Diet and Food Access Are Risk Factors for Early Onset Colorectal Cancer Mortality

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Consumption of fruit and vegetables was found to be protective while consuming sweet snacks and candy along with supercenters and warehouse clubs as a primary food source were determined to be risk factors for early onset colorectal cancer mortality.

Consumption of sweet snacks and candy and poor access to healthy food, as indicated by supercenters and warehouse clubs as a primary food source, were determined to be a risk factors for early onset colorectal cancer (EOCRC) mortality, according to a large database analysis presented at the American College of Gastroenterology (ACG) 2023 Annual Scientific Meeting in Vancouver, Canada.

In a multivariate linear regression model that included variables for demographics, risk factors, and access, several risk factors were associated with EOCRC mortality. These factors included sweet snacks and candy (P = .0016), diabetes (P = .0022), supercenters and warehouse clubs as the main food source (P = .0438), a sedentary lifestyle (P = .0204), rural county (P <.0001), and African American ethnicity (P = .0094). Protective characteristics included consumption of more fruits and vegetables (P = .0099), female gender (P = .0324), and high socioeconomic status (P <.0001).

"Dietary counseling to include increased fruit and vegetable intake and decreased sweet snack and candy intake may reduce early onset colorectal cancer mortality," lead investigator William K. Oelsner, MD, from the University of Tennessee HSC College of Medicine Chattanooga, said during a presentation of the results. "Population-based public health initiatives aimed at improving the food environment may lower early-onset colorectal cancer mortality, particularly in Southern US."

The data source for the analysis was the Surveillance, Epidemiology, and End Results (SEER) program and the CDC: National Program of Cancer Registries (NPCR), which together include 100% of cancer-related mortality in the United States, Oelsner noted. Early onset mortality for the analysis was defined as death occurring between the ages of 20 and 49 years.

Data from these databases were further overlapped with information from the Nielsen Home Scan National Consumer Panel, the United States Department of Agriculture, and County Health Rankings and Roadmaps, to identify food source and potential dietary patterns. A Pearson correlation was applied along with multi-linear regression modeling to find potential correlations.

The dataset for the analysis included 68,495 individuals from 1307 counties across the United States. Counties with fewer than 10 cases in the 20-year period from 1999 to 2020 were excluded from the analysis. Initial data from the mortality database identify a disproportionate density of EOCRC mortality in the Southern region of the United States.

On Pearson Correlation, dietary patterns and food environment were found to be significantly correlated with EOCRC mortality. By location, the strongest correlation was food environment index, which had a -0.46 correlation with mortality (P <.0001). Additionally, household consumption of fruits and vegetables, packaged sweet snacks, and consumption of butter, margarine, and solid fats were also strongly correlated with EOCRC mortality (P <.0001).

"High early onset colorectal cancer mortality counties had unhealthy food environments, and consumed fewer fruits and vegetables and consumed more meat and soda," said Oelsner.

In the multivariate linear regression modeling, demographics and CRC risk factors were also included in the analysis. With these factors included, higher consumption of fruits and vegetables was found to be protective (P = .0116) whereas consumption of candy and sweets was a risk factor for EOCRC mortality (P = .0037). Without demographics and CRC risk factors included, other factors such as soda and meat intake were also found to be risk factors (P <.0001); however, Oelsner noted, it was not stated whether this was processed meat or fresh.

Community access to specific food sources was also factored into the model, to see the potential role of access to healthy food. This was meant to simulate healthy food deserts or swamps within the United States. In this analysis, protective properties included access to specialty food stores (P <.0001); however, when factoring in demographics and risk factors this was not a contributing factor. With these factors included supercenters and warehouse clubs as a food source were found to be risk factors for EOCRC mortality (P = .0442).

"Specialty food stores are protective when compared to all other food sources," said Oelsner. "Supercenters and warehouse clubs are a risk factor, suggesting bulk packaged food is a risk factor for early-onset CRC mortality."

When looking at all these factors in conjunction with the counties where these events occurred most frequently, high mortality plus an unhealthy food environment was more commonly seen in the Southern United States. Moreover, there were a few small pockets of high mortality seen in areas of healthy food environments, these pockets of EOCRC mortality were seen throughout the country.

"Unhealthy food environment had significant overlap in areas of high EOCRC mortality," said Oelsner. "The subset of high early onset CRC mortality in healthy food environments requires further study."


Oelsner W, Kahloon A, Vijayvargiya P. Early Onset Colorectal Cancer Mortality is Higher in the Southeast US and Significantly Associated with Poor Food Environment. Presented at: ACG 2023 Annual Meeting; October 20-25, 2023. Abstract 6.