Ultra-Processed Food, Drink Tied to Heart Disease, Earlier Death

Marlene Busko

May 29, 2019

Adults whose diet included more ultra-processed foods and beverages — such as ice cream, soda, and hamburgers — were more likely to develop cardiovascular disease (CVD) or die sooner than others who had a more wholesome diet, in two large European cohorts.

In the NutriNet-Santé study of adults in France, those who had a 10% higher intake of ultra-processed foods and beverages had an 11% to 13% higher rate of CVD, coronary heart disease, and cerebrovascular disease over about 5 years.

And in the SUN study of university graduates from the Seguimiento Universidad de Navarra, Spain, those who consumed more than four servings of ultra-processed food and beverages a day were 62% more likely to die of all causes over about a decade than those who consumed less than two servings per day.

The studies led by Bernard Srour, PharmD, PhD, MPH, fellow, University of Paris, France, and Anaïs Rico-Campà, PharmD, University of Navarra, Pamplona, Spain were published online May 29 in BMJ.

"These findings add to growing evidence of an association between ultra-processed food and adverse health outcomes that has important implications for dietary advice and food policies," according to Mark A. Lawrence, PhD, and Phillip I. Baker, PhD, Deakin University, Geelong, Australia, writing in an accompanying editorial.

"The dietary advice is relatively straightforward: eat less ultra-processed food and more unprocessed or minimally processed food," they stress.

Educate on Risks of Ultra Processed Products, Promote Whole Foods

The researchers and editorialists both urge governments to develop health policies to address this risk.

"It is therefore important to inform consumers about these associations," Srour and colleagues conclude, "and to implement actions targeting product reformulation (eg, improving nutritional quality and reducing the use of unnecessary additives), taxation, and communication to limit the proportion of ultra-processed foods in the diet and promote the consumption of unprocessed or minimally processed foods instead."

Similarly, Rico-Campà and colleagues conclude that "discouraging the consumption of ultra-processed foods; targeting products, taxation, and marketing restrictions on ultra-processed products; and promotion of fresh or minimally processed foods, should be considered part of important health policy to improve global public health."

Lawrence and Baker echo these words but also maintain that reformulation of highly processed foods is not the solution.  

"Policymakers should shift their priorities away from food reformulation — which risks positioning ultra-processed food as a solution to dietary problems — towards a greater emphasis on promoting the availability, affordability, and accessibility of unprocessed or minimally processed foods," they write.

And evidence is accumulating that the harms from ultra-processed foods might be partly related to changes in the gut microbiome, they point out.

Intake Has Tripled in 20 Years, but at What Cost to Health?

Ultra-processed foods — that is, foods with many ingredients that have been added to allow for a longer shelf-life, to be more palatable, and/or save on food preparation time — are a growing part of the diet in many countries.

Between 1990 and 2010, the consumption of ultra-processed food almost tripled, from 11% to 32% of daily calories, Rico-Campà and colleagues write.

These foods and beverages often contain more saturated fat and total fat, added sugar and salt, and less fiber and vitamins, Srour and colleagues note.

They may also contain additives such as glutamates, emulsifiers, sulfites, and carrageenan, or contaminants formed during heat processing or in package liners.

Previous studies have linked consumption of ultra-processed foods with increased risks of cancer, obesity, hypertension, dyslipidemia, irritable bowel syndrome, and all-cause mortality.

The research groups set out to examine how consumption of highly processed food and drink was associated with CVD in the NutriNet-Santé cohort and all-cause mortality in the SUN cohort.

Risk of CVD in the NutriNet-Santé Study

In the ongoing NutriNet-Santé study launched in 2009, adults in France were invited to complete web-based questionnaires in which they recorded all foods and beverages consumed in the previous 24 hours and indicated portion sizes based on photographs of common foods.

Srour and colleagues analyzed data from 83,247 women (79%) and 21,912 men who were on average 43 years old when they entered the study and completed 5.7 food surveys during 2 years.

They divided participants into quartiles based on consumption of highly processed foods and beverages.

Compared to participants with the lowest intake of ultra-processed food and drink, those with the highest consumption were younger (36 vs 48 years) and more likely to be less active, current smokers, and eat less fruit, vegetables, and dietary fiber.  

On average, ultra-processed foods accounted for 17.6% of the overall diet in men and 17.3% of the overall diet in women.

