Exploring the Relationship Between Gastric Cancer and Nutritional Risk Factors: Insights from the Korea National Health Insurance Database

doi:10.21203/rs.3.rs-4349887/v1

Background

Gastric cancer is a global public health concern, ranking as the third most common cause of cancer-related deaths despite its decreasing incidence over the last five decades. Gastric cancer rates vary across regions, which may be attributable to factors such as Helicobacter pylori infection, environmental factors, and genetic predispositions.

Objective

We aimed to examine the association between gastric cancer, nutrient intake, and lifestyle parameters in Korean adults.

Methods

The study was conducted in Korea and utilised the KNHANES dataset (2012–2016) to explore nutritional risk factors associated with gastric cancer. Multivariable analysis was conducted to confirm the association of micronutrients and specific food items using questionnaires designed to collect data on individuals' consumption frequency and nutrient intake.

Results

This study enrolled 18,894 participants, including individuals diagnosed with gastric cancer. Factors associated with gastric cancer included male sex, advanced age, low body mass index, and regular consumption of meals prepared outside the home. Multivariate analysis indicated that lower intake of protein (OR 0.98, 95% CI 0.97–0.99, p < 0.001), fat (OR 0.99, 95% CI 0.98–0.99, p < 0.004), and thiamine (OR 0.59, 95% CI 0.45–0.76, p < 0.001) and higher intake of niacin (OR 1.05, 95% CI 1.02–1.08, p < 0.001) correlated with an increased risk of gastric cancer. Additionally, specific dietary items such as tteok (rice cake) and soju contributed to an elevated risk of gastric cancer (OR 1.21, 95% CI, 1.01–1.40; OR 1.14, 95% CI, 1.03–1.25; p < 0.001).

Conclusions

We found an association between gastric cancer and various nutrient and lifestyle parameters in a nationally representative sample of Korean adults. Nutrient intake and lifestyle-related factors play a pivotal role in influencing the prevalence of gastric cancer, suggesting that tailored interventions could mitigate gastric cancer risk in specific populations.

Gastric cancer

nutrients

micronutrients

food

lifestyle

Gastric cancer represents a global public health challenge, despite a decrease in its incidence over the last 50 years. According to GLOBOCAN 2023, approximately one million new cases of gastric cancer are reported annually, with two-thirds of these resulting in death ^{[1, 2]}.

The highest gastric cancer incidence rates were observed in Eastern Asia for both males and females. In particular, males in Japan (48.1%), Mongolia (47.2%), and Korea (39.7%) exhibited the highest rates globally. Furthermore, the highest mortality rates were observed in Eastern Asia in both males (21.1%) and females (8.8%). Although the incidence of gastric cancer is decreasing in Korea, the disease remains one of the most common malignant tumours worldwide.

Previous epidemiological studies have suggested that Helicobacter pylori infection and family history play important roles in the aetiology of gastric cancer ^[3–6]. Additionally, smoking, occupational exposure, previous gastric surgery, and low socioeconomic status increase the risk of gastric cancer.

Dietary factors linked to a heightened risk of gastric cancer include obesity, and alcohol consumption ^[7], and the consumption of salt-preserved foods ^[8]. In contrast, the consumption of fresh fruits, vegetables, and antioxidant vitamins may decrease the risk of gastric cancer.

Previous studies have indicated an elevated risk of gastric cancer associated with a high consumption of staple foods, noodles, dumplings, and bread ^{[9, 10]}. Overeating can be detrimental to the stomach, potentially raising the risk of gastric cancer due to the physical damage to the gastric mucosa caused by repeated stretching of the stomach lining. Moreover, the traditional Korean diet has been linked to gastric cancer, possibly due to continuous irritation of the stomach wall from the consumption of salty and spicy foods, which could contribute to the development of gastric cancer. Although various other dietary factors have been associated with gastric cancer, the evidence varies and remains inconclusive.

In this study, we aimed to investigate the association between gastric cancer and nutrient intake, socioeconomic factors, and eating habits using data from the Korea National Health and Nutritional Examination Survey (KNHANES).

