Association between consumption of ultra-processed foods and all cause mortality: SUN prospective cohort study

Anaïs Rico-Campà, Miguel A Martínez-González, Ismael Alvarez-Alvarez, Raquel de Deus Mendonça, Carmen de la Fuente-Arrillaga, Clara Gómez-Donoso, Maira Bes-Rastrollo, Anaïs Rico-Campà, Miguel A Martínez-González, Ismael Alvarez-Alvarez, Raquel de Deus Mendonça, Carmen de la Fuente-Arrillaga, Clara Gómez-Donoso, Maira Bes-Rastrollo

Abstract

Objective: To evaluate the association between consumption of ultra-processed foods and all cause mortality.

Design: Prospective cohort study.

Setting: Seguimiento Universidad de Navarra (SUN) cohort of university graduates, Spain 1999-2018.

Participants: 19 899 participants (12 113 women and 7786 men) aged 20-91 years followed-up every two years between December 1999 and February 2014 for food and drink consumption, classified according to the degree of processing by the NOVA classification, and evaluated through a validated 136 item food frequency questionnaire.

Main outcome measure: Association between consumption of energy adjusted ultra-processed foods categorised into quarters (low, low-medium, medium-high, and high consumption) and all cause mortality, using multivariable Cox proportional hazard models.

Results: 335 deaths occurred during 200 432 persons years of follow-up. Participants in the highest quarter (high consumption) of ultra-processed foods consumption had a higher hazard for all cause mortality compared with those in the lowest quarter (multivariable adjusted hazard ratio 1.62, 95% confidence interval 1.13 to 2.33) with a significant dose-response relation (P for linear trend=0.005). For each additional serving of ultra-processed foods, all cause mortality relatively increased by 18% (adjusted hazard ratio 1.18, 95% confidence interval 1.05 to 1.33).

Conclusions: A higher consumption of ultra-processed foods (>4 servings daily) was independently associated with a 62% relatively increased hazard for all cause mortality. For each additional serving of ultra-processed food, all cause mortality increased by 18%.

Study registration: ClinicalTrials.gov NCT02669602.

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 of study participants. SUN=Seguimiento Universidad de Navarra
Fig 2
Fig 2
Kaplan-Meier incidence for consumption of ultra-processed foods, adjusted through inverse probability weighting. See table 3 footnote † for adjustment factors
Fig 3
Fig 3
Subgroup and sensitivity analyses for association between consumption of ultra-processed foods and all cause mortality (highest versus lowest quarter of consumption). See table 3 footnote † for adjustment factors. CVD=cardiovascular disease
Fig 4
Fig 4
Restricted cubic splines analysis of association between consumption of ultra-processed foods and all cause mortality. Dotted lines represent 95% confidence intervals

