The more ultra-processed food Americans eat, the higher their risks of cardiovascular disease (CVD) and cardiovascular mortality, according to a recent analysis of data from the Framingham Offspring Study. Results are published in the Journal of the American College of Cardiology.
Previous research has shown not only that ultra-processed foods — which are calorie-dense and nutrient poor — make up 58% of the American caloric diet, but that the additives in these foods can disrupt the microbiome and endocrine systems. Further, the necessary processing these foods undergo can “remove beneficial nutrients and naturally occurring bioactive components.” Previous studies have continuously linked ultra-processed foods to hypertension, metabolic syndrome, and type 2 diabetes, as well as increased risks of CVD, coronary heart disease (CHD), cerebrovascular events, and all-cause mortality.
Yet although current cardiovascular guidelines stress the consumption of minimally processed foods, such as fruits and vegetables, whole grains, and nuts, recommendations to minimize the intake of ultra-processed foods receive considerably less emphasis.
“Cardiovascular diseases (CVDs) remain a leading cause of chronic disability and death worldwide. Poor diet is a major modifiable CVD risk factor and represents a critical target of cardiovascular prevention efforts. Ultra-processed foods (i.e., highly processed industrial formulations made with little or no whole foods) provide 58% of daily calories in the average U.S. diet and are increasingly consumed worldwide,” wrote Filippa Juul, MS, PhD, and colleagues, who conducted of the Framingham Offspring Study.
To do so, they collected data on the diets of 3,003 adults with no history of CVD, via a food frequency questionnaire quadrennially (1991-2008), which they used to collect information on food frequency, anthropometric measures, and sociodemographic and lifestyle factors. Diet quality was assessed with the Dietary Guidelines for Americans Adherence Index (DGAI) 2010, which assessed intake of 14 food groups and 11 healthy choice or nutrient intake recommendations.
Participants were followed for a mean of 18.0 years. Most were middle aged (mean age: 53.5 years), overweight (mean BMI: 27.3 kg/m2), and more than half were women (55.1%). Most also reported a high level of physical activity (52.9%). Information on the incidence of CVD was available through 2014, and for mortality, until 2018.
From 1991-2014/2017, researchers recorded 648 cases of overall CVD, including 251 cases of hard CVD and 163 cases of hard congestive heart disease (CHD).
Patients with the highest intake of ultra-processed foods had higher CVD incidence compared with those who consumed the least (6.64 versus 3.36 per 1,000 person-years of hard CVD, respectively), as well as higher rates of CHD (2.00 versus 4.36 per 1,000 person-years of hard CVD).
At baseline, participants consumed 7.5 servings/day of ultra-processed foods. Just a 1 standard deviation increase in consumption of ultra-processed food intake — equaling 2.9 servings — was associated with a 22% increased risk of hard CVD and a 30% increased risk of hard CHD after controlling for age, sex, education level, smoking status, alcohol intake, and physical activity.
Further, each additional daily serving of ultra-processed foods was associated with a 7% increase in the risk of hard CVD, a 9% increase in hard CHD, a 5% increase in overall CVD, and a 9% increase in CVD mortality.
Upon performing a secondary analysis, and after a mean follow-up of 20.2 years, Juul and colleagues found that higher intake of ultra-processed food was associated with an increased risk of overall CVD (multivariable-adjusted HR: 1.05; 95% CI: 1.02-1.08) and CVD mortality (multivariable-adjusted HR: 1.09; 95% CI: 1.02-1.16), but not with total mortality (multivariable-adjusted HR: 1.01; 95% CI: 0.99-1.04).
Researchers also found that different foods could increase risks of CVD. For example, eating bread was associated with an increased risk of incident hard CVD, hard CHD, and overall CVD. Eating ultra-processed meats was associated with increased risks of hard and overall VD, but not hard CHD. Other associations were as follows:
- Salty snack foods: increased risk of incident hard CVD and CHD, but not overall CVD.
- Low-calorie soft drinks: increased risk of overall CVD.
- Sugar-sweetened beverages, yogurt, sweets and desserts, fast foods, and other ultra-processed foods (i.e., non-dairy coffee whitener, margarine, liquor, and chili sauce): no statistically significant associations.
But researchers also found positive associations. Eating breakfast cereals, for example, was associated with decreased risk of overall CVD, and each additional daily serving of minimally processed foods was associated with a 3% lower risk of incident overall CVD (HR: 0.97 95% CI: 0.95-0.99); however, this association was only significant in age-adjusted models, not multivariable-adjusted models.
Robert J. Ostfeld, MD, MSc, of Montefiore Health System, Bronx, and Kathleen E. Allen, MS, RD, of the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, wrote in an accompanying editorial:
“When interpreting these findings, it is important to note the limitations and strengths of the study. Limitations include: 1) potential for residual confounding; 2) inaccuracies inherent to food frequency questionnaires; 3) inability to prove causality given the study’s observational design; and 4) homogeneity of the population, which limits generalizability. Strengths include: 1) long-term prospective follow-up; 2) rigorous assessment of outcomes; and 3) exclusion of individuals with CVD at baseline to limit potential reverse causality.”
These results bolster the need to reduce the consumption of ultra-processed foods in Americans, Ostfeld and Allen acknowledged. The path to do so, however, is not yet clear.
“Recognizing that multiple factors feed into individual food choice, where do we go from here? Reducing the consumption of ultra-processed foods requires additional substantial collaborative policy reform, implementation of widespread educational programs, marketing and labeling changes (such as using NOVA categories to label foods), and improved access to affordable less-processed foods, among other initiatives. Ultimately, the goal should be to make the unhealthy choice the hard choice and the healthy choice the easy choice,” they wrote.
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Higher consumption of ultra-processed foods is associated with an increased risk of both cardiovascular disease (CVD) incidence and mortality.
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Just a 1 standard deviation increase in consumption of ultra-processed food intake — equaling 2.9 servings — was associated with a 22% increased risk of hard CVD and a 30% increased risk of hard congestive heart disease.
Liz Meszaros, Deputy Managing Editor, BreakingMED™
The current analyses were unfunded. The Framingham Heart Study is conducted and supported by the National Heart, Lung, and Blood Institute (NHLBI) in collaboration with Boston University (Contract No. N01-HC-25195).
Juul reported no conflicts of interest.
Ostfeld has received research grants from the Purjes and Greenbaum Foundation and consulted for Better Therapeutics, and is a speaker for Main Street Vegan Academy and the International Plant-Based Nutrition Healthcare Conference; serves on the Board of Di[1]rectors (uncompensated) for T. Colin Campbell Center for Nutrition Studies; sits on the Scientific Advisory Board (uncompensated) for Physician Committee for Responsible Medicine; and consults for Brightplate.
Allen reported no disclosures.
Cat ID: 102
Topic ID: 74,102,730,102,308,4,914,192,94,925
