The Correlation between Lifestyle, Nutrition, Vitamin Deficiency and Human Papillomavirus (HPV) Cervical Changes

Abstract

Human Papillomavirus has emerged as a distinct cause of cervical changes in young women. Its prevalence is continuously growing and is considered at epidemic proportions with 20 million Americans already infected and 5.5 million new cases reported annually. (Center for Disease Control and Prevention, Tracking the Hidden Epidemics., Trends in STDs in the U.S. 2000, Atlanta, Georgia, 2000)

There are known risk factors associated with HPV cervical changes and cervical cancer. These known risk factors are the number of one’s sexual partners, age at first coitus, smoking and use of oral contraception.

The objective of this study was to investigate the relationship between known risk factors and unknown risk factors, such as nutrition, vitamin deficiency and other lifestyle variables (i.e., drug/alcohol use, exercise and sleep habits), on HPV cervical changes.

The results of this study may increase awareness for the general public, influence behavior and aid in the prevention of the disease in young women. New streams of clinical information may prevent the progression of the disease to cancer in women who are already infected, as HPV has been implicated in the pathogenesis of cervical cancer, the number one gynecologic cancer in the world.

Materials and Methods:

This two-arm study was performed between 2002 and 2004 in Lenox Hill Hospital’s ambulatory clinic and physicians’ offices in New York City. Approval was granted by the hospital’s Institutional Review Board. Each woman gave written informed consent prior to participation.

A questionnaire to determine lifestyle and nutritional habits was distributed to female volunteers between the ages of 18 and 35 (part 1 of the study). A previous pap smear was a requirement for participation. However, whether the results of the pap smear were normal or abnormal was not a consideration for recruitment.

Blood serum levels of vitamins C, E, and beta carotene were obtained for part 2 of the study, and processed by Quest Laboratory. These vitamins were selected for testing because an increased number of reports had suggested that these antioxidants may act to prevent the development of various malignancies (22).

Statistical analysis included Chi-Square, ANOVA, a Student T-test and 2x2 table to identify association between study variables.

Results:

One hundred sixty-four (164) women participated in the study. One hundred (61%) of the participants had abnormal pap smear results, and sixty-four (39%) had normal pap smear results. Of the 164, only eighty-four (51%) participated in part 2 of the study and had blood serum tests performed. A power analysis performed prior to the initiation of the study showed that 146 women were required to demonstrate a difference in response rate from 30% in the control group (normal pap smears) to 50% or more in the treatment group (abnormal pap smears), with a power of 0.80 or a significance level of 0.05.

Of the eighty-four participants who took the blood test, forty-one (48.8%) were in the abnormal group and forty-three (51.1%) were in the normal group.

A total of 35 women from both groups were found to have an antioxidant deficiency. The number of women deficient in one or more of the vitamins measured was higher in the abnormal group (20 in the abnormal group compared to 15 in the normal group). A total of five (5) participants were deficient in more than one of the vitamins measured.

The analysis of blood tests to determine deficiencies in the normal versus abnormal group was not statististically significant, p= 0.0676 with a relative risk of 0.9945 when results of vitamins E, C, and beta carotene were combined.

When vitamin results were looked at individually, the results were: Vitamin C p= 0.44, Beta Carotene p= 0.54, Vitamin E gamma p= 0.51. One vitamin result showed statistical significance, Vitamin E alpha p= 0.04, but higher, (rather than lower) than the normal level, indicating no deficiency. Upon investigation, it was determined that only one participant had an abnormally high level which could be attributed to abnormal lipid levels. When reviewing the questionnaire, this participant was not taking any vitamin supplements at the time she completed the questionnaire, therefore the possibility of overdosing was eliminated.

The total number of sexual partners in the abnormal group (8.7) was higher than in the normal group (4.8), p= 0.0072 and was very significant.

Forty-three (26.2%) of the participants had sex prior to age 16. Twenty-nine (17.6%) had abnormal pap smears. The incidence of abnormal pap smears in women who had sex prior to 16 years of age when compared to those who had sex after 16 years of age was not statistically significant, p= 0.08.

Thirty-nine of the participants were smokers. Twenty-seven percent (27%) of the smokers had abnormal pap smears and 18.7% of the smokers had normal pap smears. When comparing the number of smokers in the abnormal group to the number of smokers in the normal group, the results were not statistically significant, p= 0.07.

The use of oral contraception was not surveyed in this study, therefore, it is unknown if participants used oral contraception as their birth control method. However, oral contraception is a known co-factor that may modulate the risk of progression from HPV infection to HSIL or cervical cancer.

Forty-one (25%) of the participants had other types of sexually transmitted diseases and 39 (23.7%) had both an STD and HPV. All but two of the participants with STDs were in the abnormal pap smear group.

Ninety-six (58.5%) out of the 164 participants indicated that they ate a reasonably balanced diet. Vitamin deficiencies were found in 19 of the participants who indicated that their diets were reasonably balanced, and 17 of these participants were in the abnormal pap group. Since the term "reasonably balanced" is self-interpretative, the 19 participants who assumed that their diets were reasonably balanced yet still displayed deficiencies were advised to obtain nutritional counseling.

Supplementation, sleep patterns, exercise, and alcohol/drug use were also measured. The abnormal pap smear group took fewer vitamins, slept less than 8 hours per night and exercised less than the normal pap smear group. The abnormal group also consumed more alcohol, used more drugs and smoked more than the normal group.

Conclusions:

The sample size for the second arm of the study (the blood test) was not adequate to meet the number required for a power of 0.05; therefore, the lack in sufficient numbers of participants weakened the results.

Known risk factors for HPV cervical changes, such as number of sexual partners, held true for this sample population of women with abnormal pap smears. High risk behaviors, such as smoking and age at first coitus, although not statistically significant, were very close.

There were slight differences in the nutritional habits of the two groups. There were more high protein/low carbohydrate diets, reasonably balanced and vegetarian diets and less junk foods consumed in the group with normal pap smears (see appendix L). However, vitamin deficiencies were present in both groups.

The results of this study did not provide new or additional evidence correlating nutrition, vitamin deficiency and cervical changes in women. To deter the risk of the progression of HPV cervical changes to cervical cancer, women should have follow-up appointments with their doctors following diagnosis of HPV, avoid or stop smoking, practice safe sex, use a birth control method other than oral contraception, and increase their daily intake of antioxidants through food and supplementation.