The Sulfur Microbial Diet Is Associated With Increased Risk of Early-Onset Colorectal Cancer Precursors

Gastroenterology. 2021 Nov;161(5):1423-1432.e4. doi: 10.1053/j.gastro.2021.07.008. Epub 2021 Jul 14.


Background & aims: Diet may contribute to the increasing incidence of colorectal cancer (CRC) before age 50 (early-onset CRC). Microbial metabolism of dietary sulfur produces hydrogen sulfide (H2S), a gastrointestinal carcinogen that cannot be easily measured at scale. As a result, evidence supporting its role in early neoplasia is lacking.

Methods: We evaluated long-term adherence to the sulfur microbial diet, a dietary index defined a priori based on increased abundance of 43 bacterial species involved with sulfur metabolism, with risk of CRC precursors among 59,013 individuals who underwent lower endoscopy in the Nurses' Health Study II (1991-2015), a prospective cohort study with dietary assessment every 4 years through validated food frequency questionnaires and an assessment of dietary intake during adolescence in 1998. The sulfur microbial diet was characterized by intake high in processed meats, foods previously linked to CRC development, and low in mixed vegetables and legumes. Multivariable logistic regression for clustered data was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

Results: We documented 2911 cases of early-onset adenoma. After adjusting for established risk factors, higher sulfur microbial diet scores were associated with increased risk for early-onset adenomas (ORquartile [Q]4 vs Q1, 1.31; 95% CI, 1.10-1.56, Ptrend = .02), but not serrated lesions. Compared with the lowest, women in the highest quartile of sulfur microbial diet scores had significantly increased risk of early-onset adenomas with greater malignant potential (ORQ4 vs Q1, 1.65 for villous/tubulovillous histology; 95% CI, 1.12-2.43; Ptrend = .04). Similar trends for early-onset adenoma were observed based on diet consumed during adolescence. In contrast, no clear association for adenomas was identified after age 50.

Conclusions: Our findings in a cohort of young women support a role for dietary interactions with gut sulfur-metabolizing bacteria in early-onset colorectal carcinogenesis, possibly beginning in adolescence.

Keywords: Cancer Biogeography; Colorectal Adenoma; Colorectal Carcinogenesis; FFQ; Hydrogen Sulfide.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adenomatous Polyps / diagnosis
  • Adenomatous Polyps / epidemiology*
  • Adult
  • Age of Onset
  • Bacteria / metabolism*
  • Colonic Polyps / diagnosis
  • Colonic Polyps / epidemiology*
  • Colorectal Neoplasms / diagnosis
  • Colorectal Neoplasms / epidemiology*
  • Diet / adverse effects*
  • Female
  • Gastrointestinal Microbiome*
  • Humans
  • Hydrogen Sulfide / adverse effects
  • Hydrogen Sulfide / metabolism
  • Middle Aged
  • Precancerous Conditions / diagnosis
  • Precancerous Conditions / epidemiology*
  • Prospective Studies
  • Risk Assessment
  • Risk Factors
  • Sulfur Compounds / administration & dosage
  • Sulfur Compounds / adverse effects*
  • Sulfur Compounds / metabolism
  • Time Factors
  • United States / epidemiology


  • Sulfur Compounds
  • Hydrogen Sulfide