EPIC-Norfolk: Key Findings


Healthy living 'can add 14 years'

With so much information available nowadays on healthy lifestyles, it can seem confusing to the average person as to what is beneficial to our health, and in turn, this makes it difficult for health professionals to encourage people to make changes to their habits. In EPIC-Norfolk, we demonstrated the combined impact of four healthy behaviours: not smoking, exercising, eating fruits and vegetables, and drinking alcohol moderately, relating this to normal every day activities. People were counted as exercising if they did as little as an hour a week. And those with a certain level of vitamin C in their blood were considered to be eating enough fruit and vegetables. People who drank between one to fourteen units of alcohol a week (around nine 125 ml glasses of wine, or seven pints of 3-4% beer) were considered "moderate" drinkers as opposed to drinking none, or more.

Our results clearly showed that people who drink moderately, exercise, quit smoking and eat five servings of fruit and vegetables each day live on average 14 years longer than people who adopt none of these behaviours. This result demonstrates that modest and achievable lifestyle changes can have a marked effect on health.

Khaw et al., Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study . PLoS Medicine5 (1) e12. dol:10.1371/journal.pmed.0050012 Published January 8 2008


Coping well with stress can cut the risk of a stroke.

We examined the relationship between sense of coherence, an indicator of a person's ability to adapt to social stress, and subsequent stroke risk. Participants with a strong sense of coherence, who reported that they took less time to adapt to life events, had a 24 per cent lower risk of stroke over a 7 year follow-up independent of other factors. Sense of coherence is a measure of how strongly a person believes that what happens in their life is comprehensible, manageable and meaningful. These results show that those people who have the ability to cope with stress can reduce their risk of having a stroke by around a quarter.

Paul G. Surtees, Nicholas W.J. Wainwright, Robert L. Luben, Nicholas J. Wareham, Sheila A. Bingham, and Kay-Tee Khaw Adaptation to social adversity is associated with stroke incidence: evidence from the EPIC-Norfolk prospective cohort study Stroke 2007: 38: 1447 - 1453 


Eating breakfast is good for you.

Eating breakfast is on the decline. We investigated the association between percentage of total daily energy intake consumed at breakfast and weight change over the follow-up period in our cohort and found that although all participants gained weight during the course of the study, those who consumed 22 to 50% of their energy at breakfast had the lowest BMI compared to people who consumed only 0 to 10% of their energy at breakfast and a 1% increase in the proportion of total energy consumed at breakfast time was associated with 21g less weight gain. These findings indicate consuming a higher proportion of total daily calories at breakfast is associated with relatively lower weight gain in middle age.

Purslow LR, Sandhu MS, Forouhi N, et al. Energy Intake at Breakfast and Weight Change: Prospective Study of 6,764 Middle-aged Men and Women. Am J Epidemiol 2007; Dec 12


Physical activity and increased longevity.

While physical activity has been associated with improving health, including reducing risk of heart disease and stroke, it is not clear how much physical activity is needed for health benefits.  Many studies have only looked at leisure time physical activity but not taken into account work based activity.  In EPIC-Norfolk we developed a simple pragmatic index of physical activity, suitable for use in general practice, which combines both work and leisure time physical activity.  Men and women who were moderately active or active had about one third lower risk of death from any causes or of having heart disease or strokes over the next eight years compared to men and women who were inactive. Compared to being inactive, (sedentary work, no leisure time physical activity), even those who were moderately inactive, (sedentary work with up to half and hour physical activity such as cycling, swimming, keep fit etc., or standing work such as hairdresser, guard, shop assistant without leisure time activity), had about 20% lower risk of death and cardiovascular disease.  Not being completely inactive compared to being inactive was comparable to being about three years younger in terms of longevity. Even relatively small and relatively achievable differences in physical activity are associated with big differences in health. 

Khaw KT et al.  Work and leisure time physical activity assessed using a simple, pragmatic validated questionnaire and incident cardiovascular disease and all cause mortality in men and women:  The European Prospective Investigation into Cancer in Norfolk prospective population study.  Int J Epidemiology 2006; Aug;35(4):1034-43.


Obesity and cancer risk

Obesity appears to be a risk factor for a number of cancers including breast cancer in women after the menopause, and kidney cancer. Avoiding obesity may be one way to reduce risk of a number of cancers. Identifying why obesity may increase cancer risk may help us understand how better to prevent or treat cancer.

Lahmann PH, et al. Body size and breast cancer risk: findings from the European Prospective Investigation into Cancer And Nutrition (EPIC). Int J Cancer 2004;111:762-71.

Pischon T et al. Body size and risk of renal cell carcinoma in the European Prospective Investigation into Cancer and Nutrition (EPIC). Int J Cancer. 2006;118:728-38. 2:


Sex hormone levels in women and breast cancer risk.

