Ultra-Processed Foods Are Ultra-Bad For The Heart

According to a recent prospective observational study headed by the New York University School of Public Health, these ultra-processed food choices account for 58% of the daily calorie intake for the average American. Findings link higher consumption of ultra-processed foods with an increased risk of cardiovascular disease incidence and cardiovascular disease mortality. 

This study followed over 3,000 adults who were enrolled in the Framingham Offspring Study for up to 20 years, indicating that the participants consumed on average 7.5 serving of ultra-processed foods daily, and for each additional serving the risk of CVD increased by another 7% with the risk of CVD mortality increasing by 9%.

“The consumption of ultra-processed foods makes up over half of the daily calories in the average American diet and are increasingly consumed worldwide,” said Filippa Juul, Ph.D., lead author, and a faculty fellow at New York University School of Public Health. “Ultra-processed foods are ubiquitous and include many foods that are marketed as healthy, such as protein bars, breakfast cereals, and most industrially produced breads … Our findings add to a growing body of evidence suggesting cardiovascular benefits of limiting ultra-processed foods. As poor diet is a major modifiable risk factor for heart disease, it represents a critical target in prevention efforts.”

Globally, CVD remains a leading cause of chronic disability and death, with poor dietary choices being a major modifiable risk factor that represents a significant target for prevention efforts. Ultra-processed foods are highly industrial formulations that are made with little or no whole foods using techniques that will typically remove beneficial nutrients and other bioactive components in the process while adding non-beneficial ingredients like flavoring, coloring, additives, and preservatives. Additionally, the authors noted that “Beyond nutrient composition, processing modifies the physical structure of the food matrix which may alter nutrient bioaccessibility, absorption kinetics, and the gut microbiota profile.”

Studies have linked the consumption of ultra-processed foods with metabolic disorders including obesity, diabetes, hypertension, and metabolic syndrome, but few have investigated the role of ultra-processed foods in relation to cardiovascular disease risk. This study utilized data from the FOS to examine this role, and after excluding participants with pre-existing CVD or missing data the study involved 3,003 adults with an average age of 53.5 years. Two-thirds of the participants were either former or current smokers, 5,8% had diabetes, and 19% had high blood pressure; prevalence was higher among those who were high consumers of ultra-processed foods compared to their counterparts who were low consumers. 

Diet was assessed using food questionnaires where participants reported their frequency of eating certain types of foods, as well as during in-person examinations. The US Department of Agriculture Nutrient Database was used to calculate nutrient intakes. Using a modified version of the NOVA Framework questionnaires food items were classified into 5 categories:

1. Unprocessed or minimally processed foods, including fresh, dry, or frozen plant and animal foods
2. Processed culinary ingredients, including table sugar, oils, fats, salts, and other items used in kitchens to make culinary preparations
3. Processed foods, including foods such as canned fish and vegetables and artisanal cheeses
4. Ultra-processed foods, including industrial formulations made with no or minimal whole foods and produced with additives such as flavorings or preservatives
5. Culinary preparations, which encompassed mixed dishes that were indicated to be homemade or assumed to be homemade due to lack of detailed information.

Participant diet was examined in relation to events including incident hard CVD and hard coronary heart disease; during an 18 year follow-up period, a total of 648 cardiovascular events occurred including 251 cases of hard CVD and 163 cases of CHD, with 713 deaths that included 108 CVD deaths. Those with the highest intakes of ultra-processed were found to have had higher incidence rates compared to those consuming the least amount of ultra-processed food choices. 

Comparing those who consumed the least amounts of ultra-processed foods with those with the highest levels revealed that those with the highest intake had higher incident rates per 1000 person-years of hard CVD and hard CHD, and each additional daily serving above the 7.5 average was associated with a 7% increase in the risk of hard CVD, 9% increase in the risk of hard CHD, 5% increase in overall CVD, and a 9% increased risk in cardiovascular disease mortality. 

Analyzing individual foods type revealed that bread intake was associated with an increased risk of hard CVD, hard CHD, and overall mortality, while ultra-processed meat intake was associated with an increased risk of hard CVD and overall CVD. Additionally, salty snack foods were associated with an increased risk of hard CVD and CHD, and consumption of low-calorie soft drinks was associated with an increased risk of overall CVD. “Each additional daily serving of minimally processed foods was associated with a 3% lower risk of incident overall CVD in age-adjusted models,” note the authors. 

It was also noted that the study was not without limitations due to the observational nature of the study, and they can not rule out the potential for measurement error in dietary assessment and under/overestimation of the ultra-processed food intake due to misclassification which was mainly based on questionnaire responses. Additionally, the participants were primarily Caucasian, with higher education levels and income limiting how the findings can be generalized to the total US population. 

Regardless of the limitations the team still says that their findings have important potential implications for cardiovascular disease prevention: “From a public health perspective, our study suggests the need for increased efforts to implement population-wide strategies,” they wrote. Juul concluded, “Population-wide strategies such as taxation on sugar-sweetened beverages and other ultra-processed foods and recommendations regarding processing levels in national dietary guidelines are needed to reduce the intake of ultra-processed foods. Of course, we must also implement policies that increase the availability, accessibility, and affordability of nutritious, minimally processed foods, especially in disadvantaged populations. At the clinical level, there is a need for increased commitment to individualized nutrition counseling for adopting sustainable heart-healthy diets.” The authors added, “Another promising strategy is to require front-of package warning labels on ultra-processed products.”

“… given the prevalence of ultra-processed food consumption and given that ultra-processed foods tend to displace more healthful foods in the diet, timely action to curb the consumption of ultra-processed foods is needed … Recognizing that multiple factors feed into individual food choice, where do we go from here? Ultimately, the goal should be to make the unhealthy choice the hard choice and the healthy choice the easy choice,” writes Robert J. Ostfeld  MD, MSc, and Kathleen E. Allen, MS, RD, in an accompanying editorial. 

"We have become a society that accepts food additives that we can't pronounce or explain, foods that mimic other foods, foods that are reduced to a shadow of the original product. We don't question, we just grab for the ease of getting our next meal," says Stephanie Schiff is a registered dietitian at Northwell Health's Huntington Hospital.

"A great tip when food shopping is to shop the perimeter of the supermarket," she said. "Usually located within center aisles will be canned, packaged and processed foods, while the outer perimeter tends to have fresh foods."

"Reading the food label is also important when shopping," said Nicole Roach, a cardiac dietitian at Lenox Hill Hospital."When looking at the food label the ingredient list will tell you exactly what's in the item you're consuming. The ingredient list is written in order of the highest ingredient quantity to the lower ingredient quantity. When reading the list if an item is made with many non-beneficial ingredients/nutrient, processed/refined sugars and food additives, it may not be the best option.”

“We need to go back to our parents' and grandparents' and great-grandparents' days. We need to prioritize, and put our health first. We need to make the consumption of whole foods a pleasure, and a fun activity, rather than a chore," Schiff said. "We need to realize that we don't lose anything by eating healthfully, but succumbing to the lure of ultra-processed foods may lead to consequences we may not be able to recover from.”