Ultra-Processed Food Consumption and Mortality: Three Cohort Studies in the United States and United Kingdom

Ten-year trajectories of ultra-processed food intake and prospective associations with cardiovascular diseases and all-cause mortality: findings from the Whitehall II cohort study

BACKGROUND

Ultra-processed food (UPF) intake has been associated with adverse health outcomes; however, research on UPF intake and cardiovascular disease (CVD) prognosis has largely neglected its longitudinal pattern over time. This study investigated trajectories of UPF intake over a decade and their prospective associations with the risk of fatal and non-fatal CVD, as well as all-cause mortality, using data spanning from 16 to 19 years.

METHODS

This study utilized data from the British Whitehall II cohort study, including 7,138 participants (68.3% male; median baseline age 60.4 years), all free of CVD at baseline. Dietary intake was assessed using a validated 127-item food frequency questionnaire at three time points: phase 3 (1991-1994), phase 5 (1997-1999), and phase 7 (2002-2004). UPF intake was estimated using the Nova classification, and group-based trajectory modelling identified different longitudinal consumption patterns. Phase 7 (2002-2004) was the baseline for subsequent monitoring of cardiovascular events and mortality outcomes until 2019/2021. Multivariate Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for socio-demographics, lifestyle, diet quality, energy intake, and clinical factors.

RESULTS

Three distinct UPF trajectory groups were identified: high (26.2% of participants), moderate (52.9%) and low UPF intake (20.9%). All groups showed a slight increase in UPF intake over time. Over the median follow-up of 16 years for incident cases and 19 years for mortality, we observed 1,128 incident CVD events, 859 CHD cases and 1,314 deaths. The highest vs. lowest UPF intake group had a 23% higher risk of CVD (HR 1.23, 95% CI 1.01 to 1.40), and a 32% higher risk of CHD (HR 1.32, 95% CI 1.06 to 1.65). No significant associations were observed between UPF trajectory groups and CVD mortality, CHD mortality, or all-cause mortality.

CONCLUSIONS

Sustained high UPF intake over 10 years was associated with increased risks of non-fatal CVD and CHD but not with CVD-specific, CHD-specific, or all-cause mortality. These findings suggest that sustained high intake of UPF may be a modifiable risk factor for preventing non-fatal cardiovascular risks.

Ultra-processed foods and risk of all-cause mortality: an updated systematic review and dose-response meta-analysis of prospective cohort studies

BACKGROUND

Ultra-processed food (UPF) consumption has been steadily increasing globally, yet the associated risk of all-cause mortality remains unclear. We aimed to assess the risk of all-cause mortality of UPFs via an updated systematic review and dose-response meta-analysis.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, and Cochrane Library for studies published until July 2, 2024, in addition to referred studies included in the previous systematic review. Prospective cohort studies assessing the association between NOVA classification-defined UPF consumption and all-cause mortality were included. Dose-response meta-analysis via a random-effect model was used to combine the results with hazard ratio (HR) as an effect measure.

RESULTS

Overall, 18 studies with 1,148,387 participants (173,107 deaths) were identified. Compared to the lowest, participants with the highest UPF consumption had a 15% increased risk of all-cause mortality (HR = 1.15, 95% CI 1.09-1.22; I2 = 83.0%). Furthermore, a 10% higher risk of all-cause mortality was detected with each 10% increment in UPF consumption (HR = 1.10, 95% CI 1.04-1.16; I2 = 91.0%). Dose-response analysis showed a positive linear association (Pdose-response < 0.001). Moreover, subgroups and sensitivity analyses indicated consistent findings, while meta-regression analyses suggested sex distributions partially explained heterogeneity, with a higher risk of all-cause mortality in males.

CONCLUSIONS

Our updated meta-analysis, incorporating a greater number of newly published cohort studies using NOVA classification with the largest sample size to date, strengthens the evidence linking higher UPF consumption to increased all-cause mortality risk. Strategies such as dietary guidelines and policies for limiting UPF consumption worldwide should be encouraged.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023467226.