In the Europe wide EPIC study, women who had higher blood levels of sex hormones including testosterone (male hormones) as well as oestrogen (female hormone) appear to have higher risk of breast cancer. We know that obesity is associated with higher levels of sex hormones and also higher risk of breast cancer in postmenopausal women. If we can identity dietary and other lifestyle factors that influence sex hormone levels in women, this may indicate ways to lower breast cancer risk.

Kaaks R et al. Serum sex steroids in premenopausal women and breast cancer risk within the European Prospective Investigation into Cancer and Nutrition (EPIC). J Natl Cancer Inst 2005;97:755-65.]

Rinaldi S et al. Anthropometric measures, endogenous sex steroids and breast cancer risk in postmenopausal women: A study within the EPIC cohort.
Int J Cancer. 2006;118:2832-9.


Dietary sodium and potassium intake and blood pressure.

High blood pressure increases risk of stroke and heart attack. High sodium, or salt intake has been associated with increased risk of high blood pressure but it is not clear whether changing salt intake within the usual range that is realistic in the general community is likely to have an influence on blood pressure. In EPIC-Norfolk, men and women who consumed the least salt, (about 5 grams daily), in every day life had lower average blood pressure and were at half the risk of having hypertension (high blood pressure) compared with those who consumed the most amount of salt, (about 10 grams daily). Even within the usual range of salt intake in the community, small and easily achievable reductions in salt intake, e.g. by less than a teaspoon daily, (about 5 grams), may halve a person's chances of getting high blood pressure. In contrast, high dietary intake of potassium, found in plant foods such as fruit and vegetables appears to protect against high blood pressure.

Khaw KT et al. Blood pressure and urinary sodium in men and women: the Norfolk Cohort of the European Prospective Investigation into Cancer (EPIC-Norfolk). Am J Clin Nutr 2004;80:1397-403.


Bowel Cancer: High dietary fibre protects against effects of high meat intake.

There is a much controversy as to whether high meat intake increases risk of bowel cancer. In the European study, we have found that high dietary fibre intake lowers and high meat intake increases risk of bowel cancer. However, there is an interaction between the different foods. Meat intake increases cancer risk only in those people with low intakes of dietary fibre; high dietary fibre or high fish intake appear to protect against the effects of meat intake and risk of bowel cancer.

Norat T et al. Meat, fish, and colorectal cancer risk: the European Prospective Investigation into cancer and nutrition.J Natl Cancer Inst. 2005;97:906-16.

Bingham SA et al. Dietary fibre in food and protection against colorectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC): an observational study. Lancet 2003;361:1496-501.


Eating fruits and vegetables reduces the risk of an early death.

We examined the blood levels of vitamin C in almost 20,000 EPIC participants. We found that a rise in the level of vitamin C equivalent to a 50g per day increase in fruit and vegetable consumption could cut the risk of dying early from any cause by 20 per cent. This roughly corresponds to eating an extra apple a day €“ adding two more daily portions of fruit and vegetables could reduce the risk by as much as half. These findings hold regardless of people's age, blood pressure or whether they smoked.

We also found that men and women with the highest levels of vitamin C were 60 to 70 per cent less likely to die from heart attacks or strokes than those with the lowest levels.

These are some of the largest effects of a small change in diet ever detected. They show that there could be significant health gains from even a small increase in fruit and vegetable consumption.

Published in the Lancet, March 2001 (Lancet 357(9257): 657-663)


High impact sports may preserve bone density.

We examined data from over 5,000 EPIC participants aged 45-74 who had attended for a second health check. At the check, ultrasound measurements of the heels were made. Low heel bone ultrasound values (low attenuation) are known to be associated with low bone mineral density.
The participants also completed a questionnaire on their physical activity. From this questionnaire, people's recreational activities were classified into four groups according to levels of impact. Activities with no impact included swimming and snooker. Badminton and step aerobics, for example, were classified into the highest impact group.

We found that reported time spent on high impact physical activity was strongly and positively associated with higher ultrasound levels, regardless of people's age and weight. Men who reported taking part in high impact activities for more than two hours a week had around 10% higher ultrasound levels than men who recorded no activity of this type. For women, the high impact group had levels 3% higher, an effect similar in size to an age difference of four years. Women who climbed stairs more often also had higher ultrasound measurements, and those who spent more time watching television had lower levels.

Our results suggest that participation in high impact activities may help preserve bone density and reduce the risk of fracture for people in mid-life. However, this would not be appropriate for older people, who have thinner bones, as these activities could increase the likelihood of falls and fractures.

Published in the British Medical Journal, January 2001 (BMJ 322(7279): 140-146)

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last updated: 20 September 2010