Skip to main content
Download PDF

Higher adherence to the EAT-Lancet reference diet is inversely associated with mortality in a UK population of cancer survivors

BMC Medicine volume 23, Article number: 286 (2025) Cite this article

Abstract

Background

Significant advancements in treatment and care, as well as early detection, have contributed to an increase in cancer survival rates. Recently, the EAT-Lancet Commission on Food, Planet, Health proposed the “planetary health diet” but to date, no study has investigated the potential associations between adherence to the EAT-Lancet reference diet and mortality in cancer survivors. To determine whether higher adherence to the EAT-Lancet reference diet is associated with lower risk for all-cause, cancer, and cardiovascular mortality in cancer survivors.

Methods

Data from the prospective UK Biobank study were used. Information from UK Biobank’s Touchscreen questionnaire was used to develop a score reflecting adherence to the EAT-Lancet reference diet. Cox proportional hazards regression was used to assess the association of the EAT-Lancet reference diet score with all-cause, cancer, and cardiovascular mortality in cancer survivors.

Results

Within 25,348 cancer survivors, better adherence to the EAT-Lancet reference diet was inversely related to all-cause mortality (hazard ratio (HR): 0.97, 95% confidence interval (CI): 0.95–0.99), 1 unit increase) and cancer mortality (HR: 0.98, 95% CI: 0.96–1.00), while mostly null associations were observed for major cardiovascular mortality (HR: 0.99, 95% CI: 0.95–1.03).

Conclusions

Our findings suggest the adoption of the EAT-Lancet reference diet is associated with lower all-cause and cancer-specific mortality among cancer survivors.

Peer Review reports

Background

Advances in early diagnosis and treatment options have contributed to the ongoing increase in cancer survival rates [1, 2]. According to the European Commission, it is estimated that over 12 million cancer survivors are living in Europe [3]. With the improvement in survival rates, there is an urgent need for evidence-based diet and lifestyle recommendations, tailored to the needs of cancer survivors. Although a wealth of knowledge exists on the link between potentially modifiable lifestyle factors and cancer risk, fewer studies have investigated how different lifestyle factors, including diet, might influence post-diagnosis outcomes [4,5,6,7] and more research on this topic is needed.

Research on the relationship between modifiable lifestyle factors and survival in cancer patients is limited and often reports conflicting results. Some studies have linked higher body weight, obesity, smoking, and alcohol consumption to increased mortality [8,9,10]. Conversely, engaging in physical activity and following high-quality dietary patterns, as well as consuming specific foods or food groups, have been associated with a reduced risk of death [5, 6, 8,9,10,11]. However, several studies did not confirm these associations, resulting in mixed findings [10]. Recently, the Global Cancer Update Programme published two comprehensive reviews on breast and colorectal cancer prognosis. These systematic reviews rated the data on dietary factors and outcomes after breast or colorectal cancer diagnosis as limited/ limited-suggestive for lower risk of the examined outcomes [12, 13]. Evidence on other cancers with respect to survival is even more sparse.

The EAT-Lancet Commission on Food, Planet, Health proposed in 2019 the “planetary health diet,” also known as the EAT-Lancet reference diet. It is a mainly plant-based diet that, according to the EAT-Lancet Commission, addresses the environmental impact of food production and consumption better than most national food-based dietary guidelines [14]. The EAT-Lancet reference diet takes a similar stance on plant-based items as most national food-based dietary guidelines but is stricter in terms of animal-based product consumption, while plant protein sources are emphasized more strongly. Despite the widespread interest it generated, few studies have investigated whether the EAT-Lancet reference diet is also associated with lower risk of non-communicable diseases in the general population using cohort data. Most have reported a modest lower risk for all-cause mortality and non-communicable disease risk (e.g., cancer, cardiovascular disease, diabetes) with better adherence [15,16,17,18,19,20,21,22,23]. To the best of our knowledge, no published study has investigated the adherence to the EAT-Lancet reference diet in cancer survivors and its association with mortality.