Associations between degree of food processing and all-cause and cause-specific mortality: a multicentre prospective cohort analysis in 9 European countries

Background

Ultra-processed food (UPF) consumption has been linked with higher risk of mortality. This multi-centre study investigated associations between food intake by degree of processing, using the Nova classification, and all-cause and cause-specific mortality.

Methods

This study analyzed data from the European Prospective Investigation into Cancer and Nutrition. All-cause mortality and cause-specific mortality due to cancer, circulatory diseases, digestive diseases, Parkinson's disease, and Alzheimer's disease served as endpoints. Hazard ratios (HRs) and 95% CIs were estimated using multivariable Cox proportional hazards regression models. Substitution analyses were also performed.

Findings

Overall, 428,728 (71.7% female) participants were included in the analysis and 40,016 deaths were documented after 15.9 years of follow-up. UPFs (in percentage grams per day [g/d]) were positively associated with all-cause mortality (HRs per 1-SD: 1.04; 95% CI: 1.02,1.05), as well as mortality from circulatory diseases (1.09; 95% CI: 1.07,1.12), cerebrovascular disease (1.11; 95% CI: 1.05,1.17), ischemic heart disease (1.10; 95% CI: 1.06,1.15), digestive diseases (1.12; 95% CI: 1.05,1.20), and Parkinson's disease (1.23; 95% CI: 1.06,1.42). No associations were found between UPFs and mortality from cancer or Alzheimer's disease. Replacing processed and UPFs with unprocessed/minimally processed foods was associated with lower mortality risk.

Interpretation

In this pan-European analysis, higher UPF consumption was associated with greater mortality from circulatory diseases, digestive diseases, and Parkinson's disease. The results support growing evidence that higher consumption of UPFs and lower consumption of unprocessed foods may have a negative impact on health.

Funding

l'Institut National du Cancer, and World Cancer Research Fund International.

Ultra-processed Food Intake During Pregnancy and its Impact on Maternal Diet Quality and Weight Change: A Systematic Review of Observational Studies

PURPOSE OF REVIEW

Adequate and balanced nutrition during pregnancy is essential for both the mother's and fetus's health. The increased dietary intake of ultra-processed foods (UPFs) and their significant share in the diet negatively affects diet quality and gestational weight gain during pregnancy. The aim of this systematic review was to examine the association of UPFs consumption with diet quality and gestational weight change among healthy pregnant women, using data from observational studies (PROSPERO Identifier: CRD42023468269) from the last 10 years.

RECENT FINDINGS

A search was performed in Pubmed, Wiley, Scopus, and Web of Science, and studies published in english language were selected. Study selection and data extraction were made by determining the exclusion and eligible inclusion criterias according to the PECOS framework. Of the 12 studies included, 5 were longitudinal cohort studies and 7 were cross-sectional studies. On average, half of the energy in the participants' daily diets came from UPFs in 3 studies, but the energy share of UPFs was about 20-30% in the remainder studies. UPFs-enriched maternal diet was associated with less dietary intake of legumes, vegetables, fruits and protein sources (seafood and plant protein, total protein) and greater consumption of refined grains compared to those who consume less UPFs. In parallel, UPFs consumption was negatively associated with Healthy Eating Index. UPF intake during pregnancy has a negative impact on diet quality and gestational weight gain. Increasing awareness of UPFs during this period may reduce potential complications during pregnancy and fetal growth.

Ultra-processed foods and cardiovascular disease: analysis of three large US prospective cohorts and a systematic review and meta-analysis of prospective cohort studies

Background

Prospective associations between total and groups of ultra-processed foods (UPF) and cardiovascular disease (CVD) remained to be characterised. Our aim was to assess the association of total and group-specific UPF intakes with CVD, coronary heart disease (CHD), and stroke in three large prospective cohorts of US adults. Additionally, we conducted a systematic review and meta-analyses on the existing evidence on the associations of total UPF intake with these outcomes.

