Original Article

Dietary Inflammatory Index and Head and Neck Cancer: A Multicenter Case-Control Study in Iran

Please cite this article as follows: Narmcheshm S, Seyyedsalehi MS, Sasanfar B, Rashidian H, Hadji M, Mohebbi E, et al. Dietary inflammatory index and head and neck cancer: a multicenter case-control study in Iran. J Res Health Sci. 2024; 24(3):e00624. doi:10.34172/jrhs.2024.159

Background

The global burden of diseasse study in 2017 reported that 5.3 % of all cancers are related to head and neck cancer (HNC).¹ HNC includes cancers of the oral cavity, oropharynx, nasopharynx, hypopharynx, and larynx. The HNC’s prevalence has recently increased in Iran, with the age-standardized rate rising from 4.8 per 100 000 in 2003 to 8.5 in 2008.² Patients with HNC have different complications including, breathing and eating difficulties, and cancer treatment imposes a significant financial burden on patients and their families.³ Therefore, prevention is the best strategy for all people, and identifying the risk factors is vital.

Tobacco (both cigarette and waterpipe) and alcohol consumption are major risk factors for HNC.⁴ Other important risk factors include asbestos exposure, human papillomavirus infection, and opium use.^5,6 Evidence shows the protective effect of fruits and vegetables against HNC.⁴ However, the recent comprehensive review of nutritional factors and cancer risk by the World Cancer Research Fund and the American Cancer Institute concluded that the data on the association between several dietary components with HNC is not convincing.⁵

Chronic inflammation has been recognized as one of the possible mechanisms of carcinogenesis, including HNC.⁷ Dietary components have been shown to have anti-inflammatory and pro-inflammatory effects.⁸ Dietary components such as phenols, antioxidant vitamins, and other nutrients have been associated with the development of several cancers. Some studies have investigated the association between one or several foods or nutrients and cancer risk separately; however, dietary components are consumed together and have synergic or antagonistic interactions. To deal with this, the Dietary Inflammatory Index (DII) was proposed to compute the inflammatory effects of the overall diet.⁹ Several studies have investigated the association between DII and cancers such as colorectal, breast, prostate, and endometrium.^10,11 Few studies have been conducted on the association between DII and aerodigestive tract cancer,^12,13 and most data come from non-Asian countries with different dietary habits.^14-16 As such, studies on the association between DII and the risk of HNC, especially in southwestern Asia, are rare. The present study used a large case-control study among the Iranian population to determine the association between DII and the risk of HNC development within the Iranian population.

Methods

Participants and study design

The Iranian Study of Opium and Cancer (IROPICAN) is a multicenter case-control study conducted between 2018 to 2020 in referral hospitals affiliated with Universities of Medical Sciences in 10 provinces of Iran, including Sistan and Baluchestan, Kerman, Bushehr, Hormozgan, Khorasan Razavi, Golestan, Mazandaran, Kermanshah, and Tehran.¹⁷ We selected cases and controls from the IROPICAN study. There were 876 pathologically confirmed HNC patients who received a cancer diagnosis in less than one year and with no history of any cancers. HNCs in this study were the ICD-O-3 codes of HNC, including the oral, larynx, and pharyngeal cancers (i.e., C00-C09, C11, C12, C14, C31, and C32).

We included 3409 controls who were frequently matched with cases based on age (in 5-year intervals), gender, and residential place. They were selected from hospital visitors who were without cancer, were not family members or friends of the cancer patients, and were visiting the hospital for reasons other than their health complaints.

Participants were asked detailed questions about opium use and its history (e.g., age at initiation, duration, frequency, typical amount, and route), tobacco use (e.g., cigarettes, naswar, chopogh, and waterpipe), history of alcohol consumption, demographic and socioeconomic factors (e.g. age, ethnicity, rural/urban status, education, and occupational history), physical activity (using the validated International Physical Activity Questionnaire, IPAQ¹⁸). Information on various aspects of health (personal and family history of cancer) was also obtained. Socioeconomic status (SES) was determined by combining data on education, income, and ownership of some household appliances using principal component analysis. The SES score determined for the control group was used to classify participants into three groups: high, medium, and low social classes. Physical activity workload (PPWL) was estimated based on the job history of participants using the Finland Job Exposure Matrix (FINJEM) ¹⁹. Based on the PPWL scores in control groups, participants were divided into three groups: sedentary (zero PPWL-years), moderate (PPWL-years above zero and less than or equal to 4.80), and heavy (PPWL-years above 4.80). Dental health was assessed by considering decayed, missing, and filled teeth, and participants were divided into three groups based on the scores of the control group.

