Guangdong Medical University, Dongguan, China
3Guangzhou Medical University, Xinzao, Panyu District, Guangzhou 511436, China
4The Affliated Qingyuan Hospital (Qingyuan People's Hospital), Guangzhou Medical University
5Shantou University Medical College,Shantou 515063
,
China
# These authors contributed to this work equally.
*Corresponding authors: Weiqiang Yin (yinweiqiang88@163.com); Jianxing He
(drjianxing.he@gmail.com), Department of Thoracic Surgery and Oncology, the First Affiliated
Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease &
National Clinical Research Center for Respiratory Disease, Guangzhou, 510120, China
Abstract
Cancer remains a leading global cause of death, with its burden increasingly shaped by
demographic shifts and dietary factors. This study utilized the Global Burden of Disease (GBD)
2021 database to evaluate cancer burdens attributable to dietary risks from 1990 to 2021,
accounting for differences by age, gender, region, and socioeconomic level, and projected trends
through 2050 using a Bayesian Age-Period-Cohort model. The global disability-adjusted life years
(DALYs) attributable to dietary risks declined from 302.48 to 189.62 per 100,000 population
(AAPC: -1.49%) over three decades, yet disparities remain prominent across Socio-Demographic
Index (SDI) regions. High-SDI countries, such as Luxembourg, achieved substantial reductions,
while low-SDI nations like Lesotho and Zimbabwe experienced rising burdens, driven by
inadequate dietary quality and limited health resources. Key dietary risks, including low intake of
whole grains, milk, and red meat, demonstrated improvement in high-income countries but
worsening trends in many low- and middle-income regions. Projections suggest a continued global
decline in cancer burden attributable to dietary factors by 2050, with high-income regions
benefiting most, while Latin America, the Caribbean, North Africa, and the Middle East may
experience slower progress or transient increases. Additionally, the burden of poor dietary
practices is expected to rise sharply among individuals aged 75 years and older, underscoring the
compounding effects of aging populations. These findings highlight the urgent need for culturally
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is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 1, 2024. ; https://doi.org/10.1101/2024.11.30.24318246doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
tailored dietary interventions and evidence-based policies to address disparities, reduce cancer
burdens, and improve outcomes for vulnerable populations globally.
Keywords:Cancer burden; Dietary risks; Global analysis; Disability-adjusted life years;
Cancer projections
Introduction
Cancer remains a significant global public health issue and is the second leading cause of death
worldwide. Between 1990 and 2019, age-standardized incidence and mortality rates for cancer
demonstrated a decreasing trend. However, the onset of the COVID-19 pandemic led to a
subsequent increase in global age-standardized mortality rates in 2020 and 2021, partially
reversing previous progress1. The International Agency for Research on Cancer (IARC) projects
that the number of new cancer cases worldwide will rise from approximately 20 million in 2022 to
over 35 million by 2050—an increase of 77%2, underscoring the immense disease burden faced by
the global population.Understanding modifiable risk factors for cancer, particularly those related
to dietary habits that are relatively easier to intervene upon, is essential for informing cancer
prevention and control strategies. Diet has been established as a major modifiable risk factor for
cancer in multiple studies3. Adherence to the Mediterranean diet, characterized by an emphasis on
vegetables, fruits, whole grains, nuts, seeds, legumes, moderate consumption of fish, olive oil, and
alcohol, and reduced intake of red or processed meats and dairy products, has been shown to
reduce cancer risk4–6. Nevertheless, prior research has often focused on single dietary patterns or
nutrients, and largely centered on digestive system cancers such as esophageal and colorectal
cancer7–10. There remains a lack of comprehensive analysis evaluating various dietary factors
across all cancer types and geographic regions, particularly regarding the impact of dietary
disparities across different regions on cancer burden.
To address this research gap, this study evaluates cancer risk attributable to dietary factors from
1990 to 2021, incorporating potential confounding factors such as gender, age, region, and
socioeconomic level. Leveraging the Global Burden of Disease (GBD) database, this study
provides a comprehensive assessment of the impact of dietary factors on the global cancer burden,
encompassing a wide range of cancer types beyond the digestive system. Using a Bayesian
Age-Period-Cohort (BAPC) model, we aim to project the impact of dietary risk factors on cancer
incidence and mortality trends globally and regionally through 2050. Our findings will inform
evidence-based dietary adjustments in different regions to reduce cancer risk and mortality,
providing actionable recommendations to mitigate the future cancer burden associated with diet.