Methods

UPF intake was assessed through food frequency questionnaires in the Nurses' Health Study (NHS; n = 75,735), Nurses' Health Study II (NHSII; n = 90,813), and Health Professionals Follow-Up Study (HPFS; n = 40,409). Cox regression estimated cohort-specific associations of total and group-specific UPF intake with risk of CVD (cases = 16,800), CHD (cases = 10,401), and stroke (cases = 6758), subsequently pooled through fixed-effect models. Random-effects meta-analyses pooled existing prospective findings on the UPF-CVD association identified on Medline and Embase up to April 5, 2024, without language restrictions. Risk of bias was assessed with the Newcastle-Ottawa Scale, funnel plots, and Egger's tests, and meta-evidence was evaluated using NutriGrade.

Findings

The baseline mean (SD) age was 50.8 years (7.2) for the NHS, 36.7 years (4.6) for the NHSII, and 53.4 years (9.6) for the HPFS. The proportion of participants of White race was 97.7% in the NHS, 96.4% in the NHSII, and 94.9% in the HPFS. Among the three cohorts, multivariable-adjusted hazard ratios [HRs (95% CIs)] for CVD, CHD, and stroke for the highest (vs. lowest) total UPF intake quintile were 1.11 (1.06-1.16), 1.16 (1.09-1.24), and 1.04 (0.96-1.12), respectively. UPF groups demonstrated divergent associations. Sugar-/artificially-sweetened drinks and processed meats were associated with higher CVD risk, whereas inverse associations were observed for bread/cold cereals, yoghurt/dairy desserts, and savoury snacks. Meta-analysing 22 prospective studies showed that total UPF intake at the highest category (vs. lowest) was associated with 17% (11%-24%), 23% (12%-34%), and 9% (3%-15%) higher CVD, CHD, and stroke risk. Meta-evidence quality was high for CHD, moderate for CVD, and low for stroke.

Interpretation

Total UPF intake was adversely associated with CVD and CHD risk in US adults, corroborated by prospective studies from multiple countries, also suggesting a small excess stroke risk. Nutritional advice for cardiovascular health should consider differential consequences of group-specific UPF. Replication is needed in racially/ethnically-diverse populations.

Funding

National Institutes of Health (NIH) grants supported the NHS, NHSII, and HPFS.

Ultra-processed food consumption and risk of cardiovascular events: a systematic review and dose-response meta-analysis

Background

Ultra-processed food (UPF) consumption continues to increase worldwide. However, evidences from meta-analyses are limited regarding the effects on cardiovascular events (CVEs).

Methods

A meta-analysis was performed to assess the dose-response relationship of UPF consumption and CVEs risk (including the morbidity and mortality of cardiovascular causes, and myocardial infarction, stroke, transient ischemic attack, coronary intervention). Databases (PubMed, EMBASE, Cochrane Library, and Web of Science) were searched for observational studies published in English language up to October 24, 2023. Generalized least squares regression and restricted cubic splines were used to estimate the linear/nonlinear relationship. PROSPERO CRD 42023391122.

Findings

Twenty studies with 1,101,073 participants and 58,201 CVEs cases with a median follow-up of 12.2 years were included. A positive linear relationship between UPF intake and CVEs risk was identified. In addition, positive correlation between coronary heart disease and UPF consumption in terms of daily serving and daily energy proportion. No significant association of UPF consumption with the risk of cerebrovascular disease was observed. Briefly, 10% increase of UPF by daily weight proportion was associated with a 1.9% increase of CVEs risk (RR = 1.019; 95% CI, 1.007-1.031; P = 0.002), an additional daily serving corresponding to 2.2% CVEs risk increase (RR = 1.022; 95% CI, 1.013-1.031; P < 0.001), and 10% increase by daily energy proportion corresponding to 1.6% CVEs risk increase (RR = 1.016; 95% CI, 1.002-1.030; P = 0.022).

Interpretation

UPF consumption were associated with a higher risk of CVEs in the positive linear relationship. Our findings highlight the importance of minimizing UPF consumption for cardiovascular health and might be help to pursue public health policies in control of UPF consumption.

Funding

This work was supported by the Key Research and Development Program of Shaanxi Province (2023-ZDLSF-22), the Innovative Talent Support Program of Shaanxi Province (2022KJXX-106), and the Key Research and Development Program of Shaanxi Province (2023-YBSF-424).