EPIC - European Prospective Investigation into Cancer and Nutrition


The European Prospective Investigation into Cancer and Nutrition (EPIC) study is one of the largest cohort studies in the world, with more than half a million (521 000) participants recruited across 10 European countries and followed for almost 15 years.

Rationale and Study Design (Riboli E and Kaaks R; International Journal of Epidemiology 1997; 26 (Suppl. 1): S6–S14).

Methods. EPIC is a multi-centre prospective cohort study designed to investigate the relation between diet, nutritional and metabolic characteristics, various lifestyle factors and the risk of cancer. The study is based in 22 collaborating centres in nine European countries and includes populations characterized by large variations in dietary habits and cancer risk. Data are collected on diet, physical activity, sexual maturation and reproductive history, lifetime consumption of alcohol and tobacco, previous and current illnesses and current medication. Following a common protocol and using identical equipment, blood samples are collected, aliquoted into plasma, serum, white blood cells and erythrocytes, and stored in liquid nitrogen at –196°C for future laboratory analyses on cancer cases and matched healthy controls. Anthropometric measurements are taken according to a standard protocol. It is planned to include around 400 000 middle-aged (40 - 69) men and women.

Modifiable causes of premature death in middle-age in Western Europe: results from the EPIC cohort study

Muller et al. BMC Medicine (2016) 14:87. DOI 10.1186/s12916-016-0630-6

Note that while this observational study is prospective, it is not controlled and therefore remains subject to chance, bias and confounding.

"20% of men and 11% of women in Europe (15 countries in the European Union, EU15) who reach the age of 40 can be expected to die prematurely based on current mortality rates." There exists an estimated incidence of death prior to age 70 years among an otherwise healthy non-smoking population is approximately 4%.

Comparison of population attributable fractions (AF) from the Global Burden of Diseases (GBD) analysis with those from the present EPIC analysis. Estimates from the GBD are taken from the website http://vizhub.healthdata.org/gbd-compare. They are the estimated attributable fractions for death in Western Europe for the age range 50–69 years for each risk factor.

Population attributable fractions (%, 95% CI) GBD / EPIC

Tobacco smoking: 25 (22–27) / 31 (31 – 32)
Dietary risks (poor diet, low fresh fruit / vegs): 23 (21–26) / 14 (12 – 16)
High blood pressure: 15 (13–17) / 9 (7 – 11)
High body mass index (>30): 14 (12–15) / 3 (2 – 5)
High waist-to-hip ratio (fat distribution): 10 (8 – 12)
Physical inactivity / low physical activity: 9 (8–11) / 7 (5 – 9)
High alcohol use (2 - 6 standard drinks day): 8 (7–9) / 4 (3 – 4)

Difference between GBD and EPIC risk estimations are explained in the paper: "There are three possible explanations for these differences. Firstly, the estimates of relative risk used in the calculations might differ – indeed, we estimated modest relative risks for overweight and obesity and physical inactivity. Secondly, the distribution of the risk factors used for the GBD computations might differ from the distribution in EPIC which, for example, includes relatively few very heavy consumers of alcohol or very obese participants. This is a well-known phenomenon in prospective cohort studies, also called “healthy volunteer” effect. Finally, the reference or counterfactual distributions used for the AF calculations might differ. For instance, the GBD used a “theoretical minimum-risk exposure distribution”. On the other hand, we have chosen to not necessarily use a theoretically “optimal” exposure distribution in all cases."

Risk may be combined, eg. (EPIC) poor diet (14%) + inactivity (7%) + overweight (3%) = 24%. It is also important to remember that expressions of risk are relative, not absolute and that the EPIC study employed, "Flexible parametric survival models to model risk of death conditional on risk factors, and survival functions." "Attributable fractions (AF) for deaths prior to age 70 years were calculated based on the fitted models."

"AF's and survival functions cannot be interpreted as the expected effects on mortality if individuals were to change their lifestyle or diet, but rather reflect comparisons of individuals with a given, constant pattern of exposures, or hypothetical scenarios in which no-one in the population is exposed to a given risk factor."