Methods
Data source
The present study utilized the latest data from the GBD 2021 database, a comprehensive global
health repository encompassing detailed information on 371 diseases, 88 risk factors, and
numerous injuries11,12. The primary data sources for GBD 2021 include vital registration systems,
verbal autopsies, surveys, censuses, surveillance systems, and cancer registries, providing critical
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evidence for estimating disease incidence and mortality rates.
Definition
We identified 9 dietary risk factors (detailed in the supplementary table s1) that satisfied the GBD
selection standards for inclusion as risk factors. These criteria involve the significance of the risk
factor in terms of disease burden or policy impact, the availability of adequate data to estimate
exposure, the strength of epidemiological evidence supporting a causal association between
exposure and health outcomes, and the availability of data to quantify the magnitude of this
association per unit change in exposure. Additionally, evidence must support the generalizability
of these effects across different populations. The process for evaluating the epidemiological
evidence of causality for each diet-disease pair is comprehensively documented elsewhere and
summarized in the appendix11.
Global cancer burden estimates
Colon and rectum cancer, stomach cancer, breast cancer, tracheal, bronchus, and lung cancer, and
esophageal cancer data, including neoplasm-related deaths, DALYs, and corresponding
age-standardized rates, were obtained from the Global Health Data Exchange (GHDx) website
(https://vizhub.healthdata.org/gbd-results/). The DALYs and mortality for these neoplasms were
classified using the International Classification of Diseases, Tenth Revision
(ICD-10)13(supplementary table s2). Prostate cancer data, which predominantly consisted of
negative values, was excluded from the analysis due to its limited interpretability.
Statistics
In this study, Joinpoint regression analysis was performed using Joinpoint 5.1.0 to compute the
annual percentage change (APC) and average annual percentage change (AAPC) in cancer
mortality and DALYs rates14. This widely applied statistical model facilitates the identification of
significant turning points in disease trends, as well as overall patterns over specified time intervals.
Decomposition analysis was employed to quantify the individual contributions of population age
structure, population growth, and epidemiological changes to cancer-related disability-adjusted
life years (DALYs) associated with dietary risk, providing a clear understanding of these factors'
influence on the overall cancer burden14. Additionally, Pearson's correlation coefficient was
calculated to assess the relationship between the Socio-Demographic Index (SDI) and
age-standardized cancer DALYs15,16. To evaluate cross-country health inequalities, we used the
slope index of inequality and the concentration index to measure both absolute and relative health
disparities. The slope index was derived by regressing cancer incidence, mortality, and DALYs on
a relative social position scale based on GDP per capita, with heteroskedasticity controlled using a
weighted regression model. The concentration index was calculated by fitting the observed
cumulative distribution of the population by income to the Lorenz curve for cancer burden,
followed by numerical integration of the area under the curve17,18. Finally, the Integrated Nested
Laplace Approximation (INLA) framework combined with the Bayesian Age-Period-Cohort
(BAPC) model was used to predict future trends in cancer burden. The BAPC model, based on
Global Burden of Disease (GBD) data from 1990 to 2021 and population projections from the
World Health Organization, provides accurate forecasts while addressing convergence issues
common to traditional Bayesian Markov Chain Monte Carlo (MCMC) methods19. All statistical
analyses and data visualizations were performed using R 4.4.1, with statistical significance
defined at P < 0.05.
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is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 1, 2024. ; https://doi.org/10.1101/2024.11.30.24318246doi: medRxiv preprint
Result
Global Reduction and Regional Disparities in Diet-Related Cancer Burden
Based on the Global Burden of Disease (GBD) database, the global disability-adjusted life years
(DALYs) attributable to dietary risk factors for cancer decreased substantially from 302.48 per
100,000 population in 1990 to 189.62 per 100,000 in 2021, with an average annual percentage
change (AAPC) of -1.49% (95% CI: -1.57 to -1.42). This trend indicates a significant reduction in
the global burden of diet-related cancers over the past three decades. Notably, Kazakhstan (DALY
AAPC: -3.25%), China (-2.57%), Turkmenistan (-2.81%), and Luxembourg (-2.30%)
demonstrated the greatest reductions in cancer burden. Conversely, the burden increased in
Lesotho (+2.21%), Zimbabwe (+1.08%) and Romania (+0.80%). At the Socio-Demographic Index
(SDI) regional level, countries in high-SDI regions exhibited a marked declining trend in DALYs
(-1.50%), including Austria (-2.34%) and Luxembourg (-2.30%). Middle-SDI regions
demonstrated greater heterogeneity, with substantial improvements in Kyrgyzstan (-2.53%) and
Uzbekistan (-2.38%) but a rising burden in countries such as the Philippines (+0.70%) and
Romania (+0.80%). Low-SDI regions displayed similarly diverse trends, with significant
reductions in Burundi (-1.57%) and Rwanda (-1.55%) but marked increases in Zimbabwe and
Lesotho, underscoring disparities in health resource allocation and intervention intensity (table1).
