left1905001 1 Introduction Worldwide

Etudes

left1905001
1

Introduction
Worldwide, it is estimated that more than one million women are diagnosed with breast cancer every year, and more than 410,000 will die from the disease. In low- and middle-income countries (LMCs), the infrastructure and resources for routine screening mammography are often unavailable. In such lower resource settings, breast cancers are commonly diagnosed at late stages. Due to late diagnoses there is less chance of survival in those women.

(Coughlin and Ekwueme, 2009)
Worldwide Breast cancer effect women at large scale. Due to this, the study is conducted to check some major risk factors of breast cancer. Before defining the technical things firstly basic concepts of cancer will be discussed.
1.1 Cancer
Cancer is a disease caused by unbreakable division of abnormal cell in body parts.

In human body there is a process in which normally human cells grow and divide to form new cells as body need them. When cells grow older or damage they die and new cell take their place.

When cancer develops this process breakdown. As in body the cells become more and more abnormal the old cells survive when they should die and new cell form when there is no need in body. Due to this, extra cells divide without stopping and form tumors.

Cancer can start almost anywhere in body and destroy the process of cell division. Some cancers are in solid form which are masses of tissue. Some are not in solid form such as, LUKIMIA “cancer of blood” do not form solid tumor.
Cancer may or may not spread in body. Cancerous tumors that can spread into nearby tissues is called malignant. These tumors grows and cancer cell breakoff and travel to distance place in body through the blood or the lymph system and form new tumors far from the original tumors.

The tumors which do not spread in body called benign. It do not spread or infect nearby tissues. Benign tumors is sometime quite large, however when removed they mostly do not grow back, whereas malignant tumors sometime do.

1.2 Types of Cancer
There are many types of cancer. General names of some cancers are as follow.

Carcinoma
Sarcoma
Leukemia
Lymphoma and myeloma
Central nervous system cancers
Gastric cancer
Lung cancer
Skin cancer
Breast cancer
Many more
1.3 Worldwide Breast Cancer
Breast cancer is the second most common cancer overall (1.4 million cases, 10.9%) but ranks 5th as cause of death (458,000, 6.1%). Breast cancer is the most frequent cancer among women with an estimated 1.38 million new cancer cases diagnosed in 2008 (23% of all cancers), and ranks second overall (10.9% of all cancers). It is now the most common cancer both in developed and developing regions with 690,000 new cases estimated in each region. Incidence rates vary from 19.3 per 100,000 women in Eastern Africa to 89.9 per 100,000 women in Western Europe, and are high (greater than 80 per 100,000) in developed regions of the world (except Japan) and low (less than 40 per 100,000) in most of the developing region (Ferlay etal, 2008).
Breast cancer incidence and mortality rates remain highest in developed countries compared with developing countries, as a result of differential use of screening mammograms and disparities in lifestyle and hereditary factors (Althuis etal, 2005).

Breast cancer incidence and mortality vary considerably by world region. In general, the incidence is high (greater than 80 per 100,000) in developed regions of the world and low (less than 30 per 100,000), though increasing, in developing regions; the range of mortality rates is much less because of the more favorable survival of breast cancer in (high-incidence) developed regions. The incidence of breast cancer is increasing almost everywhere. This unfavorable trend is due in part to increases in risk factors (decreased childbearing and breast-feeding, increased exogenous hormone exposure, and detrimental dietary and lifestyle changes, including obesity and less physical activity). On the other hand, mortality is now decreasing in many high-risk countries due to a combination of intensified early detection efforts and the introduction of Mammographic screening, resulting in the diagnosis of more small, early stage tumors, and advances in treatment. (Parkin etal, 2000)
1.4 Breast Cancer in Pakistan
Breast cancer is the most frequently diagnosed cancer in Pakistani females. Highest frequencies of breast cancer have been noted in Pakistani women compared to other Asian countries. (Faheem etal, 2007)
In many developed and developing countries including Pakistan, breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death in women. Among 4575 women presenting to the Cancer Research Foundation of Pakistan between 1987 and 1994 with breast lumps, 1201 (26%) were found to have breast cancer. (Usmani etal, 1996)
1.5 The Anatomy of a Female Breast
According to National Cancer Institute a mature human female’s breast consists of fat, connective tissue and thousands of lobules and tiny glands which produce milk. The milk of a breastfeeding mother goes through tiny ducts (tubes) and is delivered through the nipple.

The breast, like any other part of the body, consists of billions of microscopic cells. These cells multiply in an orderly fashion. New cells are made to replace the ones that died.

Fig 1.1

To understand breast cancer it is important to understand lymph system of breast
1.5.1 The Lymph (lymphatic) System of The Breast
By American cancer society the lymph system is important to understand because it is one way breast cancers can spread. This system has several parts.

Lymph nodes are small, bean-shaped collections of immune system cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the breast. Lymph contains tissue fluid and waste products, as well as immune system cells. Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes.

Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes). Some lymphatic vessels connect to lymph nodes inside the chest (internal mammary nodes) and either above or below the collarbone (supraclavicular or infraclavicular nodes).

If the cancer cells have spread to lymph nodes, there is a higher chance that the cells could have also gotten into the bloodstream and spread (metastasized) to other sites in the body. The more lymph nodes with breast cancer cells, the more likely it is that the cancer may be found in other organs as well.

Presence of cancer in one or more lymph nodes often affects the treatment plan. Still, not all women with cancer cells in their lymph nodes develop metastases, and some women can have no cancer cells in their lymph nodes and later develop metastases.

1.6 Breast Cancer
Breast cancer usually starts off in the inner lining of milk ducts or the lobules that supply the milk. As we know there is a system in body in which normally human cells grow and divide to form new cells as body need them. When cells grow older or damage they die and new cell take their place. Cancer starts when cells begin to grow out of control. When growth of cells become abnormal and cell grown and divided even when there is no need of cell in that body part due to this process tumor may be form in that part of body . Breast cancer is a malignant tumor that starts in the cells of the breast. A malignant tumor is a group of cancer cells that can grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body. The disease occurs almost entirely in women, but men can get it, too. Breast cancer can be start at different part of breast. A breast cancer that started off in the lobules is known as lobular carcinoma, while one that from in the ducts is called ductal carcinoma.

Fig 1.3

1.6.1 Types of Breast Cancer
Invasive Breast Cancer: in this type of breast cancer the cancer cell spread into other part of body and effect other part of body. The cancer cells break out from inside the lobules or ducts and invade nearby tissue. With this type of cancer, the abnormal cells can reach the lymph nodes, and eventually make their way to other organs (metastasis), such as the bones, liver or lungs. The abnormal (cancer) cells can travel through the bloodstream or the lymphatic system to other parts of the body; either early on in the disease, or later.

Non-invasive Breast Cancer: in this type of breast cancer the cancer do not spread to other part of body .this is when the cancer is still inside its place of origin and has not broken out. Cancer which is inside the lobules and do not spread called Lobular carcinoma. While cancer inside the milk ducts is known as ductal carcinoma. Sometimes, this type of breast cancer is called “pre-cancerous”; this means that although the abnormal cells have not spread outside their place of origin, they can eventually develop into invasive breast cancer.

1.6.2 Symptoms of Breast Cancer
A symptom is only felt by the patient, and is described to the doctor or nurse, such as a headache or pain. A sign is something the patient and others can detect, for example, a rash or swelling.

The first symptoms of breast cancer are usually an area of thickened tissue in the woman’s breast, or a lump. The majority of lumps are not cancerous; however, women should get them checked by a health care professional.

Women who detect any of the following signs or symptoms should tell their doctor (NHS, UK):
A lump in a breast
A pain in the armpits or breast that does not seem to be related to the woman’s menstrual period
Pitting or redness of the skin of the breast; like the skin of an orange
A rash around (or on) one of the nipples
A swelling (lump) in one of the armpits
An area of thickened tissue in a breast
One of the nipples has a discharge; sometimes it may contain blood
The nipple changes in appearance; it may become sunken or inverted
The size or the shape of the breast changes
The nipple-skin or breast-skin may have started to peel, scale or flake.
Fig 1.4. Some of the possible early signs of breast cancer
1.6.3 Causes of Breast Cancer
Experts are not definitively sure what causes breast cancer. It is hard to say why one person develops the disease while another does not. We know that some risk factors can impact on a woman’s likelihood of developing breast cancer. These are:
1. Gender – Simply being a woman is the main risk factor for developing breast cancer. Men can develop breast cancer, but this disease is about 100 times more common among women than men. This is probably because men have less of the female hormones estrogen and progesterone, which can promote breast cancer cell growth
2. Getting Older – The older a woman gets, the higher is her risk of developing breast cancer; age is a risk factor. Over 80% of all female breast cancers occur among women aged 50+ years (after the menopause).

3. Genetics – women who have a close relative who has/had breast or ovarian cancer are more likely to develop breast cancer.

A systematic review given by United Kingdom determine the relationship between common genetic variants and cancer risk .this report show rapidly increasing frequency of breast cancer and common genetic variants. They identified 46 published case-control studies that have examined the effect of common alleles of 18 different genes on breast cancer risk. Of these, 12 report show statistical significant association
(Catherine etal, 1999)
4. Family History of Breast Cancer- Breast cancer risk is higher among women whose close blood relatives have this disease. Having one first-degree relative (mother, sister, or daughter) with breast cancer approximately doubles a woman’s risk. Having second first-degree relative increases her risk about 3-fold.The exact risk is not known, but women with a family history of cancer in a father or brother also have an increased risk of breast cancer.

5. Dense Breast Tissue – Women with dense breast tissue have a greater chance of developing breast cancer. Breasts are made up of fatty tissue, fibrous tissue, and glandular tissue. Someone is said to have dense breast tissue (as seen on a mammogram) when they have more glandular and fibrous tissue and less fatty tissue. Women with dense breast on mammogram have a risk of breast cancer that is 1.2 to 2 times that of women with average breast density. Dense breast tissue can also make mammograms less accurate. A number of factors can affect breast density, such as age, menopausal status, certain medications (including menopausal hormone therapy), pregnancy and genetics.

6. Menstrual Periods – Women who have had more menstrual cycles because they started menstruating early (before age 12) and/or went through menopause later (after age 55) have a slightly higher risk of breast cancer. The increase in risk may be due to a longer lifetime exposure to the hormones estrogen and progesterone
7. Obesity – Obesity is one of the major risk of breast cancer. Study confirms that obesity is an important risk factor for postmenopausal breast cancer, but only among women who have never taken HRT. Lifetime weight gain is also a strong predictor of breast cancer. (Morimoto etal, 2002). Being overweight or obese after menopause increases breast cancer risk. Before menopause your ovaries produce most of your estrogen, and fat tissue produces a small amount of estrogen. After menopause (when the ovaries stop making estrogen), most of a woman’s estrogen comes from fat tissue. Having more fat tissue after menopause can increase your chance of getting breast cancer by raising estrogen levels. Also, women who are overweight tend to have higher blood insulin levels. Higher insulin levels have also been linked to some cancers, including breast cancer.

8. Alcohol Consumption – the more alcohol a woman regularly drinks, the higher her risk of developing breast cancer is. A study was conducted on a large cohort of women. Researcher found a modest and significant positive association between alcohol consumption and breast cancer risk.

(Zhang etal, 2007)
9. Radiation Exposure – undergoing X-rays and CT scans may raise a woman’s risk of developing breast cancer slightly. Scientists at the Memorial Sloan-Kettering Cancer Center found that women who had been treated with radiation to the chest for a childhood cancer have a higher risk of developing breast cancer.

10. HRT (Hormone Replacement Therapy) – The Million Women Study was set up to investigate the effects of specific types of HRT on incident and fatal breast. Current use of HRT is associated with an increased risk of incident and fatal breast cancer. The effect is substantially greater for oestrogen-progesterone combinations than for other types of HRT.

11. Certain Jobs – women who worked at night prior to a first pregnancy had a higher risk of eventually developing breast cancer. Certain jobs, especially those that bring the human body into contact with possible carcinogens and endocrine disruptors are linked to a higher risk of developing breast cancer.
Some studies show that irregular working hours, including working at night have serious psychological and physiological effects. In nationwide population based case-control study they examined the relationship between late night jobs and breast cancer the study show the positive association between breast cancer and working at night.

(Lie and Kjarheim, 2006).

12. Breastfeeding – Some studies suggest that breastfeeding may slightly lower breast cancer risk, especially if it is continued for 1½ to 2 years.
13. Physical Activity – Evidence is growing that physical activity in the form of exercise reduces breast cancer risk. Because physical activity help to maintain the weight and burn the extra fats in body and help to reduce the risk of breast cancer.