In this study, we aimed to investigate the association between the EAT-Lancet reference diet and all-cause, cancer and cardiovascular mortality, overall and by pre-defined potential effect modifiers, in a sub-sample of the United Kingdom (UK) Biobank cohort comprising cancer survivors (i.e., with a previously recorded cancer diagnosis at the time of study recruitment).

Methods

Study population

The UK Biobank cohort is a large, population-based prospective study with over 500,000 participants throughout the UK. Detailed information on the study design, methods, and rationale of the cohort has been previously reported [24]. During the baseline assessment, information on medical, dietary, anthropometric, and lifestyle factors was collected, including information on alcohol use, smoking status, physical activity, education, reproductive history, and previous illnesses, including cancer. Study participants consented to be followed using linkages to NHS registers where health events and deaths were recorded.

A flowchart of the study population can be seen in Additional File 1: Fig. S1. Participants were included in the analyses if they had a recorded cancer diagnosis before their recruitment in the UK Biobank, based on linked data from cancer registries. Detailed information on the study population selection can be found in the Additional file 2: Additional Study Methodology. The mean time between cancer diagnosis and study recruitment was 8.56 ± 7.60 years.

Participants with a recorded death date between the date of recruitment and the latest date of complete information (30 September 2021 for England and Wales; 31 October 2021 for Scotland) were considered as all-cause mortality cases. When either the primary or secondary cause of death was recorded as C00–C97 or D00–D48 (10th Revision of the International Statistical Classification of Diseases, Injuries, and Causes of Death), these were considered cancer mortality cases; when they were recorded as I00–I25 or I27–I88 (10th Revision of the International Statistical Classification of Diseases, Injuries, and Causes of Death), they were considered cardiovascular mortality cases.

Adherence to the EAT-Lancet reference diet

Dietary information collected via the UK Biobank Touchscreen questionnaire was used to develop a score that reflects adherence to the EAT-Lancet reference diet. Information on dietary intake and the methodology related to the development of the score can be found in the Additional file 2: Additional Study Methodology [25].

Study participants received a score based on whether each component of their diet was within the cut-offs of the EAT-Lancet reference diet (Additional file 2: Table S1). The dietary intake for females was rescaled to reflect a daily dietary intake of 2000 kcal, rounded to the nearest whole number (see Additional file 2: Table S1). The sum of all components resulted in each participant’s overall EAT-Lancet reference diet score. Each component contributed equally to the overall EAT-Lancet reference diet score. Our scoring approach was largely based on the one described by Knuppel et al. [17]. When the UK Biobank Touchscreen information did not sufficiently capture the necessary information to operationalize the score like Knuppel et al., different scoring approaches were used (Additional file 2: Table S1). The score ranged from zero to eleven, with higher scores reflecting higher adherence to the EAT-Lancet reference diet. The score was additionally categorized into three groups, based on tertiles of the score in the study population.

Statistical analyses

Categorical variables were presented by percentages and continuous variables by arithmetic means and standard deviations (SD) for descriptive purposes.

Cox proportional hazards regression models were used to assess the association of the EAT-Lancet reference diet score with all-cause, cancer, and cardiovascular mortality in cancer survivors. The association with all-cause mortality was further explored in survivors of three frequently diagnosed cancer types (i.e., primary breast, primary prostate, and primary colorectal cancer). Entry time was defined as a participant’s age at study recruitment and exit time as a participant’s age at death, loss to follow-up, or end of follow-up, whichever came first.

The EAT-Lancet reference diet score was included in the models as continuous and as a categorical variable. We followed a tiered approach to adjust for potential confounders. Model 1 was stratified for age (5-year intervals), study assessment region (10 regions), and sex. Model 2 was further adjusted for education, Townsend deprivation index (quintiles; as an indicator for socio-economic status), smoking status (never, former, current, prefer not to answer/missing), body mass index (BMI) categories (≤ 18.5 kg/m2,18.5–24.9 kg/m2, 25.0–29.9 kg/m2, ≥ 30 kg/m2, missing; according to the World Health Organization classification [26]), physical activity (< 75 min per week, 75–150 min per week, > 150 min per week, prefer not to answer/missing), alcohol consumption (never, former, current drinker, prefer not to answer/missing), self-reported changes in the diet in the past 5 years, and time between the initial cancer diagnosis and study recruitment.

