LITERATURE REVIEWS

The Benefits of Dietary Fiber Intake on

Reducing the Risk of Cancer: An Umbrella
Review of Meta-analyses
Marc P. McRae, MSc, DC, FACN, DACBN
ABSTRACT

Objective: The purpose of this study was to review previously published meta-analyses on the effectiveness of
dietary fiber on reducing the incidence of cancer.
Methods: An umbrella review of all published meta-analyses was performed. A PubMed search from January 1, 1980
to June 30, 2017 was conducted using the following search strategy: (fiber OR fibre) AND (meta-analysis OR
systematic review) AND (cancer OR carcinoma). Only English-language publications that provided quantitative
statistical analysis on cancer were retrieved.
Results: Nineteen meta-analyses comparing highest vs lowest dietary fiber intake were retrieved for inclusion in this
umbrella review. There was a statistically significant reduction in the relative risk (RR) of colorectal, esophageal,
gastric, and pancreatic cancer (RR = 0.52-0.88); however, statistically significant heterogeneity was observed in the
meta-analyses on esophageal, gastric, and pancreatic cancer. There was a statistically significant reduction in the RR
of breast cancer (RR = 0.85-0.93).
Conclusion: This review suggests that those consuming the highest amounts of dietary fiber may benefit from a
reduction in the incidence of developing colorectal cancer, and there also appears to be a small reduction in the
incidence of breast cancer. (J Chiropr Med 2018;17:90-96)
Key Indexing Terms: Dietary Fiber; Meta-analysis; Neoplasms

INTRODUCTION data were too inconsistent to draw a conclusion on the

association between dietary fiber and cancer risk. 13
In 2017, in the United States, it is estimated that there
Given the inconsistency of the existing literature, a
will be approximately 1.67 million new cases of cancer
pooling of information from individual trials could provide
diagnosed, and 600 000 deaths from this disease are
a more precise and accurate estimate of dietary fibers role in
projected to occur. 1 Epidemiologic studies show that
reducing the incidence of cancer. To achieve this result,
dietary factors are believed to play an important role in
many investigators have turned to performing a powerful
the prevention of cancer, among which dietary fiber has
statistical method known as meta-analysis. Meta-analyses
received considerable interest. 2 Increased intake of dietary are fundamental to provide the highest level of evidence to
fibers has been associated with decreased risk of several
best inform health care decision making. Because of the
cancers, such as colorectal and breast cancer. 3-7 However,
current inconsistency in the literature on the benefits of
the results of many epidemiologic studies have shown
dietary fiber’s ability to reduce cancer incidence, the
conflicting results, with some showing a weak or null
purpose and objective of this paper is to summarize the
association. 8-12 Furthermore, the 2007 World Cancer
evidence from previously published meta-analyses regard-
Research Fund’s second expert report concluded that the
ing the effectiveness of dietary fiber in reducing the
Department of Basic Sciences, National University of Health incidence of cancer.
Sciences, Lombard, Illinois.
Corresponding author: Marc P. McRae, MSc, DC, FACN, METHODS
DACBN, Department of Basic Sciences, National University of
Health Sciences, 200 E. Roosevelt Road, Lombard, IL 40148. An umbrella review was selected for this study. An
Tel.: + 1 630 889 6592. (e-mail: [email protected]). umbrella review provides a summary of existing published
Paper submitted September 11, 2017; in revised form meta-analyses and systematic reviews and determines
November 27, 2017; accepted December 13, 2017.
whether authors addressing similar review questions
1556-3707
© 2018 National University of Health Sciences. independently observe similar results and arrive at similar
https://doi.org/10.1016/j.jcm.2017.12.001 conclusions. 14 Inclusion criteria for assessing the
Journal of Chiropractic Medicine McRae 91
Volume 17, Number 2 Dietary Fiber and Cancer