Assessment of dietary intake and dietary inflammatory index scoring

To assess the dietary intake of participants, we used a validated 130-item food frequency questionnaire (FFQ) which was designed for Persian Cohort Study.²⁰ Cases and controls were asked to answer the FFQ based on their dietary habits one year before cancer diagnosis and one year before the interview, respectively. Total energy and nutrient intake were calculated using the USDA Food Composition Table.²¹ The DII score was computed based on the method suggested by Shivappa using 38 food parameters, including energy, carbohydrate, fat, protein, fiber, cholesterol, mono-unsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA), n-3 fatty acids, n-6 fatty acids, saturated fats (SFAs), trans fat, thiamin, riboflavin, niacin, pyridoxine, folic acid, cobalamin, vitamins A, C, and D, alpha-tocopherol, β-carotene, zinc, selenium, magnesium, iron, caffeine, onion, garlic, black tea, coffee, flavan-3-ol, flavones, flavonols, flavonones, anthocyanidins, and isoflavones.⁹ Then, the residual method was used to calculate energy-adjusted quantities of all these parameters before analyzing the DII score.²²

Statistical analysis

All statistical analyses were performed by Stata software (Stata 14.1, College Station, Texas 77845 USA). Two-sided P values < 0.05 were considered statistically significant. Participants were classified into tertiles of DII scores based on the distribution in the control group. To examine the association between DII and odds of HNC, unconditional logistic regression analysis was used which was controlled for several covariates. The full model was adjusted for energy (kcal/d), age (years), gender (female, male), province (10 provinces), socioeconomic status (low, medium, and high), tobacco use (yes, no), opium use (yes, no), alcohol use (yes, no), dental health (poor, moderate, and good), and physical activity (sedentary, moderate, and high). The trend of odds ratios (ORs) was examined using the median of DII as a continuous variable in the logistic regression models. An interaction term was added to models to analyze the interaction between DII and tobacco or opium use and the risk of HNC. The P value for interactions was estimated by the likelihood ratio test between models with and without the interaction term. We recruited 894 HNC patients from the IROPICAN study and 3483 apparently healthy controls whose data has been used in this study. Participants with unusual energy intake (less than 500 and over 4500 kcal/d) were considered outliers (18 subjects out of 894 patients and 74 subjects out of 3484 controls) and were omitted.

Results

Totally 876 patients and 3409 healthy controls were recruited for the present study. Almost a quarter of the participants in both groups were female (Table 1). Tobacco smoking and opium use were more common among the cases. Regular alcohol use was scarce in both groups. The physical activity status of the participants in both groups was almost similar. Energy and dietary intakes did not significantly differ between patients and controls (Table 2). As observed, the intake of energy, carbohydrate, and trans fatty acids increased from tertile 1 to tertile 3 of DII. However, the intake of vegetables, tomato, garlic, onion, dairy, legumes, and tea decreased.

Table 3 presents the association between DII scores and the risk of all subtypes of HNC and total HNC. After adjusting for confounders, a more pro-inflammatory diet was associated with an increased risk of all HNC (OR [95% CI]: 1.31 [1.06-1.62]; P-trend = 0.013). Additionally, there was a significant association between DII and lip and oral cavity cancer (OR [95% CI]: 1.56 [1.16-1.66]; P-trend = 0.004) in the adjusted model. Notably, an inflammatory diet was associated with an increased risk of pharynx cancer even after adjustment for confounders (OR T3 vs. T1: 2.08 [1.14-3.79]; P-trend = 0.02). There was no significant association between DII and larynx cancer, and no interaction was seen between DII and opium use. However, an interaction was found between tobacco use and DII on the risk of HNC, meaning that participants who used tobacco and had higher DII scores were at a greater risk of HNC compared to participants who did not use tobacco and were in the first tertile (OR T3 vs. T1 [95% CI]: 2.52 [1.78-3.57]; P-interaction = 0.03, as depicted in Table 4). It is worth noting that participants who did not use tobacco or opium but were in the third tertile of DII were still at great risk of HNC (OR T3 vs. T1 [95% CI]: 1.66 [1.20-2.29]).

Discussion

This study found that DII is positively associated with HNC risk overall. In addition, there was a significant association between DII and lip and oral cavity cancer and pharynx cancer. However, no significant association was found between DII and larynx cancer. There was an interaction between tobacco use and DII in determining the risk of HNC, whereas no interaction effect was found between opium use and DII.

DII is a marker of the pro-inflammatory potential of the diet. Some studies with large sample sizes investigated the association between DII and HNC worldwide, but they are limited, especially in low and middle-income countries.^{12,15,16,23,24} Our overall findings are consistent with these studies, indicating that a pro-inflammatory diet, as indicated by higher DII scores, is associated with HNC.

Previous studies evaluated the interaction effect of tobacco or smoking with DII on HNC risk, however, but none of them have assessed the interaction between opium use and DII on HNC.¹⁶ Shivappa et al reported a positive association between DII and laryngeal cancer in a case-control study in Italy,²⁵ which is in contrast with our findings. Furthermore, we found a positive significant association between DII and pharynx cancer which is in line with Shivappa’s case-control study in Italy.²³ Mazul et al reported a significant interaction between smoking, alcohol intake, and DII on HNC risk.¹⁶ We assessed opium use in detail, including its interaction effect, finding no interaction effect between opium use and DII on HNC risk. Overall, tobacco use was more prevalent in our population compared to opium use. Moreover, based on the information in Table 1, opium use was not consistent with DII tertiles, indicating that the distribution of opium users in the DII tertiles is not similar. Therefore, we cannot conclude that opium users have a more pro-inflammatory diet.

