Ultra-Processed Food Consumption and Risk of Cardiovascular Disease: Prospective Cohort Study and Meta-analysis

Table of Contents

Overall Summary

Overview

This research investigated the link between ultra-processed food (UPF) consumption and cardiovascular disease (CVD) risk using data from three large US cohorts and a meta-analysis of existing studies. The study analyzed dietary intake and CVD incidence over several years, adjusting for potential confounding factors like lifestyle and medical history, to understand the impact of UPF on heart health.

Key Findings

Strengths

Areas for Improvement

Significant Elements

Table 1

Description: Provides baseline characteristics of the participants in the three cohorts (NHS, NHSII, HPFS) stratified by total UPF intake quintiles, showing differences in demographics, lifestyle factors, and dietary patterns.

Relevance: Highlights the characteristics of individuals consuming different levels of UPF and potential confounding factors that need to be considered.

Figure 2

Description: Displays the pooled hazard ratios and confidence intervals for the associations between specific UPF groups and cardiovascular outcomes (CVD, CHD, stroke).

Relevance: Visually demonstrates the divergent associations of different UPF groups with cardiovascular risk, emphasizing the importance of considering specific food types within the UPF category.

Conclusion

This study provides strong evidence for an association between higher UPF consumption and increased risk of CVD, particularly CHD. The findings highlight the importance of considering the specific types of UPF consumed, as some groups are linked to higher risk while others show inverse associations. These results have significant implications for public health recommendations and dietary guidelines, suggesting that reducing overall UPF intake, especially of processed meats and sugary drinks, may be beneficial for cardiovascular health. Further research in diverse populations and using more objective dietary assessment methods is needed to confirm these findings and explore the underlying mechanisms.

Section Analysis

Summary

Overview

This section summarizes the research paper's background, methods, findings, and interpretation regarding the association between ultra-processed food (UPF) consumption and cardiovascular disease (CVD) risk. It highlights the adverse association of total UPF intake with CVD and CHD risk, corroborated by a meta-analysis of prospective studies. The section also emphasizes the divergent associations of different UPF groups with cardiovascular risk, suggesting the need for nuanced dietary advice.

Key Aspects

Strengths

Suggestions for Improvement

Methods

Overview

This section meticulously details the methodologies employed in the research, encompassing the cohorts studied, dietary assessment methods, identification of cardiovascular disease (CVD) events, and statistical analyses. It provides a comprehensive overview of the data collection, processing, and analysis techniques used to investigate the association between ultra-processed food (UPF) consumption and CVD risk.

Key Aspects

Strengths

Suggestions for Improvement

Results

Overview

This section presents the key findings from the analysis of the three cohorts (NHS, NHSII, and HPFS) and the systematic review and meta-analysis of existing literature. It details the baseline characteristics of the participants, the associations between total UPF intake and cardiovascular outcomes, and the divergent associations observed for specific UPF groups.

Key Aspects

Strengths

Suggestions for Improvement

Non-Text Elements

Table 1

Table 1, titled 'Age-standardised baseline characteristics of the Nurses' Health Study (NHS), NHSII, and the Health Professionals Follow-Up Study (HPFS) participants, according to total ultra-processed food intake,' presents demographic and lifestyle characteristics of participants across three cohorts (NHS, NHSII, and HPFS), stratified by quintiles of total ultra-processed food (UPF) intake. The table shows that participants with the highest total UPF intake tended to have higher energy intake, lower AHEI scores, and higher prevalence of smoking and obesity. For example, the mean total UPF caloric contribution ranged from 15.3-20.8% in the lowest quintile (Q1) to 42.8-49.6% in the highest quintile (Q5).

First Mention

Text: "The proportion of participants of White race was 97.7% in the NHS, 96.4% in the NHSII, and 94.9% in the HPFS (Table 1)."

Context: This sentence appears in the first paragraph of the Results section, providing an overview of the baseline characteristics of the three cohorts.

Relevance: Table 1 provides a descriptive overview of the study population, highlighting key differences in baseline characteristics between participants with varying levels of UPF intake. This information is crucial for understanding the context of the subsequent analyses and interpreting the associations between UPF intake and cardiovascular outcomes.