effectiveness of dietary fiber to reduce cancer incidence will have In regard to the methodological quality of the 19
to include meta-analyses that surveyed cancer incidence within meta-analyses in this umbrella review, the mean quality
normal populations (with no geographic, race, or sex restrictions) appraisal score was 8 of 10, where 14 (74%) meta-analyses
while comparing the relative rates (RRs) or odds ratios (ORs) of scored as high quality; 2 (10%) satisfied medium quality;
those with the highest vs lowest dietary fiber intakes. and 3 (16%) satisfied low quality. These 3 low quality
As meta-analyses started appearing in medical literature meta-analyses included a paper by Trock et al 15 and 2
in the early 1980s, a systematic literature search of PubMed papers by Howe et al. 16,25 Although these 3 meta-analyses
and CINAHL from January 1, 1980 to June 30, 2017 was have been deemed lower quality, they were still included in
conducted using the following search strategy: (fiber OR this umbrella review because they provide useful informa-
fibre) AND (meta-analysis OR systematic review) AND tion regarding the role dietary fiber has for reducing the
(cancer OR carcinoma OR adenoma). incidence of colorectal cancer and breast cancer.
Abstracts, conference proceedings, and gray literature The meta-analyses presented in Tables 1 and 2 are based
were not included as the focus of this umbrella review; it on dietary surveys, which compare the highest vs lowest
was restricted to peer-reviewed, full-length papers indexed daily dietary fiber consumption on the incidence of
only in PubMed and CINAHL. The titles and abstracts from developing gastrointestinal related cancers (Table 1) and
the literature search were scanned, and only nongastrointestinal cancers, such as breast, prostate,
English-language publications that provided quantitative endometrial, and renal cancer (Table 2). However, the
statistical analysis (RRs and ORs) on cancer incidence were meta-analysis by Liu et al 33 was not entered into either table
retrieved. Meta-analyses or systematic reviews that did not because this was the only meta-analysis that investigated
present study-specific summary data using a minimum of 4 the impact of fiber consumption on cancer mortality and not
randomized controlled trials were excluded. cancer incidence. This particular meta-analysis assessed 5
For the published meta-analyses that were accepted into clinical studies with a total population of 640,482
this review, the following information was extracted and participants and provided a hazard ratio of 0.83, which
entered into a Microsoft Excel spreadsheet: number of was statistically significant (P b .05). There was no
publications included in the meta-analysis, number of total statistically significant observation of either heterogeneity
participants, and pooled treatment effects for RRs or ORs. or publication bias in this particular meta-analysis.
Although not always present, the meta-analyses were also For populations that consumed the highest dietary fiber
analyzed for their disclosure of quality assessment, intake, the incidence of colorectal cancer was significantly
statistical heterogeneity (Cochran’s Q test and I 2 statistic), reduced in 4 of the 5 meta-analyses, with the RR ranging
and publication bias (visual inspection of funnel plots and between 0.53 and 0.88 for those that were statistically
Egger or Begg regression test). A methodological quality significant (Table 1). However, for 2 of these 4
appraisal was conducted for all meta-analyses using the meta-analyses, statistically significant heterogeneity was
Critical Appraisal Checklist for Systematic Reviews, which observed. The only nonsignificant meta-analysis, by Asano
was developed by the Umbrella Review Methodology and McLeod, 17 had an RR of 1.04.
Working Group. 14 This checklist consists of 10 items, in Esophageal, gastric, and pancreatic cancers were also
which each item within the instrument can receive 1 point significantly reduced in all 5 meta-analyses, with the OR
for an overall quality score that could range from 0 to 10. ranging between 0.52 and 0.66 (Table 1). However,
Meta-analyses with quality scores ranging from 0 to 4 were statistically significant heterogeneity was observed in 4 of
labeled as low quality, those with scores between 5 and 7 the 5 of these meta-analyses.
were labeled as medium quality, and those with scores of 8 The incidence of breast cancer was significantly reduced
to 10 were labeled as high quality. Because this is a in all 3 meta-analyses, with the RR ranging between 0.85
descriptive summary review of meta-analyses, no statistical and 0.93 (Table 2). Although the incidence of endometrial
analyses were performed. cancer was significantly reduced (OR = 0.71), the reduction
in the incidence of prostate cancer was not statistically
significant. Finally, the incidence of renal cell cancer was
significantly reduced with an RR of 0.84.
RESULTS
The initial search strategy identified 88 articles; after
careful review, 19 meta-analyses were retrieved for
inclusion into this umbrella review. 15-33 A flow chart of DISCUSSION
the meta-analyses selection process is provided in Figure 1. When comparing participants with the highest intakes of
The 2 meta-analyses by Hajishafiee et al 34 and Kim and Je 35 total dietary fiber to those with the lowest intakes relative to
were not included in the umbrella review because they used the incidence of developing colorectal cancer, 4 of the 4
only 2 and 3 clinical studies, respectively, to calculate their meta-analyses in this umbrella review presented statistically
effect size on cancer mortality RR. significant reductions that ranged between 12% and
92 McRae Journal of Chiropractic Medicine
Dietary Fiber and Cancer June 2018