P values for trend were calculated using the median value of the tertiles in the models. We conducted pre-planned stratified analyses by potential effect modifiers including sex, BMI, smoking status, alcohol intake status, self-reported recent dietary changes, and time between the initial cancer diagnosis and study recruitment. Sensitivity analyses were conducted, restricting the analyses to participants with at least two years of follow-up time. Analyses were conducted using Stata version 13 (StataCorp, TX). Associations with a two-sided P < 0.05 were considered statistically significant.

Results

After an average follow-up of 11.5 years, 4781 deaths were recorded in the 25,348 cancer survivors of the UK Biobank cohort.

Almost 64% of the study participants were female with a mean age of 60 years at recruitment (Table 1). Almost 40% had a college or university degree, less than 10% were current smokers, and roughly one-third had a BMI of 18.5–24.9 kg/m2. Participants with higher EAT-Lancet reference diet scores were more likely to be female; they were less likely to currently smoke or drink alcohol (Table 1). No marked differences were observed across the score categories in education, overweight/obesity, or physical activity.

Table 1 Baseline characteristics of the study population, overall and by categories reflecting adherence to the EAT-Lancet reference diet
Full size table

The association between the EAT-Lancet reference diet, as expressed via a score, and all-cause mortality is shown in Table 2. Higher adherence to the EAT-Lancet reference diet was inversely associated with all-cause mortality (hazard ratio (HR)continuous: 0.97, 95% confidence interval (CI): 0.95–0.99; HRhigh vs. low: 0.90, 95% CI: 0.84–0.99; p-trend: 0.004). When investigating the association in study population sub-groups diagnosed with selected primary cancer types (Table 3), higher adherence to the EAT-Lancet reference diet was inversely associated with all-cause mortality in participants diagnosed with breast cancer (HRcontinuous: 0.95, 95% CI: 0.92–0.99; HRhigh vs. low: 0.86, 95% CI: 0.76–0.98). A null association was seen in those diagnosed with colorectal cancer (HRcontinuous: 0.98; 95% CI: 0.92–1.05; HRhigh vs. low: 0.88; 95% CI: 0.68–1.13), while a positive association was seen for the continuous model in those diagnosed with prostate cancer (HRcontinuous: 1.06, 95% CI: 1.01–1.12; HRhigh vs. low: 1.18; 95% CI: 0.98–1.43).

Table 2 The association between the EAT-Lancet reference diet and mortality in cancer survivors
Full size table
Table 3 The association between the EAT-Lancet reference diet and all-cause mortality in cancer survivors of selected primary cancer types
Full size table

The association between the EAT-Lancet reference diet, as expressed via a score, and cause-specific mortality is shown in Table 2. In analyses combining the primary and secondary causes of death, higher adherence to the EAT-Lancet reference diet was inversely associated with cancer mortality (HRcontinuous: 0.98, 95% CI: 0.96–1.00; HRhigh vs. low: 0.92, 95% CI: 0.85–0.99; p-trend: 0.04). Null associations were seen in analyses on cardiovascular mortality in both the continuous and categorical models (HR continuous: 0.99, 95% CI: 0.95–1.03; HRhigh vs. low: 0.95, 95% CI: 0.82–1.09; p-trend: 0.36). Analyses restricted to the primary cause of death were largely similar (Additional File 2: Table S2), with slightly wider CIs due to the lower number of events.

The results of stratified analysis using predefined potential effect modifiers can be seen in Fig. 1 (all-cause mortality), Fig. 2 (cancer mortality), and Fig. 3 (cardiovascular mortality). Some differences were seen between the different groups for all-cause mortality, cancer mortality, or cardiovascular mortality. Depending on the outcome, females, people with a BMI of 18.5–24.9 kg/m2 or ≥ 30 kg/m2, current alcohol drinkers, and those diagnosed with cancer over 10 years before recruitment showed stronger inverse associations. Restricting the analyses to study participants with at least 2 years of follow-up time did not significantly modify our results (Figs. 1, 2, and 3).