This observational study was conducted in Korea and was based on the KNHANES dataset (2012–2016), aiming to explore nutritional risk factors for gastric cancer.

KNHANES is a yearly cross-sectional health and nutritional survey conducted by the Division of Chronic Disease Surveillance of the Korea Centers for Disease Control and Prevention and the Korean Ministry of Health and Welfare. Utilising a multistage, complex sampling methodology ensures that the survey is representative of the country’s non-institutionalised population. The KNHANES dataset is publicly available on the Korea Centers for Disease Control and Prevention website and is frequently used for research.^[17]

The initial sample comprised 39,157 participants who completed health interviews, health behaviour surveys, and health examination surveys. The exclusion criteria for the study included individuals aged <19 years (N=8,447), missing values for baseline characteristics and cancer history (N=9,299), and missing nutritional survey data (N=2,517). Ultimately, 18,894 participants were included in this study (Figure 1).

Nutritional survey data

This study examined 24-h dietary recall data (KNHANES, 2012–2016), aiming to determine daily food consumption and nutrient intake trends. A qualified dietitian visited the participants’ homes to administer the nutrition survey and examined dietary habits, food consumption frequency, and dietary intake through face-to-face interviews. The survey included information on meal patterns, dining out, family meals, supplement usage, nutrition knowledge, food labelling awareness, and food security. The food frequency questionnaire comprised 63 essential food items that provided energy and nutrients. The food intake questionnaire employed a 24-h recall method, allowing respondents to report their consumption of various dishes and foods, aided by various measuring tools ^[11].

Statistical analysis

All values are presented as means ± standard deviations. Student’s t-test was used to compare continuous variables, whereas the chi-square or Fisher’s exact test was utilised for categorical variables. Logistic regression analyses were conducted to determine odds ratios (ORs) with 95% confidence intervals (CI), adjusting for potential confounders. P-values <0.05 were considered statistically significant. Statistical analyses were performed using SAS 9.2 (SAS Institute Inc., Cary, NC, USA).

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of the Yonsei University Gangnam Severance Hospital (reference number: 2023-0663-001). The requirement for informed consent from the participants was waived because of the anonymity of data sourced from the KNHANES database. All procedures were conducted in compliance with the approved protocol and adhered to pertinent guidelines and regulations.

Baseline characteristics

Our analysis enrolled 18,894 individuals, including both patients with gastric cancer and controls. Table 1 presents the participants’ characteristics. The average age of the participants was 51.5 years. Information regarding smoking and alcohol consumption habits was collected through a questionnaire and used as a covariate in association analyses. The average age of patients diagnosed with gastric cancer was 68.0 ± 9.6, which was notably higher than that of the overall sample. Furthermore, the prevalence of gastric cancer was higher among women than among men (62.4 vs. 40.4%, P < 0.001). Overall, patients with gastric cancer tended to be in the first quartile of household income, and relatively few were in the fourth quartile. Similarly, most patients placed in the lower quartiles of educational attainment, with few placing in the fourth quartile, suggesting lower socioeconomic status. Additionally, gastric cancer was significantly more prevalent outside of fasting periods (5.3 ± 1.8 vs. 4.3 ± 1.6, P < 0.001). Univariate analysis indicated that age, male sex, body mass index (BMI), alcohol consumption, frequency of eating outside of fasting periods, lower education level, lower household income, and hypertension could be considered risk factors for gastric cancer. Table 2 demonstrates that multivariate logistic regression analysis further identified several risk factors for gastric cancer, including male sex, advanced age, lower BMI, smoking status, and a high frequency of consuming meals outside the home.

Micronutrients

Table 3 presents the intake of vitamins and minerals among participants who completed the nutritional survey. Notably, individuals with gastric cancer exhibited significantly lower intake of protein (1092.5 ± 691.3 vs. 901.1 ± 628.1, P < 0.001) and fat (41.8 ± 34.8 vs. 24.8 ± 18.2, P < 0.001) than controls. Additionally, the overall caloric intake (1981.2 ± 915.6 vs 1720.5 ± 628.7, P < 0.001) was lower among gastric cancer participants than among the controls.