Evidence suggested that the intake of a diet high in pro-inflammatory parameters accompanied by smoking could exacerbate carcinogenesis. Smoking and alcoholic consumption have been linked with increased oxidative stress.^26,27 Smoking-associated oxidative stress activates the inflammatory response pathway, triggering a cascade of events in which the production and release of reactive oxygen species (ROS) at the site of damage and inflammation potentially increase oxidative damage to macromolecular targets, which may lead to cancer initiation and progression.²⁸

The positive association between the DII and HNC might be mediated through the excess production of cytokines such as interleukin-6 (IL-6), IL-8, platelet-derived growth factor, and vascular endothelial growth factor in the tumor microenvironment, which are responsible for carcinogenic activities like anti-apoptosis, tumor angiogenesis, and metastasis.²⁹ Inflammatory cytokines can affect the oral microbiota, which in turn can cause an increased risk of periodontitis and cancer.^30-32 Moreover, the direct impact of carbohydrate consumption on the mouth microbiota, leading to increased populations of lactobacilli bacteria, can be another pathway.³ The oral cavity, pharynx, and larynx are all connected anatomical sites, so dysbiosis in one site can lead to dysbiosis in another.³⁴

This study has several strengths. To our knowledge, this is the first large multicenter case-control study in the East Mediterranean region examining the association between DII and the risk of HNC. Additionally, the large sample size allowed us to study the association between DII and overall HNC and its subsites, including oral cavity and larynx cancers. The patients were pathologically confirmed by a pathologist. We also adjusted for several confounding variables, including tobacco, opium, and alcohol use, province, socioeconomic status, dental health, and physical activity. Using a validated FFQ was another strength of the current study.²⁰

However, this study suffers from some limitations. The lack of an Iranian food composition table is one of the main limitations as food components would differ by country due to environmental and food processing factors. However, using the international food composition table minimizes this problem. Moreover, several Iranian studies showed an association between DII scores calculated using this food composition table, inflammatory index, and health status.^35-37

Conclusion

In conclusion, subjects who consumed a pro-inflammatory diet had an increased risk of lip and oral cavity cancer and pharynx cancer compared to those who consumed a low-inflammatory diet in this Iranian population. This is the first study in Iran to examine this association, and the results suggest that increasing the intake of anti-inflammatory dietary factors such as plant-based foods rich in fiber and phytochemicals and reducing the intake of pro-inflammatory factors such as fried or processed foods rich in saturated fat or animal protein may be a strategy for reducing the risk of HNC. This can also be the key measure of avoiding tobacco use, indicating that the interaction between a pro-inflammatory diet and tobacco use leads to strikingly higher risks of HNC.

Acknowledgments

This study was conducted using data from the IROPICAN study, which was funded by the National Institute for Medical Research Development (NIMAD) with project No.17198. The authors thank all participants and the healthcare workers who patiently support this study.

Authors’ Contribution

Conceptualization: Kazem Zendehdel, Fatemeh Toorang, Saba Narmcheshm.

Data curation: Fatemeh Toorang, Saba Narmcheshm.

Formal analysis: Fatemeh Toorang, Saba Narmcheshm, Bahareh Sasanfar.

Funding acquisition: Kazem Zendehdel, Paolo Boffetta.

Investigation: Kazem Zendehdel, Fatemeh Toorang, Monireh Sadat Seyyedsalehi, Elham Mohebbi, Ahmad Naghibzadeh-Tahami, Hamideh Rashidian, Bahareh Sasanfar.

Methodology: Kazem Zendehdel, Fatemeh Toorang, Paolo Boffetta, Saba Narmcheshm, Elham Mohebbi, Maryam Hadji.

Project administration: Fatemeh Toorang, Monireh Sadat Seyyedsalehi, Elham Mohebbi, Ahmad Naghibzadeh-Tahami, Hamideh Rashidian, Maryam Hadji.

Resources: Paolo Boffetta, Kazem Zendehdel.

Software: Fatemeh Toorang, Bahareh Sasanfar.

Supervision: Kazem Zendehdel, Fatemeh Toorang.

Validation: Fatemeh Toorang, Saba Narmcheshm.

Visualization: Kazem Zendehdel, Fatemeh Toorang, Paolo Boffetta, Saba Narmcheshm.

Writing–original draft: Saba Narmcheshm.

Writing–review & editing: Saba Narmcheshm, Kazem Zendehdel, Fatemeh Toorang, Paolo Buffetta.

Competing Interests

The authors declare no potential conflict of interests.

Ethical Approval

The IROPICAN study received the ethical code from the NIMAD committee (IR.NIMAD.REC.1394.027). None of the data are published in the name of the participants.

Funding

This study analyzed the IROPICAN study, which was granted by NIMAD (project code: No.17198).It was partially supported by a grant from the Italian Association for Cancer Research (IACR) (No. GI 60742).

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