Fig. 1
figure 1

The association between the EAT-Lancet reference diet and all-cause mortality, stratified by pre-defined potential effect modifiers

Full size image
Fig. 2
figure 2

The association between the EAT-Lancet reference diet and cancer mortality, stratified by pre-defined potential effect modifiers

Full size image
Fig. 3
figure 3

The association between the EAT-Lancet reference diet and cardiovascular mortality, stratified by pre-defined potential effect modifiers

Full size image

Discussion

In this cohort of 25,348 cancer survivors, we observed modest inverse associations between the EAT-Lancet reference diet and the risk of all-cause mortality and cancer-specific mortality. To the best of our knowledge, this is the first study to date exploring the adherence to the EAT-Lancet reference diet and its association with mortality in cancer survivors.

Low adherence to the EAT-Lancet reference diet was observed in our study population (score 0–4: 48.4%; score 5–7: 24.0%; score ≥ 8: 4.9%). Our findings are in line with previous publications that have found that cancer survivors do not follow healthy diets post diagnosis, with low adherence to most indices/guidelines investigated [10, 27,28,29]. Irrespective of the dietary indices, guidelines, or dietary recommendations examined in each study, cancer survivors generally adhered to the recommendation to abstain from smoking but otherwise scored poorly in terms of adhering to diet-related recommendations (e.g., 5-A-Day; World Cancer Research Fund/American Institute for Cancer Research; American Cancer Society) [10, 27,28,29]. The existing evidence highlights an area where further investment is needed to facilitate the adoption of healthier habits in the post-diagnosis period and investigate the barriers (e.g., treatment side-effects affecting appetite or taste) to healthy habit adoption in this population.

Despite the continuous increase in the number of people surviving their cancer diagnosis, thanks to early detection, screening programs, effective therapies, and care, few studies have investigated the association between post-diagnosis lifestyle and its relationship with mortality. To the best of our knowledge, few observational studies have investigated the association between the EAT-Lancet reference diet and mortality, including cancer-specific mortality [23, 30]. However, all these associations were estimated based on the dietary intake of a population free of cancer at the time of data collection, and as such are not directly comparable to our findings.

Limited evidence exists on whether the post-diagnosis lifestyle is associated with better post-diagnosis outcomes (e.g., recurrence, disease-free survival) in cancer survivors. The few studies in the available literature suggest that higher adherence to different dietary indices, dietary guidelines, or lifestyle patterns might be associated with a lower risk of all-cause mortality [4, 7, 10, 12] and improved survival [31]. The scarcity of evidence is particularly worrisome given that in the absence of evidence-based recommendations tailored to the needs of cancer survivors, most government bodies are simply recommending following the guidelines developed for the general population. As such, these recommendations and guidelines are unlikely to take into account the particular needs of cancer survivors (e.g., treatment side effects, need for long-term medication use). This lack of evidence-based recommendations tailored to the needs of cancer survivors has unfortunately been filled in many instances by practices not supported by the literature (e.g., excessive dietary supplement use) [32, 33].

In our study, we observed a null association between the EAT-Lancet reference diet and cardiovascular mortality. Studies in the literature have highlighted that, compared with people without cancer, adult cancer survivors have a significantly higher risk of cardiovascular disease [34]. We hypothesize that the lack of an association between the EAT-Lancet reference diet and cardiovascular mortality in our study might suggest that, given their higher risk and the monitoring they receive post-cancer diagnosis, cancer survivors are likely to receive medication (e.g., statins, antihypertensive drugs) and might not receive an additional benefit of diet on top of that.

The results of our stratified analyses highlighted some differences in the association between the adherence to the EAT-Lancet reference diet and mortality (all-cause or cause-specific). The sex-specific differences we observed could potentially be explained by the differential associations seen for the two main sex-specific cancers (i.e., breast and prostate cancer). Studies in prostate cancer survivors have reported heterogeneity of the effect of diet on survival based on survivors’ Gleason score [35]. Unfortunately, information on survivors’ Gleason score is not available in the UK Biobank and could not be used as an adjusting or stratifying variable in our study.