Nutritional survey for specific food items

In Table 4, we assessed the association of gastric cancer with the weekly dietary frequency of the 30 most consumed food items among participants who completed the nutritional survey. Univariate analysis revealed that the weekly dietary frequency of rice, dumpling, rice cake, kimchi stew, stir-fried pork, sundae, chicken, soju, beer, and makgeolli consumption influenced the risk of gastric cancer.

Association of gastric cancer with micronutrients and food item for multivariate analysis

In multivariate logistic regression analysis, the risk of gastric cancer remained higher in the group with low intake of protein (OR 0.98, 95% CI 0.97–0.99, p < 0.001) and fat (OR 0.99, 95% CI 0.98–0.99, p < 0.004), as demonstrated in Table 5. For micronutrients, we observed an association between lower intake of thiamine (OR 0.59, 95% CI 0.45–0.76, p < 0.001) and higher intake of niacin (OR 1.05, 95% CI 1.02–1.08, p < 0.001) and gastric cancer risk. However, sodium and potassium intake did not appear to affect gastric cancer incidence.

In the case of specific food items, multivariate analysis unveiled a significant association between the consumption of rice cake and soju and the risk of gastric cancer (OR 1.21, 95% CI 1.01–1.40; and OR 1.14, 95% CI 1.03–1.25; p < 0.001).

In this study, we identified associations between gastric cancer and various nutritional and lifestyle factors in a nationally representative sample of Korean adults. Our findings underscore the role of factors such as advanced age, male sex, body mass index, socioeconomic status, and eating outside of fasting periods in association with gastric cancer. Moreover, reduced intake of protein and fat, as well as thiamine deficiency, along with increased consumption of rice cake and soju, were identified as determining factors associated with gastric cancer risk.

Previous studies have suggested that the incidence of gastric cancer is associated with environmental factors, including socioeconomic status, occupational exposure, alcohol consumption, smoking, dietary habits, and consumption of salt-preserved foods ^[12-15]. Among these factors, dietary intake exhibited the strongest association with gastric cancer. In previous studies, a high-salt diet has been linked to the risk of gastric cancer ^[16], whereas high consumption of fresh fruits and vegetables has demonstrated protective effects ^[17], which is consistent with the findings of our study. However, we found no association between sodium or potassium intake and gastric cancer risk.

A previous meta-analysis reported a 17% increase in gastric cancer risk associated with the consumption of salted fish and a 15% increased risk per 40 g of pickled vegetable consumption ^[18]. Bouras et al. suggested that high intake of salted fish was associated with an increased risk of gastric cancer, whereas the consumption of salt itself, along with several other high-salt products, showed nominal associations ^[19]. This study revealed no effect of either sodium or potassium intake on gastric cancer risk; however, multivariate analysis results revealed that soy and kimchi stew intakes were associated with the disease. Yet, accurately measuring the total amount of salt consumed in an individual’s diet is challenging and prone to errors in a standard epidemiological study setting ^[20]. The higher consumption of sodium by Koreans, than that by other groups, may be attributed to soup-based diets ^[21,22]. The mechanisms responsible for the observed associations are complex and extend beyond sodium chloride. The high consumption of salt-preserved foods may be an indicator of poor diet quality and low socioeconomic status, potentially increasing susceptibility to H. pylori infection and thereby raising the risk of gastric cancer ^[23].

Smoking and alcohol consumption are recognised as carcinogenic factors ^[24-26]. Individuals who smoker or consume alcohol tend to prefer salty food ^[22], whereas smokers typically have a low intake of fruit and dairy products but a high intake of fast food ^[27]. Previous studies have demonstrated a dose–response relationship between the number of cigarettes smoked and the risk of gastric cancer ^[28,29]. Moreover, former male (but not female) smokers tend to be at an increased risk of gastric cancer. Furthermore, the shorter the interval since quitting smoking, the higher the risk of gastric cancer, even after accounting for cigarette-years. In our study, we observed an association between smoking and gastric cancer. However, the mechanisms underlying this relationship remain unclear, although several have been proposed. Nitrosamines and other nitroso compounds found in cigarette smoke may play a role in the development of gastric cancer ^[30,31]. Cigarette smoking has also been associated with an increased risk of transitioning to dysplasia and intestinal metaplasia, which are key steps in gastric carcinogenesis ^[32]. Additionally, a randomised crossover study demonstrated that smoking can delay stomach emptying and gastroesophageal reflux disease, which are closely associated with the development of cardiac cancer ^[33,34].

