Association between Dietary Energy Density and Obesity-Associated Cancer: Results from the Women's Health Initiative

J Acad Nutr Diet. 2018 Apr;118(4):617-626. doi: 10.1016/j.jand.2017.06.010. Epub 2017 Aug 17.


Background: Dietary energy density (DED) is the ratio of energy (kilocalories or kilojoules) intake to food weight (grams) and is a measure of diet quality. Consumption of foods high in DED has been associated with weight gain in adults.

Objective: To investigate the association between baseline DED and incident obesity-associated cancers in the Women's Health Initiative.

Design: Prospective cohort study of clinical trial and observational study participants.

Participants/setting: Postmenopausal women aged 50 to 79 years (N=92,295) enrolled in the observational study or the calcium and vitamin D trial and hormone replacement therapy trials of the Women's Health Initiative.

Main outcome measures: Incident, medical record-adjudicated, obesity-related cancers during follow-up. Exposure variable was DED (kilocalories per gram for the total diet) from self-reported dietary intake at baseline using a food frequency questionnaire.

Statistical analyses: The associations between DED and each incident cancer, or any obesity-related cancer, were examined using competing-risks regression models, with death as a competing risk. Body mass index-stratified models were generated to investigate body mass index as a potential modifying factor.

Results: DED was associated with higher body mass index (28.9±6.0 vs 26.3±4.9) and waist circumference (89.3±14.2 vs 82.4±12.4 cm) for DED quintiles 5 vs 1, respectively. DED was associated with a 10% increased risk of any obesity-related cancer (subhazard ratioQ5 vs Q1: 1.1, 95% CI 1.03 to 1.2; P=0.004). This increased risk appeared limited to women who were normal weight at enrollment.

Conclusions: Higher DED may be a contributing factor for obesity-related cancers, especially among normal-weight postmenopausal women and, as such, could serve as a modifiable behavior for dietary interventions to reduce obesity-associated cancer risk.

Keywords: Cancer; Energy density; Obesity; Postmenopausal women.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Body Mass Index
  • Clinical Trials as Topic
  • Diet / adverse effects*
  • Energy Intake*
  • Female
  • Humans
  • Middle Aged
  • Neoplasms / etiology*
  • Obesity / complications*
  • Observational Studies as Topic
  • Postmenopause
  • Prospective Studies
  • Risk Factors
  • Waist Circumference
  • Weight Gain
  • Women's Health