Ultra-processed food intake and risk of cardiovascular disease: prospective cohort study (NutriNet-Santé)

Bernard Srour, Léopold K Fezeu, Emmanuelle Kesse-Guyot, Benjamin Allès, Caroline Méjean, Roland M Andrianasolo, Eloi Chazelas, Mélanie Deschasaux, Serge Hercberg, Pilar Galan, Carlos A Monteiro, Chantal Julia, Mathilde Touvier, Bernard Srour, Léopold K Fezeu, Emmanuelle Kesse-Guyot, Benjamin Allès, Caroline Méjean, Roland M Andrianasolo, Eloi Chazelas, Mélanie Deschasaux, Serge Hercberg, Pilar Galan, Carlos A Monteiro, Chantal Julia, Mathilde Touvier

Abstract

Objective: To assess the prospective associations between consumption of ultra-processed foods and risk of cardiovascular diseases.

Design: Population based cohort study.

Setting: NutriNet-Santé cohort, France 2009-18.

Participants: 105 159 participants aged at least 18 years. Dietary intakes were collected using repeated 24 hour dietary records (5.7 for each participant on average), designed to register participants' usual consumption of 3300 food items. These foods were categorised using the NOVA classification according to degree of processing.

Main outcome measures: Associations between intake of ultra-processed food and overall risk of cardiovascular, coronary heart, and cerebrovascular diseases assessed by multivariable Cox proportional hazard models adjusted for known risk factors.

Results: During a median follow-up of 5.2 years, intake of ultra-processed food was associated with a higher risk of overall cardiovascular disease (1409 cases; hazard ratio for an absolute increment of 10 in the percentage of ultra-processed foods in the diet 1.12 (95% confidence interval 1.05 to 1.20); P<0.001, 518 208 person years, incidence rates in high consumers of ultra-processed foods (fourth quarter) 277 per 100 000 person years, and in low consumers (first quarter) 242 per 100 000 person years), coronary heart disease risk (665 cases; hazard ratio 1.13 (1.02 to 1.24); P=0.02, 520 319 person years, incidence rates 124 and 109 per 100 000 person years, in the high and low consumers, respectively), and cerebrovascular disease risk (829 cases; hazard ratio 1.11 (1.01 to 1.21); P=0.02, 520 023 person years, incidence rates 163 and 144 per 100 000 person years, in high and low consumers, respectively). These results remained statistically significant after adjustment for several markers of the nutritional quality of the diet (saturated fatty acids, sodium and sugar intakes, dietary fibre, or a healthy dietary pattern derived by principal component analysis) and after a large range of sensitivity analyses.

Conclusions: In this large observational prospective study, higher consumption of ultra-processed foods was associated with higher risks of cardiovascular, coronary heart, and cerebrovascular diseases. These results need to be confirmed in other populations and settings, and causality remains to be established. Various factors in processing, such as nutritional composition of the final product, additives, contact materials, and neoformed contaminants might play a role in these associations, and further studies are needed to understand better the relative contributions. Meanwhile, public health authorities in several countries have recently started to promote unprocessed or minimally processed foods and to recommend limiting the consumption of ultra-processed foods.

Study registration: ClinicalTrials.gov NCT03335644.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Figures

Fig 1
Fig 1
Flowchart for study sample, NutriNet-Santé cohort, France, 2009-18
Fig 2
Fig 2
Relative contribution (%) of each food group to consumption of ultra-processed food in diet
Fig 3
Fig 3
Spline plot for linearity assumption of association between proportion of ultra-processed food in diet and risks of overall cardiovascular, coronary heart, and cerebrovascular diseases. Restricted cubic spline SAS macro developed by Desquilbet and Mariotti