Articles identified through database

searches (n = 88)

Articles excluded due to not being

relevant (n = 61), reviews (n = 6)

Potential meta-analyses identified (n = 21)

Meta-analyses excluded due to less

than 4 clinical studies used (n = 2)

Meta-analyses included in umbrella review (n = 19)

Fig 1. Flow chart of meta-analysis selection.

Table 1. High vs Low Dietary Fiber Intake on the Incidence of Developing Gastrointestinal Related Cancers
Meta-analysis No. of No. of Egger or Quality
Authors and Cancer Studies in Participants Main Findings Q Test I2 Begg Test Assessment and
Date Type Meta-analysis in Meta-analysis of Meta-analysis P Value Statistic P Value Outcome
Trock et al. 199015 Colorectal 16 15 379 OR = 0.57, P b .001 P b .001

Howe et al. 199216 Colorectal 13 15 574 RR = 0.53, P b .001

Asano and Colorectal 5 3641 RR = 1.04, NS NS 5 Cochrane

McLeod 200217 5/5 high quality

Aune et al. 201118 Colorectal 18 200 066 RR = 0.88, P b .05 NS 0 NS

Ben et al. 201419 Colorectal 20 132 102 RR = 0.72, P b .05 P = .002 55 NS NOS
14/20 high quality

Coleman et al. Esophageal 8 9688 OR = 0.66, P b .05 P b .001 83 NS

201320
Sun et al. 201521 Esophageal 15 16 885 OR = 0.52, P b .05 P b .001 72 NS NOS
9/15 high quality

Zhang et al. 201322 Gastric 21 580 064 OR = 0.58, P b .05 P = .001 62 NS NOS
14/21 high quality

Wang et al. 201523 Pancreatic 14 38 141 OR = 0.54, P b .05 P = .043 41 NS NOS

NR

Mao et al. 201724 Pancreatic 14 38 141 OR = 0.52, NS 7 NS NOS 10/14 high

P b .05 quality
NOS, Newcastle-Ottawa Scale; NR, not reported; NS, not significant; OR, odds ratio; RR, relative risk.
Journal of Chiropractic Medicine McRae 93
Volume 17, Number 2 Dietary Fiber and Cancer

Table 2. High vs Low Dietary Fiber Intake on the Incidence of Developing Nongastrointestinal Cancers
Meta-analysis No. of No. of Egger or Quality
Authors and Cancer Studies in Participants in Main Findings Q Test I2 Begg Test Assessment
Date Type Meta-analysis Meta-analysis of Meta-analysis P Value Statistic P Value and Outcome
Howe et al. 199025 Breast 12 10 522 RR = 0.85, P = .001

Dong et al. 201126 Breast 10 712 195 RR = 0.89, P b .05 NS 0 NS

Aune et al. 201227 Breast 16 999 271 RR = 0.93, P b .05 NS 0 NS

Chen et al. 201628 Breast 24 3 662 421 RR = 0.88, P b .05 P = .001 59 NS Jadad 18/24
high quality

Bandera et al. 200729 Endometrial 8 12 312 OR = 0.71, P b .05 NS 21 Intentionally

not performed

Sheng et al. 201530 Prostate 17 140 179 OR = 0.89, NS P = .005 54 NS NOS 9/17
high quality

Wang et al. 201531 Prostate 16 136 979 RR = 0.94, NS NS 40 NS NOS 5/16 high
quality

Huang et al. 201432 Renal Cell 6 938 664 RR = 0.84, P b .05 NS 24 NS NOS 2/6
high quality
NOS, Newcastle-Ottawa Scale; NS, not significant; OR, odds ratio; RR, relative risk.