Global Trends in Cancer Burden Attributable to Top Three Dietary Risk
Globally, the leading dietary risk factors contributing to the cancer burden were diet high in red
meat, diet low in milk, and diet low in whole grains, each demonstrating considerable geographic
and temporal variability. The burden of diet high in red meat decreased significantly in
high-income regions, particularly in Europe and North America countries, with AAPCs between
-1.48% and -2.31%, while a contrasting increasing trend was noted in low- and middle-income
regions, including sub-Saharan Africa, South America, and Southeast Asia, with AAPCs up to 2.34%
(Fig. 1 A-C, supplementary table s3). The cancer burden attributable to Diet low in milk showed
significant declines in North America, Europe, and Oceania (AAPC ranging from -2.05% to
-19.2%), whereas positive AAPCs were observed in South Asia, Africa, and the Caribbean,
indicating insufficient dairy consumption in these regions(Fig. 1 D-F, supplementary table s3).
Low whole grain intake demonstrated a declining burden in high-income regions such as North
America and Australia (AAPC from -2.32% to -1.40%), while increasing trends persisted in Latin
America, the Middle East, and sub-Saharan Africa (AAPC between 0.60% and 2.70%) (Fig. 1 G-I,
supplementary table s3).
Specific Dietary Risk Factors and Their Associations with Cancer Types
In 2021, poor dietary practices remained major contributors to cancer-related DALYs globally. For
instance, high red meat consumption was associated with a breast cancer burden of 28.37 DALYs
(95% CI: -0.0092 to 60.54). Colorectal cancer showed a significant burden attributable to several
dietary factors:Diet low in whole grains (50.19 DALYs; 95% CI: 20.37-76.30), diet low in fiber
(3.58 DALYs; 95% CI: 1.58-5.50), diet high in processed meat (15.11 DALYs; 95% CI: -3.60 to
30.93), diet low in calcium (24.70 DALYs; 95% CI: 18.17-31.02), and diet low in milk (42.99
DALYs; 95% CI: 11.73-71.23). Additionally, gastric cancer was linked to diet low in vegetables
(20.78 DALYs; 95% CI: -4.68 to 102.38) and diet high in sodium (44.53 DALYs; 95% CI: -7.45
to 222.31), while diet low in fruits was linked to the burden of tracheal, bronchial, and lung cancer
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(18.46 DALYs; 95% CI: 9.49-26.90).(supplementary table s4) There were no significant
associations observed between the cancer burden and other dietary factors, such as diet high in
trans fatty acids, diet low in omega-6polyunsaturated fatty acids, diet low in seafood omega-3
fatty acids, diet low in legumes,diet low in nuts and seeds, or diet high in sugar-sweetened
beverages.
Socioeconomic Disparities(SDI) and Shifting Patterns in Diet-Related Cancer Burden
The global diet-related cancer burden is predominantly driven by colorectal cancer, particularly in
high-SDI regions, while gastric and esophageal cancers contribute significantly in low-SDI
regions. This pattern highlights the interplay between dietary habits and levels of socioeconomic
development, with the cancer burden shifting towards colorectal and breast cancers as SDI
increases (Fig. 2 A-B, supplementary table s7). The inter- and intra-regional disparities in dietary
risk-related cancer burden across 204 countries and 21 regions further underscore the role of
socioeconomic context. Low-SDI regions showed relatively stable intraregional variation but
significant interregional differences, whereas middle- and high-SDI regions demonstrated
substantial variability both within and across regions. Central Asia exhibited particularly
pronounced intraregional disparities, with DALY rates ranging from approximately 200 to over
400 per 100,000 population (Fig. 2 C-D, supplementary table s6). From 1990 to 2021, the
association between SDI and DALY rates for diet-related cancers exhibited an increasing trend,
with the slope of the relationship rising from 272.16 (95% CI: ~222.18-322.15) in 1990 to 299.17
(95% CI: ~258.70-339.63) in 2021. The concentration index (CI) for diet-related cancer burden
remained negative in both years, at -0.17 in 1990 and -0.18 in 2021, indicating better health
outcomes among disadvantaged populations. However, the absolute increases in both slope and CI
values indicate that inequality in cancer burden attributable to dietary risk factors has worsened
over time (Fig. 2 E-F, supplementary table s7).