References

    1. World Health Organization. Cardiovascular diseases (CVDs) fact sheet. WHO. [cited 2018 Jun 1].
    1. Mozaffarian D. Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review. Circulation 2016;133:187-225. 10.1161/CIRCULATIONAHA.115.018585
    1. Wilkins E, Wilson L, Wickramasinghe K, et al. European Cardiovascular Disease Statistics 2017. European Heart Network, Brussels. [cited 2018 Jun 1].
    1. Perk J, De Backer G, Gohlke H, et al. European Association for Cardiovascular Prevention & Rehabilitation (EACPR) ESC Committee for Practice Guidelines (CPG) European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J 2012;33:1635-701. 10.1093/eurheartj/ehs092
    1. Eckel RH, Jakicic JM, Ard JD, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(Suppl 2):S76-99. 10.1161/01.cir.0000437740.48606.d1
    1. Monteiro CA, Moubarac JC, Cannon G, Ng SW, Popkin B. Ultra-processed products are becoming dominant in the global food system. Obes Rev 2013;14(Suppl 2):21-8. 10.1111/obr.12107
    1. Moodie R, Stuckler D, Monteiro C, et al. Lancet NCD Action Group Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013;381:670-9. 10.1016/S0140-6736(12)62089-3
    1. Moubarac JC, Batal M, Martins AP, et al. Processed and ultra-processed food products: consumption trends in Canada from 1938 to 2011. Can J Diet Pract Res 2014;75:15-21. 10.3148/75.1.2014.15
    1. Martins AP, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Increased contribution of ultra-processed food products in the Brazilian diet (1987-2009). Rev Saude Publica 2013;47:656-65. 10.1590/S0034-8910.2013047004968
    1. Juul F, Hemmingsson E. Trends in consumption of ultra-processed foods and obesity in Sweden between 1960 and 2010. Public Health Nutr 2015;18:3096-107. 10.1017/S1368980015000506
    1. PAHO. Ultra-processed food and drink products in Latin America: Trends, impact on obesity, policy implications. 2015.
    1. Luiten CM, Steenhuis IH, Eyles H, Ni Mhurchu C, Waterlander WE. Ultra-processed foods have the worst nutrient profile, yet they are the most available packaged products in a sample of New Zealand supermarkets--CORRIGENDUM. Public Health Nutr 2016;19:539. 10.1017/S1368980015002840
    1. Adams J, White M. Characterisation of UK diets according to degree of food processing and associations with socio-demographics and obesity: cross-sectional analysis of UK National Diet and Nutrition Survey (2008-12). Int J Behav Nutr Phys Act 2015;12:160. 10.1186/s12966-015-0317-y
    1. Cediel G, Reyes M, da Costa Louzada ML, et al. Ultra-processed foods and added sugars in the Chilean diet (2010). Public Health Nutr 2018;21:125-33.
    1. Costa Louzada ML, Martins AP, Canella DS, et al. Ultra-processed foods and the nutritional dietary profile in Brazil. Rev Saude Publica 2015;49:38.
    1. Martínez Steele E, Baraldi LG, Louzada ML, Moubarac JC, Mozaffarian D, Monteiro CA. Ultra-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study. BMJ Open 2016;6:e009892. 10.1136/bmjopen-2015-009892
    1. Moubarac JC, Batal M, Louzada ML, Martinez Steele E, Monteiro CA. Consumption of ultra-processed foods predicts diet quality in Canada. Appetite 2017;108:512-20. 10.1016/j.appet.2016.11.006
    1. Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA, Evidence from Canada Consumption of ultra-processed foods and likely impact on human health. Public Health Nutr 2013;16:2240-8. 10.1017/S1368980012005009
    1. Poti JM, Mendez MA, Ng SW, Popkin BM. Is the degree of food processing and convenience linked with the nutritional quality of foods purchased by US households? Am J Clin Nutr 2015;101:1251-62. 10.3945/ajcn.114.100925
    1. Slimani N, Deharveng G, Southgate DA, et al. Contribution of highly industrially processed foods to the nutrient intakes and patterns of middle-aged populations in the European Prospective Investigation into Cancer and Nutrition study. Eur J Clin Nutr 2009;63(Suppl 4):S206-25. 10.1038/ejcn.2009.82
    1. Marrón-Ponce JA, Sánchez-Pimienta TG, Louzada MLDC, Batis C. Energy contribution of NOVA food groups and sociodemographic determinants of ultra-processed food consumption in the Mexican population. Public Health Nutr 2018;21:87-93. 10.1017/S1368980017002129