The ultra-processed foods and beverages in the diet came mostly from sugary products such as candy, ice cream, and pastries (28% of the ultra-processed products), processed fruit and vegetables such as soups or canned fruit (18%), beverages such as sodas (16%), breakfast cereals and starchy foods such as bread or prepared pasta meals (12%), and meat and fish products such as chicken nuggets or fish fingers (11%).

The other highly processed foods were dairy products (8%), fats and sauces (5%), and salty snacks (2%).  

Most of the products (85%) were in the lowest nutritional quality category.

After adjusting for multiple confounders, compared with participants in the lowest quartile of consumption of ultra-processed foods and beverages, those in the highest quartile were significantly more likely to develop CVD (hazard ratio [HR], 1.12), coronary heart disease (HR, 1.12), and cerebrovascular diseases (HR, 1.11) over a median 5.2 years of follow-up.

Does Lower Intake of Less Processed Foods or Additives Up Risk?

"Part of the association between intake of ultra-processed food and risk of CVD may partly come from the simultaneous lower consumption of non-ultra-processed foods," the authors suggest.   

"A second interpretation" may be that additives in the ultra-processed foods increase the risk of developing CVD.

"Although maximum authorized levels normally protect consumers against adverse effects of individual substances in certain food products, the health impact of the cumulative intake across all ingested foods and potential cocktail or interaction effects remain largely unknown," they note.

And heat treatments to manufacture these foods "produce neoformed contaminants, such as acrylamide in fried potatoes, biscuits, bread, or coffee, and acrolein in grilled sausages and caramel candies," they write.

In addition, "ultra-processed foods might be contaminated by contact materials (those suspected of migrating from packaging), among which is bisphenol A in some plastic packaging."

And there may be a harmful synergistic effect between, for example, ingested artificial sweeteners in beverages and preservatives in ready-to-eat meals.  

Thus, further studies are needed to investigate the relative impact of nutritional composition, food additives, contact materials, and neoformed contaminants on the association between highly processed foods and the risk of CVD.

"Our research team," Srour and colleagues write, "is currently launching a large scale [program] on chronic exposure to food additives (single substances and multi-exposure 'cocktails') and health."

Risk of All-Cause Death Over a Decade in the SUN Study

Meanwhile Rico-Campà and colleagues analyzed data from 7786 men and 12,113 women aged 20 to 91 (mean age 37) who filled out a 136-item food frequency questionnaire in 1999-2014.

During a median follow-up of 10.4 years, 335 people died.

On average, participants in the highest quartile of consumption of ultra-processed foods consumed more fast food, fried foods, processed meats, and sugar-sweetened beverages than participants in the other quartiles, and they had the lowest intake of vegetables, fruits, olive oil, alcohol, and fiber, and were least adherent to a Mediterranean-type diet.

The ultra-processed foods and beverages were mainly processed meats such as hamburger and sausages (15%), sugar-sweetened beverages (15%), dairy products such as ice cream (12%), French fries (11%), and pastries such as doughnuts, muffins, and croissants (10%).

The remaining ultra-processed foods and beverages were cookies (8%), soups (6%), fried foods (6%), artificially sweetened beverages (5%), breakfast cereals (3%), pizza (2%), liquor (2%), margarine (1%), and mayonnaise (1%).

Compared with participants who consumed fewer than two servings a day of ultra-processed foods and beverages (lowest quartile), those who consumed more than four servings a day (highest quartile) had a significantly increased risk of all cause death (HR, 1.62), after adjusting for multiple confounders, during a median 10.4-year follow-up.

For each additional serving of ultra-processed foods, the risk of all-cause mortality increased by 18% (HR, 1.18).

However, in secondary endpoints, compared with participants in the lowest quartile, those in the highest quartile of consumption of highly processed foods did not have a significantly higher risk of cardiovascular death (HR, 2.16; 95% CI, 0.92 - 5.06) or cancer deaths (HR, 1.22; 95% CI, 0.70 - 2.12).

"Our findings reinforce the existing evidence on the negative impact of ultra-processed foods on the overall incidence of chronic diseases and all-cause mortality. Altogether these results support the nonbeneficial effects of ultra-processed foods, which currently represent a major portion of the calories consumed in many countries," the researchers conclude.

The researchers and editorialists have reported no relevant financial disclosures.

BMJ. Published online May 29, 2019. SUN study, NutriNet-Santé study, Editorial

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