Age, Gender, and Decomposition Analysis of Diet-Related Cancer Burden
Age-stratified analysis indicated that the burden of diet-related cancers increases significantly with
age, particularly among individuals aged 75 years and older. In the 75-79 age group, DALYs
exceeded 50,000 in both males and females, with cancer-related mortality peaking in this cohort.
Males experienced a higher burden across most age groups, highlighting a disproportionate impact
of diet-related cancers on men (Fig. 3 A-B, supplementary table s8). Decomposition analysis
further revealed that population growth and aging were the primary drivers of the increased cancer
burden attributable to dietary factors, while improvements in epidemiological factors partially
mitigated the overall impact. Population growth contributed approximately 1 million DALYs,
while aging accounted for an additional increase of 500,000 DALYs (Fig. 3 C-D, supplementary
table s9).
Projected Trends in Cancer DALYs Attributable to Dietary Risks Up to 2050
Projections for dietary risk-related cancer DALYs from 2022 to 2050 suggest a global decline in
age-standardized cancer DALYs, from 344.27 to 223.71 per 100,000 population. High-income
regions are projected to exhibit the steepest decline, while a relatively slower rate of decline is
anticipated in Latin America and the Caribbean. A transient rebound in cancer mortality is
expected in North Africa and the Middle East between 2025 and 2030. While the burden is
expected to decrease continuously among individuals aged 25-54, a sharp increase is projected for
the elderly population, particularly in the 75-95 age group, reflecting the significant impact of
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population aging on the future cancer burden attributable to dietary Factors(Fig. 4, supplementary
table s10).
Discussion
Our study, based on the Global Burden of Disease (GBD) data from 1990 to 2021, provides an
in-depth analysis of the impact of dietary factors on cancer burden and its changing trends,
revealing significant regional disparities influenced by socioeconomic and dietary characteristics.
Over the past three decades, the global cancer burden attributable to dietary factors has decreased
by an average of 1.49% annually. However, the degree of improvement is uneven across different
regions and populations. High Socio-Demographic Index (SDI) countries such as Austria and
Luxembourg have significantly reduced the burden of colorectal cancer through dietary
optimization and screening measures, whereas low-SDI countries like Lesotho and Zimbabwe
continue to experience rising burdens of gastric and esophageal cancers due to poor dietary
nutrition and insufficient resources. Additionally, the burden of diet-related cancers varies
significantly by gender and age, with males and individuals aged 75 years and older being
disproportionately affected. These findings underscore the importance of culturally tailored health
education programs, dietary optimization, increased intake of key nutrients, and the promotion of
dietary-related cancer screening measures as essential pathways to reducing the global cancer
burden.
The impact of dietary factors on specific cancers is highly targeted, providing a scientific basis for
precision interventions through understanding the complex underlying pathophysiological
mechanisms. Low whole grain intake, for example, reduces dietary fiber, disrupts gut microbiota,
and increases the risk of exposure to carcinogens such as nitrosamines and bile acids, thereby
significantly increasing the incidence of colorectal cancer20 21. Low calcium intake weakens the
protective function of epithelial cells, heightening the risk of esophageal cancer 22 23. In
high-income countries, policies promoting whole grain and calcium-enriched foods have yielded
substantial success; for instance, Northern Europe has effectively reduced the burden of colorectal
cancer 24 and esophageal cancer 25 through food subsidies and health labeling policies. Conversely,
sub-Saharan Africa and Southeast Asia face persistently high burdens of gastric and esophageal
cancers due to insufficient calcium and dietary fiber intake 26, coupled with high salt and pickled
food consumption 27 28. Addressing this requires the implementation of regional policies that
promote the consumption of calcium-rich and fiber-rich foods, the introduction of legumes and
root crops, the development of affordable calcium-fortified foods, and strengthened health
education targeting high-salt and pickled food consumption to achieve dietary improvements and
reduce disease burden.