14. Night Work-Several studies have suggested that women who work at night for example, nurses on a night shift may have an increased risk of developing breast cancer. This is a fairly recent finding, and more studies are looking at this issue. Some researchers think the effect may be due to changes in levels of melatonin, a hormone whose production is affected by the body’s exposure to light, but other hormones are also being studied.

1.7 Dietary Habits and Risk of Breast Cancer
A balanced diet is one that gives our body the nutrition it needs to function properly. In order to get truly balanced nutrition, we should obtain the majority of our daily calories from fresh fruits and vegetables, whole grains, and lean proteins. Our body needs a combination of nutrients to function and feel good. How much energy we need will depend on sex, age, and amount of physical exercise. Healthy eating is a matter of balance. We obtain energy and nutrients from carbohydrates, fat and protein, vitamins and minerals. But if the amount of nutrients are not accurate it may affect the health in different ways
Many studies have looked for a link between women eating habits and breast cancer risk. Studies have indicated that diet may play a role in risk of breast cancer. Diet which may increase the risk of breast cancer are as follow.

1.7.1 Dietary Fats – Food that contain fats include oils, butter and margarine as well as the fat in meats, fish and nuts hidden fats in sweets, biscuits, cakes and other foods may increase the risk of breast cancer. Women who take higher amount of fats in their food have an increased risk of breast as compared to those who take less .The EPIC study has shown that women who ate higher levels of saturated fats had double the risk of breast cancer compared to those eating the least.

1.7.2 Sugars, Carbohydrates and Breast Cancer – Eating too much sugar can make you put on weight and as we know that being overweight increases the risk of breast cancer in post-menopausal women. There is no strong evidence of a direct link between sugars and carbohydrates and breast cancer. But a large study of Chinese women in the USA reported that for women younger than 50 a high carbohydrate diet slightly increased the risk of developing breast cancer.

1.7.3 Some Food That Increase the Risk of Breast Cancer
According to cancer research UK some food increase the risk of breast cancer and the excessive use of these food may be unhealthy. These foods are as follow
Fatty cuts of meat
Meat products
Butter and ghee
cheese, especially hard cheese
Cream, soured cream and ice cream
Some snacks and chocolate products
Biscuits, cakes and pastries
8. Fried and oily food
On the bases of different studies we can say that dietary habits play a vital role in risk of breast cancer. More use of vegetables, fresh juices, vitamin c intake, green-tea intake may decrease the risk of breast cancer while high intakes of animal proteins, red meat, food full of fats may increase the risk of breast cancer.

1.8 Role of Life Style in Risk of Breast Cancer
Life style play important role in development of breast cancer. Because people who have a healthy life style may have less chance of breast cancer. Different studies showed that different life habits effect life in many ways. For example sleeping habits, eating habits, daily routine, working timing, physical activities, etc.
It is estimated that worldwide 25% of breast cancer are due to overweight/obesity and a sedentary life style. (Mctiernan, 2003). Women who spend happy life having less chance of breast cancer. Stressful life and stressful event that occur in life increase the risk of breast cancer. Physical activity play important role to decrease the risk of breast cancer. However studies showed that healthy life style decrease the risk of breast cancer. There are many factors included in life style such as physical activity, sleeping habits, stress many more.

1.8.1 Stressful life
With the development of society, the rhythm of modern life is becoming faster and faster. Many people have suffered from the stress and strain of life. So stress has become a part of life. Psychologically speaking, stress is a kind of disease of modern society. There are many causes of stress which come from work, family and social life.

Stressful life increase the risk of different disease as well as it increase the risk of breast cancer. Different studies investigate the relationship between stressful life and breast cancer. Studies shows that women whose life are stressful and different stressful event occur in their life have greater chance of breast cancer as compare to those who wer spending stress free life.

1.8.2 Physical Activity
Health and physical activity are often closely associated with each other. You feel you are able to perform to your best ability in any field whether it be sporting or academically when you are healthy. Health is the most important thing in our lives it can determine the way we live our life. Physical activity is any movement that results in expenditure of energy, it can be branched out in to many different categories that include exercise, fitness, active living, active recreation and sport. Physical activity may affect hormonal concentrations and energy balance, it is investigate whether everyday exercise is related to the risk of breast cancer. Result show Physical activity during leisure time and at work is associated with a reduced risk of breast cancer. (Thune etal, 1997). Many studies prove that lack of physical activity increase the risk of breast cancer. Increase in physical activity has a good effect on health it decrease the risk of many disease as well as breast cancer.

1.8.3 Passive smoking
Passive smoking can damage your body because secondhand smoke c0ntain more than 4,000 chemicals, many of which are irritants and toxin, and some of which are known to cause cancer. Passive smoking from all forms of tobacco is harmful. It has been suggested that cigarette smoking (both active and passive) is a risk factor for breast cancer. Smoking is a one of major risk factor of many disease as well as breast cancer. People who smoke or they are secondhand smoker have many times greater chance of having breast cancer many studies proved that passive smoking is also injurious for health as like active smoking.

1.8.4 Sleeping Habits
The importance of sleep to a sense of well-being is evident to anyone who has spent a sleepless night. However, the amount of sleep necessary for good health. Most sleep professionals, as well as the National Sleep Foundation, recommend that adults obtain 8 hours of sleep per night.
American Cancer Society (ACS) observed the association between sleep duration and mortality risk from breast cancer. Both short and long self-reported sleep durations were associated with an increased risk of death. Study show women sleeping 5 hours or less was 15% greater than for those sleeping 7 hours. Similarly, sleeping 9 or more hours was associated with a 42% increase in risk of mortality from breast cancer (Patel etal, 2004). Studies show there is effect of sleeping habits in human life. Sleeping time must be moderate. Because studies showed positive association between breast cancer and women who sleep for short time and also for those who sleep for a long time.

1.9 Factor Reducing the Risk of Breast Cancer
Breast cancer prevention starts with healthy habits. Lifestyle changes and eating healthy diet have been shown in studies to decrease breast cancer risk even in high-risk women. The following are steps we can take to lower the risk of breast cancer
Balanced body weight
Plenty use of vegetables and fruit (more than 5 cups a day).

Limited fat intake less than 20% of total calories per day).
eliminated food intake with the highest fat content (like fried foods and margarine)
Eat foods high in omega-3 fatty acids.

Avoid trans fats, red meats, and smoked foods
Avoid smoking and alcohol intake
Use of low fat milk
Vitamin intake
Breast-feed
Healthy life style
Physical activity

714375034290 O
B
J
C
T
I
V
E
00 O
B
J
C
T
I
V
E

Research
1.10 Research Objectives
The main objectives of this research were
To determine the role of life style and dietary habits in risk of breast cancer
To check the association between life style and breast cancer
To check the association between life style and dietary habits
To access the different risk factors of contracting breast cancer with respect to its exposer.

5718810939802
002

Literature Review
PhiHip (1975) conducted a study in California. In this study the authors were determine the role of life style and dietary habits in risk of different cancer. They were presently 2 years into a 6-year prospective study of the 100,000 Adventists currently living in California. At the outset, they collect detailed information on diet. The result showed that 77 breast cancer cases and controls. 5 foods were associated with breast cancer, but the association with fried potatoes was highly significant (p < 0.01). It is important to note that the next highest relative risk was for the use of hard fat (margarine, butter, or shortening) for frying. This association together with the association with fried potatoes and fried foods in general raises the possibility that carcinogens may be produced by excessive heating of fat during frying. The distribution of type of fat used for frying was not significantly different in heavy and light users of fried foods, so it is likely that the observed associations with fried foods and type of fat used for frying are independent. Four of the 5 foods associated with breast cancer are consistent with the hypothesis that fat intake is related to breast cancer. However, it seems that the evidence implicating dietary factors in the etiology of breast cancer.

Willett, et al (1987) conducted a study to check that dietary fat is one of the major risk factor of breast cancer. In U.S. registered nurses who were 34 to 59 years of age. 89,538 participants were selected. During four years of follow-up, 601 cases of breast cancer were diagnosed among the 89,538 nurses in the study. After adjustment for known determinants in multivariate analyses, the relative risk of breast cancer among women in the highest quintile of calorie-adjusted total fat intake, as compared with women in the lowest quintile, was 0.82 (95 percent confidence limits, 0.64 and 1.05). The corresponding relative risks were 0.84 (confidence limits, 0.66 and 1.08) for saturated fat, 0.88 (0.69 and 1.12) for linoleic acid, and 0.91 (0.70 and 1.18) for cholesterol intake. Similar results were found for both postmenopausal and premenopausal women.

Ewertz and Gil (1990) conducted a study to check the influence of dietary factors. In particular the intake of fat and beta-carotene, on breast-cancer risk was evaluated in a case-control study. Over a 1 year period 1,486 breast cancer cases diagnosed in Denmark. The control group was selected by using stratified random sample. 1,336 women from the general population were selected as controls. Data on usual diet prior to the breast cancer diagnosis were collected by self-administered questionnaires. A highly significant trend (p < 0.001) of increasing risk was observed with increasing fat intake, the RR for the highest quartile being 1.45 (95% Cl 1.17-1.80) compared with the lowest. However, information was not available to allow adjustment for the possible confounding effect of energy intake. The risk of breast cancer was not associated with consumption of vegetables rich in beta-carotene, multi-vitamin tablets or other dietary supplements, coffee, tea, sugar or artificial sweeteners.

Vasa (1991) investigated important emotional losses, difficult life situations, and psychological characteristics in risk of breast cancer. It was case-control study of 87 breast cancer patients and their controls. In a second part, the effect of stressful life events preceding cancer diagnosis on survival was studied in an 8-year follow-up of the breast cancer group. The control group was selected from the general female population and matched for sex, age, number of child-births, and language. The findings showed that breast cancer patients had significantly more life events, important losses, and difficult life situations prior to the discovery of the breast tumor than controls. The analysis indicated that important losses during a 6-year prodromal period and life event scores prior to examination on both the 12-month and modified 6-year Social Readjustment Rating Scale were associated with subsequent development of breast cancer. The association persisted after adjustment for marital status, education, and social class. The findings of the survival analyses indicated that life events in the 12 months preceding the onset of breast cancer and lower social class were associated with a smaller chance of disease-free and overall survival after controlling for clinical factors.

Brinton and Swanson (1992) conducted a study to check the relation of age, lifetime changes in body size and Tallness in risk of breast cancer .1529 breast cancer patients and 1901 control subjects was selected for study. An increased risk of breast cancer diagnosed at both young (< 50 years) and older ages, with adult height of 68 inch or more increasing risk by nearly 50 to 80% compared with statures of less than 62 inch. The association of risk with weight was less clear. Subjects who described themselves as heavier than average at ages 8 to 9 or 16 years were at reduced risk, particularly for older-onset breast cancer. Higher body mass indices based on reported weights during early adulthood were also associated with reduced risk. Measures of body mass beyond the age of 20, however, were less strongly related to risk.

Knektl, et al (1996) conducted a study in Finland during 1966-1972. Data was collected from different areas of Finland. The relationship between intake of dairy products and risk of breast cancer was studied in 4697 initially cancer-free women, aged 15 years or over. During a 25 year follow-up period after the collection of food consumption data, 88 breast cancers were diagnosed. Intakes of foods were calculated from dietary history interviews covering the habitual diet of examinees over the preceding year. There was a significant inverse gradient between milk intake and incidence of breast cancer, the age-adjusted relative risk of breast cancer being 0.42 (95% confidence interval (0.24-0.74) between the highest and lowest tertiles of milk consumption. The associations with respect to other dairy products were not significant. Adjustment for potential confounding factors, i.e. smoking, body mass index, number of childbirths, occupation and geographic area, resulted in only a minor change in the milk intake -breast cancer relation. Nor did adjustment for intake of other foodstuffs and nutrients, e.g. energy, carbohydrates, protein, fat, vitamins and trace elements, alter the results. No significant interactions between milk intake and demographic or dietary variables or time of cancer diagnosis were observed. Study suggest that there was a protective effect, dietary or habitual, associated with consumption of milk that overwhelms the associations between different other factors and risk of breast cancer.