47%. 15,16,18,19 However, we must appreciate these positive unfortunately it will be the second most common cause of
results with some caution because statistically significant cancer mortality, second only to lung cancer in
h et e r o g en e i t y w a s o b s e r v e d i n 2 o f t h e s e 4 cancer-related deaths. 1 In regard to the mechanism of
meta-analyses. 15,19 There was 1 meta-analysis published action for reducing the incidence of colorectal cancer, it is
by Asano and McLeod that did not report a statistical possible that dietary fiber increases stool bulk, and this
significant reduction but instead reported an RR of 1.04. 17 dilutes carcinogen concentrations in the colonic lumen.
This finding may be accounted for by the fact that the 5 Coupled with a shortened fecal transit time, the time during
clinical trials used in this particular meta-analysis were which luminal carcinogens may be in contact with
solely randomized clinical controlled trials, whereas the 4 gastrointestinal epithelial cells decreases. 36 Dietary fiber
previous meta-analyses, which observed statistically signif- may also bind to both carcinogens and primary and
icant reductions, used clinical studies that were observa- secondary bile acids to promote their excretion in the
tional case-controlled or cohort studies. This paradoxical feces. Bacterial fermentation of fibers to short chain fatty
finding has been noted in many other dietary interventions, acids such as acetate, propionate and butyrate decreases
in which randomized controlled trials of diet-related factors luminal pH, which helps decrease the conversion of primary
have not yet shown any conclusive associations between bile acids to carcinogenic secondary bile acids. 37 Butyrate,
diet and cancer incidence. 2 a 4-carbon short chain fatty acid, also provides 70% of
In regard to the gastrointestinal system beyond the colon energy for healthy normal colonic epithelial cells and has
and rectum, 5 separate meta-analyses found statistically been shown to have antineoplastic actions by inhibiting
significant reductions in the RR for developing esophageal, cancer cell proliferation and inducing apoptosis and cell
gastric, and pancreatic cancer with reductions ranging cycle arrest, as well as increasing cell differentiation in
between 34% and 48%. 20-24 However, we must appreciate colon cancer tissue. 36,37 It is well established that
these positive results with some caution because statisti- inflammation is directly associated with cancer progression,
cally significant heterogeneity was observed in 4 of these 5 and it has been observed that butyrate also plays an
meta-analyses. 24 Curiously, the I 2 statistic and the Q-test’s anti-inflammatory role by inhibiting the transcription factor
P values were very different for the pancreatic cancer NF-κB, which results in a reduced concentration of the
meta-analyses, considering they were designed using the proinflammatory cytokines interleukin-6 and tumor necro-
same 14 clinical trials and observed nearly identical OR sis factor-α. 38,39 Butyrate’s beneficial effects are mediated
(0.54 vs 0.52). 23,24 at the epigenetic level through the inhibition of histone
In 2017, in the United States, it is estimated that deacetylases (HDACs), which consequently regulates the
colorectal cancer will be only the fourth most common expression of downstream genes such as NF-κB and
cancer diagnosis in men and women combined, but p53. 39,40 The HDACs are important for gene expression,
94 McRae Journal of Chiropractic Medicine
Dietary Fiber and Cancer June 2018