Interestingly, our data also reveal that high trans-fatty acid intake, low omega-6 polyunsaturated
fatty acid intake, low seafood omega-3 fatty acid intake, and high sugar-sweetened beverage
intake do not show a significant association with cancer burden, in contrast to previous research
that has highlighted their carcinogenic potential. Prior studies suggest that trans fats may increase
ovarian cancer risk by inducing inflammation 29, and excessive omega-6 intake may interfere with
omega-3 fatty acid utilization, thereby promoting tumorigenesis 30 31. These discrepancies may
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reflect the complexity of cancer etiology, the overall effect of dietary patterns, or the dilution of
associations for specific regions or subpopulations in global analyses.
Our findings further indicate that differences in adverse dietary factors across geographic, age, and
gender dimensions necessitate more precise strategies for intervention. At the geographic level,
high-SDI countries have reduced the burden of diet-related cancers through long-term policy
interventions, such as the European "Healthy Food Label Program" 32, which has increased the
selection of whole grain and low-fat food options among residents. In contrast, low-SDI countries
continue to bear a high burden of diet-related cancers, particularly in regions with high incidence
rates of gastric and esophageal cancers 33, due to a lack of health resources and weak dietary
education. For these countries, international aid or regional cooperation could support
community-based dietary improvement programs that teach methods for preparing low-cost,
nutrient-dense diets 34 35 36. Regarding age distribution, the burden of diet-related cancers
increases significantly with age, particularly among individuals aged 75 years and older,
underscoring the importance of dietary interventions during middle age to prevent cancer burden
in later life. Gender differences also show that males bear a higher burden of diet-related cancers
compared to females, likely related to dietary behaviors and higher red meat consumption 37 38.
Thus, policy interventions for male populations should focus on limiting high-risk foods, such as
processed meats and high-fat snacks, and promoting healthy alternatives.
The carcinogenic mechanisms of adverse dietary factors differ significantly across SDI regions,
underscoring the importance of targeted policy interventions. In high-SDI countries, processed
foods, high-fat diets, and low dietary fiber intake are the main risks 39 40. These countries can
reduce the burden of diet-related cancers by restricting the sale of processed foods, optimizing
nutrition standards, and providing subsidies for healthy foods. Northern Europe's subsidy for
whole grain foods, which has significantly increased the prevalence of healthy diets, serves as a
successful example 41. In low-SDI countries, deficiencies in key nutrients, such as calcium and
dietary fiber, are the primary carcinogenic drivers 42, closely linked to traditional single dietary
patterns and poverty. Promoting the cultivation of fiber-rich crops through agricultural policy and
improving calcium intake through school nutrition programs are recommended interventions.
Meanwhile, middle-SDI countries face the dual challenge of dietary transition, with both high-salt
pickled foods and processed foods posing threats. These countries should adopt a "dual-path
dietary policy," which aims to reduce high-salt food consumption through campaigns similar to
the salt reduction initiatives in the Americas and Europe 43, while also implementing fiscal
controls on ultra-processed foods and guiding residents toward healthy alternatives. Such
differentiated intervention strategies can effectively address dietary issues across different SDI
regions, thereby reducing the global burden of diet-related cancers.
Future projections of the cancer burden attributable to dietary factors highlight significant regional
disparities and complexities among different populations, emphasizing the urgent need for global
health interventions. Although the age-standardized DALYs for diet-related cancers are projected
to decline globally from 344.267 to 223.713 per 100,000, this improvement is not uniform
between high-income and low-income regions. For example, high-income countries are expected
to experience a further decline in diet-related cancer burden, benefiting from the long-term
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promotion of whole grain and dairy product consumption 44, whereas Latin America and the
Caribbean are likely to see only modest declines, indicating gaps in the coverage of intervention
measures. Mortality projections for North Africa and the Middle East suggest a temporary rebound
in cancer-related deaths between 2025 and 2030, potentially due to the continuation of traditional
high-salt dietary practices. Simultaneously, the burden among those aged 75 years and older is
expected to rise substantially, underscoring the impact of aging populations. Precision
interventions, such as designing nutrient-fortified dietary plans for the elderly, enhancing
screening services, and ensuring that health resources can accommodate the needs of an aging
population, are crucial for driving improvements in global health outcomes and ensuring equitable
distribution of health resources worldwide.