The findings supporting an inverse association with survival in survivors with BMI ≥ 30 kg/m2 are in line with a recent study reporting no association of greater adiposity at diagnosis (measured by imaging) with worse survival among cancer survivors [36]. The reasons behind the observed survival benefits after cancer diagnosis are not entirely clear. This phenomenon could be explained by the association of obesity with less aggressive tumor subtypes with better survival outcomes, the reported higher tolerance of some anticancer therapies in patients with overweight/obesity, and the benefit of energy reserves in supporting the body during cancer treatment [33]. Larger studies will be necessary to look at different types of cancer. A recent study urged for the development and testing of intervention studies to increase our understanding of the health benefits of optimal body composition in cancer survivors [37].

The strengths of this study included the prospective study design and the substantial number of confirmed prevalent cases, but it also has some limitations. Dietary information was only available at baseline for the entire study population and may not reflect the long-term lifestyle habits of the study participants. To overcome this, we adjusted the study results by self-reported dietary changes. Another limitation is the lack of information on cancer stage and treatment and the potential effect these could have had on the dietary intake of the study population. To overcome this, we stratified our results based on the time between cancer diagnosis and inclusion in the study, assuming that the potential adverse effects of treatment are lessening over time. The dietary data collected with the Touchscreen questionnaire did not include all relevant information, so some components of the EAT-Lancet reference diet could not be operationalized in our study. Further, multivariable-adjusted models were unable to account for total energy intake calculated from the Touchscreen questionnaire due to the lack of dietary-related questions asked at recruitment. To account for potential reverse causation, we examined associations by follow-up time. However, results did not differ significantly when we excluded deaths that occurred during the first two years of follow-up. Cancer survivors that participated in the study are potentially healthier or have less aggressive disease compared with cancer survivors who did not participate in the UK Biobank cohort. As such, the present results might not be generalizable in people with more aggressive cancers.

Conclusions

In conclusion, this large population-based study provides evidence to support that adherence to the diet proposed by the EAT-Lancet expert commission is associated with lower all-cause and cancer-specific mortality among cancer survivors. Additional studies are needed in this specific population to further assess their post-diagnosis needs as well as the perceived barriers to the adoption of healthy lifestyle habits.

Data availability

This work has been conducted using the UK Biobank Resource (application number 81738). The UK Biobank is an open access resource and bona fide researchers can apply to use the UK Biobank dataset by registering and applying at http://ukbiobank.ac.uk/register-apply/.

Abbreviations

BMI:

Body mass index

CI:

Confidence interval

HR:

Hazard ratio

SD:

Standard deviation

UK:

United Kingdom

References

  1. Miller KD, Nogueira L, Devasia T, Mariotto AB, Yabroff KR, Jemal A, et al. Cancer treatment and survivorship statistics, 2022. CA Cancer J Clin. 2022;72(5):409–36.

    Article  PubMed  Google Scholar 

  2. De Angelis R, Sant M, Coleman MP, Francisci S, Baili P, Pierannunzio D, et al. Cancer survival in Europe 1999–2007 by country and age: results of EUROCARE–5-a population-based study. Lancet Oncol. 2014;15(1):23–34.

    Article  PubMed  Google Scholar 

  3. European Commission. A cancer plan for Europe. Available from: https://commission.europa.eu/strategy-and-policy/priorities-2019-2024/promoting-our-european-way-life/european-health-union/cancer-plan-europe_en.

  4. Inoue-Choi M, Robien K, Lazovich D. Adherence to the WCRF/AICR guidelines for cancer prevention is associated with lower mortality among older female cancer survivors. Cancer Epidemiol Biomarkers Prev. 2013;22(5):792–802.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Karavasiloglou N, Pestoni G, Faeh D, Rohrmann S. Post-diagnostic diet quality and mortality in females with self-reported history of breast or gynecological cancers: results from the Third National Health and Nutrition Examination Survey (NHANES III). Nutrients. 2019;11(11):2558.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Karavasiloglou N, Pestoni G, Wanner M, Faeh D, Rohrmann S. Healthy lifestyle is inversely associated with mortality in cancer survivors: results from the Third National Health and Nutrition Examination Survey (NHANES III). PLoS ONE. 2019;14(6):e0218048.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Castro-Espin C, Agudo A. The role of diet in prognosis among cancer survivors: a systematic review and meta-analysis of dietary patterns and diet interventions. Nutrients. 2022;14(2):348. https://doiorg.publicaciones.saludcastillayleon.es/10.3390/nu14020348. PMID:35057525;PMCID:PMC8779048.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Peisch SF, Van Blarigan EL, Chan JM, Stampfer MJ, Kenfield SA. Prostate cancer progression and mortality: a review of diet and lifestyle factors. World J Urol. 2017;35(6):867–74. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s00345-016-1914-3.