Thune, et al (1997) evaluated the influence of physical activity, both at work and during leisure time, on the risk of breast cancer in a cohort of 25,624 premenopausal and postmenopausal women. Data on parity, dietary factors, and body-mass index allowed adjustment for potentially confounding factors, and reassessment of physical activity after three to five years gave an indication of the effect of sustained physical activity on the risk of breast cancer. There were 351 incident cases of breast cancer (100 among premenopausal women and 251 among postmenopausal women) among 25,624 women. The mean length of follow-up was 14.0 years (median, 13.7), and the median age at diagnosis was 54.7 years (range, 36.3 to 68.0). there was a 52 percent reduction in risk was observed among the women who reported doing heavy manual labor (relative risk, 0.48; 95 percent confidence interval, 0.25 to 0.92). The overall adjusted risk of breast cancer decreased in a dose–response manner with increasing activity level during leisure time (P for trend = 0.04). Women who exercised at least four hours a week during leisure time had a 37 percent reduction in the risk of breast cancer (relative risk, 0.63; 95 percent confidence interval, 0.42 to 0.95). Results support the idea that physical activity protects against breast cancer. Activity during both leisure time and work reduced the overall risk. There was a significant inverse relation between leisure-time activity and the risk of breast cancer.

Negri, et al (1997) determined the relationship between breast cancer risk and family history of cancer in first-degree relatives. This was investigated using data from a case-control study conducted in Italy between June 1991 and April 1994 on 2,569 women aged less than 75 years, with histologically confirmed incident breast cancer, and 2,588 control women admitted to hospital for acute, non-neoplastic, non-gynaecological conditions. Relative to women with no history, those with a family history of breast cancer had an odds ratio (OR) of 2.4 with 95% confidence interval (CI 1.9 to 3.0), and those with family history of intestinal cancer had an OR of 1.3 (95% CI 1.0 to 1.7). No significant relations emerged between breast cancer risk and family history of prostate (OR 1.1), ovarian (OR 1.3), cervical or endometrial (OR 1.2) or other cancers, except gallbladder (OR 8.6). The OR for family history of any type of cancer except breast cancer was 1.1. For family history of breast cancer the ORs were similar across strata of age of the proband, being 2.4 below age 45, 2.2 at age 45–59 and 2.7 above age 60, and whether the relative affected was the mother, sister(s) or both, while the risk appeared higher if the age at onset of breast cancer in the relative was lower than 40 years (OR 3.5), rather than higher (OR 2.2). Thus, these results, based on the investigation of all neoplasms in first-degree relatives, confirm that breast cancer risk is increased in women with a family history of breast cancer, while there was no material association with family history of cancer in general, excluding breast cancer.

Xo, et al (2001) determined the Association of body size and fat distribution with risk of breast cancer among Chinese women. A case-control study was conducted. In-person interviews and anthropometric measurements were completed for 1,459 women newly diagnosed with breast cancer from 25 to 64 years of age and 1,556 controls frequency-matched to cases on age. Unconditional logistic regression was employed to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CI) related to anthropometric variables and self-reported body weight. Currently measured weight, body mass index BMI: weight (kg)/ height(m)2 or height was each found to be positively related to risk of postmenopausal breast cancer in a dose-response manner, with ORs (95% CI) being 2.0 (1.4-3.0), 2.0 (1.2-3.2) or 1.7 (1.2-2.5), respectively, for the highest category of weight, BMI or height compared to the lowest category of these variables. These variables were unrelated to premenopausal breast cancer risk. Reported weight at ages >40 years and weight gain after age 20 were more predictive for postmenopausal breast cancer than weight at an earlier age. After adjustment for BMI, waist-to-hip ratio was related to an increased risk of premenopausal OR = 1.7 with C.I (1.3-2.3) for the highest category compared to the lowest category but not postmenopausal breast cancer. This study suggests that, even in a relatively thin Chinese population, weight gain and height are related to an increased risk of postmenopausal breast cancer, while central fat distribution was associated with premenopausal breast cancer. General weight control may be an effective measurement for breast cancer prevention.

Davis, et al (2001) investigated weather exposure to light at night increase the risk of breast cancer in women.  Case patients (n = 813), aged 20–74 years, were diagnosed from November 1992 through March 1995; control subjects (n = 793) were identified by random selection and were frequency matched according to 5-year age groups. An in-person interview was used to gather information on sleep habits and bedroom lighting environment in the 10 years before diagnosis and lifetime occupational history. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by use of conditional logistic regression, with adjustment for other potential risk factors. Breast cancer risk was increased among subjects who frequently did not sleep during the period of the night when melatonin levels are typically at their highest (OR = 1.14 for each night per week; 95% CI = 1.01 to 1.28). Risk did not increase with interrupted sleep accompanied by turning on a light. There was an indication of increased risk among subjects with the brightest bedrooms. Graveyard shiftwork was associated with increased breast cancer risk (OR = 1.6; 95% CI = 1.0 to 2.5), with a trend of increased risk with increasing years and with more hours per week of graveyard shiftwork (P = .02, Wald chi-squared test). The results of this study provide evidence that indicators of exposure to light at night may be associated with the risk of developing breast cancer.

Kropp and Chang-Claude (2002) suggested that both active and passive smokers have an increased risk of breast cancer compared with women who have never been either actively or passively exposed. Data on lifetime active and passive smoking were collected in 1999–2000 from 468 predominantly premenopausal breast cancer patients diagnosed by age 50 years and 1,093 controls were selected who had previously participated in a German case-control study conducted in 1992–1995. Both cases and controls were compared with never active/passive smokers, former smokers and current smokers had odds ratios of 1.2 (95% confidence interval (CI): 0.8, 1.7) and 1.5 (95% CI: 1.0, 2.2), respectively, and ever active smokers had an odds ratio of 1.3 (95% CI: 0.9, 1.9). The risk increased with duration of smoking and decreased after cessation of smoking. Among never active smokers, ever passive smoking was associated with an odds ratio of 1.6 (95% CI: 1.1, 2.4). Exposure to environmental tobacco smoke during childhood or before the first pregnancy did not appear to increase breast cancer risk. At greatest risk were women who had a high level of exposure to both passive and active smoking (odds ratio = 1.8, 95% CI: 1.2, 2.7). This study strengthens the hypothesis of a causal relation between active and passive smoke exposures and breast cancer risk.

Morimoto, et al (2002) assessed the relationship of several anthropometric measures and risk of postmenopausal breast cancer in 85,917 women aged 50–79 at entry in the Women’s Health Initiative Observational Study. Women were enrolled during 1993–1998 at 40 clinics in the US and 1030 developed invasive breast cancer by April 2000. Results shows Anthropometric factors were not associated with breast cancer among women who had ever used hormone replacement therapy (HRT). Among HRT non-users, heavier women (baseline body mass index (BMI) ; 31.1) had an elevated risk of postmenopausal breast cancer. (Relative risk (RR) is 2.52 with 95% confidence interval 1.62 to 3.93) compared to slimmer women (baseline BMI ? 22.6). The elevation in risk associated with increasing BMI appeared to be most pronounced among younger postmenopausal women. Change in BMI since age 18, maximum BMI, and weight were also associated with breast cancer in HRT non-users. It is concluded that obesity is an important risk factor for postmenopausal breast cancer, but only among women who have never taken HRT. Lifetime weight gain is also a strong predictor of breast cancer.

Boyd, et al (2003) carried out a meta-analysis of this association to include all papers published up to July 2003. Case–control and cohort studies that examined the association of dietary fat, or fat-containing foods, with risk of breast cancer were identified. A total of 45 risk estimates for total fat intake were obtained. Descriptive data from each study were extracted with an estimate of relative risk and its associated 95% confidence interval (CI). The summary relative risk, comparing the highest and lowest levels of intake of total fat, was 1.13 (95% CI: 1.03–1.25). Cohort studies (N=14) had a summary relative risk of 1.11 (95% CI: 0.99–1.25) and case–control studies (N=31) had a relative risk of 1.14 (95% CI 0.99–1.32). Significant summary relative risks were also found for saturated fat (RR, 1.19; 95% CI: 1.06–1.35) and meat intake (RR, 1.17; 95% CI 1.06–1.29). Combined estimates of risk for total and saturated fat intake, and for meat intake, all indicate an association between higher intakes and an increased risk of breast cancer. Case–control and cohort studies gave similar results.

Lillberg, et al (2003) prospectively investigated the relation between stressful life events and risk of breast cancer among 10,808 women from the Finnish Twin Cohort. Life events and breast Cancer risk factors were assessed by self-administered questionnaire in 1981. A national modification of a standardized life event inventory was used, examining accumulation of life events and individual life events and placing emphasis on the 5 years preceding completion of the questionnaire. Through record linkage with the Finnish Cancer Registry, 180 incident cases of breast cancer were identified in the cohort between 1982 and 1996. The multivariable adjusted hazard ratio for breast cancer per one-event increase in the total number of life events was 1.07 (95% confidence interval (CI): 1.00, 1.15). This risk estimate rose to 1.35 (95% CI: 1.09, 1.67) when only major life events were taken into account. Independently of total life events, divorce/separation (hazard ratio (HR) = 2.26, 95% CI: 1.25, 4.07), death of a husband (HR = 2.00, 95% CI: 1.03, 3.88), and death of a close relative or friend (HR = 1.36, 95% CI: 1.00, 1.86) were all associated with increased risk of breast cancer. The findings suggest a role for life events in breast cancer etiology through hormonal or other mechanisms.

Malin, et al. (2003) investigated the associations of breast cancer risk with vegetables, fruits and related micronutrient intake in a population-based case–control study among Chinese women in Shanghai, where dietary patterns differ substantially from other study populations. Included in the study were 1,459 incident breast cancer cases and 1,556 frequency-matched controls. Usual dietary habits were assessed by in-person interviews. Logistic regression was used to compute adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to measure strength of the associations. There was no association between breast cancer risk and total vegetable intake. The risk of breast cancer declined, however, with increasing intake of dark yellow-orange vegetables (trend test, p = 0.02), Chinese white turnips (trend test, p ? 0.001), and certain dark green vegetables (trend test, p ? 0.001) with adjusted OR in the highest quintile being 0.79 (95% CI = 0.60–0.98), 0.67 (95% CI = 0.53–0.85) and 0.65 (95% CI = 0.51–0.83) respectively. Intake of fruits, except watermelons and apples, was inversely associated with breast cancer risk (p-values for trend tests ?0.05). Study suggests that high intake of certain vegetables and fruits may be associated with a reduced risk of breast cancer.

Verkasalo, et al (2005) hypothesized that there was an inverse association between sleep duration and breast cancer risk, possibly due to greater overall melatonin production in longer sleepers. This population-based study includes information from women born in Finland before 1958. Sleep duration, other sleep variables, and breast cancer risk factors were assessed by self-administered questionnaires given in 1975 and in 1981. Breast cancer incidence data for 1976 to 1996 was obtained from the Finnish Cancer Registry. Hazard ratios (HR) and 95% confidence intervals (CI) were obtained from Cox proportional hazards models adjusting for potential confounders. Altogether, 242 cases of breast cancer occurred over the study period among the 12,222 women with sleep duration data in 1975. For these women, the HRs for breast cancer in the short (?6 hours), average (7-8 hours), and long sleep (?9 hours) duration groups were 0.85 (CI, 0.54-1.34), 1.0 (referent), and 0.69 (CI, 0.45-1.06), respectively. Analysis restricted to the 7,396 women (146 cases) whose sleep duration in 1975 and 1981 were in the same duration group (stable sleepers) yielded HRs of 1.10 (CI, 0.59-2.05), 1.0, and 0.28 (CI, 0.09-0.88), with a decreasing trend (P = 0.03). This study provides some support for a decreased risk of breast cancer in long sleepers.

Verkasalo, et al ( 2005) conducted a multistate population-based case-control study of 4033 women with invasive breast cancer and 5314 community women without breast cancer in which we inquired about women’s sleep in the recent past and during adult lifetime. Relative to women who slept 7.0 – 7.9 h/night, the multivariate odds ratio for developing breast cancer among women who slept an average of 9 h or more per night approximately 2 years prior to interview was 1.13 (95% CI 0.93 – 1.37). The multivariate adjusted odds ratio for the continuous term was 1.06 (95% CI 1.01 – 1.11), suggesting a 6% increase in risk for every additional hour of sleep. Similar patterns were observed for average lifetime adult sleep duration. They found little evidence that sleeping few hours per night was associated with breast cancer risk. The result of this study suggest that sleep duration is modestly associated with an increased breast cancer risk. In contrast, short duration of sleep (<7 h/night) is not substantially associated with increased risk.