    1. Baraldi LG, Martinez Steele E, Canella DS, Monteiro CA. Consumption of ultra-processed foods and associated sociodemographic factors in the USA between 2007 and 2012: evidence from a nationally representative cross-sectional study. BMJ Open 2018;8:e020574. 10.1136/bmjopen-2017-020574
    1. Rauber F, da Costa Louzada ML, Steele EM, Millett C, Monteiro CA, Levy RB. Ultra-Processed Food Consumption and Chronic Non-Communicable Diseases-Related Dietary Nutrient Profile in the UK (2008−2014). Nutrients 2018;10:587. 10.3390/nu10050587
    1. Monteiro CA, Cannon G, Moubarac JC, Levy RB, Louzada ML, Jaime PC. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutr 2018;21:5-17.
    1. Louzada ML, Martins AP, Canella DS, et al. Impact of ultra-processed foods on micronutrient content in the Brazilian diet. Rev Saude Publica 2015;49:45.
    1. Fardet A. Minimally processed foods are more satiating and less hyperglycemic than ultra-processed foods: a preliminary study with 98 ready-to-eat foods. Food Funct 2016;7:2338-46. 10.1039/C6FO00107F
    1. Zinöcker MK, Lindseth IA. The Western Diet-Microbiome-Host Interaction and Its Role in Metabolic Disease. Nutrients 2018;10:E365. 10.3390/nu10030365
    1. Zhang Y, Huang M, Zhuang P, et al. Exposure to acrylamide and the risk of cardiovascular diseases in the National Health and Nutrition Examination Survey 2003-2006. Environ Int 2018;117:154-63. 10.1016/j.envint.2018.04.047
    1. DeJarnett N, Conklin DJ, Riggs DW, et al. Acrolein exposure is associated with increased cardiovascular disease risk. J Am Heart Assoc 2014;3:e000934. 10.1161/JAHA.114.000934
    1. Rancière F, Lyons JG, Loh VHY, et al. Bisphenol A and the risk of cardiometabolic disorders: a systematic review with meta-analysis of the epidemiological evidence. Environ Health 2015;14:46. 10.1186/s12940-015-0036-5
    1. Singh K, Ahluwalia P. Effect of monosodium glutamate on lipid peroxidation and certain antioxidant enzymes in cardiac tissue of alcoholic adult male mice. J Cardiovasc Dis Res 2012;3:12-8. 10.4103/0975-3583.91595
    1. Chassaing B, Koren O, Goodrich JK, et al. Dietary emulsifiers impact the mouse gut microbiota promoting colitis and metabolic syndrome. Nature 2015;519:92-6. 10.1038/nature14232
    1. Zhang Q, Bai Y, Yang Z, Tian J, Meng Z. The molecular mechanisms of sodium metabisulfite on the expression of K ATP and L-Ca2+ channels in rat hearts. Regul Toxicol Pharmacol 2015;72:440-6. 10.1016/j.yrtph.2015.05.021
    1. Bhattacharyya S, O-Sullivan I, Katyal S, Unterman T, Tobacman JK. Exposure to the common food additive carrageenan leads to glucose intolerance, insulin resistance and inhibition of insulin signalling in HepG2 cells and C57BL/6J mice. Diabetologia 2012;55:194-203. 10.1007/s00125-011-2333-z
    1. Louzada ML, Baraldi LG, Steele EM, et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med 2015;81:9-15. 10.1016/j.ypmed.2015.07.018
    1. Canella DS, Levy RB, Martins AP, et al. Ultra-processed food products and obesity in Brazilian households (2008-2009). PLoS One 2014;9:e92752. 10.1371/journal.pone.0092752
    1. Schnabel L, Buscail C, Sabate J-M, et al. Association Between Ultra-Processed Food Consumption and Functional Gastrointestinal Disorders: Results From the French NutriNet-Santé Cohort. Am J Gastroenterol 2018;113:1217-28. 10.1038/s41395-018-0137-1
    1. Tavares LF, Fonseca SC, Garcia Rosa ML, Yokoo EM. Relationship between ultra-processed foods and metabolic syndrome in adolescents from a Brazilian Family Doctor Program. Public Health Nutr 2012;15:82-7. 10.1017/S1368980011001571
    1. Juul F, Martinez-Steele E, Parekh N, Monteiro CA, Chang VW. Ultra-processed food consumption and excess weight among US adults. Br J Nutr 2018;120:90-100. 10.1017/S0007114518001046
    1. Rauber F, Campagnolo PD, Hoffman DJ, Vitolo MR. Consumption of ultra-processed food products and its effects on children’s lipid profiles: a longitudinal study. Nutr Metab Cardiovasc Dis 2015;25:116-22. 10.1016/j.numecd.2014.08.001
    1. Mendonça RD, Pimenta AM, Gea A, et al. Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra Follow-Up (SUN) cohort study. Am J Clin Nutr 2016;104:1433-40. 10.3945/ajcn.116.135004