and the levels of these enzymes are increased in tumor cells; too few long-term, large-population, randomized controlled
thus, a decrease in HDAC activity is associated with the trials have undertaken the goal to analyze this potential
suppression of tumor cell growth. 41 In regard to esophageal causal relationship between dietary fiber and cancer
and gastric cancer, dietary fiber has been shown to scavenge incidence. Finally, while no Tolerable Upper Intake Level
nitrites, which are the precursors of the gastrointestinal has been established for total fiber intake, it should be
cancer causing N-nitroso compounds. 20 noted that minor side effects have been observed, such as
When comparing participants with the highest intakes of flatulence, abdominal bloating, loose stools or diarrhea,
total dietary fiber to those with the lowest intakes relative to the and abdominal cramping. 46
incidence of developing breast cancer, 4 of the 4 meta-analyses
in this umbrella review presented with statistically significant
Limitations
reductions that ranged between 7% and 15%. 25-28 The
meta-analysis on endometrial cancer also observed a statisti- This umbrella review has several limitations that should
cally significant reduction of 29%. 29 However, although the be acknowledged. First, confounding factors are always a
range in reduction for prostate cancer was between 6% and potential threat to the validity of any meta-analysis. For
11%, the observations from both of these 2 meta-analyses were instance, people who have high dietary fiber intakes tend to
not statistically significant. 30,31 have other healthy behaviors, such as being more physically
In 2017, it is estimated that, in the United States, breast active, having lower dietary intakes of saturated fat and
cancer will be the most common cancer diagnosis overall processed meats, and avoiding smoking and excessive
and the second leading cause of death from cancer in alcohol intake. Fortunately, the majority of studies included
women. 1 Dietary fiber effects on reducing the incidence of in the meta-analyses that were involved in this umbrella
breast cancer was not as strong as compared to effects review did adjust for potential confounding factors, but the
observed with colorectal cancer, and this may be attributed possibility of residual confounders cannot be excluded.
to dietary fibers’ different mechanisms of action at these 2 Second, self-reported dietary fiber intake is most often
very different sites. Prolonged exposure to estrogen is a assessed using food frequency questionnaires; because
strong risk factor for breast and endometrial cancer, and these dietary assessment tools were not specifically
reductions in circulating estrogens have been observed in developed for dietary fiber intake, it is possible that
participants who are consuming larger quantities of dietary misclassifications and measurement errors regarding fiber
fiber. 42 It has been proposed that dietary fibers can bind to doses and types are quite likely. This problem may also be
estrogens in the lumen of colon and increase their fecal compounded by the fact that dietary fiber may be defined
excretion. 27 In addition, dietary fiber may also reduce differently by the various food frequency questionnaire
intestinal enzymatic activity of β-glucuronidase, which is databases in use. 46 A third limitation is that the
responsible for the hydrolysis of conjugated estrogens prior meta-analyses reviewed here represent a heterogeneous
to their absorption by colonic epithelial cells. 43 Other group of clinical studies composed from a diverse group of
components in dietary fiber, such as antioxidants, phenolic participants of different ages, sexes, races, and ethnic
acids, and lignans, may also be protective against breast and groups: therefore, readers are cautioned against specifying
endometrial cancer. Lignans such as enterodiol and enter- these results to any specific sociodemographic group.
olactone are phytoestrogens that are derived from the Finally, as in all literature reviews, the quality of this
noncarbohydrate dietary fibers called lignins, and they possess umbrella review is directly related to the quality of the
weak estrogenic-inhibiting effects. 44 Dietary fiber may also included meta-analyses, which are dependent upon the
promote weight loss, and because adipocytes produce estrogen design and reporting quality of the individual meta-analysis
at a proportional amount relative to their size, there would be a itself, as well as on the quality of the individual studies used to
subsequent reduction in the levels of estrogen. 27 conduct the meta-analysis. Fortunately, the majority (84%) of
The Dietary Guidelines for Americans states that the the meta-analyses in this umbrella review were apprised as
adequate intake value of dietary fiber consumption is 25 to having moderate to high methodological quality.
38 g/day, but the 2009 to 2010 National Health and
Nutrition Examination Survey shows that the daily intake
of fiber in the United States is only 17 g/d. 45 Therefore, CONCLUSION
emphasizing fiber consumption for health promotion and This umbrella review suggests that those consuming the
disease prevention is a critical public health goal, and highest amounts of dietary fiber may benefit from a
by aggressively promoting the Dietary Guidelines for reduction in the incidence of developing colorectal cancer,
Americans recommendation of at least 25 to 38 g/d of total as well as a small reduction in developing breast cancer.
dietary fiber, this may prevent a significant number of new These findings have important public health implications,
cancer cases. Although the evidence in this umbrella especially in light of the finding by Liu et al, 33 who
review supports the beneficial association of dietary fiber determined that individuals with the highest dietary fiber
on reducing the incidence of colorectal and breast cancer, consumption reduced their cancer mortality by 17%.
Journal of Chiropractic Medicine McRae 95
Volume 17, Number 2 Dietary Fiber and Cancer