Zhang, et al, (2007) conducted a case-control study in Southeast China between 2004 and 2005. The incidence cases were 1009 female patients aged 20–87 years with histologically confirmed breast cancer. The 1009 age-matched controls were healthy women randomly recruited from breast disease clinics. Information on duration, frequency, quantity, preparation, type of tea consumption, diet and lifestyle were collected by face-to-face interview using a validated and reliable questionnaire. Conditional logistic regression analyses were used to estimate odds ratios (ORs) and associated 95% confidence intervals. Compared with non-tea drinkers, green tea drinkers tended to reside in urban, have better education and have higher consumption of coffee, alcohol, soy, vegetables and fruits. After adjusting established and potential confounders, green tea consumption was associated with a reduced risk of breast cancer. The ORs were 0.87 (0.73–1.04) in women consuming 1–249 g of dried green tea leaves per annum, 0.68 (0.54–0.86) for 250–499 g per annum, 0.59 (0.45–0.77) for 500–749 g per annum and 0.61 (0.48–0.78) for ?750 g per annum, with a statistically significant test for trend (P < 0.001). Similar dose–response relationships were observed for duration of drinking green tea, number of cups consumed and new batches prepared per day. It was conclude that regular consumption of green tea can protect against breast cancer.

Zhang, et al ( 2007) conducted a systematic search of five databases and performed a meta-analysis of studies of breast cancer risk and recurrence published between 1998 and 2009, encompassing 5,617 cases of breast cancer. Summary relative risks (RR) were calculated using a fixed effects model, and tests of heterogeneity across combined studies were conducted. They identified two studies of breast cancer recurrence and seven studies of breast cancer incidence. Increased green tea consumption (more than three cups a day) was inversely associated with breast cancer recurrence (RR = 0.73, 95% CI: 0.56–0.96). An analysis of case–control studies of breast cancer incidence suggested an inverse association with a pooled RR of 0.81 (95% CI: 0.75, 0.88) while no association was found among cohort studies of breast cancer incidence. Combining all studies of breast cancer incidence resulted in significant heterogeneity. Available epidemiologic evidence supports the hypothesis that increased green tea consumption may be inversely associated with risk of breast cancer recurrence.

Luo, et al, (2011) examined the association between smoking and risk of invasive breast cancer. In total 3520 incident cases of invasive breast cancer were identified during an average of 10.3 year of follow-up. Compared with women who had never smoked. Breast cancer was elevated by 9% among former smokers (hazard ratio 1.09 with 95 % CI 1.02 to 1.17) and by 16 % among current smoker (hazard ratio 1.16 with CI 1.00 to 1.34). Significantly higher breast cancer risk was observed in active smokers with high intensity and duration of smoking. The highest breast cancer risk was found among women who had smoked for ? 50 years or more (hazard ratio 1.35 with CI 1.03 to 1.77) compared with all lifetime non-smoker, hazard ratio 1.45 with (CI 1.06 to 1.98 ) compared with life time non-smoker with no exposer to passive smoking. However the result show active smoking was associated with an increase in breast cancer. There was also a suggestion of an association between passive smoking and increase risk of breast cancer.

Michailidou, et al (2013) reported a meta-analysis of 9 genome-wide association studies, including 10,052 breast cancer cases and 12,575 controls of European ancestry, from which we selected 29,807 SNPs for further genotyping. These SNPs were genotyped in 45,290 cases and 41,880 controls of European ancestry from 41 studies in the Breast Cancer Association Consortium (BCAC). The SNPs were genotyped as part of a collaborative genotyping experiment involving four consortia (Collaborative Oncological Gene-environment Study, COGS) and used a custom Illumina iSelect genotyping array, comprising more than 200,000 SNPs. They identified SNPs at 41 new breast cancer susceptibility loci at genome-wide significance (P < 5 × 10?8). Further analyses suggest that more than 1,000 additional loci are involved in breast cancer susceptibility.

DeSantis, et al (2013) provided an overview of female breast cancer statistics in the United States, including data on incidence, mortality, survival, and screening. Approximately 232,340 new cases of invasive breast cancer and 39,620 breast cancer deaths are expected to occur among US women in 2013. One in 8 women in the United States will develop breast cancer in her lifetime. Breast cancer incidence rates increased slightly among African American women; decreased among Hispanic women; and were stable among whites, Asian Americans/Pacific Islanders, and American Indians/ Alaska Natives from 2006 to 2010. Historically, white women have had the highest breast cancer incidence rates among women aged 40 years and older; however, incidence rates are converging among white and African American women, particularly among women aged 50 years to 59 years. Incidence rates increased for estrogen receptor-positive breast cancers in the youngest white women, Hispanic women aged 60 years to 69 years, and all but the oldest African American women. In contrast, estrogen receptor-negative breast cancers declined among most age and racial/ethnic groups. These divergent trends may reflect etiologic heterogeneity and the differing effects of some factors, such as obesity and parity, on risk by tumor subtype. Since 1990, breast cancer death rates have dropped by 34% and this decrease was evident in all racial/ethnic groups except American Indians/Alaska Natives. Nevertheless, survival disparities persist by race/ethnicity, with African American women having the poorest breast cancer survival of any racial/ethnic group. Continued progress in the control of breast cancer will require sustained and increased efforts to provide high-quality screening, diagnosis, and treatment to all segments of the population

57791353403603
003

Research Methodology
A study was conducted to determine “Role of life style and dietary habits in risk of breast cancer”. This chapter deal with methodology strategy under which research has been carried out. All steps taken from beginning to the end of the research work are technically known as methodology or research procedure. Following are the steps that have been adopted in conducting this research.

3.1 Target Population
“The population about which we want to make inference on the bases of sample information is known as target population.”
The target for the present study is based on women and it consisted of females having breast cancer as well as who do not have this disease included from two different hospitals of Lahore.

3.2 Sampled population
For this study the sample population was the women having breast cancer present in department of oncology in Jinnah and Anmol hospital Lahore.
3.3 Research Type
A unmatched case-control study was conducted with equal number of cases and controls.
3.4 Sample size and Technique
A sample of 300 (150 cases and 150 controls) was obtained by using time based sampling technique. From selected sample data of cases were collected during the period of 9th November to 30th November from oncology department of Jinnah hospital as well as Anmol hospital Lahore. Data of controls were obtained from different areas of Lahore during the same time period.
3.5 Research Criteria
3.5.1 Inclusion Criteria
For the present study only females were eligible. Both married and single women were included in study. Women having age of 20 and grater were included.

Both pre and postmenopausal females were included.
3.5.2 Exclusion Criteria
Males were excluded from study
All the patients having any other cancer rather than breast cancer were excluded from study
3.6 Study Instrument
A pre-tested structured questionnaire was used to interview 300 subjects from the study area.

The instrument of data collection was a well oriented questionnaire, which has been made after careful and keen study of the risk factors for breast cancer. The data has been collected by the surveyor herself. It was a face to face survey.

3.6.1 Performa
The questionnaire was simple in nature; it was consisted of total 44 questions. It includes the general information, life style, dietary habits of both patient of breast cancer and other who do not have breast cancer. The first 8 questions were used to collect personal information of the respondents. The Performa is attached to the appendix. Some variables of Performa are defined as below
BMI (Body Mass Index) is define as the weight in kilograms divided by the square of height in meters (kg/m2).

BMI= Weight (Kg)/ Height (m2)
In this present study, height in centimeters and weight in kilograms were measured physically with the consent of respondents. Height was converted from centimeter to meter square. BMI was categories into ? 24.9 and >24.9 according to risk factor criteria.

Literacy is just the ability to read, write, listen, comprehend and speak a language (sector, 2004). In this study the education was coded as literate and illiterate. The respondents who were above middle considered as literate.

Socio-economic status was determined by collecting the information on total income status of self and/or husband and any other member of the house. Those who had some regular source of income with an income of rupee below ten thousand were coded as ‘poor’ and otherwise coded as ‘not poor’.

A respondent who had a history of passive smoker and those who are currently passive smokers were coded as passive smoker other one non-passive smoker.

High soda intake is define as people who take daily carbonated water of one glass.

3.6.2 Coding Scheme of Questionnaire
Coding is necessary for the measurement of variables in SPSS. To measure the variables the coding which was used is as follow.

Table 3.1: Coding scheme of questionnaire
Variables Options Codes
1 Disease status Control
case 0
1
2 Age 20-35
36-50
51-65
66-80 1
2
3
4
3 BMI Normal
Overweight or obese 0
1
4 Area Rural
Urban 0
1
5 Education Uneducated
Educated 0
1
6 Marital status Single
Married
Widowed
Divorced 1
2
3
4
7 Monthly income Poor
Middle class
High class 0
1
2
8 Question No 11- 32 Yes
No 1
0
9 Question No 33- 44 Strongly agree
Agree
Neutral
Disagree
Strongly disagree 5
4
3
2
1
3.7 Field Experience
The respondent’s behavior was good. Mostly respondents refused to fill up the questionnaire but after explaining the objective of the study, they agreed to cooperate. Though at some places the behavior of some persons was not encouraging but it was a good experience overall.

3.8 Ethical Consideration
The research process includes consent and confidentiality. Verbal and written consent was obtained from the respondents prior to their interview. The respondents were able to understand the importance of their role in the completion of research. The participants were not forced to participate in the research. The confidentiality of the participants was also ensure by not disclosing their names or personal information in the research. Only relevant details that helped in answering the research questions were included.

3.9 Technique of Analyses
The data were entered and analyzed by using IBM SPSS statistics version 17.
Both descriptive and inferential tools are used for data analyses. Through frequencies and graphs descriptive part of study is describe. Person’s Chi-Square/Fisher’s Exact test with odd ratio was used to determine the association of each risk factor with breast cancer.
3.9.1. Person’s Chi-Square Test
The chi-square distribution was obtained by F.R.Helmert (1843-1917), a German physicist in 1875. Later in 1900, Karl Pearson (1857-1936) shows that as “n” approaches to infinity a discrete multinomial distribution may be transferred and made to approach a chi-square distribution. The distribution has broad applications such as a test of goodness of fit, as a test of independence, as a test of homogeneity. The chi-square distribution contains only one parameter called the degree of freedom.

Assumptions:
1. Data are assumed a random sample.

2. Independence between each observation recorded in the contingency table, that is, each subject can only have one entry in the chi-square table
3. The expected frequency for each category should be at least 5.

Hypothesis
Ho: There is no association between breast cancer and risk factor.

H1: there is association between breast cancer and risk factor.

Level of Significance
? =0.05
Test Statistic
For (r x c) contingency table
x2=(OIJ-EIJ)2EIJWhere
Eij= RT*CTGTx2= Person’s cumulative test statistic which asymptotically approaches a chi-square distribution
oij = an observed frequency
EIJ = an expected (theoretical) frequency, asserted by Ho
RT = row total
CT = column total
GT = grand total
Chi square can also be calculated by using another formula
For 2 x 2 Contingency Table
x2= n(ad-bc)2(a+b)(c+d)(a+c)(b+d)Exposed
Yes No Total
Yes a B r1No c D r2Total c1c2 n
where
a No of individuals who are exposed and have disease
b No of individuals who are exposed and do not have disease
c No of individuals who are not exposed and have disease
d No of individuals who are not exposed and do not have disease
r1 Total number of exposed individuals
r2 Total number of non-exposed individuals
c1 Total number of diseased individuals
c2 Total number of non-diseased individual
n Total number of individual in study
Level of Significance
Reject Ho if
P-value ; ?
Conclusion
Conclusion is based on p-value, if p-value is less than ? then we reject the null hypothesis and conclude that there is an association between breast cancer and risk factor.

3.9.2 Fisher’s Exact Test
Hypothesis
Ho: there is no association between breast cancer and risk factor
H1: there is association between breast cancer and risk factor
Test statistic
Fisher’s exact = R1!R2!C1!C2!n!a!b!c!d!Level of significance
Reject Ho if
P-value ; ?
Conclusion
Conclusion is based on p-value, if p-value is less than ? then we reject the null hypothesis and conclude that there is an association between breast cancer and risk factor.

3.9.3 Odds Ratio
An odds ratio (OR) is a measure of association between an exposure and an outcome. The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. If value of OR=1 we can say exposure does not affect odds of outcome if value of OR;1 then we can say exposure associated with higher odds of outcome an if OR;1 then exposure associated with lower odds of outcome
OR=P11-P1P2/(1-P2) = P1/q1p2/q2 = p1q2p2q13.9.4 Confidence Interval of Odds Ratio
The (1-?) * 100% confidence interval (CI) is used to estimate the precision of the OR. A large CI indicates a low level of precision of the OR, whereas a small CI indicates a higher precision of the OR. It is important to note however, that unlike the p value, the 95% CI does not report a measure’s statistical significance. In practice, the 95% CI is often used as a proxy for the presence of statistical significance if it does not overlap the null value (e.g. OR=1). Nevertheless, it would be inappropriate to interpret an OR with 95% CI that spans the null value as indicating evidence for lack of association between the exposure and outcome.