    Article  CAS  PubMed  Google Scholar 

  9. Nechuta S, Chen WY, Cai H, Poole EM, Kwan ML, Flatt SW, et al. A pooled analysis of post-diagnosis lifestyle factors in association with late estrogen-receptor-positive breast cancer prognosis. Int J Cancer. 2016;138(9):2088–97. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/ijc.29940.

    Article  CAS  PubMed  Google Scholar 

  10. van Zutphen M, Kampman E, Giovannucci EL, van Duijnhoven FJB. Lifestyle after colorectal cancer diagnosis in relation to survival and recurrence: a review of the literature. Curr Colorectal Cancer Rep. 2017;13(5):370–401. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s11888-017-0386-1.

    Article  PubMed  PubMed Central  Google Scholar 

  11. George SM, Ballard-Barbash R, Shikany JM, Caan BJ, Freudenheim JL, Kroenke CH, et al. Better postdiagnosis diet quality is associated with reduced risk of death among postmenopausal women with invasive breast cancer in the women’s health initiative. Cancer Epidemiol Biomarkers Prev. 2014;23(4):575–83. https://doiorg.publicaciones.saludcastillayleon.es/10.1158/1055-9965.EPI-13-1162.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Tsilidis KK, Cariolou M, Becerra-Tomás N, Balducci K, Vieira R, Abar L, et al. Postdiagnosis body fatness, recreational physical activity, dietary factors and breast cancer prognosis: Global Cancer Update Programme (CUP Global) summary of evidence grading. Int J Cancer. 2023;152(4):635–44.

    Article  CAS  PubMed  Google Scholar 

  13. Tsilidis KK, Markozannes G, Becerra-Tomás N, Cariolou M, Balducci K, et al. Post-diagnosis adiposity, physical activity, sedentary behaviour, dietary factors, supplement use and colorectal cancer prognosis: Global Cancer Update Programme (CUP Global) summary of evidence grading. Int J Cancer. 2024;155(3):471–85. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/ijc.34904.

    Article  CAS  PubMed  Google Scholar 

  14. EAT-Lancet Commission. Summary report of the EAT-Lancet commission. Food Planet Health. Healthy Diets From Sustainable Food Systems. 2019. https://eatforum.org/content/uploads/2019/07/EAT-Lancet_Commission_Summary_Report.pdf.

  15. Berthy F, Brunin J, Allès B, Fézeu LK, Touvier M, Hercberg S, et al. Association between adherence to the EAT-Lancet diet and risk of cancer and cardiovascular outcomes in the prospective NutriNet-Santé cohort. Am J Clin Nutr. 2022;116(4):980–91.

    Article  PubMed  Google Scholar 

  16. Ibsen DB, Christiansen AH, Olsen A, Tjønneland A, Overvad K, Wolk A, et al. Adherence to the EAT-Lancet diet and risk of stroke and stroke subtypes: a cohort study. Stroke. 2022;53(1):154–63.

    Article  PubMed  Google Scholar 

  17. Knuppel A, Papier K, Key TJ, Travis RC. EAT-Lancet score and major health outcomes: the EPIC-Oxford study. Lancet. 2019;394(10194):213–4.

    Article  PubMed  Google Scholar 

  18. Xu C, Cao Z, Yang H, Hou Y, Wang X, Wang Y. Association between the EAT-Lancet diet pattern and risk of type 2 diabetes: a prospective cohort study. Front Nutr. 2021;8:784018.