It should also be borne in mind that the EPIC quantification of smoking status appears to rely on the facile classification of smoking status of 'never', 'former', or 'current smokers'. For a considerably better and more accurate understanding of this widespread and recurrent institutional and epidemiological weakness see: Assessment of Cigarette Smoking in Epidemiologic Studies. Weitkunat R, et al. Beiträge zur Tabakforschung International/Contributions to Tobacco Research Volume 25;No. 7:September 2013

Publications and related activities


McGrath, MC. Osteopathic Treatment and TMJ pain dysfunction syndrome. (1991) New Zealand Register of Osteopaths Journal, vol 5.

McGrath, MC. Osteopathic Management of the degenerative hip joint. New Zealand Register of Osteopaths Journal, 1993: vol 6.

McGrath, MC. Review of the role of intra-abdominal pressure as a mechanism for the reduction of axial loading in the lumbar spine. New Zealand Register of Osteopaths Journal, 1990, 4:8–14. (abridged from dissertation for Postgraduate diploma in Biomechanics, University of Strathclyde, Glasgow. 1990)

McGrath, MC. Sacral stress fracture in a female distance runner. Journal of Osteopathic Education, 1994, 4(2):63-4.

McGrath, MC. New Zealand Osteopathic Snapshot Survey 1995. New Zealand Register of Osteopaths, May 1995.

McGrath, MC. Spina bifida occulta in the lumbosacral spine: anatomical observations of the posterior soft tissues related to radiological findings in cadavers. Thesis by research, submitted in fulfilment for the degree of Master of Science, anatomy, University of Otago, Dunedin, NZ. June 1998

Inaugural (1st ICAOR) international conference on Advances in Osteopathic Medicine Research, British College of Osteopathic Medicine, London. Accepted abstract (based on MSc (anat)(Otago) thesis: Spina bifida occulta of the lumbosacral spine: anatomical observations of the posterior soft tissues related to radiological findings in cadavers, May 1999.

New Zealand Acute Low Back Pain Guide October 2004 Accident Rehabilitation and Compensation Insurance Corporation (ACC), Wellington. Acknowledgements: Member of ALBP Guide developing Expert Panel and Osteopathic representative (since 1997).

McGrath, MC. A review of the physiology of cranial osteopathy: viewpoint. Journal of Osteopathic Medicine, 2003, 6(2):84-86.

International Conference (3rd ICAOR) for Advances in Osteopathic Medicine Research, Victoria University of Technology, Melbourne. Anatomical evidence for sutural motion of the cranial bones.Review of the anatomical literature of the cranial bones and sutural biology; McGrath MC, Mercer S, Received ‘best young researcher award’ . Presentation highlighted the paucity of morphological and biological evidence for cranial bone movement, February 2002

McGrath, MC. Clinical considerations of sacroiliac joint anatomy: a review of function, motion and pain. Journal of Osteopathic Medicine, 2004, 7(1):16-24.

McGrath, MC. Tayles, N. Anatomical observations related to radiological findings in spina bifida occulta (SBO) of the lumbar spine. Journal of Osteopathic Medicine, 2004, 7(2):70-78.

McGrath, MC. Zhang, M. Lateral branches of the dorsal sacral nerve plexus and the long posterior sacroiliac ligament. Surgical and Radiological Anatomy, 2005, 27(4):327-30.

McGrath, MC. Palpation of the sacroiliac joint: an anatomical and sensory challenge. International Journal of Osteopathic Medicine 9 (2006) 103 – 107 March 2006. doi: 10.1016/j.ijosm.2006.03.001

McGrath, MC, Zhang, M. Australia and New Zealand Association of Clinical Anatomists Conference (ANZACA) 3rd/4th September, 2005, Otago School of Medical Sciences, Dunedin, NZ. Poster presentation : ‘The detailed morphology of the long posterior sacroiliac ligament’.

Keynote address Australian Osteopathic Convocation, September 2007 Christchurch, NZ: Chronic Back Pain: The Sacroiliac Region: The Devil’s in the Morphological Detail’.

Dunedin Osteopathic Peer Group: organised, developed and run in the Department of Anatomy and Structural Biology, University of Otago, November 24th, 2007: Review of SIJ morphology and motion, new morphological research in the posterior sacroiliac region, anatomy laboratory session of pelvis.