Unfortunately, the mean dietary fiber intake in the United REFERENCES

States is 17 g/d, which is considerably less than the
recommended intake of 25 to 38 g/d. 45 Future 1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA
well-designed, large, multicenter, randomized controlled Cancer J Clin. 2017;67(1):7-30.
studies are required to confirm these associations. 2. Kerr J, Anderson C, Lippman SM. Physical activity, sedentary
behaviour, diet, and cancer: an update and emerging new
evidence. Lancet Oncol. 2017;18(8):e457-e471.
3. Cade JE, Burley VJ, Greenwood DC. Dietary fibre and risk of
breast cancer in the UK Women's Cohort Study. Int J
FUNDING SOURCES AND CONFLICTS OF INTEREST Epidemiol. 2007;36(2):431-438.
No funding sources or conflicts of interest were reported 4. Park Y, Brinton LA, Subar AF, Hollenbeck A, Schatzkin A.
Dietary fiber intake and risk of breast cancer in postmeno-
for this study. pausal women: the National Institutes of Health-AARP Diet
and Health Study. Am J Clin Nutr. 2009;90(3):664-671.
5. Li Q, Holford TR, Zhang Y, et al. Dietary fiber intake and risk
of breast cancer by menopausal and estrogen receptor status.
CONTRIBUTORSHIP INFORMATION Eur J Nutr. 2013;52(1):217-223.
6. Peters U, Sinha R, Chatterjee N, et al. Dietary fibre and
Concept development (provided idea for the research): colorectal adenoma in a colorectal cancer early detection
M.P.M. programme. Lancet. 2003;361(9368):1491-1495.
Design (planned the methods to generate the results): M.P.M. 7. Tantamango YM, Knutsen SF, Beeson L, Fraser G, Sabate J.
Association between dietary fiber and incident cases of colon
Supervision (provided oversight, responsible for orga- polyps: the adventist health study. Gastrointest Cancer Res.
nization and implementation, writing of the manuscript): 2011;4(5-6):161-167.
M.P.M. 8. Wen W, Shu XO, Li H, et al. Dietary carbohydrates, fiber, and
Data collection/processing (responsible for experi- breast cancer risk in Chinese women. Am J Clin Nutr. 2009;
ments, patient management, organization, or reporting 89(1):283-289.
9. Zaineddin AK, Buck K, Vrieling A, et al. The association
data): M.P.M. between dietary lignans, phytoestrogen-rich foods, and fiber
Analysis/interpretation (responsible for statistical analysis, intake and postmenopausal breast cancer risk: a German case-
evaluation, and presentation of the results): M.P.M. control study. Nutr Cancer. 2012;64(5):652-665.
Literature search (performed the literature search): M.P.M. 10. Deschasaux M, Zelek L, Pouchieu C, et al. Prospective
Writing (responsible for writing a substantive part of the association between dietary fiber intake and breast cancer risk.
PLoS One. 2013;8(11)e79718.
manuscript): M.P.M. 11. Platz EA, Giovannucci E, Rimm EB, et al. Dietary fiber and
Critical review (revised manuscript for intellectual distal colorectal adenoma in men. Cancer Epidemiol Bio-
content, this does not relate to spelling and grammar markers Prev. 1997;6(9):661-670.
checking): M.P.M. 12. Fuchs CS, Giovannucci EL, Colditz GA, et al. Dietary fiber
and the risk of colorectal cancer and adenoma in women. N
Engl J Med. 1999;340(3):169-176.
13. Norat T, Aune D, Chan D, Romaguera D. Fruits and
vegetables: updating the epidemiologic evidence for the
WCRF/AICR lifestyle recommendations for cancer preven-
tion. Cancer Treat Res. 2014;159:35-50.
14. Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H,
Practical Applications Tungpunkom P. Summarizing systematic reviews: methodolog-
• Dietary fiber consumption has been postulat- ical development, conduct and reporting of an umbrella review
approach. Int J Evid Based Healthc. 2015;13(3):132-140.
ed to reduce the incidence of cancer, but 15. Trock B, Lanza E, Greenwald P. Dietary fiber, vegetables, and
unfortunately there is much discrepancy colon cancer: critical review and meta-analyses of the epidemi-
when it comes to individual cohort and ologic evidence. J Natl Cancer Inst. 1990;82(8):650-661.
case-controlled studies. 16. Howe GR, Benito E, Castelleto R, et al. Dietary intake of fiber
and decreased risk of cancers of the colon and rectum:
• By combining the meta-analyses on these evidence from the combined analysis of 13 case-control
clinical outcomes as an umbrella review, we studies. J Natl Cancer Inst. 1992;84(24):1887-1896.
can show that increased dietary fiber intake 17. Asano T, McLeod RS. Dietary fibre for the prevention of
may help reduce the incidence of gastroin- colorectal adenomas and carcinomas. Cochrane Database
testinal and breast cancers. More high-quality Syst Rev. 2002;2CD003430.
18. Aune D, Chan DS, Lau R, et al. Dietary fibre, whole grains,
research is needed regarding the association and risk of colorectal cancer: systematic review and dose-
between use of chiropractic services and risk response meta-analysis of prospective studies. BMJ. 2011;
of adverse drug events. 343:d6617.
19. Ben Q, Sun Y, Chai R, Qian A, Xu B, Yuan Y. Dietary fiber
intake reduces risk for colorectal adenoma: a meta-analysis.
Gastroenterology. 2014;146(3):689-699.
96 McRae Journal of Chiropractic Medicine
Dietary Fiber and Cancer June 2018