Author Contributions
Study conceptualization: Jianxing He, and Weiqiang Yin. Accessed and verified the underlying
data reported in the manuscript: Jinghao Liang and Yijian Lin. Data curation: Zishan Huang,
Yijian Lin, Jingchun Ni, Jihao Qi, and Hongmiao Lin. Formal analysis: Yiwen Cai, Yijian Lin,
Liangyi Yao, and Jihao Qi. Designed Fig.s and tables: Yuanqing Liu, Weijie Yang, and Zishan
Huang. Writing original draft of the manuscript: Jinghao Liang, Dianhan Lin, and Yijian Lin.
Review and editing of the manuscript: Jinghao Liang, Yijian Lin, Luoyao Yang, Jihao Qi,
Jingchun Ni, Yiwen Cai, and Liangyi Yao. Jinghao Liang, Yijian Lin, and Zishan Huang
contributed equally to this work. All authors read and approved the final version of the manuscript,
had full access to all the data, and are responsible for the decision to submit for publication.
Declaration of interests
The authors declare no competing interests.
Data Availability
Data used in this analysis are accessible through the Global Health Data Exchange (GHDx)
platform. This study utilizes primary data from the Global Burden of Disease (GBD) 2021, which
are available for download online.
Acknowledgment
This study received no funding.
Ethics approval and consent to participate
Ethical approval was not required for this study, as it utilized publicly available, anonymized data
aggregated at the population level.
Consent for publication
Not applicable.
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is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 1, 2024. ; https://doi.org/10.1101/2024.11.30.24318246doi: medRxiv preprint
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is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 1, 2024. ; https://doi.org/10.1101/2024.11.30.24318246doi: medRxiv preprint
Reference
1. Schumacher, A. E. et al. Global age-sex-specific mortality, life expectancy, and population
estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the
impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global
Burden of Disease Study 2021. The Lancet 403, 1989–2056 (2024).
2. Bray, F. et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and
mortality worldwide for 36 cancers in 185 countries. CA. Cancer J. Clin. 74, 229–263 (2024).
3. Afshin, A. et al. Health effects of dietary risks in 195 countries, 1990–2017: a systematic
analysis for the Global Burden of Disease Study 2017. The Lancet 393, 1958–1972 (2019).
4. Fan, Y. et al. Effects of diets on risks of cancer and the mediating role of metabolites. Nat.
Commun. 15, 5903 (2024).
5. Chan, D. S. M. et al. Red and Processed Meat and Colorectal Cancer Incidence:
Meta-Analysis of Prospective Studies. PLoS ONE 6, e20456 (2011).
6. Trichopoulou, A., Bamia, C. & Trichopoulos, D. Anatomy of health effects of Mediterranean
diet: Greek EPIC prospective cohort study. BMJ 338, b2337–b2337 (2009).
7. Mayne, S. T., Playdon, M. C. & Rock, C. L. Diet, nutrition, and cancer: past, present and
future. Nat. Rev. Clin. Oncol. 13, 504–515 (2016).
8. Giles, E. D. et al. Trends in Diet and Cancer Research: A Bibliometric and Visualization
Analysis. Cancers 15, 3761 (2023).
9. Rock, C. L. et al. American Cancer Society guideline for diet and physical activity for cancer
prevention. CA. Cancer J. Clin. 70, 245–271 (2020).
10. Mentella, M. C., Scaldaferri, F., Ricci, C., Gasbarrini, A. & Miggiano, G. A. D. Cancer and
Mediterranean Diet: A Review. Nutrients 11, 2059 (2019).
11. Brauer, M. et al. Global burden and strength of evidence for 88 risk factors in 204 countries
and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of
Disease Study 2021. The Lancet 403, 2162–2203 (2024).
12. Ferrari, A. J. et al. The GBD 2021 findings were crucial for policymakers, public health
professionals, and researchers as they facilitated the identification of health disparities within
and between populations, monitoring changes over time, gauging health advancements, and
shaping strategies to address post-COVID-19 health inequalities. The Lancet 403, 2133–2161
(2024).
13. Tran, K. B. et al. The global burden of cancer attributable to risk factors, 2010–19: a
systematic analysis for the Global Burden of Disease Study 2019. The Lancet 400, 563–591
(2022).
14. Kim, H.-J., Fay, M. P., Feuer, E. J. & Midthune, D. N. Permutation tests for joinpoint
regression with applications to cancer rates. Stat. Med. 19, 335–351 (2000).
