Different levels of ultra-processed food and beverage consumption and associations with environmental sustainability and all-cause mortality in EPIC-NL

BACKGROUND

The adverse health effects of high ultra-processed food and drink consumption (UPFD) are well documented. However, its environmental impact remains unclear and the separate effects of ultra-processed foods (UPF) and drinks (UPD) on all-cause mortality are not previously studied.

OBJECTIVES

To assess the association between levels of UPFD, UPF and UPD consumption with diet-related environmental impacts and all-cause mortality in Dutch adults.

METHODS

Habitual diets were assessed by FFQ in 1993-1997 among 38,261 participants of the EPIC-NL cohort. The mean follow-up time was 18.2 years (SD 4.1), 4,697 deaths occurred. FFQ-items were categorized according to the NOVA classification. Associations with quartiles of UPFD, UPF, and UPD consumption and environmental impact indicators were analyzed using general linear models and with all-cause mortality by Cox proportional hazard models. The lowest UPFD, UPF, UPD consumption quartiles were used as comparator.

RESULTS

The average UPFD consumption was 181 (SD 88) g per 1000 kcal. High UPF consumption was statistically significantly inversely associated with all environmental impact indicators (_Q4vsQ1: -13.6% to -3.0%) whereas high UPD consumption was, except for land use, statistically significant positively associated with all environmental impact indicators (_Q4vsQ1: 5.9% to 1.2%). High UPFD consumption was heterogeneously associated with environmental impacts (_Q4vsQ1: 2.6% to -4.0% ). After multivariable adjustment, the highest quartiles of UPFD and UPD consumption were significantly associated with all-cause mortality (HR_Q4vsQ1 1.20, 95%CI 1.10,1.30 and HR_Q4vsQ1 1.19, 95%CI 1.09,1.29, respectively). UPF consumption of Q2 and Q3 were associated with a borderline significant lower risk of all-cause mortality (HR_Q2vsQ1 0.93, 95% CI 0.85,1.00; HR_Q3vsQ1 0.91, 95% CI 0.84,0.99), while Q4 was not statistically significant (HR_Q4vsQ1 1.05, 95% CI 0.96,1.15).

CONCLUSIONS

Reducing UPD consumption could lower environmental impact and all-cause mortality risk, however this was not shown for UPF. When categorizing foods consumption by their degree of processing trade-offs are observed for human and planetary health aspects.

Adherence to the EAT-Lancet Healthy Reference Diet in Relation to Risk of Cardiovascular Events and Environmental Impact: Results From the EPIC-NL Cohort

Background The Healthy Reference Diet (HRD) was created to formulate dietary guidelines that would be healthy and sustainable. We aimed to construct a diet score measuring adherence to the HRD and to explore its association with cardiovascular events and environmental impact. Methods and Results We included 35 496 participants from the population-based EPIC-NL (European Prospective Investigation into Cancer and Nutrition-Netherlands) study. HRD scores were calculated using data from food frequency questionnaires (0-140). Data on morbidity and mortality were retrieved through linkage with national and death registries. Data on environmental impact indicators were obtained from life cycle assessments. Associations between adherence to the HRD and cardiovascular events were estimated with Cox proportional hazard models. Linear regression analysis was conducted for the adherence to the HRD and each environmental indicator. High adherence to the HRD was associated with 14%, 12%, and 11% lower risks of cardiovascular disease (hazard ratio [HR]_Q4vsQ1, 0.86 [95% CI, 0.78-0.94]), coronary heart disease (HR_Q4vsQ1, 0.88 [95% CI, 0.78-1.00]), and total stroke (HR_Q4vsQ1, 0.89 [95% CI, 0.72-1.10]), respectively. High HRD adherence was associated with 2.4% (95% CI, -5.0 to 0.2) lower greenhouse gas emissions, 3.9% (95% CI, -5.2 to -2.6) less land use, 0.5% (95% CI, -2.6 to 1.6), less freshwater eutrophication, 3.3% (95% CI, -5.8 to -0.8), less marine eutrophication, 7.7% (95% CI, -10.8 to -4.6), less terrestrial acidification, and 32.1 % (95% CI, 28.5-35.7) higher blue water use. Conclusions High adherence to the HRD was associated with lower risk of cardiovascular disease, coronary heart disease, and modestly lower levels of most environmental indicators but a higher level of blue water use.

