Abstract
The association between colorectal cancer (CRC) incidence and dietary habits has been a central focus of epidemiological research. This review aims to synthesize the multidimensional analytical approaches used in the scientific literature to examine the CRC–nutrition relationship. Current studies evaluate this complex interaction across at least 21 analytical axes. These include a priori dietary indices (e.g., Mediterranean diet score, Healthy Eating Index), a posteriori data-driven dietary patterns (e.g., principal component analysis), inflammatory potential scores (DII, EDIP), analyses of specific macro- and micronutrients, fatty acid profiles, gene–diet interactions, tumor subsite and sex-specific analyses. Findings consistently indicate that Mediterranean or “Healthy/Prudent” dietary patterns rich in fiber, whole grains, fruits, vegetables, fish, and unsaturated fats, and low in red and processed meats and refined carbohydrates, reduce CRC risk. Conversely, Western-type diets with high proinflammatory and hyperinsulinemic potential are linked to increased risk. Moreover, clinical endpoints such as survival and recurrence after diagnosis are also influenced by dietary patterns. This review highlights both the breadth and depth of evidence underpinning dietary recommendations for CRC prevention and management and outlines potential avenues for future research.
1. Introduction
Colorectal cancer (CRC) is among the most common cancers worldwide, with a complex etiology involving interactions between genetic and environmental factors (Zheng et al., 2022). Among environmental determinants, diet stands out as the most important modifiable component influencing CRC risk (Kim et al., 2022). Over the past two decades, numerous epidemiological studies have shifted focus from single nutrients toward overall dietary patterns, emphasizing their cumulative impact on cancer risk (Tabung et al., 2017). Increasingly sophisticated analytical methods have been applied to clarify the CRC–nutrition relationship. The purpose of this review is to systematically summarize the major analytical axes used to study this complex interplay and, based on current evidence, delineate protective and risk-enhancing dietary profiles.
2. Methods: A systematic search was conducted in the Web of Science Core Collection database to identify scientific publications examining the relationship between colorectal cancer and nutrition. The search strategy was structured to capture records where the topic field (TS) contained any of the following cancer-related terms: “colorectal cancer,” “colon cancer,” “rectal cancer,” “colorectal neoplasms,” or “CRC,” combined with any of the following nutrition-related terms: “nutrition,” “diet,” “dietary intake,” “dietary patterns,” “nutrients,” “food consumption,” “dietary intervention,” or “nutrition therapy.”
The final search string was: TS=(((“colorectal cancer” OR “colon cancer” OR “rectal cancer” OR “colorectal neoplasms” OR “CRC”)) AND (“nutrition” OR “diet” OR “dietary intake” OR “dietary patterns” OR “nutrients” OR “food consumption” OR “dietary intervention” OR “nutrition therapy”))
To focus on original research and review articles, the following document types were excluded: Correction, Note, Retracted Publication, News Item, Reprint, Data Paper, Publication With Expression of Concern, Bibliography, Biographical-Item, Discussion, Retraction, Letter, Editorial Material, Book Chapter, Meeting Abstract, and Proceeding Paper.
Publications were ranked according to their relevance, and the top 100 most relevant articles were reviewed in detail. Insights derived from these articles formed the basis of this manuscript.
3. Results. The literature demonstrates that the CRC–diet relationship has been investigated along at least 21 analytical axes, including a priori diet indices, a posteriori dietary patterns, nutrient-based approaches, inflammatory and insulinemic potential scores, analyses of specific food groups, fatty acid profiles, micronutrients and phytochemicals, sex- and tumor subsite-specific analyses, gene–diet interactions, and post-diagnosis survival and quality of life.
Evidence consistently points to the protective role of Mediterranean and “Prudent/Healthy” dietary patterns and plant-forward diets, while Western dietary patterns characterized by high intake of red and processed meat, refined grains, sugars, and saturated/trans fats are linked to increased risk. Several studies also show that dietary factors influence prognosis, with healthier patterns associated with better survival and improved quality of life.
4. Discussion: Synthesizing findings across multiple analytic frameworks, a coherent dietary profile emerges that is protective against CRC. This profile includes high intake of fiber, whole grains, fruits, vegetables, fish, poultry, unsaturated fats such as olive oil, calcium-rich dairy, and adequate magnesium. Such a diet corresponds closely to Mediterranean and plant-based models, which have consistently demonstrated reduced CRC risk (Castelló et al., 2022; Garcia-Larsen et al., 2019; Huncharek et al., 2009; Jakszyn et al., 2020; Ma et al., 2010; Yarmand et al., 2024).