(1-?) 100% Confidence Interval for odds ratio
(OR)1±1.96?x2

5391150-1143004
4

Statistical Analyses
To fulfil the objectives of this study both descriptive as well as inferential statistic were applied on collected data. Descriptive statistic summarizes a given data set, which can either be a representation of the entire population or a sample.

4.1 Descriptive Statistics
4.1.1. Count and Percentages
Table 4.1: Frequency and Percentage of the Demographic Characteristics
variables Frequency
300 Percentage
%
Age(years) 20-35
36-50
51-65
66-80 70
124
91
15 23.3
41.3
30.3
5.0
Area of living Rural
Urban 86 214 28.7
71.3
Marital status Single
Married
Widowed
Divorced 20
215
57
8 6.7 71.7 19.0 2.7
Educational status Educated
Uneducated 152
148 50.7
49.3
Socio-economic status Lower class
Middle class
Upper middle class
Upper class 75
89
89
47 25.0
29.7
29.7
15.7
BMI status (kg/m2) Normal
Over weight 149
151 49.7
50.3

The qualitative variables were explored by expressing them in term of counts and percentages (table 4.1). Out of 300 study sample all the respondent were females 300 (100%). The respondent were mostly among 36-50 years of age group (41.3%) followed by 51-65 years of age group (30.3%), 20-35 years of age group (23.3%) and 66-80 years of age group (5.0%). Also 71.3% of the respondent were from urban area of living while only 28.7% were from rural area of living. A large proportion of respondent were married (71.7%) while 19.0%, 6.7% and 2.7% were widowed, single and divorced respectively. About 50.7% of the study sample was literate and remaining 49.3% was illiterate. There were 25.0% respondent who had low socio-economic status 29.7% respondent belong from middle class same as 29.7% respondent had upper middle class socio-economic status and remaining 15.7% belong from upper class. About 49.7% had normal BMI and 50.3% respondent were overweight.

4.1.2. Cross-Tabulation between Breast Cancer and Risk Factors
In this section the few tables has been discussed with respect to cross tabulation between Breast Cancer and risk factors in term of count and percentages. The risk factors are further categorized into
General characteristics
Life style of the respondent
Dietary habits of respondent
Table 4.2: Cross-Tabulation between Breast Cancer and General Characteristics
Variables Control
150 (%) Case
150 (%) Total
300(%)
Age 20-35
36-50
51-65
66-80 44(29.3%)
54(36%)
44(29.3%)
8(5.3%) 26(17.3%)
70(46.6%)
47(31.3%)
7(4.6%) 70(23.3%)
124(41.3%)
91(30.3%)
15(5%)
Area Rural
Urban 32(21.3%)
118(78.7%)
54(36%)
96(64%) 86(28.7%)
214(71.3%)
Educational status Educated
Uneducated 89 (59.3%)
61 (40.7%) 59 (39.3%)
91 (60.7%) 148 (49.3%)
152 (50.6%)
Marital status Single
Married
Widowed
Divorced 12 (8%)
115 (76.7%)
23 (15.3%)
0 (0%) 8 (5.3%)
100 (66.7%)
34 (22.7%)
8 (5.3%) 20 (6.6%)
215 (71.7%)
57 (19%)
8 (2.6%)
socio-economic status Lower class
Middle class
Upper middle class
Upper class 3 (2%)
45(30%)
75(50%)
27(18%) 72 (48%)
44 (29.3%)
14 (9.3%)
20 (13.3%) 75 (25%)
89 (29.7%)
89 (29.7%)
47 (15.7%)
BMI status (kg/m2) Normal
Over weight 110(73.3%)
40(26.7%) 39 (26%)
111 (74%) 149 (49.7%)
151(50.3%)
Family history Positive
Negative 14(9.3%)
136(90.7%) 64 (42.7%)
86 (57.3%) 78 (26%)
222 (74%)

Table 4.2 showed the cross-tabulation of breast cancer and risk factors (General Characteristics). All the cases and controls were females the percentage of females was 50% and 50% cases and controls respectively. A high percentage of both groups were among 36-50 years of age group (cases 46.6% and controls 36.0%). About 64% and 78.7% cases and controls respectively were from urban area. The percentage of cases with illiterate status (60.7%) was observed to be much higher than that controls (40.7%). A large proportion of both groups were seemed into the married group (66.7% cases and 76.7% controls).

The percentage of cases with lower socio-economic status (48%) was observed to b higher as compared to controls (2%). Overweight was found for 74% cases and 26.7% controls. Family history of cancer was positive for about 42.7% in cases while 9.3% in controls.

Table 4.3: Cross-Tabulation between Breast Cancer and Life style
Breast cancer
Variable controls cases total
150(%) 150(%) 300(%)
Passive smoker Yes
No 32 (21.3%)
118 (78.7%) 60 (40%)
90 (60%) 92
208
Occurrence of stressful event Yes
No 27 (18%)
123 (82%) 96 (64%)
54 (36%) 123
177
Type of stressful event Death of close relation
Financial problem
Personal issue 21 (14%)
1(.6%)
5 (3.3%) 36 (24%)
18 ((12%)
42 (28%) 57
19
47
Working women Yes
No 37 (24.6%)
113(75.3%)
13 (8.6%)
137 (91.3)
50
250
Good relation with family Yes
No 148 (98.7%)
2 (1.3%) 128 (85.3)
22 (14.6%) 276
24
Stressful routine Yes
No 34 (22.7%)
116 (77.3%) 119 (79.3%)
31 (20.7%) 153
147
Daily exercises Yes
No 55 (36.7%)
95 (63.3%) 12 (8%)
138 (92%) 67
233
Sleep early at night Yes
No 113 (75.3%)
37 (24.6%) 91 (60.7%)
59(39.3%) 204
96
Spend leisure time in watching tv Yes
No 65 (43.3%)
85 (56.7%) 88 (58.7%)
62 41.3%) 153
147
Did house hold work by own self Yes
No 102 (68%)
48 (32%) 101 (67.3%)
49 (32.7%) 203
97
Have mad or servant Yes
No 21 (14%)
129 (86%) 27 (18%)
123 (82%) 48
252
Table 4.3 indicated the cross-tabulation between breast cancer and risk factors (Life Style). Out of 150 (21.3%) controls and (40%) cases are passive smokers. It was observed that large proportion of women who are patient of breast cancer were passive smoker. The occurrence of stressful event is much larger in case group (64%) as compare to control group (18%). The proportion of different stressful event in cases such as death of close relation, financial problem and personal issues were recoded respectively as (24%), (12%) and (28%). Both groups have good relation with their families for cases it was (85.3%) and for controls group it was (98.7%). About 79.3% cases and 22.7% controls daily routine was stressful this percentage is greater for cases group. Only 8% respondent from cases did exercise daily while 36.7% controls did exercises daily it was observed that a large proportion of controls did exercise daily while for cases that proportion was much lesser. 75.3% controls slept early at night and 60.7 % controls slept early, there was not any big difference observed between the percentages of both group. 58.7% cases and 43.3% controls spend their leisure time by watching TV. Both the groups’ proportion for doing house hold work approximately same (68% cases and 67.3% controls). About 14% and 18% controls and cases respectively have mad or servant for their house hold work that showed a large percentage of both groups don’t have any mad or servant for their house hold work . 24.6% respondent from controls and 8.6% respondent from cases were working women. It was observed that working women percentage is higher in controls.

Table 4.4: Cross-Tabulation between Breast Cancer and dietary habits
Breast cancer
Variable controls cases total
150(%) 150(%) 300 (%)
Take green tea Yes
No 56 (37%)
94 (62.7%) 12 (8%)
138 (92%) 68 (22.7%)
232 (77.3%)
Take vitamins supplement Yes
No 70 (46.7%)
80 (53.3%) 25 (13.9%)
125 (83.3%) 95 (31.7%)
205 (68.3)
Drink milk Yes
No 90 (60%)
60 (40%) 77 (51.3%)
73 (48.7%) 167 (55.7%)
133 (44.3%)
Type of milk Full cream
Regular milk 0 (0%)
90 (60%) 27 (18%)
50 (33%) 27 (9%)
140 (46.7%)
Ghee use for cooking Yes
No 15 (10%)
135 (90%) 98 (65.3%)
52 (34.7%) 113 (37.7%)
187 (62.3%)
Red meat is a part of meal Strongly agree
Agree
Neutral
Disagree
Strongly disagree 4 (2.7%)
38 (25.3%)
51 (34%)
43 (28.7%)
14 (9.3%) 26 (17.3%)
38 (25.3%)
60 (40%)
25 (16.7%)
1 (0.7%) 30 (10%)
76 (25.3%)
111 (37%)
68 (22.7%)
15 (5%)
Take fresh juices Strongly agree
Agree
Neutral
Disagree
Strongly disagree 20 (13.3%)
74 (48.3%)
34 (22.7%)
16 (10.7%)
6 (4%) 18 (12%)
3 (2%)
8 (5.3%)
21 (14%)
100 (66.7%) 38 (12.7%)
77 (25.7%)
42 (14%)
37 (12.3%)
106 (35.3%)
Often take drinks contain soda Strongly agree
Agree
Neutral
Disagree
Strongly disagree 13 (8.7%)
19 (12.7%)
34 (22.7%)
28 (18.7%)
56 (37.3%) 20 (13.3%)
21 (14%)
49 (32.7%)
39 (26%)
21 (14%) 33 (11%)
40 (13%)
83 (27.7%)
67 (22.3%)
77 (25.7%)
Often eat fish Strongly agree
Agree
Neutral
Disagree
Strongly disagree 1 (0.7%)
26 (17.3%)
50 (33.3%)
53 (35.3%)
20 (13.3%) 0 (0%)
5 (3%)
22 (14.7%)
59 (39.3%)
64 (42.7%) 1 (1%)
31 (10.3%)
72 (24%)
112 (37.3%)
84 (28%)
Prefer to eat white meat Strongly agree
Agree
Neutral
Disagree
Strongly disagree 19 (12.7%)
75 (50%)
46 (30.7%)
8 (5.3%)
2 (1.3%) 20 (13.3%)
45 (30%)
37 (24.7%)
31(20.7%)
17 (11.3%) 39 (13%)
120 (40%)
87 (29%)
39 (13%)
19 (6.3%)
Mostly like to eat fresh vegetables Strongly agree
Agree
Neutral
Disagree
Strongly disagree 101 (67.3%)
31 (20.7%)
8 (5.3%)
8 (5.3%)
2 (1.3%) 0 (0%)
37 (24.7%)
75 (50%)
28 (18.7%)
10 (6.7%) 101 (33.7%)
68 (22.7%)
83 (27.7%)
36 (12%)
12 (4%)
Fruit is a part of daily food Strongly agree
Agree
Neutral
Disagree
Strongly disagree 26 (17.3%)
42 (28%)
57 (38%)
23 (15.3%)
2 (1.3%) 2 (1.3%)
32 (21.3%)
48 (32%)
45 (30%)
23 (15.3%) 28 (9.3%)
74 (24.7%)
105 (35%)
68 (22.7%)
25 (8.3%)
Fried things are part of meal Strongly agree
Agree
Neutral
Disagree
Strongly disagree 2 (1.3%)
20 (13.3%)
26 (17.3%)
68 (45.3%)
34 (22.7%) 12 (8%)
26 (17.3%)
40 (26.7%)
67 (44.7%)
5 (3.3%) 14 (4.7%)
46 (15.3%)
66 (22%)
135 (45%)
39 (13%)
Mostly eat white bread in break fast Strongly agree
Agree
Neutral
Disagree
Strongly disagree 20 (13.3%)
26 (17.3%)
21 (14%)
37 (24.7%)
46 (30.7%) 22 (14.7%)
8 (5.3%)
19 (12.7%)
61 (40.7%)
40 (26.7%) 42 (14%)
34(11.3%)
40 (13.3%)
98 (32.6%)
86 (28.7%)
Mostly you eat fast food Strongly agree
Agree
Neutral
Disagree
Strongly disagree 1 (0.6%)
10 (6.7%)
38 (25.3%)
36 (24%)
65 (43.3%) 6 (4%)
14 (9.3%)
45 (30%)
59 (39.3%)
26 (17.3%) 7 (2.3%)
24 (8%)
83 (27.7%)
95 (31.7%)
91 (30.3%)
Green salad is part of your meal Strongly agree
Agree
Neutral
Disagree
Strongly disagree 19 (12.7%)
43 (28.7%)
43 (28.7%)
16 (10.7%)
29 (19.3%) 3 (2%)
18 (12%)
38 (25.3%)
51 (34%)
40 (26.7%) 22 (7.3%)
61 (20.3%)
81 (27%)
66 (22%)
69 (23%)
Table 4.4 indicated the cross-tabulation between breast cancer and risk factors (dietary habits). Out of 300 women only 68 women take green tea at daily bases. In case group women who take green tea were only 8% found to be lesser than that controls (37%) there was a large difference in percentages of case and control for green tea intake. This proportion is higher in controls. It was observed that 46.7% women from control group take vitamin supplement from case group 13.9% of females take vitamin supplement it was observed that higher proportion of controls take vitamin supplement daily. 60% of females drink milk regularly from controls group and 51.3% women from case group take milk regularly there was no much difference noticed for both groups. Full cream milk used by 18% of cases and not a single women in controls take full cream milk. The percentage of cases who take regular milk was 33% and for controls it was 60% which was much greater as compared to cases. A high percentage of cases 65.3% use ghee for cooking where this percentage was 10 for controls. Out of 150 cases 42.6% (17.3+25.3) were agreed that they use red meat often 17.3% (16.7+0.6) were disagreed from it a large proportion 40% were neutral while from controls only 28% were agreed 34% were neutral and 38% (28.7+9.3) disagreed.it was observed that greater percentage of cases were agreed that they use red meat often while this percentage was much lesser for controls. A large proportion of controls were agreed that they take fresh juices, that proportion was 61.6% (13.3+48.3) and only 14.7%(10.7+4) respondent were disagreed while 14% females from cases group were agreed and 80.7% (14+66.7) women were disagreed . It was observed that women of control group have greater proportion for intake of fresh juices. In control group 21.4% (8.7+12.7) females were agreed that they take drinks which contain soda and 56% (18.7+37.3) women were disagreed on it whereas in cases group 27.3% (13.3+14) were agreed and 40% (26+14) were disagreed that they often take drinks which contain soda. Both group percentages were not much different for intake of drinks which contain soda. It was observed that a small proportion of both groups eat fish 18% (0.7+17.3) controls and 3% (0+3) were agreed 48.6% (35.3+13.3) controls and 82% (39.3+42.7) cases were disagreed. Percentages showed that large proportion of cases was not eat fish. The percentage of controls who were agreed for often use of fresh vegetables were 88% (67.3 +20.7) which was much higher than that of cases 24.7% (0+24.7) large proportion of cases were neutral which was 50% and 6.6% (5.3+1.3) controls as well as 25.4% (18.7+6.7) cases were disagreed. The percentage for use of vegetables is much higher in control group as compare to case group. In controls it was observed that 45.3% (17.3+28) were agreed that they often eat fruits 38% were neutral and 16.6% (15.3+1.3) were disagreed that they often eat fruits while from cases 22.6% (1.3+21.3) were agreed 32% were neutral 45.3% (30+15.3) were disagreed. Percentages showed women from control group often take fruits while smaller proportion of cases often take fruits. It was observed that 14.6% (1.3+13.3) controls and 25.3% (8+17.3) cases were agreed that they eat fried things 68% (45.3+22.7) controls and 77.7% (44.7+33) cases were disagreed on it. It was observed proportion for use of fried things was greater for cases. 30.6% (13.3+17.3) women from controls were agreed that they often eat bread in breakfast 55% (24.7+30.7) were disagreed whereas from cases 20 % (14.7+5.3) were agreed and 67.4% (40.7+26.7) were disagreed that they eat bread in breakfast. Large percentages of both group were disagreed on it. 7.3% (0.6+6.7) controls and 13.3% (9.3+4) cases were agreed that they often eat fast food while 77.3% (24+43.3) controls and 56.6% (39.3+17.3) cases were disagreed. It was observed that small proportion of both group mostly eat fast food. In controls 41.4% (12.7+28.7) were agreed that they eat salad 30% (10.7+19.3) were disagreed whereas 14% (2+12) cases were agreed 48.7% (22+26.7) were disagreed. A great percentage of control used salad often.
4.2 Inferential Statistics
4.2.1. Association between Breast Cancer and Risk Factors
Table 4.5: Association between Breast Cancer and General Characteristics.