Ultra-processed food consumption patterns among older adults in the Netherlands and the role of the food environment

PURPOSE

To describe the patterns of ultra-processed foods (UPFs) consumption in the Netherlands; to test if exposure to the food environment is associated with UPFs consumption; and if this association differed across educational levels and neighbourhood urbanisation.

METHODS

Cross-sectional study using 2015-data of 8104 older adults from the Dutch EPIC cohort. Proportion of UPFs consumption was calculated from a validated food-frequency questionnaire. Exposure to the food environment was defined as proximity and availability of supermarkets, fast-food restaurants, full-service restaurants, convenience stores, candy stores and cafés. Consumption of UPFs was expressed as both percentage of total grams and total kilocalories.

RESULTS

The study population was aged 70(± 10 SD) years and 80.5% was female. Average UPFs consumption was 17.8% of total food intake in grams and 37% of total energy intake. Those who consumed greater amounts of UPFs had a poorer overall diet quality. Adjusted linear regression models showed that closer proximity and larger availability to any type of food retailer was associated with lower UPFs consumption (both in grams and kilocalories). Somewhat stronger significant associations were found for proximity to restaurants (β = - 1.6%, 95% confidence interval (CI) = - 2.6; - 0.6), and supermarkets (β = - 2.2%, 95%CI = - 3.3; - 1.1); i.e., Individuals living within 500 m from the closest supermarket, as compared to 1500 m, had 2.6% less calories from UPFs. No differences were found on analyses stratified for urbanisation and education.

CONCLUSIONS

Using various measures of exposure to the food environment, we found that exposure to restaurants and supermarkets was associated with somewhat lower consumption of UPFs.

Residential exposure to fast-food restaurants and its association with diet quality, overweight and obesity in the Netherlands: a cross-sectional analysis in the EPIC-NL cohort

Background

Unhealthy food environments may contribute to unhealthy diets and risk of overweight and obesity through increased consumption of fast-food. Therefore, we aimed to study the association of relative exposure to fast-food restaurants (FFR) with overall diet quality and risk of overweight and obesity in a sample of older adults.

Methods

We analyzed cross-sectional data of the EPIC-NL cohort (n = 8,231). Data on relative FFR exposure was obtained through linkage of home address in 2015 with a retail outlet database. We calculated relative exposure to FFR by dividing the densities of FFR in street-network buffers of 400, 1000, and 1500 m around the home of residence by the density of all food retailers in the corresponding buffer. We calculated scores on the Dutch Healthy Diet 2015 (DHD15) index using data from a validated food-frequency questionnaire. BMI was categorized into normal weight (BMI < 25), overweight (25 ≤ BMI < 30), and obesity (BMI ≥ 30). We used multivariable linear regression (DHD15-index) and multinomial logistic regression (weight status), using quartiles of relative FFR exposure as independent variable, adjusting for lifestyle and environmental characteristics.

Results

Relative FFR exposure was not significantly associated with DHD15-index scores in the 400, 1000, and 1500 m buffers (β_Q4vsQ1= -0.21 [95 %CI: -1.12; 0.70]; β_Q4vsQ1= -0.12 [95 %CI: -1.10; 0.87]; β_Q4vsQ1 = 0.37 [95 %CI: -0.67; 1.42], respectively). Relative FFR exposure was also not related to overweight in consecutive buffers (OR_Q4vsQ1=1.10 [95 %CI: 0.97; 1.25]; OR_Q4vsQ1=0.97 [95 %CI: 0.84; 1.11]; OR_Q4vsQ1= 1.04 [95 %CI: 0.90–1.20]); estimates for obesity were similar to those of overweight.

Conclusions

A high proportion of FFR around the home of residence was not associated with diet quality or overweight and obesity in this large Dutch cohort of older adults. We conclude that although the food environment may be a determinant of food choice, this may not directly translate into effects on diet quality and weight status. Methodological improvements are warranted to provide more conclusive evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-021-00713-5.