In the case of alcohol, its impact on gastric cancer involves the generation of inflammatory markers and oxidative stress compounds induced by inflammation, such as oxygen radical species ^[24]. Another possible hypothesis for the association between gastric cancer risk and alcohol consumption lies in the fact that ethanol, being soluble in fat, could potentially have detrimental effects on the gastric mucosa ^[35]. A previous study reported that the most popular type of alcoholic beverage in Korea is soju (58.2%), followed by beer (35.6%) ^[36]. Kim et al. found that individuals who consumed soju exhibited a heightened gastric cancer risk, although the association did not reach statistical significance. Contrary to previous findings, we, for the first time, unveil a statistically significant correlation between both beer and soju consumption and gastric cancer in Korean patients.

Our findings also suggest an association between tteok (rice cake) consumption and gastric cancer. Korean traditional rice cakes, known as ‘tteok’, are generally perceived as a healthy food because they are made from rice and often include various nutritious ingredients such as nuts, beans, and pumpkin. They are steamed until the cake is light and chewy. However, their health benefits are controversial. Although rice cakes consist predominantly of carbohydrates and are not directly associated with gastric cancer, they have been linked to gastrointestinal diseases such as peptic ulcer diseases and intestinal obstruction ^[37,38]. This association is believed to be related to delayed gastric emptying. Given that rice is the primary ingredient, previous research directions remain consistent in high frequency of meals associated with gastric cancer ^[39]. Further prospective studies are needed to confirm the causes behind this.

To the best of our knowledge, this study is the first to compare not only micronutrients but also various dietary components, including food types, among individuals with gastric cancer and normal participants. Our findings specifically emphasise primary dish groups as potential contributors to gastric cancer in the Korean population, suggesting a previously unreported association between disease onset and soju and tteok consumption. Furthermore, we found that gastric cancer risk was correlated with factors such as older age, male sex, lower body mass index, smoking, and regular consumption of meals prepared outside the home.

Our study had several limitations. First, we were unable to account for the H. pylori status of the study participants. Second, the study design was cross-sectional rather than longitudinal, limiting our ability to discuss associations between risk factors and exposure over time. Third, the number of participants with gastric cancer included in the study was lower than expected based on national prevalence estimates. This could be attributed to the characteristics of the KNHANES dataset, which primarily consists of individuals undergoing regular health screenings and may have a bias toward those with better health outcomes. Volunteers for research studies and individuals undergoing routine health checkups often have higher socioeconomic status, potentially introducing selection bias and influencing the study findings.

In summary, our study identified associations between gastric cancer and various nutrient and lifestyle parameters in a nationally representative sample of Korean adults. These findings underscore the importance of considering individual factors such as advanced age, male sex, low body mass index, and lower intake of protein and fat, alongside higher intake of niacin and increased consumption frequency of soju and tteok, in assessing the risk of gastric cancer. Nutrient intake and lifestyle-related factors play a pivotal role in influencing the prevalence of gastric cancer, suggesting that tailored interventions could potentially mitigate gastric cancer risk in specific populations.

Ethics approval and consent to participate

Consent for publication

Availability of data and materials Data Availability:

Data from each year's survey are made accessible to the public at no cost by the end of the subsequent year. In addition, the KCDC releases survey manuals and shares initial findings with the official KNHANES website (http://knhanes.cdc.go.kr).

Competing interests

Funding

This study was funded by Korean Gastric Cancer Association (KGCA0219B1).

Authors' contributions

Acknowledgements

Conceptualization: Y.N.K., C.Y.K

Data curation: Y.N.K.

Formal analysis: Y.N.K.

Funding acquisition: Y.N.K.