15. Chen, J. et al. Global, regional, and national burden of cancers attributable to particulate
matter pollution from 1990 to 2019 and projection to 2050: Worsening or improving? J.
Hazard. Mater. 477, 135319 (2024).
16. Li, W. et al. Global cancer statistics for adolescents and young adults: population based study.
J. Hematol. Oncol.J Hematol Oncol 17, 99 (2024).
17. Cao, F. et al. Global burden and cross-country inequalities in autoimmune diseases from 1990
to 2019. Autoimmun. Rev. 22, 103326 (2023).
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 1, 2024. ; https://doi.org/10.1101/2024.11.30.24318246doi: medRxiv preprint
18. Ordunez, P. et al. Rheumatic heart disease burden, trends, and inequalities in the Americas,
1990–2017: a population-based study. Lancet Glob. Health 7, e1388–e1397 (2019).
19. Knoll, M. et al. An R package for an integrated evaluation of statistical approaches to cancer
incidence projection. BMC Med. Res. Methodol. 20, 257 (2020).
20. Hullings, A. G. et al. Whole grain and dietary fiber intake and risk of colorectal cancer in the
NIH-AARP Diet and Health Study cohort. Am J Clin Nutr 112, 603–612 (2020).
21. Song, M., Garrett, W. S. & Chan, A. T. Nutrients, foods, and colorectal cancer prevention.
Gastroenterology 148, 1244–60 e16 (2015).
22. Smolinski, K. N. et al. Activation of the esophagin promoter during esophageal epithelial cell
differentiation. Genomics 79, 875–80 (2002).
23. Li, Q. et al. Protective Effect of Dietary Calcium Intake on Esophageal Cancer Risk: A
Meta-Analysis of Observational Studies. Nutrients 9, (2017).
24. Ratjen, I. et al. Postdiagnostic Mediterranean and Healthy Nordic Dietary Patterns Are
Inversely Associated with All-Cause Mortality in Long-Term Colorectal Cancer Survivors. J
Nutr 147, 636–644 (2017).
25. Jeurnink, S. M. et al. Variety in vegetable and fruit consumption and the risk of gastric and
esophageal cancer in the European Prospective Investigation into Cancer and Nutrition. Int J
Cancer 131, E963-73 (2012).
26. Shah, S. C. et al. Associations between calcium and magnesium intake and the risk of
incident gastric cancer: A prospective cohort analysis of the National Institutes of
Health-American Association of Retired Persons (NIH-AARP) Diet and Health Study. Int J
Cancer 146, 2999–3010 (2020).
27. Tsugane, S. Salt, salted food intake, and risk of gastric cancer: epidemiologic evidence.
Cancer Sci 96, 1–6 (2005).
28. Sangija, F., Martin, H. & Matemu, A. African nightshades (Solanum nigrum complex): The
potential contribution to human nutrition and livelihoods in sub-Saharan Africa. Compr Rev
Food Sci Food Saf 20, 3284–3318 (2021).
29. Yammine, S. et al. Dietary and Circulating Fatty Acids and Ovarian Cancer Risk in the
European Prospective Investigation into Cancer and Nutrition. Cancer Epidemiol Biomark.
Prev 29, 1739–1749 (2020).
30. Mouradian, M., Kikawa, K. D., Johnson, E. D., Beck, K. L. & Pardini, R. S. Key roles for
GRB2-associated-binding protein 1, phosphatidylinositol-3-kinase, cyclooxygenase 2,
prostaglandin E2 and transforming growth factor alpha in linoleic acid-induced upregulation
of lung and breast cancer cell growth. Prostaglandins Leukot Essent Fat. Acids 90, 105–115
(2014).
31. Simopoulos, A. P. Evolutionary aspects of diet, the omega-6/omega-3 ratio and genetic
variation: nutritional implications for chronic diseases. Biomed Pharmacother 60, 502–7
(2006).
32. Narciso, A. & Fonte, M. Making Farm-to-Fork Front-of-the-Pack: Labelling a Sustainable
European Diet. Int. J. Sociol. Agric. Food 27, 54–70 (2021).
33. Hong, M. Z. et al. Global burden of major gastrointestinal cancers and its association with
socioeconomics, 1990-2019. Front Oncol 12, 942035 (2022).
34. Oldewage Theron, W. H. & Kruger, R. Impact of food aid on food variety and dietary
diversity of an elderly community in Sharpeville, South Africa. J Nutr Health Aging 13,
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 1, 2024. ; https://doi.org/10.1101/2024.11.30.24318246doi: medRxiv preprint
300–8 (2009).