Variable Chi-square p-value
Age 6.859 0.077
Area 7.890 0.05
Educational status 12.002 0.001*
Socio-economic status 106.343 0.00*
BMI-status 67.216 0.00*
Family history 43.313 0.00*
*Significant at p-value <0.05
Further the data was analyzed to find out the association between breast cancer and risk factors.

Table 4.5 showed the association between breast cancer and general characteristics. Educational-status, socio-economic status, BMI and family history of cancer were resulted as significant risk factor associated with breast cancer as P-value < ?. While there were no association observed with these variables age and area because for these two variables P-value was greater than ?.
Table 4.6: Association between Breast Cancer and Life Style
Variable Chi-square p-value
Passive smoker 12.291 0.00*
Diabetic patient 0.169 0.681
Stressful life event 65.60 0.00*
Type of stressful event 13.977 0.01*
Stressful routine 96.67 0.00*
Working women 13.824 0.00*
Daily exercise or walk 35.53 0.00*
Sleeping routine 7.414 0.06
Did house hold work 0.015 0.902
Watching tv in leisure time 7.056 0.008*
*Significant at p-value< 0.05
Table 4.6 indicated the association between breast cancer and life style of the respondents. This associations is checked for number of variables. For passive smoker, stressful life event, type of stressful event, stress full routine, daily exercise, watching TV in leisure time the results were significant as the calculated p-value < ? . For variables diabetic patient, did household work by own self and sleeping routine the results were insignificant.
Table 4.7: Association between Breast Cancer and Dietary Habits.

Variable Chi-square p-value
Take green tea 36.815 0.00*
Excessive use of black tea 3.660 0.056
Intake of vitamin supplement 31.194 0.00*
Daily intake of milk 2.283 .131
Oil use for cooking 107.630 0.00*
Use of Red meat 32.89 0.00*
Fresh juices 199.60 0.00*
Drinks contain soda 22.01 0.00*
Use of fresh vegetables 172.058 0.001*
Often eat Fruits 47.46 0.00*
Fried things 32.467 0.00*
Fried potatoes 14.44 0.06
Use of white bread 16.021 0.03*
Excessive use of fast food 27.11 0.00*
Daily use of salad 42.22 0.00*
*Significant at p-value< 0.05
Table 4.6 indicated the association between breast cancer and dietary habits of respondent. Variables daily intake of milk and excessive use of black tea were not associated with breast cancer while intake of green tea, intake of vitamin supplement, oil use for cooking use of red meat use of fresh juices, use of fruits often, use of fried things use of white bread excessive use of fast food and daily use of salad were significant as p-value < ?.
4.2.2 0dds Ratio for Breast Cancer and Risk Factors with 95% Confidence Interval.

Table 4.8: odds ratio for risk factors
Variable Odds-ratio 95% C.I
Lower Upper
BMI-status 7.827 4.682 13.085
Family history 7.229 3.819 13.686
Passive smoker 2.458 1.477 4.091
Stressful life event 8.099 4.750 13.808
Working women 0.290 0.147 0.572
Stressful routine 13.09 7.558 22.696
Daily exercise 0.150 0.076 0.296
Take green tea 0.146 0.074 0.287
Intake of vitamin supplement 0.229 0.134 0.391
Ghee use for cooking 16.96 9.28 31.865
Use of red meat 2.071 1.307 3.281
Fresh juices 0.053 0.026 0.106
Use of fresh vegetables 0.262 0.153 0.448
Often eat Fruits 0.329 0.205 0.529
Use of fried things 2.979 1.837 4.830
Excessive use of fast food 1.753 1.084 2.835
Daily use of salad 0.232 0.142 0.377
Table 4.8 described the odds ratio for different risk factors with 95% confidence interval. Tables shows there was 7.827% greater chance of having breast cancer in those whom BMI is greater than 24.9 and consider as over weighted or obese as compare to those who have normal BMI with 95% C.I of (4.682-13.085) which was observed as significant . Women who had family history of any type of cancer were 7.229 times more likely to develop breast cancer than those who don’t had family history with 95% C.I (3.819 – 13.686). As 1 was not laying between upper and lower limit of ORs it showed that the result is significant or we can say that family history of cancer is a risk factor of breast cancer. There were 2.458 times greater risk of having cancer with 95% C.I (1.477- 4.091) in those women who were passive smokers the results are also significant for ORs. Those women who had some stressful life event such as death of close relations, financial issues and some personal issues have 8.099 times chance of having breast cancer as compare to those who don’t . The 95% C.I = (4.750-13.808) which was significant for OR. There were 13.09 times more likely to develop breast cancer with 95% C.I (7.558-22.696) in those who’s routine were stressful as compare to those who’s routine were relax . Those who use ghee for cooking have 16.69 times more likely to having breast cancer as compare to those who us oil or homemade ghee for cooking with 95% C.I (9.28-31.865). Women who used red meat mostly in their meal had 2.071 times more risk of breast cancer as compare to those who used it sometime and for this OR the 95% C.I (1.307-3.281) which was significant. There were 2.929 times more likely to having breast cancer who mostly eat fried things and 1.753 times greater chance of having breast cancer in those who often eat fast food with 95% C.I (1.837-4.830) and C.I (1.084-2.835) respectively.
Some variables odds ratio show that those variables decrease the risk of breast cancer. Table show that there were 3.45 (1/0.290) time lesser chance of having disease in working women with 95% C.I (0.147-0.572) which is significant with respect to odds ratio. As working women were educated and they have more awareness may be just because of that they have lesser chance of having breast cancer. Those women who take exercise daily have 6.7(1/0.150) times less likely to having breast cancer as compare to those who didn’t take exercise. Because exercise helps to maintain the weight and physical activity help to improve the immune system therefore exercise may reduce the risk of breast cancer. There were 6.85 (1/0.146) times less chance of breast cancer in those who often take green tea. Because green tea helps to digest food, help to reduce weight and have many more benefits so it may reduce the risk of breast cancer. Women who take vitamin supplement daily have 4.37 (1/0.229) time lesser chance of having breast cancer as compare to those who didn’t take any vitamin supplement. Vitamin supplement was result as protective against breast cancer because if there is lack of vitamin in body so it will be harmful for body and body function may not work properly and they may cause many disease as well as breast cancer so, in this way vitamin supplement may reduce the risk. Women who take fresh juices often have 18.86 (1/0.053) time less chance of having breast cancer. There were 3.82 (1/0.262) times less likely to having breast cancer who ate vegetables mostly. Those who eat fruits daily have 3.04 (1/0.329) times greater risk of having breast cancer as compare to those who don’t eat fruits daily. Those women who used salad regularly were 4.31(1/0.232) times less likely to develop breast cancer than those who didn’t take salad regularly. Use of fresh juices, vegetables and fruits is healthy because it provide good nutrients and minerals to our body so they were resulted as protective against breast cancer .These all variables were also significant with respect to 95% C.I of ORs.