20. Coleman HG, Murray LJ, Hicks B, et al. Dietary fiber and the risk 34. Hajishafiee M, Saneei P, Benisi-Kohansal S, Esmaillzadeh A.
of precancerous lesions and cancer of the esophagus: a systematic Cereal fibre intake and risk of mortality from all causes, CVD,
review and meta-analysis. Nutr Rev. 2013;71(7):474-482. cancer and inflammatory diseases: a systematic review and
21. Sun L, Zhang Z, Xu J, Xu G, Liu X. Dietary Fiber Intake meta-analysis of prospective cohort studies. Br J Nutr. 2016;
Reduces Risk for Barrett's Esophagus and Esophageal 116(2):343-352.
Cancer. Crit Rev Food Sci Nutr. 2017;57(13):2749-2757. 35. Kim Y, Je Y. Dietary fibre intake and mortality from
22. Zhang Z, Xu G, Ma M, Yang J, Liu X. Dietary fiber intake cardiovascular disease and all cancers: a meta-analysis of
reduces risk for gastric cancer: a meta-analysis. Gastroenter- prospective cohort studies. Arch Cardiovasc Dis. 2016;
ology. 2013;145(1):113-120. 109(1):39-54.
23. Wang CH, Qiao C, Wang RC, Zhou WP. Dietary fiber intake 36. Zeng H, Lazarova DL, Bordonaro M. Mechanisms linking
and pancreatic cancer risk: a meta-analysis of epidemiologic dietary fiber, gut microbiota and colon cancer prevention.
studies. Sci Rep. 2015;5:10834. World J Gastrointest Oncol. 2014;6(2):41-51.
24. Mao QQ, Lin YW, Chen H, et al. Dietary fiber intake is 37. Fung KY, Cosgrove L, Lockett T, Head R, Topping DL. A
inversely associated with risk of pancreatic cancer: a meta- review of the potential mechanisms for the lowering of
analysis. Asia Pac J Clin Nutr. 2017;26(1):89-96. colorectal oncogenesis by butyrate. Br J Nutr. 2012;108(5):
25. Howe GR, Hirohata T, Hislop TG, et al. Dietary factors and 820-831.
risk of breast cancer: combined analysis of 12 case-control 38. Kundu JK, Surh YJ. Emerging avenues linking inflammation
studies. J Natl Cancer Inst. 1990;82(7):561-569. and cancer. Free Radic Biol Med. 2012;52(9):2013-2037.
26. Dong JY, He K, Wang P, Qin LQ. Dietary fiber intake and risk 39. Encarnação JC, Abrantes AM, Pires AS, Botelho MF. Revisit
of breast cancer: a meta-analysis of prospective cohort studies. dietary fiber on colorectal cancer: butyrate and its role on
Am J Clin Nutr. 2011;94(3):900-905. prevention and treatment. Cancer Metastasis Rev. 2015;
27. Aune D, Chan DS, Greenwood DC, et al. Dietary fiber and 34(3):465-478.