Conversely, diets high in red and processed meats, refined carbohydrates, saturated and trans fats, and added sugars consistently show positive associations with CRC incidence (Magalhães et al., 2011; Ma et al., 2024; Ungvári et al., 2025). Importantly, adherence to healthier dietary patterns after diagnosis has also been associated with improved survival and quality of life (Fretwell et al., 2025; Zhu et al., 2013).
These findings underscore the importance of considering diet not only in CRC prevention but also in disease management and survivorship care.
5. Conclusion: The relationship between nutrition and colorectal cancer reflects the interplay of numerous dietary and lifestyle factors rather than isolated components. The scientific literature has explored this connection across at least 21 analytical axes, ranging from dietary indices and data-driven patterns to biomarkers, gene–diet interactions, and post-diagnosis outcomes. The overwhelming body of evidence strongly supports the adoption of Mediterranean-style, plant-based, fiber- and micronutrient-rich diets, with reduced intake of red/processed meats and refined foods, both for primary prevention and for improving prognosis after diagnosis. These insights provide a strong foundation for public health policies and clinical guidelines targeting CRC prevention and management.
Table: Evidence matrix
| Analytical Approach | Level of Evidence | Endpoint | Example Foods/Nutrients | Key References |
|---|---|---|---|---|
| A priori dietary indices | Strong | Incidence | Mediterranean Diet (MD), HEI, DASH | Zhong et al., 2020; El Kinany et al., 2025; Erben et al., 2018 |
| A posteriori patterns | Strong | Incidence | Western diet vs. Prudent diet | Magalhães et al., 2012; Flood et al., 2008; Chen et al., 2015 |
| Nutrient-pattern PCA | Moderate | Incidence | Vitamin/mineral-rich patterns | Moskal et al., 2016 |
| Gene–diet interactions | Moderate | Incidence | PPARγ, FTO × fat intake | Murtaugh et al., 2005; Gholamalizadeh et al., 2023 |
| Specific food groups | Strong | Incidence | Fruits, vegetables, dairy | Ralston et al., 2014; Bakken et al., 2018 |
| Micronutrients | Strong | Incidence | Folate, carotenoids, vitamins C & E | Kim et al., 2009; Leenders et al., 2014 |
| Fatty acids | Strong | Incidence | EPA, DHA, DPA, n-6/n-3 ratio | Hodge et al., 2015; Lu et al., 2023; Shin et al., 2020 |
| Inflammatory/insulin scores | Strong | Incidence | DII, EDIH, EDIP | Tabung et al., 2017; Chu et al., 2025 |
| Antioxidant balance scores | Moderate | Incidence | OBS (antioxidants, vitamins) | Chang et al., 2024 |
| Intermediate biomarkers | Moderate | Incidence | Fecal water toxicity, plasma retinol | Pearson et al., 2009; Leenders et al., 2014 |
| Microbiome | Moderate | Incidence | Fusobacterium, Prevotella, Olsenella | Vogtmann et al., 2025; Mukherji & Weinberg, 2020 |
| Tumor sub-localization | Moderate | Incidence | Distal colon vs. proximal colon | Annema et al., 2011 |
| Sex stratification | Moderate | Incidence | Folate protective in women | Kim et al., 2009 |
| Early-onset/age | Weak | Incidence | Gut microbiome in <50 yrs | Mukherji & Weinberg, 2020 |
| Combined lifestyle | Strong | Incidence | Healthy lifestyle index | Zhang et al., 2018 |
| Temporal dietary changes | Moderate | Incidence | Pro- vs anti-inflammatory shifts | Tabung et al., 2017 |
| Cooking methods | Moderate | Incidence | High-heat cooking, smoking | Lee et al., 2009 |
| Anthropometry | Moderate | Incidence | Waist circumference, ABSI | Andreasson et al., 2019; Huang et al., 2024 |
| Prognosis/quality of life | Moderate | Prognosis | Mediterranean diet + PA | Balhareth et al., 2019; Schoenberg, 2016 |
| Psychosocial determinants | Weak | Behavior | Diet beliefs, fiber intake | Zaharek-Girgasky et al., 2015 |
| Molecular pathology | Weak | Incidence | KRAS mutations, diet | El Asri et al., 2020 |
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