    Article  PubMed  Google Scholar 

  19. Colizzi C, Harbers MC, Vellinga RE, Verschuren WM, Boer JM, Temme EH, et al. Adherence to the EAT-Lancet healthy reference diet in relation to coronary heart disease, all-cause mortality risk and environmental impact: results from the EPIC-NL Cohort. J Am Heart Assoc. 2023;12(8):e026318.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Zhang S, Dukuzimana J, Stubbendorff A, Ericson U, Borné Y, Sonestedt E. Adherence to the EAT-Lancet diet and risk of coronary events in the Malmö Diet and Cancer cohort study. Am J Clin Nutr. 2023;117:903–9.

  21. Langmann F, Ibsen DB, Tjønneland A, Olsen A, Overvad K, Dahm CC. Adherence to the EAT-Lancet diet is associated with a lower risk of type 2 diabetes: the Danish Diet, Cancer and Health cohort. Eur J Nutr. 2023;62(3):1493–502.

    Article  CAS  PubMed  Google Scholar 

  22. López GE, Batis C, González C, Chávez M, Cortés-Valencia A, López-Ridaura R, et al. EAT-Lancet Healthy Reference Diet score and diabetes incidence in a cohort of Mexican women. Eur J Clin Nutr. 2023;77(3):348–55.

    Article  PubMed  Google Scholar 

  23. Karavasiloglou N, Thompson AS, Pestoni G, Knuppel A, Papier K, Cassidy A, Kühn T, Rohrmann S. Adherence to the EAT-Lancet reference diet is associated with a reduced risk of incident cancer and all-cause mortality in UK adults. One Earth. 2023;6(12):1726–34. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.oneear.2023.11.002. PMID:38130482;PMCID:PMC10731983.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Sudlow C, Gallacher J, Allen N, Beral V, Burton P, Danesh J, et al. UK biobank: an open access resource for identifying the causes of a wide range of complex diseases of middle and old age. PLoS Med. 2015;12(3):e1001779.

    Article  PubMed  PubMed Central  Google Scholar 

  25. British Dietetic Association. Portion sizes: food fact sheet. 2021; Available from: https://www.bda.uk.com/resource/food-facts-portion-sizes.html.

  26. WHO Consultation on Obesity ( 1999: Geneva, Switzerland) & World Health Organization. Obesity: preventing and managing the global epidemic : report of a WHO consultation. World Health Organization. 2000. https://iris.who.int/handle/10665/42330.

  27. Tjon-A-Joe S, Pannekoek S, Kampman E, Hoedjes M. Adherence to diet and body weight recommendations among cancer survivors after completion of initial cancer treatment: a systematic review of the literature. Nutr Cancer. 2019;71(3):367–74.

    Article  PubMed  Google Scholar 

  28. Lei YY, Ho SC, Cheng A, Kwok C, Lee CKI, Cheung KL, et al. Adherence to the world cancer research fund/American institute for cancer research guideline is associated with better health-related quality of life among Chinese patients with breast cancer. J Natl Compr Canc Netw. 2018;16(3):275–85.

    Article  PubMed  Google Scholar 

  29. Blanchard CM, Courneya KS, Stein K. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society’s SCS-II. J Clin Oncol. 2008;26(13):2198–204.

    Article  PubMed  Google Scholar 

  30. Stubbendorff A, Sonestedt E, Ramne S, Drake I, Hallström E, Ericson U. Development of an EAT-Lancet index and its relation to mortality in a Swedish population. Am J Clin Nutr. 2022;115(3):705–16.

    Article  PubMed  Google Scholar 

  31. Ratjen I, Enderle J, Burmeister G, Koch M, Nöthlings U, Hampe J, et al. Post-diagnostic reliance on plant-compared with animal-based foods and all-cause mortality in omnivorous long-term colorectal cancer survivors. Am J Clin Nutr. 2021;114(2):441–9.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Marian MJ. Dietary supplements commonly used by cancer survivors: are there any benefits? Nutr Clin Pract Off Publ Am Soc Parenter Enter Nutr. 2017;32(5):607–27.

    Google Scholar 

  33. Zhang FF, Hudson MM, Chen F, Li Z, Huang IC, Bhakta N, et al. Dietary supplement use among adult survivors of childhood cancer: a report from the St. Jude Lifetime Cohort Study. Cancer. 2023;129(10):1602–13.

