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Research

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

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1451 (Published 29 May 2019) Cite this as: BMJ 2019;365:l1451

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Association between consumption of ultra-processed foods and all cause mortality

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Ultra-processed food and adverse health outcomes
  1. Bernard Srour, PhD candidate in epidemiology1,
  2. Léopold K Fezeu, assistant professor of nutritional epidemiology1,
  3. Emmanuelle Kesse-Guyot, senior researcher in nutritional epidemiology1,
  4. Benjamin Allès, junior researcher in nutritional epidemiology1,
  5. Caroline Méjean, senior researcher in nutritional epidemiology2,
  6. Roland M Andrianasolo, PhD candidate in epidemiology1,
  7. Eloi Chazelas, PhD candidate in epidemiology1,
  8. Mélanie Deschasaux, postdoctoral researcher in epidemiology1,
  9. Serge Hercberg, professor of nutrition and public health13,
  10. Pilar Galan, senior researcher in nutritional epidemiology1,
  11. Carlos A Monteiro, professor of nutrition and public health4,
  12. Chantal Julia, assistant professor of nutrition and public health13,
  13. Mathilde Touvier, senior researcher in nutritional epidemiology, and head of the EREN Team1
  1. 1Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), Inserm U1153, Inra U1125, Cnam, University of Paris 13, Nutritional Epidemiology Research Team (EREN), Bobigny, France
  2. 2MOISA, University of Montpellier, INRA, CIRAD, CIHEAM-IAMM, Montpellier SupAgro, Montpellier, France
  3. 3Public Health Department, Avicenne Hospital, AP-HP, Bobigny, France
  4. 4Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil
  1. Correspondence to: B Srour b.srour{at}eren.smbh.univ-paris13.fr (or @bernardsrour on Twitter)
  • Accepted 19 March 2019

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.

Footnotes

  • Contributors: BS, CJ, EKG, CM, BA, and MT designed the research. SH, PG, MT, CJ, and EK-G conducted the research. BS performed the statistical analysis. BS drafted the manuscript. MT supervised the writing. BS, LKF, EK-G, BA, CM, RA, EC, MD, SH, PG, CAM, CJ, and MT contributed to the data interpretation and revised each draft for important intellectual content. All authors read and approved the final manuscript. MT had primary responsibility for the final content and is the guarantor. The corresponding author (BS) attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: The NutriNet-Santé study was supported by the Ministère de la Santé, Santé Publique France, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut National de la Recherche Agronomique (INRA), Conservatoire National des Arts et Métiers (CNAM), and Université Paris 13. BS was funded by the French National Cancer Institute (grant No INCa_8085) and Fondation de France. Researchers were independent from funders. Funders had no role in the study design, the collection, analysis, and interpretation of data, the writing of the report, and the decision to submit the article for publication.

  • 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.

  • Ethical approval: The NutriNet-Santé study is conducted according to the Declaration of Helsinki guidelines and was approved by the institutional review board of the French Institute for Health and Medical Research (IRB Inserm 0000388FWA00005831) and the “Commission Nationale de l’Informatique et des Libertés” (CNIL 908450/909216).

  • Transparency: The manuscript’s guarantor (MT) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

  • Data sharing: No additional data available.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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