Investigation: Y.N.K., C.Y.K

Methodology: Y.N.K., C.Y.K

Project administration: Y.N.K., C.Y.K

Resources: Y.N.K

Software: Y.N.K., C.Y.K

Supervision: C.Y.K

Validation: C.Y.K

Visualization: C.Y.K

Writing - original draft: C.Y.K

Writing - review & editing: C.Y.K

Author Disclosures: The authors report no conflict of interest relevant to this article.

Declaration of Generative AI and AI-assisted technologies in the writing process: During the preparation of this work the author(s) used [NAME TOOL / SERVICE] in order to [REASON]. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.

Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin 2023;73:17-48.
Iwu CD, Iwu-Jaja CJ. Gastric Cancer Epidemiology: Current Trend and Future Direction. 2023;3:256-268.
Hansson L-E, Nyrén O, Hsing AW, Bergström R, Josefsson S, Chow W-H, et al. The risk of stomach cancer in patients with gastric or duodenal ulcer disease. 1996;335:242-249.
Molloy R, Sonnenberg AJG. Relation between gastric cancer and previous peptic ulcer disease. 1997;40:247-252.
Yaghoobi M, Bijarchi R, Narod SA. Family history and the risk of gastric cancer. British Journal of Cancer 2010;102:237-242.
Choi IJ, Kim CG, Lee JY, Kim Y-I, Kook M-C, Park B, et al. Family history of gastric cancer and Helicobacter pylori treatment. 2020;382:427-436.
Barstad B, Sørensen T, Tjønneland A, Johansen D, Becker U, Andersen I, et al. Intake of wine, beer and spirits and risk of gastric cancer. 2005:239-243.
Tsugane S, Sasazuki SJGc. Diet and the risk of gastric cancer: review of epidemiological evidence. 2007;10:75-83.
Kwak JH, Eun CS, Han DS, Kim YS, Song KS, Choi BY, et al. Gastric Cancer and the Daily Intake of the Major Dish Groups Contributing to Sodium Intake: A Case-Control Study in Korea. Nutrients 2021;13.
Richa, Sharma N, Sageena G. Dietary factors associated with gastric cancer - a review. Translational Medicine Communications 2022;7:7.
Kweon S, Kim Y, Jang MJ, Kim Y, Kim K, Choi S, et al. Data resource profile: the Korea National Health and Nutrition Examination Survey (KNHANES). Int J Epidemiol 2014;43:69-77.
Gupta S, Tao L, Murphy JD, Camargo MC, Oren E, Valasek MA, et al. Race/ethnicity-, socioeconomic status-, and anatomic subsite-specific risks for gastric cancer. 2019;156:59-62. e54.
Raj A, Mayberry J, Podas TJPMJ. Occupation and gastric cancer. 2003;79:252-258.
Tramacere I, Negri E, Pelucchi C, Bagnardi V, Rota M, Scotti L, et al. A meta-analysis on alcohol drinking and gastric cancer risk. 2012;23:28-36.
Wu B, Yang D, Yang S, Zhang GJFin. Dietary salt intake and gastric cancer risk: a systematic review and meta-analysis. 2021;8:1045.
Wu X, Chen L, Cheng J, Qian J, Fang Z, Wu J. Effect of Dietary Salt Intake on Risk of Gastric Cancer: A Systematic Review and Meta-Analysis of Case-Control Studies. Nutrients 2022;14.
Naemi Kermanshahi M, Safaei E, Tutunchi H, Naghshi S, Mobarak S, Asadi M, et al. Fruit and vegetable intake in relation to gastric cancer risk: A comprehensive and updated systematic review and dose-response meta-analysis of cohort studies. Front Nutr 2023;10:973171.
Clinton SK, Giovannucci EL, Hursting SDJTJon. The world cancer research fund/American institute for cancer research third expert report on diet, nutrition, physical activity, and cancer: impact and future directions. 2020;150:663-671.