Table 4.9: summary of association between breast cancer and risk factors
Variable Chi-square p-value Odds-ratio 95% C.I
Lower Upper
BMI-status 67.216 0.00 7.827 4.682 13.085
Family history 43.313 0.00 7.229 3.819 13.686
Passive smoker 12.291 0.00 2.458 1.477 4.091
Stressful life event 65.60 0.00 8.099 4.750 13.808
Working women 13.824 0.00 0.290 0.147 0.572
Stressful routine 96.67 0.00 13.09 7.558 22.696
Daily exercise or walk 35.53 0.00 0.150 0.076 0.296
Take green tea 36.815 0.00 0.146 0.074 0.287
Intake of vitamin supplement 31.194 0.00 0.229 0.134 0.391
ghee use for cooking 107.630 0.00 16.96 9.28 31.865
Use of Red meat 32.89 0.00 2.071 1.307 3.281
Fresh juices 199.60 0.00 0.053 0.026 0.106
Use of fresh vegetables 172.058 0.001 0.262 0.153 0.448
Often eat Fruits 47.46 0.00 0.329 0.205 0.529
Fried things 32.467 0.00 2.979 1.837 4.830
Excessive use of fast food 27.11 0.00 1.753 1.084 2.835
Daily use of salad 42.22 0.00 0.232 0.142 0.377
Table 4.9 describe the summary of association between breast cancer and risk factors. Table show that BMI is significant as p-value< ? and there was 7.828 times greater chance of having disease in those women whom BMI is greater than 29.9 with 95% C.I (4.68-13.08). There was 7.229 times greater chance of contracting disease in those who had family history of cancer with 95% C.I (3.819-13.686). Which was significant as p-value< ?. Variable Passive smokers was significant and its odds ratio showed that there was 12.29 times more likely to having breast cancer in those women who were passive smokers. Working women, daily exercise, intake of green tea, intake of vitamin supplement were also significant but their odds ratio showed that these variables were protective against breast cancer. Stressful life event and stressful routine were observed as significant and there were 8.09 times more chance of having breast cancer who faced some stressful event in their life and 13.09 times more likely to having disease in those who’s routine was stressful, with 95% C.I (7.55- 22.69). Use of ghee, use of red meat, often use of fried things and excessive use of fast food were resulted as significant and have 16.96, 2.07, 2.97, 1.75, times greater chance of having disease respectively. Intake of fresh juices, use of fresh vegetables and daily use of salad and fruits were observed as significant and they were observed protective against breast cancer and there 95% C.I with respect to its odds ratio were also significant.

58293004286255
005

Results, Discussion
and Conclusion
5.1. Results and Discussion
This study was conducted to determine the role of life style and dietary habits in risk of breast cancer. The main purpose of the study was to check the association between breast cancer and different risk factors. Also different risk factors as respect to its exposer were accessed. Because the topic was on breast cancer so, all the cases and controls were female. Both descriptive and inferential statistic was applied on data. The percentage of female was 50% for cases and 50% for controls respectively. A high percentage of both groups were among 30-50 years of age group. (cases 46.6% and controls 36%). About 64% and 78.7% controls and cases respectively were from urban area. The percentage of cases with illiterate status 60.7% was observed to be much higher than that of controls 40.7%. A large proportion of both the groups were seemed into the married group (66.7% cases and 76.7% controls). The percentage of cases with lower socioeconomic-status 48% was observed to be higher as compare to controls 2%. 74% cases were found overweight while only 26.7% controls were overweight. Family history of cancer was positive for about 42.7% in cases while 9.3% in controls.
The risk of breast cancer for illiterate educational status is 2.25 times greater. The educational level of respondent is define as literate and illiterate, was found to be significant as chi-square (X2) = 12.002. Having a high education may increase the tendency of health-seeking behavior due to greater awareness as well as preventive behavior such as use of healthy diet. This research has also showed that a family history of cancer is significantly associated with developing the breast cancer. As many as 42.7% of the respondent had a family history of cancer. The risk of breast cancer is 7.229 times greater in those who have family history of cancer with 95% C.I (3.819 -13.686) Which was significant on the bases of chi-square as well as confident interval of OR. Similar findings have been reported elsewhere (Houlston, et al,1992 ; Pharoah, et al, 1997 ; Colditz, et al, 1993 ; Slattery, et al, 1993).

This study found that people with breast cancer had a higher BMI compared to normal individuals. The respondent with BMI ;24.9 kg/m2 are at 7.8 the risk of developing breast cancer as compare to people with BMI? 24.9kg/m2 which was consistent with the findings from many studies (Morimoto, et al ,2002; Hsieh, et al,1990; Møller, et al, 1994; Willett, et al, 1985; Harvie, et al, 2003).There is about 2.46 time higher risk of developing breast cancer in those women who were passive smokers. It has been suggested that cigarette smoking (both active and passive) is a risk factor for breast cancer. Smoking is a one of major risk factor of many disease as well as breast cancer. People who smoke or they are secondhand smoker have many times greater chance of having breast cancer many studies proved that passive smoking is also injurious for health as like active smoking. Passive smoking can damage the body because secondhand smoke c0ntain more than 4,000 chemicals, many of which are irritants and toxin, and some of which are known to cause cancer. The result of this study is consistent with the finding from many studies (Kropp and Chang-Claude, 2002; Luo, et al, 2011; Reynolds, et al, 2004; Smith, et al, 1994; Johnson, et al, 2000).
Age was not found to be significant for breast cancer. However it was found that in all age group from 20-80 years women may have chance of breast cancer but it was found that higher number of patient respondent were among 36-50 year of age group.
Occurrence of stressful event in risk of breast cancer give significant result. Women who had stressful event such as death of close relation, financial problem, and personal issues have 8.09 times higher risk of having breast cancer. This study result is consistence with other findings of different studies. (Lillberg, et al, 2003; Duijts, et al, 2003; Chen, et al, 1995; Protheroe, et al, 1999).

The respondent whom daily routine is stressful observed to b significant those women have 13.09 times higher chance of breast cancer as compare to those who’s daily routine is free from stress. Because daily stressful routine affect our immune system and weaken it, leaving ourselves open to attack by bugs. That’s why stressful routine affect the health in many ways. There is about 0.15 times higher risk of developing breast cancer when respondent does not take exercise or we can say that respondent who take exercise have 6.6 time lesser chance of having breast cancer. This study show that exercise have protective affect against breast cancer. Many other studies also result is consistence with the result of this study (Mcneely, et al, 2006; Monninkho, et al, 2007; Thune and Furberg, 2001, Bernstein, et al, 1994). Intake of green tea is good for health. This study show that women who did not take green tea have 0.146 time greater chance of contracting breast cancer. In other words intake of green tea 6.8 times decrease the risk of breast cancer. Different studies show that green tea have protective effect against breast cancer (Anna, et al, 2003; Suzuki, et al, 2003; Ogunleye , et al, 2009; Zhang, et al, 2006). The result of the study for intake on vitamin supplement and risk of breast cancer was significant. Odds ratio determine that women who do not take any vitamin supplement at daily bases have 0.229 times higher chance of contracting disease with 95% confidence interval ( 0.134 0.391). In other words there was 4.3 times lesser chance of contracting breast cancer in women who take vitamin supplement at daily bases. Other study also satisfied the result of this study (Shinetal,2002).

The hypotheses was made to check the association between use of ghee for cooking and risk of breast cancer. This study show significant result for the association between breast cancer and ghee use for cooking. There was 16 times likely to develop breast cancer in those women who use ghee or hard fat for cooking with 95% confidence interval (9.28 – 31.86). The respondent who used red meat often in there meal have twice time risk to develop breast cancer. Use of red meat was significantly associated with breast cancer. As we know red meat is high in fats and that fat is unsaturated which has been linked to cancers of the colon and breast as well as to heart disease. Carcinogens formed when meat is cooked. Heme iron, the type of iron found in meat that may produce compounds that can damage cells leading to cancer. That’s why excessive use of red meat is injurious for health. Most of the studies result findings were similar to the finding of this research (Cho, et al, 2006; Stefani, et al, 1997; Ronco, et al, 1996; Missmera, et al, 2003).

The result was observed to be significant when the association between breast cancer and intake of fresh juices was checked .There was 0.053 time greater chance of contracting breast cancer in women who did not take fresh juices with 95% confidence interval. It was found that 60% of respondent from control group often take fresh juices. So this study show use of fresh juices have protective effect against breast cancer. Two hypotheses were made to check the association between use of fresh vegetables and daily use of salad in risk of breast cancer. The result was found to be significant. Women who prefer to eat fresh vegetables have 3.8 times lesser chance of developing breast cancer and respondent who take salad at daily bases have 4.3 time lesser chance of contracting breast cancer with 95% C.I. The result of study show that more intake of fresh vegetables decrease the risk of contracting breast cancer. The result is consistent with the findings from other studies (Stephanie, et al, 2001; Gils, et al, 2005; Freudenheim, et al, 1996; Zhang, et al, 2009).

There was 3 times lesser chance of breast cancer in those women who often take fruits according to the results of this study. The result is significant and there was negative association between breast cancer and fruit intake. Often intake of fruit has protective effect and it decrease the risk of developing breast cancer. Many other studies also show that greater intake of fruit have protective effect against breast cancer. (Stephanie, et al, 2001; Freudenheim, et al, 1996; Zhang, et al, 2009; Gils, et al, 2005).
Results were significant for two hypothesis the first one is that is there any association between Breast Cancer and often use of fast food the second one is to check the association between fried thing and breast cancer. It was observed that there was 2.9 times higher chance of contracting breast cancer in women who often eat fried things and 1.7 times greater chance of developing breast cancer in those women who often take fast food with 95% confidence interval. The finding of the study was insignificant for diabetic patient and risk of breast cancer. This study show that intake of caffeine in form of black tea is insignificant that show black tea is not a risk factor for breast cancer. Sleep early at night, doing house hold work and watching TV in leisure time were also observed insignificant for present research.

5.2 Conclusion
Study was conducted to determine the role of life style and dietary habits in risk of breast cancer at Jinnah Hospital and Anmol hospital Lahore. Study showed that educational status, BMI, family history of cancer, passive smoker, occurrence of stressful event, stressful routine, use of ghee for cooking, excessive use of red meat, high intake of fried things and use of fast food were resulted as significant risk factors associated with breast cancer. Some other variables are also significant but those risk factors have protective effect against breast cancer such as use of green tea, daily intake of vitamin supplement, use of fresh juices, often use of fresh vegetables, high intake of fruits use of salad at daily bases and daily walk or exercise.

Breast cancer is significant with illiterate women, positive family history of cancer and those who had BMI> 24.9 and consider as overweight or obese. The respondent whom life was full of stress daily routine was stressful have greater risk of developing breast cancer. Respondent who were passive smoker, use ghee for cooking, mostly eat red meat, fast food and fried things were part of their meal have greater chance of contracting disease and all these risk factors are directly associated with breast cancer. Age, Area of living, Marital status, Socio-economic status, sleep early at night, take milk , spend leisure time in watching TV, did house hold work by own self all are insignificant.
From this study it can be determine that greater use of fruits, vegetables, juices as well as daily intake of vitamin supplement and green tea and less use of ghee, red meat, fast food and fried things may reduce the risk of breast cancer same as daily exercise and walk also paly important role to decrease the risk of breast cancer. Findings of research show that life style and dietary habits play major role in risk of breast cancer through healthy life style and healthy eating habits the risk of breast cancer may reduce.
5.3 limitation of the Research
The study had been conducted on a very small scale and covers only patient of Jinnah and Anmol hospital Lahore during the time of data collection. The scope of the research was partial fulfilment of the degree requirement that’s why we cannot enroll the hospitals in all over the Pakistan due to limited time and cost. As there are no financial sport available for students.

References
Althuis, D. M.,  Dozier, J. M.,  Anderson, W. F.,  Devesa, S. S., Brinton1, L. A., (2005). Global trends in breast cancer incidence and mortality 1973–1997, International Journal of Epidemiology, 32: 405-412.

Bernstein, L., Henderson, B. E., Hanisch, R., Sullivan-Halley, J., and Ross, R, K., (1994). Physical Exercise and Reduced Risk of Breast Cancer in Young Women, Journal of National Cancer Institute, 86:1403-1408.

Brinton, L.A., Swanson, C.A., (1992). Height and weight at various ages and risk of breast cancer, Journal of American Collage of Institute, 2, 597-609.

Boyd, N. F., Stone, J., Vogt, K. N., Connelly, B. S., Martin, L. J., and Minkin, S., (2003). Dietary fat and breast cancer risk revisited: a meta-analysis of the published literature, British Journal of Cancer, 89, 1672–1685.

Colditz, G. A., Willett, W. C., Hunter, D. J., Stampfer, M. J., Manson, J. E., Hennekens, C. H., Rosner, B. A., Speizer, F. E., (1993). Family History, Age, and Risk of Breast Cancer Prospective Data from the Nurses’ Health Study, Journal of American Medical Association, 3:338-343.

Chen, C. C., David, A. S., Nunnerley, H., Michell, M., Dawson, J. L., Berry, H. Dobbs, J., Fahy, T., (1995). Adverse life events and breast cancer: case-control study, British Medical Journal, 311: 1527.

Cho, E., Chen,W. Y., Hunter, D. J., Stampfer, M. J., Colditz, G. A., Hankinson, S. E., Willett, W. C., (2006). Red Meat Intake and Risk of Breast Cancer among Premenopausal Women, Arch Intern Med, 166:2253-2259.
DUIJTS, F. A., Zeegers, M. P. A., and Borne, B. V., (2003). The Association Between Stressful Life Events and Breast Cancer Risk: A Meta-Analyses, International Journal of Cancer, 107:1023-1029.
DeSantis, C., Ma. J., Bryan, L., Jemal, A., (2014). Breast Cancer Statistics 2013, Cancer Journal for Clinician, 64:52–62.