McGrath MC. Nicholson H, Hurst P. The long posterior sacroiliac ligament: a histological study of morphological relations in the posterior sacroiliac region. Joint Bone Spine. 2009 Jan;76(1):57-62. Epub 2008 Sep 25.(2008), doi:10.1016/j.jbspin.2008.02.015

Dunedin Osteopathic Peer Group: organised. developed and run in the Department of Anatomy and Structural Biology, University of Otago, May 24th, 2008 Clinical and anatomical considerations of the thoracic outlet syndrome. A review of morphology and current clinical research at the superior thoracic aperture and anatomy laboratory session.

Dunedin Osteopathic Peer Group: organised. developed and run in the Department of Anatomy and Structural Biology, University of Otago, December 5th, 2009 Clinical and anatomical considerations of the shoulder joint: anatomical ‘hot spots’ at the shoulder. Lecture and lab.

McGrath MC. The relationship between the long posterior sacroiliac ligament and the posterior sacrococcygeal plexus. Record number: 151710, Australasian Digital Thesis Program. Identfier: http://adt.otago.ac.nz./public/adt-NZDU20070824.142033

McGrath MC, Nicholson H. The sacral thoracolumbar fascia. Conference abstract: Fifth meeting Australia and New Zealand Association of Clinical Anatomists, November 27 – 28, 2008, University of Auckland Medical School. Clinical Anatomy 20:399 – 409 (2009)

McGrath MC, Nicholson H, Hurst P. Le long ligament sacro-iliaque posterieur : etude histologique de ses rapports dans la region sacro-iliaque posterieure. Revue du rhumatisme, November 2008. doi: 10.1016/j.rhum.2008.02.022

McGrath MC. Composite sacroiliac joint pain provocation tests: a question of clinical significance. Published online 21.08.2009 International Journal Osteopathic Medicine, doi:10.1016/j.ijosm.2009.06.002

McGrath MC, Nicholson H, Hurst P. Branch blockade of the dorsal sacral rami. Letter to the editor. Pain Medicine 2010; 11: 281 – 82

McGrath MC, Stringer MD. Bony landmarks in the sacral region: the posterior superior iliac spine and the second dorsal sacral foramina: a potential guide for sonography. Published online 10 November 2010. Surgical and Radiological Anatomy, doi: 10.1007/s00276-010-0735-0

McGrath MC, Jeffery R, Stringer MD. The dorsal sacral rami and branches: Sonographic visualisation of their vascular signature. Published on line December 2011, International Journal Osteopathic Medicine, doi:10.1016/j.ijosm.2011.09.002

McGrath MC. From distinct to indistinct, the life cycle of a medical heresy. Is osteopathic distinctiveness an anachronism? Published on line October 2012, International Journal Osteopathic Medicine,doi:10.1016/j.ijosm.2012.08.004

Singh RA, McGrath MC. Editorial - Education for practitioners and patients. Australasian Medical Journal, 2013, 6, 12, 724 - 26. http://dx.doi.org/10.4066/AMJ.2013.1952

Podiatry NZ Annual Conference, Anatomy Masterclass, Department of Anatomy, University of Otago, Thursday 13th November 2014. Contributed and co-presented.

McGrath MC. Editorial - Can a cricket ball influence societal change? Exemplifying societal dichotomy in the tolerance of risk. Australasian Medical Journal, 2014;7(12):518–521. http://dx.doi.org/10.4066/AMJ.2014.2304

McGrath MC. A global view of osteopathic practice - mirror or echo chamber? International Journal Osteopathic Medicine, doi:10.1016/j.ijosm.2015.01.004

McGrath MC. Charcot-Marie-Tooth 1A: a narrative review with clinical and anatomical perspectives. Clinical Anatomy. ePub 2015 Oct 12. Clinical Anatomy 29:547–554 (2016) doi: 10.1002/ca.22653

McGrath MC. The Vulcan Nerve Pinch - cultural iconography anchors the proposal of a novel manual approach, the Bow-strong technique. International Journal of Complementary & Alternative Medicine, 2017;5(5). DOI: 10.15406/ijcam.2017.05.00162

McGrath MC. Editorial - Precision medicine, imprecision medicine two ends of a biological telescope? The Journal of Health Design

2017;2(1):5–8. https://doi.org/10.21853/JHD.2017.15