Bouras E, Tsilidis KK, Triggi M, Siargkas A, Chourdakis M, Haidich A-BJN. Diet and risk of gastric cancer: an umbrella review. 2022;14:1764.
McLean RMJN. Measuring population sodium intake: a review of methods. 2014;6:4651-4662.
Yon M, Lee Y, Kim D, Lee J, Koh E, Nam E, et al. Major sources of sodium intake of the Korean population at prepared dish level-based on the KNHANES 2008 & 2009. 2011;16:473-487.
Song DY, Park JE, Shim JE, Lee JE. Trends in the major dish groups and food groups contributing to sodium intake in the Korea National Health and Nutrition Examination Survey 1998-2010. Korean J Nutr 2013;46:72-85.
Rawla P, Barsouk AJGRPG. Epidemiology of gastric cancer: global trends, risk factors and prevention. 2019;14:26-38.
Moy KA, Fan Y, Wang R, Gao YT, Yu MC, Yuan JM. Alcohol and tobacco use in relation to gastric cancer: a prospective study of men in Shanghai, China. Cancer Epidemiol Biomarkers Prev 2010;19:2287-2297.
Seitz HK, Cho CH. Contribution of alcohol and tobacco use in gastrointestinal cancer development. Methods Mol Biol 2009;472:217-241.
Mons U, Gredner T, Behrens G, Stock C, Brenner H. Cancers Due to Smoking and High Alcohol Consumption. Dtsch Arztebl Int 2018;115:571-577.
Lee J-K, Park B-J, Yoo K-Y, Ahn Y-OJIJoE. Dietary factors and stomach cancer: a case-control study in Korea. 1995;24:33-41.
Trédaniel J, Boffetta P, Buiatti E, Saracci R, Hirsch AJIjoc. Tobacco smoking and gastric cancer: review and meta‐analysis. 1997;72:565-573.
Ladeiras-Lopes R, Pereira AK, Nogueira A, Pinheiro-Torres T, Pinto I, Santos-Pereira R, et al. Smoking and gastric cancer: systematic review and meta-analysis of cohort studies. 2008;19:689-701.
Bergström J. Tobacco smoking and chronic destructive periodontal disease. Odontology 2004;92:1-8.
Bartsch H, Ohshima H, Pignatelli B, Calmels SJCs. Human exposure to endogenous N-nitroso compounds: quantitative estimates in subjects at high risk for cancer of the oral cavity, oesophagus, stomach and urinary bladder. 1989;8:335-362.
Correa PJCr. A human model of gastric carcinogenesis. 1988;48:3554-3560.
Johnson RD, Horowitz M, Maddox AF, Wishart JM, Shearman DJBMJ. Cigarette smoking and rate of gastric emptying: effect on alcohol absorption. 1991;302:20-23.
Lagergren J, Bergström R, Lindgren A, Nyrén OJNEjom. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. 1999;340:825-831.
Butts M, Sundaram VL, Murughiyan U, Borthakur A, Singh S. The Influence of Alcohol Consumption on Intestinal Nutrient Absorption: A Comprehensive Review. Nutrients 2023;15.
Kim MH, Kim SA, Park CH, Eun CS, Han DS, Kim YS, et al. Alcohol consumption and gastric cancer risk in Korea: a case-control study. Nutr Res Pract 2019;13:425-433.
Saitsu A, Kojima N, Kunitomo K. Retained rice cake in the stomach leading to potential intestinal obstruction. Journal of General and Family Medicine 2022;23:356-357.
Fujii M, Sakashita M, Wakamura K, Horimatsu T, Tanaka S, Obata D, et al. Multiple gastric ulcers caused by a rice cake as an intragastric foreign body. Journal of gastroenterology 2006;41:282-283.
Kim SY, Kwak JH, Eun CS, Han DS, Kim YS, Song KS, et al. Gastric Cancer Risk Was Associated with Dietary Factors Irritating the Stomach Wall: A Case-Control Study in Korea. Nutrients 2022;14.