    Article  CAS  PubMed  Google Scholar 

  34. Florido R, Daya NR, Ndumele CE, Koton S, Russell SD, Prizment A, et al. Cardiovascular disease risk among cancer survivors: the Atherosclerosis Risk In Communities (ARIC) Study. J Am Coll Cardiol. 2022;80(1):22–32.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Zucchetto A, Gini A, Shivappa N, Hébert JR, Stocco C, Dal Maso L, et al. Dietary inflammatory index and prostate cancer survival. Int J Cancer. 2016;139(11):2398–404.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Cheng E, Kirley J, Cespedes Feliciano EM, Caan BJ. Adiposity and cancer survival: a systematic review and meta-analysis. Cancer Causes Control. 2022;33(10):1219–46.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Anderson AS, Martin RM, Renehan AG, Cade J, Copson ER, Cross AJ, et al. Cancer survivorship, excess body fatness and weight-loss intervention-where are we in 2020? Br J Cancer. 2021;124(6):1057–65.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Dr. Anika Knüppel for her support in funding acquisition.

Funding

Funding for grant IIG_FULL_2021_012 was obtained from World Cancer Research Fund (WCRF UK), as part of the World Cancer Research Fund International grant programme. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author information

Authors and Affiliations

  1. Division of Chronic Disease Epidemiology, Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland

    Nena Karavasiloglou, Giulia Pestoni, Flurina Suter & Sabine Rohrmann

  2. Cancer Registry of the cantons of Zurich, Zug, Schaffhausen, and Schwyz, University Hospital Zurich, Zurich, Switzerland

    Nena Karavasiloglou & Sabine Rohrmann

  3. School of Biological Sciences, The Institute for Global Food Security, Queen’s University Belfast, Belfast, Northern Ireland, UK

    Alysha S. Thompson, Aedín Cassidy & Tilman Kühn

  4. Nutrition Group, Health Department, Swiss Distance University of Applied Sciences (FFHS)/ University of Applied Sciences and Arts of Southern Switzerland (SUPSI), Zurich, Switzerland

    Giulia Pestoni

  5. Cancer Epidemiology Unit, Nuffield, Department of Population Health , University of Oxford, Oxford, UK

    Keren Papier

  6. Department of Nutritional Sciences, University of Vienna, Vienna, Austria

    Tilman Kühn

  7. Center for Public Health, Medical University of Vienna, Vienna, Austria

    Tilman Kühn

Authors
  1. Nena Karavasiloglou
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Alysha S. Thompson
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Giulia Pestoni
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Flurina Suter
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Keren Papier
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Aedín Cassidy
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Tilman Kühn
    View author publications

    You can also search for this author inPubMed Google Scholar

  8. Sabine Rohrmann
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

Conception and design: NK, AT, GP, KP, AC, TK, SR. Data acquisition: NK, SR. Analyzing the data: NK, TK, SR. Interpretation of the data: NK, AT, GP, TK, SR. Drafting the manuscript: NK. Critically revising the manuscript: NK, AT, GP, FS, KP, AC, TK, SR. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sabine Rohrmann.

Ethics declarations

Ethics approval and consent to participate

The UK Biobank has ethical approval from the North West Multi-centre Research Ethics Committee. All participants provided informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: This file contains Figure S1. Flowchart of study participants.

12916_2025_4106_MOESM2_ESM.pdf

Additional file 2: This file contains Additional Study Methodology, Table S1. Operationalization of the components of the EAT-Lancet reference diet using the UK Biobank Touchscreen questionnaire and Table S2. The association between the EAT-Lancet reference diet and cancer- or cardiovascular-mortality in cancer survivors, based on the primary cause of death.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Karavasiloglou, N., Thompson, A.S., Pestoni, G. et al. Higher adherence to the EAT-Lancet reference diet is inversely associated with mortality in a UK population of cancer survivors. BMC Med 23, 286 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12916-025-04106-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12916-025-04106-x

Keywords

BMC Medicine

ISSN: 1741-7015

Contact us