References

    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. Gakidou E, Afshin A, Abajobir AA, et al. GBD 2016 Risk Factors Collaborators Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1345-422. 10.1016/S0140-6736(17)32366-8
    1. United Nations. Political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. Agenda item 117. 2011;(January). 10.1007/BF03038934
    1. World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: WHO. . Published 2013.
    1. Kontis V, Mathers CD, Rehm J, et al. Contribution of six risk factors to achieving the 25×25 non-communicable disease mortality reduction target: a modelling study. Lancet 2014;384:427-37. 10.1016/S0140-6736(14)60616-4
    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. 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 10.1111/obr.12107
    1. Latasa P, Louzada MLDC, Martinez Steele E, Monteiro CA. Added sugars and ultra-processed foods in Spanish households (1990-2010). Eur J Clin Nutr 2018;72:1404-12. 10.1038/s41430-017-0039-0
    1. Monteiro CA, Cannon G, Levy R, et al. NOVA. The star shines bright. Food classification. Public Health World Nutr 2016;7:28-38.
    1. Moubarac JC, Martins APB, 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. Singh GM, Micha R, Khatibzadeh S, Lim S, Ezzati M, Mozaffarian D, Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) Estimated Global, Regional, and National Disease Burdens Related to Sugar-Sweetened Beverage Consumption in 2010. Circulation 2015;132:639-66. 10.1161/CIRCULATIONAHA.114.010636
    1. Larsson SC, Orsini N. Red meat and processed meat consumption and all-cause mortality: a meta-analysis. Am J Epidemiol 2014;179:282-9. 10.1093/aje/kwt261
    1. Wang X, Lin X, Ouyang YY, et al. Red and processed meat consumption and mortality: dose-response meta-analysis of prospective cohort studies. Public Health Nutr 2016;19:893-905. 10.1017/S1368980015002062
    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. Schnabel L, Buscail C, Sabate JM, 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. Rauber F, Campagnolo PDB, 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. Schnabel L, Kesse-Guyot E, Allès B, et al. Association Between Ultraprocessed Food Consumption and Risk of Mortality Among Middle-aged Adults in France. JAMA Intern Med 2019. 10.1001/jamainternmed.2018.7289
    1. Kim H, Hu EA, Rebholz CM. Ultra-processed food intake and mortality in the USA: results from the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994). Public Health Nutr 2019:1-9.
    1. Carlos S, De La Fuente-Arrillaga C, Bes-Rastrollo M, et al. Mediterranean diet and health outcomes in the SUN cohort. Nutrients 2018;10:E439. 10.3390/nu10040439
    1. Martín-Moreno JM, Boyle P, Gorgojo L, et al. Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol 1993;22:512-9. 10.1093/ije/22.3.512
    1. de la Fuente-Arrillaga C, Ruiz ZV, Bes-Rastrollo M, Sampson L, Martinez-González MA. Reproducibility of an FFQ validated in Spain. Public Health Nutr 2010;13:1364-72. 10.1017/S1368980009993065
    1. Fernández-Ballart JD, Piñol JL, Zazpe I, et al. Relative validity of a semi-quantitative food-frequency questionnaire in an elderly Mediterranean population of Spain. Br J Nutr 2010;103:1808-16. 10.1017/S0007114509993837
    1. Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med 2003;348:2599-608.10.1056/NEJMoa025039 10.1056/NEJMoa025039
    1. Martínez-González MA, López-Fontana C, Varo JJ, Sánchez-Villegas A, Martinez JA. Validation of the Spanish version of the physical activity questionnaire used in the Nurses’ Health Study and the Health Professionals’ Follow-up Study. Public Health Nutr 2005;8:920-7.10.1079/PHN2005745 10.1079/PHN2005745
    1. Bes-Rastrollo M, Pérez-Valdivieso JR, Sánchez-Villegas A, et al. Validación del peso e índice de masa corporal auto-declarados de los participantes de una cohorte de graduados universitarios. Rev Esp Obes 2005;3:352-8.
    1. Hernán MARJ. Causal Inference. Chapman & Hall/CRC, 2019, (forthcoming).
    1. Hernán MA, Hernández-Díaz S, Werler MM, Mitchell AA. Causal knowledge as a prerequisite for confounding evaluation: an application to birth defects epidemiology. Am J Epidemiol 2002;155:176-84. 10.1093/aje/155.2.176
    1. Greenland S, Daniel R, Pearce N. Outcome modelling strategies in epidemiology: traditional methods and basic alternatives. Int J Epidemiol 2016;45:565-75. 10.1093/ije/dyw040
    1. VanderWeele TJ, Ding P. Sensitivity Analysis in Observational Research: Introducing the E-Value. Ann Intern Med 2017;167:268-74. 10.7326/M16-2607
    1. Mathur MB, Ding P, Riddell CA, VanderWeele TJ. Web Site and R Package for Computing E-values. Epidemiology 2018;29:e45-7. 10.1097/EDE.0000000000000864
    1. Willett W. Nutritional Epidemiology. 3rd ed. Oxford University Press, 2013.
    1. Sarkar SK, Chang CK, Chang CK. The simes method for multiple hypothesis testing with positively dependent test statistics. J Am Stat Assoc 1997;92:1601-8 10.1080/01621459.1997.10473682 .
    1. Gibney MJ, Forde CG, Mullally D, Gibney ER. Ultra-processed foods in human health: a critical appraisal. Am J Clin Nutr 2017;106:717-24.
    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. Martínez Steele E, Monteiro CA. Association between dietary share of ultra-processed foods and urinary concentrations of phytoestrogens in the US. Nutrients 2017;9:209. 10.3390/nu9030209
    1. Rohatgi KW, Tinius RA, Cade WT, Steele EM, Cahill AG, Parra DC. Relationships between consumption of ultra-processed foods, gestational weight gain and neonatal outcomes in a sample of US pregnant women. PeerJ 2017;5:e4091. 10.7717/peerj.4091
    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. 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. Bielemann RM, Santos LP, Costa CDS, Matijasevich A, Santos IS. Early feeding practices and consumption of ultraprocessed foods at 6 y of age: Findings from the 2004 Pelotas (Brazil) Birth Cohort Study. Nutrition 2018;47:27-32. 10.1016/j.nut.2017.09.012
    1. Rothman KJ, Gallacher JEJ, Hatch EE. Why representativeness should be avoided. Int J Epidemiol 2013;42:1012-4. 10.1093/ije/dys223
    1. Rothman K, Greenland S, Lash T. Modern Epidemiology. 3rd edn. Lippincott Williams & Wilkins. Philadelphia.
    1. Willett WC, Colditz GA. Approaches for conducting large cohort studies. Epidemiol Rev 1998;20:91-9. 10.1093/oxfordjournals.epirev.a017975
    1. Martínez-González MA, Gea A, Ruiz-Canela M. The Mediterranean Diet and Cardiovascular Health. Circ Res 2019;124:779-98.10.1056/NEJMoa1800389 10.1161/CIRCRESAHA.118.313348
    1. Martínez-González MA, Guillén-Grima F, De Irala J, et al. The Mediterranean diet is associated with a reduction in premature mortality among middle-aged adults. J Nutr 2012;142:1672-8. 10.3945/jn.112.162891
    1. Chen G-C, Zhang R, Martínez-González MA, et al. Nut consumption in relation to all-cause and cause-specific mortality: a meta-analysis 18 prospective studies. Food Funct 2017;8:3893-905. 10.1039/C7FO00915A
    1. Reedy J, Krebs-Smith SM, Miller PE, et al. Higher diet quality is associated with decreased risk of all-cause, cardiovascular disease, and cancer mortality among older adults. J Nutr 2014;144:881-9. 10.3945/jn.113.189407
    1. Alvarez-Alvarez I, Zazpe I, Pérez de Rojas J, et al. Mediterranean diet, physical activity and their combined effect on all-cause mortality: The Seguimiento Universidad de Navarra (SUN) cohort. Prev Med 2018;106:45-52. 10.1016/j.ypmed.2017.09.021

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다