    1. Mendonça RD, Lopes AC, Pimenta AM, Gea A, Martinez-Gonzalez MA, Bes-Rastrollo M. Ultra-Processed Food Consumption and the Incidence of Hypertension in a Mediterranean Cohort: The Seguimiento Universidad de Navarra Project. Am J Hypertens 2017;30:358-66.
    1. Fiolet T, Srour B, Sellem L, et al. Consumption of ultra-processed foods and cancer risk: results from NutriNet-Santé prospective cohort. BMJ 2018;360:k322. 10.1136/bmj.k322
    1. Hercberg S, Castetbon K, Czernichow S, et al. The Nutrinet-Santé Study: a web-based prospective study on the relationship between nutrition and health and determinants of dietary patterns and nutritional status. BMC Public Health 2010;10:242. 10.1186/1471-2458-10-242
    1. Vergnaud AC, Touvier M, Méjean C, et al. Agreement between web-based and paper versions of a socio-demographic questionnaire in the NutriNet-Santé study. Int J Public Health 2011;56:407-17. 10.1007/s00038-011-0257-5
    1. Lassale C, Péneau S, Touvier M, et al. Validity of web-based self-reported weight and height: results of the Nutrinet-Santé study. J Med Internet Res 2013;15:e152. 10.2196/jmir.2575
    1. Touvier M, Méjean C, Kesse-Guyot E, et al. Comparison between web-based and paper versions of a self-administered anthropometric questionnaire. Eur J Epidemiol 2010;25:287-96. 10.1007/s10654-010-9433-9
    1. Craig CL, Marshall AL, Sjöström M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003;35:1381-95. 10.1249/01.MSS.0000078924.61453.FB
    1. Touvier M, Kesse-Guyot E, Méjean C, et al. Comparison between an interactive web-based self-administered 24 h dietary record and an interview by a dietitian for large-scale epidemiological studies. Br J Nutr 2011;105:1055-64. 10.1017/S0007114510004617
    1. Lassale C, Castetbon K, Laporte F, et al. Correlations between Fruit, Vegetables, Fish, Vitamins, and Fatty Acids Estimated by Web-Based Nonconsecutive Dietary Records and Respective Biomarkers of Nutritional Status. J Acad Nutr Diet 2016;116:427-438.e5. 10.1016/j.jand.2015.09.017
    1. Lassale C, Castetbon K, Laporte F, et al. Validation of a Web-based, self-administered, non-consecutive-day dietary record tool against urinary biomarkers. Br J Nutr 2015;113:953-62. 10.1017/S0007114515000057
    1. Le Moulenc N, Deheeger M, Preziozi P, et al. Validation du manuel photo utilisé pour l’enquête alimentaire de l’étude SU.VI.MAX. [Validation of the food portion size booklet used in the SU.VI.MAX study] (in French).
    1. Black AE. Critical evaluation of energy intake using the Goldberg cut-off for energy intake:basal metabolic rate. A practical guide to its calculation, use and limitations. Int J Obes Relat Metab Disord 2000;24:1119-30. 10.1038/sj.ijo.0801376
    1. Arnault N, Caillot L, Castetbon K, et al. Table de composition des aliments, Etude NutriNet-Santé. [Food composition table, NutriNet-Santé study] (in French). Paris: Les éditions INSERM/Economica,. 2013;
    1. Monteiro CA, Cannon G, Levy RB, et al. NOVA. The star shines bright. World Nutr 2016;7:28-38.
    1. Moubarac JC, Parra DC, Cannon G, Monteiro CA. Food Classification Systems Based on Food Processing: Significance and Implications for Policies and Actions: A Systematic Literature Review and Assessment. Curr Obes Rep 2014;3:256-72. 10.1007/s13679-014-0092-0
    1. Julia C, Martinez L, Alles B, et al. Contribution of ultra-processed foods in the diet of adults from the French NutriNet-Sante study. Public Health Nutr 2018;21:27-37.
    1. van Buuren S, van BS Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res 2007;16:219-42. 10.1177/0962280206074463
    1. Sterne JA, White IR, Carlin JB, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ 2009;338:b2393. 10.1136/bmj.b2393
    1. Rubin DB. Inference and missing data. Biometrika 1976;63:581-92 10.1093/biomet/63.3.581.
    1. Rubin DB. Multiple Imputation for Nonresponse in Surveys. John Wiley & Sons, 2004.
    1. PROC MIANALYZE. The MIANALYZE Procedure: SAS/STAT(R) 9.2 User’s Guide, Second Edition. [cited 2018 Dec 19].
    1. Desquilbet L, Mariotti F. Dose-response analyses using restricted cubic spline functions in public health research. Stat Med 2010;29:1037-57.
    1. DiMeglio DP, Mattes RD. Liquid versus solid carbohydrate: effects on food intake and body weight. Int J Obes Relat Metab Disord 2000;24:794-800. 10.1038/sj.ijo.0801229