Table 1. Baseline characteristics of the study participants

Normal	Gastric cancer	Total	p-value
(N=18,665)	(N=229)	(N=18,894)	p-value
Age (years)	51.3 ± 16.8	68.0 ± 9.6	51.5 ± 16.8	< 0.001
Male sex	7536 (40.4)	143 (62.4)	7679 (40.6)	< 0.001
BMI, kg/m²	23.8 ± 3.5	22.0 ± 2.9	23.8 ± 3.5	< 0.001
smoking				< 0.001
never	11609 (62.8)	97 (43.5)	11706 (62.6)
former	391 (2.1)	0 (0.0)	391 (2.1)
current	6480 (35.1)	126 (56.5)	6606 (35.3)
Alcohol				< 0.001
no	8882 (48.0)	143 (64.1)	9025 (48.2)
mild	5865 (31.7)	35 (15.7)	5900 (31.5)
moderate	2581 (14.0)	20 (9.0)	2601 (13.9)
high	1171 (6.3)	25 (11.2)	1196 (6.4)
Hunger time	12.6 ± 2.7	12.7 ± 3.1	12.6 ± 2.7	0.695
Income				< 0.001
1^st	3698 (19.9)	94 (41.2)	3792 (20.1)
2^nd	4692 (25.2)	53 (23.2)	4745 (25.2)
3^rd	5009 (26.9)	48 (21.1)	5057 (26.9)
4^th	5199 (28.0)	33 (14.5)	5232 (27.8)
Education				< 0.001
1^st	4412 (23.8)	118 (52.0)	4530 (24.1)
2^nd	1960 (10.6)	27 (11.9)	1987 (10.6)
3^rd	6105 (32.9)	51 (22.5)	6156 (32.8)
4^th	6078 (32.8)	31 (13.7)	6109 (32.5)
Outside fasting	4.3 ± 1.8	5.3 ± 1.6	4.3 ± 1.8	< 0.001
Hypertension	4519 (24.2)	81 (35.4)	4600 (24.3)	< 0.001
Diabetes	1754 (9.4)	31 (13.5)	1785 (9.4)	0.044

*Data are presented as mean ± standard deviation or n (%). Abbreviations: BMI, body mass index

Table 2. Association of gastric cancer with baseline characteristics

Univariate model		Multivariate model
OR (95% CI)	p-value	OR (95% CI)	p-value
Age	1.08 (1.07─1.09)	< 0.001	1.07 (1.06─1.08)	< 0.001
Female Sex	0.41 (0.31─0.53)	< 0.001	0.54 (0.36─0.82)	0.004
BMI, kg/m²	0.84 (0.80─0.88)	< 0.001	0.83 (0.79─0.87)	< 0.001
smoking	1.25 (1.06─1.46)	0.007	1.23 (1.01─1.51)	0.043
alcohol	0.86 (0.74─1.01)	< 0.001
Hunger time	1.01 (0.96─1.06)	0.660
Outside fasting	0.49 (0.42─0.58)	< 0.001	1.22 (1.02─1.47)	0.030
Income	0.63 (0.55─0.71)	< 0.001
Education	0.57 (0.51─0.64)	< 0.001
Hypertension	1.71 (1.30─2.24)	< 0.001
Diabetes	1.51 (1.01─2.18)	0.035

* Abbreviations: OR; odds ratio, CI; confidence interval, BMI, body mass index;

Table 3. Comparison of dietary micronutrient intake between participants with gastric cancer and controls

Normal (n = 18,665)	Gastric cancer (n = 229)	Total (N=18,894)	P-value
Total Energy (Kcal)	1981.2 ± 915.6	1720.5 ± 628.7	1978.1 ± 913.1	< 0.001
Water (g)	1092.5 ± 691.3	901.1 ± 628.1	1090.1 ± 690.9	< 0.001
Protein (g)	68.6 ± 42.9	55.1 ± 24.5	68.4 ± 42.8	< 0.001
Fat (g)	41.8 ± 34.8	24.8 ± 18.2	41.6 ± 34.7	< 0.001
Ca (mg)	486.8 ± 320.4	455.3 ± 373.1	486.4 ± 321.1	0.205
P (mg)	1056.3 ± 554.1	941.9 ± 429.9	1055.0 ± 552.9	< 0.001
Fe (mg)	16.2 ± 29.8	15.4 ± 10.3	16.2 ± 29.6	0.311
Na (mg)	3690.2 ± 2862.1	3368.0 ± 2448.9	3686.3 ± 2857.6	0.050
K (mg)	2999.7 ± 1621.2	2823.9 ± 1598.1	2997.5 ± 1621.0	0.103
Vit A (ugRE)	698.3 ± 934.3	759.4 ± 1092.3	699.1 ± 936.3	0.401
Caroten (ug)	3401.6 ± 4854.1	3727.1 ± 5341.3	3405.6 ± 4860.3	0.360
Retinol (ug)	117.5 ± 425.4	124.7 ± 668.7	117.6 ± 429.1	0.871
Thiamine (ug)	1.8 ± 1.0	1.5 ± 0.8	1.8 ± 1.0	< 0.001
Riboflavin (ug)	1.4 ± 0.9	1.1 ± 0.8	1.4 ± 0.9	< 0.001
Niacin (ug)	15.2 ± 10.0	13.2 ± 7.2	15.2 ± 9.9	< 0.001
Vita C (ug)	93.2 ± 112.0	110.7 ± 120.1	93.4 ± 112.1	0.019