breast cancer risk: a systematic review and meta-analysis of 40. Bhat MI, Kapila R. Dietary metabolites derived from gut
prospective studies. Ann Oncol. 2012;23(6):1394-1402. microbiota: critical modulators of epigenetic changes in
28. Chen S, Chen Y, Ma S, et al. Dietary fibre intake and risk of breast mammals. Nutr Rev. 2017;75(5):374-389.
cancer: a systematic review and meta-analysis of epidemiological 41. Minucci S, Pelicci PG. Histone deacetylase inhibitors and the
studies. Oncotarget. 2016;7(49):80980-80989. promise of epigenetic (and more) treatments for cancer. Nat
29. Bandera EV, Kushi LH, Moore DF, Gifkins DM, McCullough Rev Cancer. 2006;6(1):38-51.
ML. Association between dietary fiber and endometrial cancer: a 42. Key TJ, Allen NE, Spencer EA, Travis RC. Nutrition and
dose-response meta-analysis. Am J Clin Nutr. 2007;86(6): breast cancer. Breast. 2003;12(6):412-416.
1730-1737. 43. Manoj G, Thampi BS, Leelamma S, Menon PV. Effect of
30. Sheng T, Shen RL, Shao H, Ma TH. No association between dietary fiber on the activity of intestinal and fecal beta-
fiber intake and prostate cancer risk: a meta-analysis of glucuronidase activity during 1,2-dimethylhydrazine induced
epidemiological studies. World J Surg Oncol. 2015;13:264. colon carcinogenesis. Plant Foods Hum Nutr. 2001;56(1):
31. Wang RJ, Tang JE, Chen Y, Gao JG. Dietary fiber, whole grains, 13-21.
carbohydrate, glycemic index, and glycemic load in relation to 44. Cohen LA. Dietary fiber and breast cancer. Anticancer Res.
risk of prostate cancer. Onco Targets Ther. 2015;8:2415-2426. 1999;19(5A):3685-3688.
32. Huang TB, Ding PP, Chen JF, et al. Dietary fiber intake and 45. McGill CR, Birkett A, Fulgonii Iii VL. Healthy Eating Index-
risk of renal cell carcinoma: evidence from a meta-analysis. 2010 and food groups consumed by US adults who meet or
Med Oncol. 2014;31(8):125. exceed fiber intake recommendations NHANES 2001-2010.
33. Liu L, Wang S, Liu J. Fiber consumption and all-cause, Food Nutr Res. 2016;60:29977.
cardiovascular, and cancer mortalities: a systematic review 46. Dahl WJ, Stewart ML. Position of the academy of nutrition
and meta-analysis of cohort studies. Mol Nutr Food Res. and dietetics: health implications of dietary fiber. J Acad Nutr
2015;59(1):139-146. Diet. 2015;115(11):1861-1870.