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

Cynthia A. Thomson, Tracy E. Crane, David O. Garcia, Betsy C. Wertheim, Melanie Hingle, Linda Snetselaar, Mridul Datta, Thomas Rohan, Erin LeBlanc, Rowan T. Chlebowski, Lihong Qi

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)617-626
Number of pages10
JournalJournal of the Academy of Nutrition and Dietetics
Issue number4
StatePublished - Apr 2018


  • Cancer
  • Energy density
  • Obesity
  • Postmenopausal women

ASJC Scopus subject areas

  • Food Science
  • Nutrition and Dietetics


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