*Data are presented as mean ± standard deviation. Abbreviations: Ca, calcium; P, phosphate; Fe, iron; Na, sodium; K, potassium; vit, vitamin;

Table 4. Association of gastric cancer with weekly dietary consumption frequency of the 30 most consumed food items

Variables	OR (95% CI)	P-value	Variables	OR (95% CI)	P-value
rice	0.94 (0.89-0.99)	0.028	crab sauce	1.15 (0.31-2.00)	0.739
noodle	1.03 (0.71-1.39)	0.8406	salted shrimp	1.19 (01.00-1.32)	0.739
dumpling	0.38 (0.10-0.99)	0.101	bean sprouts	0.84 (0.61-1.10)	0.267
bread	0.60 (0.27-1.00)	0.121	ssam vegetables	1.08 (0.90-1.23)	0.363
rice cake	1.31 (1.10-1.54)	< 0.001	garlic	1.08 (0.89-1.24)	0.370
soybean Paste Stew	1.10 (0.92-1.25)	0.237	ssamjang	1.08 (0.93-1.20)	0.253
kimchi Stew	0.50 (0.30-0.75)	0.003	kimchi	1.01 (0.97-1.05)	0.533
fried egg	0.90 (0.76-1.05)	0.223	pickled and fermented vegetables	1.01 (0.88-1.11)	0.885
pork belly	0.29 (0.13-0.58)	0.001	roasted seaweed	1.03 (0.93-1.12)	0.494
boiled pork	0.74 (0.26-1.47)	0.511	milk	0.91 (0.80-1.01)	0.099
stir-fried pork	0.40 (0.16-0.81)	0.028	coffee	0.98 (0.95-1.01)	0.217
beef	0.68 (0.24-1.38)	0.386	soft drink	1.06 (0.87-1.22)	0.499
sundae	0.04 (0.00-0.34)	0.010	soju	1.21 (1.10-1.30)	< 0.001
chicken	0.03 (0.00-0.17)	< 0.001	beer	0.56 (0.31-0.84)	0.020
salad	1.06 (0.87-1.22)	0.499	makgeolli	1.21 (1.00-1.36)	0.007
mackerel	1.16 (0.80-1.52)	0.371	Fruits (average)	1.07 (0.66-1.87)	0.800

* Multivariate logistic regression adjusted for age, sex, smoking, outside fasting OR; odds ratio, CI; confidence interval

Table 5. Association of gastric cancer with micronutrients and food items

micronutrients	OR (95% CI)	P-value	Food	OR (95% CI)	P-value
protein (g)	0.98 (0.97-0.99)	< 0.001	rice cake	1.21 (1.01-1.40)	0.012
fat (g)	0.99 (0.98-0.99)	0.004	soju	1.14 (1.03-1.25)	0.009
thiamine (ug)	0.59 (0.46-0.77)	< 0.001	dumpling	1.88 (0.77-3.25)	0.069
niacin (ug)	1.05 (1.02-1.08)	< 0.001

* Multivariate logistic regression adjusted for age, sex, smoking, outside fasting OR; odds ratio, CI; confidence interval

No competing interests reported.

Exploring the Relationship Between Gastric Cancer and Nutritional Risk Factors: Insights from the Korea National Health Insurance Database

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Abstract

Background

Objective

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Conclusions

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Background

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Results

Discussion

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