    1. Khan SS, Ning H, Wilkins JT, et al. Association of Body Mass Index With Lifetime Risk of Cardiovascular Disease and Compression of Morbidity. JAMA Cardiol 2018;3:280-7. 10.1001/jamacardio.2018.0022
    1. Takeuchi M, Takino J, Furuno S, et al. Assessment of the concentrations of various advanced glycation end-products in beverages and foods that are commonly consumed in Japan. PLoS One 2015;10:e0118652. 10.1371/journal.pone.0118652
    1. Uribarri J, Stirban A, Sander D, et al. Single oral challenge by advanced glycation end products acutely impairs endothelial function in diabetic and nondiabetic subjects. Diabetes Care 2007;30:2579-82. 10.2337/dc07-0320
    1. World Health Organization (WHO) - Food additives. 2017.
    1. Shannon M, Green B, Willars G, et al. The endocrine disrupting potential of monosodium glutamate (MSG) on secretion of the glucagon-like peptide-1 (GLP-1) gut hormone and GLP-1 receptor interaction. Toxicol Lett 2017;265:97-105. 10.1016/j.toxlet.2016.11.015
    1. Jang W, Jeoung NH, Cho K-H. Modified apolipoprotein (apo) A-I by artificial sweetener causes severe premature cellular senescence and atherosclerosis with impairment of functional and structural properties of apoA-I in lipid-free and lipid-bound state. Mol Cells 2011;31:461-70. 10.1007/s10059-011-1009-3
    1. Pepino MY, Tiemann CD, Patterson BW, Wice BM, Klein S. Sucralose affects glycemic and hormonal responses to an oral glucose load. Diabetes Care 2013;36:2530-5.
    1. European CHemical Agency (ECHA). Member State Committee support document for identification of 4,4’-isopropylidenediphenol (bisphenol a) as a substance of very high concern because of its toxic for reproduction (Article 57 c) properties. Adopted on 2 December 2016.
    1. Prentice RL, Mossavar-Rahmani Y, Huang Y, et al. Evaluation and comparison of food records, recalls, and frequencies for energy and protein assessment by using recovery biomarkers. Am J Epidemiol 2011;174:591-603. 10.1093/aje/kwr140
    1. Zong G, Li Y, Wanders AJ, et al. Intake of individual saturated fatty acids and risk of coronary heart disease in US men and women: two prospective longitudinal cohort studies. BMJ 2016;355:i5796. 10.1136/bmj.i5796
    1. Bernstein AM, de Koning L, Flint AJ, Rexrode KM, Willett WC. Soda consumption and the risk of stroke in men and women. Am J Clin Nutr 2012;95:1190-9. 10.3945/ajcn.111.030205
    1. Andreeva VA, Salanave B, Castetbon K, et al. Comparison of the sociodemographic characteristics of the large NutriNet-Santé e-cohort with French Census data: the issue of volunteer bias revisited. J Epidemiol Community Health 2015;69:893-8. 10.1136/jech-2014-205263
    1. Andreeva VA, Deschamps V, Salanave B, et al. Comparison of Dietary Intakes Between a Large Online Cohort Study (Etude NutriNet-Santé) and a Nationally Representative Cross-Sectional Study (Etude Nationale Nutrition Santé) in France: Addressing the Issue of Generalizability in E-Epidemiology. Am J Epidemiol 2016;184:660-9. 10.1093/aje/kww016
    1. Santé Publique France. ESTEBAN - A health study on environment, biosurveillance, physical activity and nutrition 2014-2016 (Original title in French: Etude de santé sur l’environnement, la biosurveillance, l’activité physique et la nutrition (Esteban). 2017 [cited 2018 Oct 17].
    1. Santé Publique France. Prevalence and incidence of diabetes (in French) / Epidemiological data. [cited 2018 Oct 17].
    1. Santé Publique France DREES. Health situation of the French Population in 2017 (Original title in French: L’état de santé de la population en France, Rapport 2017). [cited 2018 Oct 18].
    1. ANSES. (French Agency for Food,Environmental and Occupational Health & Safety). Individual national study for dietary intakes 3 (INCA 3) [Etude individuelle nationale des consommations alimentaires 3 (INCA 3)] (in French). 2017 Jul.
    1. Gourd E. Ultra-processed foods might increase cancer risk. Lancet Oncol 2018;19:e186. 10.1016/S1470-2045(18)30184-0
    1. Ministry of Health of Brazil. Dietary Guidelines for the Brazilian population. 2014.
    1. Haut Conseil de la Santé Publique. Avis relatif à la révision des repères alimentaires pour les adultes du futur Programme National Nutrition Santé 2017-2021. 2017 Feb.

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