Reducing cardiometabolic risk in adults with a low socioeconomic position: protocol of the Supreme Nudge parallel cluster-randomised controlled supermarket trial

Background

Unhealthy lifestyle behaviours such as unhealthy dietary intake and insufficient physical activity (PA) tend to cluster in adults with a low socioeconomic position (SEP), putting them at high cardiometabolic disease risk. Educational approaches aiming to improve lifestyle behaviours show limited effect in this population. Using environmental and context-specific interventions may create opportunities for sustainable behaviour change. In this study protocol, we describe the design of a real-life supermarket trial combining nudging, pricing and a mobile PA app with the aim to improve lifestyle behaviours and lower cardiometabolic disease risk in adults with a low SEP.

Methods

The Supreme Nudge trial includes nudging and pricing strategies cluster-randomised on the supermarket level, with: i) control group receiving no intervention; ii) group 1 receiving healthy food nudges (e.g., product placement or promotion); iii) group 2 receiving nudges and pricing strategies (taxing of unhealthy foods and subsidizing healthy foods). In collaboration with a Dutch supermarket chain we will select nine stores located in low SEP neighbourhoods, with the nearest competitor store at > 1 km distance and managed by a committed store manager. Across the clusters, a personalized mobile coaching app targeting walking behaviour will be randomised at the individual level, with: i) control group; ii) a group receiving the mobile PA app. All participants (target n = 1485) should be Dutch-speaking, aged 45–75 years with a low SEP and purchase more than half of their household grocery shopping at the selected supermarkets. Participants will be recruited via advertisements and mail-invitations followed by community-outreach methods. Primary outcomes are changes in systolic blood pressure, LDL-cholesterol, HbA1c and dietary intake after 12 months follow-up. Secondary outcomes are changes in diastolic blood pressure, blood lipid markers, waist circumference, steps per day, and behavioural factors including healthy food purchasing, food decision style, social cognitive factors related to nudges and to walking behaviours and customer satisfaction after 12 months follow-up. The trial will be reflexively monitored to support current and future implementation.

Discussion

The findings can guide future research and public health policies on reducing lifestyle-related health inequalities, and contribute to a supermarket-based health promotion intervention implementation roadmap.

Trial registration

Dutch Trial Register ID NL7064, 30th of May, 2018

Plasma and Dietary Linoleic Acid and 3-Year Risk of Type 2 Diabetes After Myocardial Infarction: A Prospective Analysis in the Alpha Omega Cohort

OBJECTIVE

To study plasma and dietary linoleic acid (LA) in relation to type 2 diabetes risk in post-myocardial infarction (MI) patients.

RESEARCH DESIGN AND METHODS

We included 3,257 patients aged 60-80 years (80% male) with a median time since MI of 3.5 years from the Alpha Omega Cohort and who were initially free of type 2 diabetes. At baseline (2002-2006), plasma LA was measured in cholesteryl esters, and dietary LA was estimated with a 203-item food-frequency questionnaire. Incident type 2 diabetes was ascertained through self-reported physician diagnosis and medication use. Hazard ratios (with 95% CIs) were calculated by Cox regressions, in which dietary LA isocalorically replaced the sum of saturated (SFA) and trans fatty acids (TFA).

RESULTS

Mean ± SD circulating and dietary LA was 50.1 ± 4.9% and 5.9 ± 2.1% energy, respectively. Plasma and dietary LA were weakly correlated (Spearman r = 0.13, P < 0.001). During a median follow-up of 41 months, 171 patients developed type 2 diabetes. Plasma LA was inversely associated with type 2 diabetes risk (quintile [Q]5 vs. Q1: 0.44 [0.26, 0.75]; per 5%: 0.73 [0.62, 0.86]). Substitution of dietary LA for SFA+TFA showed no association with type 2 diabetes risk (Q5 vs. Q1: 0.78 [0.36, 1.72]; per 5% energy: 1.18 [0.59, 2.35]). Adjustment for markers of de novo lipogenesis attenuated plasma LA associations.

CONCLUSIONS

In our cohort of post-MI patients, plasma LA was inversely related to type 2 diabetes risk, whereas dietary LA was not related. Further research is needed to assess whether plasma LA indicates metabolic state rather than dietary LA in these patients.