35. Carter, L. & Peishi, Z. Creating Momentum for Nutrition-Sensitive Agriculture: Experiences
and Lessons from the Australian Aid Program. Asian J. Agric. Dev. (2018).
36. Verly-Jr, E., Sichieri, R., Darmon, N., Maillot, M. & Sarti, F. M. Planning dietary
improvements without additional costs for low-income individuals in Brazil: linear
programming optimization as a tool for public policy in nutrition and health. Nutr J 18, 40
(2019).
37. Usher-Smith, J. A. et al. Impact of achievement and change in achievement of lifestyle
recommendations in middle-age on risk of the most common potentially preventable cancers.
Prev Med 153, 106712 (2021).
38. S. Deoula M et al. Consumption of meat, traditional and modern processed meat and
colorectal cancer risk among the Moroccan population: A large-scale case-control study. Int J
Cancer 146, 1333–1345 (2020).
39. Gonzalez, C. A. & Riboli, E. Diet and cancer prevention: Contributions from the European
Prospective Investigation into Cancer and Nutrition (EPIC) study. Eur J Cancer 46, 2555–62
(2010).
40. Isaksen, I. M. & Dankel, S. N. Ultra-processed food consumption and cancer risk: A
systematic review and meta-analysis. Clin. Nutr. 42, 919–928 (2023).
41. Saxe, H. The New Nordic Diet is an effective tool in environmental protection: it reduces the
associated socioeconomic cost of diets. Am J Clin Nutr 99, 1117–25 (2014).
42. Liang, Y. et al. Distributions and Trends of the Global Burden of Colorectal Cancer
Attributable to Dietary Risk Factors over the Past 30 Years. Nutrients 16, (2023).
43. Santos, J. A. et al. A Systematic Review of Salt Reduction Initiatives Around the World: A
Midterm Evaluation of Progress Towards the 2025 Global Non-Communicable Diseases Salt
Reduction Target. Adv Nutr 12, 1768–1780 (2021).
44. Chen, X. et al. Global burden and cross-country inequalities in stroke and subtypes
attributable to diet from 1990 to 2019. BMC Public Health 24, 1813 (2024).
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted December 1, 2024. ; https://doi.org/10.1101/2024.11.30.24318246doi: medRxiv preprint
Fig. legends
Fig. 1. Comparison of cancer DALYs attributable to the three most common dietary risks across
204 countries and territories worldwide. (A-C) Cancer DALYs attributable to a diet high in red
meat for the years 1990, 2021, and the average annual percentage change (AAPC) from 1990 to
2021. (D-F) Cancer DALYs attributable to a diet low in milk for the years 1990, 2021, and the
AAPC from 1990 to 2021. (G-I) Cancer DALYs attributable to a diet low in whole grains for the
years 1990, 2021, and the AAPC from 1990 to 2021.DALYs: Disability-adjusted life years; AAPC:
Average annual percentage change.
Fig. 2. Association between cancer and the Socio-demographic Index (SDI). (A) Global and
region-specific cancer cases for all ages, and (B) age-standardized rates, alongside the proportion
of DALYs and deaths by cancer type. (C) Association between age-standardized DALYs rate and
SDI across 21 regions, and (D) association with SDI across 204 countries. (E) Slope indexes and
(F) concentration indexes for cancer DALYs globally from 1990 to 2021.SDI: Socio-demographic
Index.
Fig. 3. Global burden of cancers by sex. (A) Global age-specific counts and rates of
disability-adjusted life years (DALYs) by sex, and (B) global age-specific counts and rates of
cancer deaths by sex. (C) Decomposition analysis of trends in cancer DALYs by sex from 1990 to
2021, and (D) decomposition analysis of trends in cancer deaths by sex from 1990 to 2021.
Fig. 4. Projections of cancer DALYs by 2050 based on the BAPC model.(A) Projected global
cancer DALYs, (B) projections for Sub-Saharan Africa, (C) projections for Southeast Asia, East
Asia, and Oceania, (D) projections for Central Europe, Eastern Europe, and Central Asia, (E)
projections for high-income countries, (F) projections for Latin America and the Caribbean, (G)
projections for North Africa and the Middle East, and (H) projections for South Asia.DALYs:
Disability-adjusted life years; BAPC: Bayesian Age-Period-Cohort model.
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