Ewertz, M., and Gill, C., (1990). Dietary factors and breast-cancer risk in Denmark, International Journal of Cancer, 46, 779-784.

Ferlay, J., Shin, H. R., Bray, F., Forman, D., Mathers, C., Parkin, D. M., (2010). Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008, International Journal of Cancer, 127:2893-917.

Forsén, A., (1991). Psychosocial Stress as a Risk for Breast Cancer, Psychotherapy and Psychosomatics, 55, 176–185.

Gils, C. H. V., Peeters, P. H. M., Bueno-de-Mesquita, H. B., (2005). Consumption of Vegetables and Fruits and Risk of Breast Cancer, Journal of American Medical Association, 293: 183-193.

Harvie, M., Hooper, L., and Howell, A.H., (2003). Central obesity and breast cancer risk: a systematic review, International Association for the Study of Obesity, 4:157-173.

Houlston, R. S., McCarter, E.,  Parbhoo, S., Scurr, J. H., Slack, J., (1992). Family history and risk of breast cancer, Journal of Med Genet, 29:154-157.

Johnson, K. C., Hu, J., Mao, J., (2000). Passive and active smoking and breast cancer risk in Canada, Cancer cases and controls, 11: 211-221.

Kropp, S., and  Chang-Claude, J., (2002). Active and Passive Smoking and Risk of Breast Cancer by Age 50 Years among German Women, American Journal of Epidemiology, 156:616-626.

Knektl, P., Jarvinen, R., Seppinen, R., Pukkala, E., and Aromaa, A., (1996). Intake of dairy products and the risk of breast cancer, British Journal of Cancer, 73, 687-691.

Luo, J., Margolis, K.L., Wactawski-Wende, J.Horn, K., Messina, C., Stefanick, M.L., Tindle, H.A., Tong, E., Rohan, T.E. (2011). Association of active and passive smoking with risk of breast cancer among postmenopausal women: a prospective cohort study, British Medical Journal, 342, 1016.

Lillberg, K., Verkasalo, P.K., Kaprio, J., Teppo, L., Hans Helenius, H., and Koskenvuo, M., (2003). Stressful Life Events and Risk of Breast Cancer in 10,808 Women: A Cohort Study, American journal of epidemiology, 5, 415-423.

Lindvig, K., and Olsen, J. H., (1994). Obesity and cancer risk, European Journal of cancer, 30: 344-350.

Missmera, S. A., Smith-Warnerc, S. A., Spiegelmana, D., et al., (2002). Meat and dairy food consumption and breast cancer: a pooled analysis of cohort studies, International journal of Epidemology, 31:78-85.

McNeely, M. L., Campbell, K. L., Rowe, B. H., Klassen, T.P., Mackey, J.R., Courneya, K. S., (2006). Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis, Canadian Medical Association Journal, 175: 10.1503.

Monninkhof, E. M., Elias, S. G., Vlems, F. A., Et al, (2007). Physical activity and breast cancer: a systematic review. Epidemiology, 18: 137-157.

Michailidou, K., Hall, P., Gonzalez-Neira, A., Ghoussaini, M., Dennis, J., et al., (2013). Large-scale genotyping identifies 41 new loci associated with breast cancer risk, Nature Genetics, 45:353–361.

Malin, A. S., Qi, D., Shu, X.-O., Gao,Y. T., Friedmann, J. M., Jin, F. and Zheng, W., (2003). Intake of fruits, vegetables and selected micronutrients in relation to the risk of breast cancer, International Journal of Cancer, 105: 413–418.

Morimoto, L.M., White, E., Chen, Z., Chlebowski, R.T., Hays, J., Kuller, L., Lopez, A.M., Manson, J., Margolis, K.L., Muti, P.C., Stefanick, M.L., McTiernan, A. , (2002). Obesity, body size, and risk of postmenopausal breast cancer, “International Journal of Studies of Cancer in Human Populations”13, 741-751.

Negri, E., Braga, C., Vecchia, C.L., Franceschi, S., and Parazzini, F., (1997). Family History of Cancer and Risk of Breast Cancer, “International journal of cancer”, 72, 735–738.

Ogunleye, A.A.,  Xue, F., Michels, K.B., (2010). Green tea consumption and breast cancer risk or recurrence: a meta-analysis, Breast cancer research and treatment, 119: 477-484.

PhiHip, R.L., (1975). Role of Life-style and Dietary Habits in Risk of Cancer among Seventh-Day Adventists, journal of cancer research, 35, 3513-3522.
Pharoah, D. P., Day, N.E., Duffy, S., Easton, D. F., and Poner, B. A. J., (1997). Family History And The Risk of Breast Cancer: A Systematic Review And Meta-Analyses, international journal of cancer, 71:800-809.

Protheroe, D., Turvey, K., Horgan, K., Benson, E., Bowers, D., Allan House, A., (1999). Stressful life events and difficulties and onset of breast cancer: case-control study, British Medical Journal, 319:1027.

Ronco, A., Stefani*, E. D.,  Mendilaharsu, M. and Deneo-Pellegrini, H., (1996). Meat, fat and risk of breast cancer: A case-control study from Uruguay, International Journal of Cancer, 65: 328-331.

Reynolds, P.,  Hurley, S., Goldberg, D.E.,  Anton-Culver, H., Bernstein, L., Deapen, D., Horn-Ross, P.L., Peel, D., Pinder, R.,  Ross, R.K., West, D., Wright, W.E., and  Ziogas, A., (2004). Active Smoking, Household Passive Smoking, and Breast Cancer: Evidence from the California Teachers Study, Journal of National Care Institute, 96: 29-37.

Slattery, M. L. And Kerber, R. A., (1993). A Comprehensive Evaluation of Family History and Breast Cancer Risk, Journal of American Medical Association, 13:1563-1568.

Smith, S.J.,  Deacon, J.M., and Chilvers, C.E., (1994). Alcohol, smoking, passive smoking and caffeine in relation to breast cancer risk in young women. UK National Case-Control Study Group, British journal of cancer, 70: 112-119.

Suzuki, y., Tsubono, y., Nakaya, y., Suzuki, y., Koizumi, y., and Tsuji, I., (2004). Green tea and the risk of breast cancer: pooled analysis of two prospective studies in Japan, British Journal of Cancer, 90, 1361–1363.

Shin, M-H., Holmes, M. D., Hankinson,  S. E., Wu, K., Colditz, G. A. and Willett, W.C., (2002). Intake of Dairy Products, Calcium, and Vitamin D and Risk of Breast Cancer, Journal of National Cancer Institute, 94: 1301-1313.

Stefani, E. D., Ronco, A., Mendilaharsu, M.,Guidobono, M. and  Deneo-Pellegrini, H., (1997). Meat intake, heterocyclic amines, and risk of breast cancer: a case-control study in Uruguay, Cancer Epidemiol Biomarkers and Prevantion, 6: 573-81.

Stephanie A., Smith-Warner, Spiegelman, D., Et al., (2001). Intake of Fruits and Vegetables and Risk of Breast CancerA Pooled Analysis of Cohort Studies, Journal of Amarican Medical Association, 258.

Thune, I., Furberg, A. S.,(2001), Physical activity and cancer risk, Medicine and Science in Sports and Exercise, 33: 530-550.

Wu, A. H., Yu, M. C., Tseng, C-C., Hankin, J., and Pike, M. C., (2003), Green tea and risk of breast cancer in Asian Americans, International Journal of Cancer, 106: 574–579.

Willett, W. C., Browne, M. L., Bain, C.,  Lipnick, R. J., Stampfer, M. J., Rosner, B., C0lditz, G. A., Hennekens, C. A., and Speizer, F. E., (1985). Relative Weight and Risk of Breast Cancer amongst Premenopausal Women, American Journal of Epidemiology, 122: 731-740.

XO, Jin ,F., Dai, Q., Shi, J.R., Potter, J.D., Brinton, L.A., Hebert, J.R., Ruan, Z., Gao, Y.T., Zheng, W., (2001). Association of body size and fat distribution with risk of breast cancer among Chinese women, “International journal of cancer”, 3, 449-55.

Zhang, M., Holman, C.D.A.J., Huang, J.P., and Xie, X., (2007). Green tea and the prevention of breast cancer: a case–control study in Southeast China, oxford Journal Carcinogenesis 28: 1074-1078.

Zhang, M., Huang,J., Xie, X., and Holman, C. D. J.,(2009). Dietary intakes of mushrooms and green tea combine to reduce the risk of breast cancer in Chinese women, International Journal of Cancer, 124: 1404-1408.

Zhang, C-X., Ho, S. C., Chen, Y-M., Fu, J-H., Cheng S-Z., and Lin, F-Y, (2009). Greater vegetable and fruit intake is associated with a lower risk of breast cancer among Chinese women, International Journal of Cancer, 125: 181–188.

PERFORMA
We are thankful to you for
Providing us your personal information
I ensure you that all the information will
Be used only for research purpose
And will be kept confidential
5781040-76200A
P
P
E
N
D
I
X
00A
P
P
E
N
D
I
X

Role Of Life Style and Dietary Habits for developing the Risk of Breast Cancer.

43053005080Date ……………………………
Name ………………………….

Type
Case …………………..

Control ……………….

4000020000Date ……………………………
Name ………………………….

Type
Case …………………..

Control ……………….

1. AGE ______________
2. Weight _____________3. Height ______________
4. BMI: ______________
5. Area
123253522225003511552857500 Rural Urban
6. Education
32829529530500447167057785003197860412750023056853873500106362537465003543302222500None under metric metric intermediate graduation above
7. Marital status
22644102730500122936029845003536952413000 Single Married Widowed
If you are not single then answer question 8 otherwise skip it
8. No of children: _____________
9. Financial status
168402033655003149603492500Dependent Independent
10. Monthly income
4889500304800034594803365500206438536830003263902222500Less &equal 25,000 26,000-35,000 36,000-45,000above 45,000
11. Do you have family history of cancer?
124333033020003232153556000 Yes No
12. Are you diabetic patient?
Yes No
13. Did any stressful event occur in life?
Yes No
If yes than move to q#14.

14. Which type pf stressful event occur in life?
Death of close relation Personal issue Financial problem other

LIFE STYLE

15. Are you working woman?
124269536195003346453365500Yes No
16. Do you have a good relation with your family?
124269536195003346453365500Yes No
17. Do your daily routine is stress full?
124269536195003346453365500Yes No
18. Do you exercise daily?
124269536195003346453365500Yes No
If yes then answer the Q19
19. Duration of your daily exercise?
20. Do you sleep early at night?
124269536195003346453365500Yes No
21. Do you sleep 8-9 hours at night?
124269536195003346453365500Yes No
22. Your sleeping quality is
4006215298450026231853556000124587029845003257553111500Good fairly good fairly poor poor
23. Do you spend your leisure time in watching television?
124269536195003346453365500Yes No
24. You did your household work by your own self?
124269536195003346453365500Yes No
25. Do you have servant for your household work?
124269536195003346453365500Yes No
Dietary habits

26. Do you take green tea?
124269536195003346453365500Yes No
27. Do you take black tea more than 2 cups a day
124269536195003346453365500Yes No
If yes answer Q28
28. How many cups of black tea you take per day?
29. Do you take any vitamins supplement at daily bases?
124269536195003346453365500Yes No
30. Do you drink milk daily
124269536195003346453365500Yes No
If yes
-1543053312550031. The milk you drink daily is
3049270527050017297405016500Full cream milk skim milk regular milk
32. Which type of oil you use for cooking
Ghee homemade ghee olive oil other oil
Please read each statement carefully and select the option which belongs to you

5. Strongly agree4. Agree3. Neutral 2. Disagree
1. Strongly disagree
SA A N D SD
33. IN your daily meal mostly red meat is a part of your food 5 4 3 2 1
34. You often eat fish 5 4 3 2 1
35. You prefer to eat white meat 5 4 3 2 1
36. You mostly like to eat fresh vegetables 5 4 3 2 1
37. Fruit is a part of you daily food 5 4 3 2 1
38. Often fried things are part of you daily meal 5 4 3 2 1
39. Often you like to eat fried potatoes 5 4 3 2 1
40. In your breakfast you eat white bread 5 4 3 2 1
41. Mostly you eat fast food 5 4 3 2 1
42. Green salad is a part of your meal 5 4 3 2 1