Critique
Visual Aspects
  • The table is well-organized, with clear headings and consistent formatting, making it easy to navigate and compare data across cohorts and UPF intake quintiles.
  • The use of abbreviations, while explained in footnotes, could be reduced for improved readability. For instance, using 'Ultra-processed food' instead of 'UPF' throughout the table might enhance clarity.
  • The table could benefit from visual cues, such as shading or bolding, to highlight key findings or comparisons of interest.
Analytical Aspects
  • The table presents a comprehensive set of baseline characteristics, including demographic factors, lifestyle behaviors, dietary intakes, and cardiovascular risk factors, allowing for a thorough characterization of the study population.
  • The stratification by UPF intake quintiles reveals important differences in characteristics, suggesting potential confounding factors that need to be considered in the subsequent analyses.
  • The table does not present statistical tests for differences in characteristics across UPF intake quintiles. Including p-values for these comparisons would strengthen the analytical value of the table.
Numeric Data
  • Mean age (years): 50.8 years
  • Proportion of White participants: 97.7 %
  • Mean total UPF caloric contribution (Q1): 17.3 %
  • Mean total UPF caloric contribution (Q5): 47.0 %
  • Median AHEI score (Q1): 54.7 points
Table 2

Table 2, titled 'Hazard ratios and 95% confidence intervals for total cardiovascular disease, coronary heart disease, and stroke associated with total UPF intake in three US cohorts of women and men: the NHS (n = 75 735; 1984–2016), NHS II (n = 90 813; 1991–2017), and HPFS (n = 40 409; 1986–2016),' presents hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between total UPF intake and cardiovascular outcomes (total CVD, CHD, and stroke) in the three cohorts. The table shows that higher total UPF intake is associated with an increased risk of CVD and CHD, with the strongest associations observed in the NHSII cohort. For example, the multivariable-adjusted HR for CVD comparing the highest to the lowest quintile of UPF intake was 1.20 (95% CI: 1.12-1.28) in the NHS, 1.50 (95% CI: 1.29-1.74) in the NHSII, and 1.15 (95% CI: 1.07-1.24) in the HPFS.

First Mention

Text: "The cohort-specific and pooled HRs of incident cardiovascular outcomes are in Tables 2 and 3."

Context: This sentence, found in the second paragraph of the Results section, introduces the main findings of the study regarding the associations between UPF intake and cardiovascular outcomes.

Relevance: Table 2 presents the primary findings of the study, demonstrating the associations between total UPF intake and cardiovascular outcomes in the three cohorts. The table provides evidence for the adverse effects of high UPF consumption on CVD and CHD risk, supporting the main hypothesis of the study.

Critique
Visual Aspects
  • The table is well-structured, with clear headings and consistent formatting, facilitating the comparison of HRs across cohorts and outcomes.
  • The use of shading to distinguish between different models (age- and energy-adjusted vs. fully-adjusted) improves readability and helps readers focus on the key findings.
  • The table could benefit from visual cues, such as bolding or asterisks, to highlight statistically significant associations.
Analytical Aspects
  • The table presents both age- and energy-adjusted and fully-adjusted models, allowing readers to assess the impact of confounder adjustment on the associations.
  • The inclusion of p-values for trend across quintiles provides a clear indication of the dose-response relationship between UPF intake and cardiovascular outcomes.
  • The table does not present information on the statistical significance of differences in HRs between cohorts. Including p-values for these comparisons would enhance the analytical value of the table.
Numeric Data
  • HR for CVD (Q5 vs. Q1), NHS: 1.2
  • HR for CHD (Q5 vs. Q1), NHSII: 1.63
  • HR for stroke (Q5 vs. Q1), HPFS: 1.04
  • p-value for trend (CVD), NHS: 0.0001
  • p-value for trend (CHD), NHSII: 0.0001
Table 3

Table 3, titled 'Pooled hazard ratios and 95% confidence intervals for total cardiovascular disease, coronary heart disease, and stroke associated with total UPF intake in three large prospective cohorts in the US: the NHS (n = 75,735; 1984–2016), NHS II (n = 90,813; 1991–2017), and HPFS (n = 40,409; 1986–2016),' presents pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between total UPF intake and cardiovascular outcomes, combining data from the three cohorts. The table shows that higher total UPF intake is associated with an increased risk of CVD and CHD, even after pooling the data. For example, the multivariable-adjusted pooled HR for CVD comparing the highest to the lowest quintile of UPF intake was 1.11 (95% CI: 1.06-1.16), and the corresponding HR for CHD was 1.16 (95% CI: 1.09-1.24).

First Mention

Text: "The cohort-specific and pooled HRs of incident cardiovascular outcomes are in Tables 2 and 3."

Context: This sentence, found in the second paragraph of the Results section, introduces the main findings of the study regarding the associations between UPF intake and cardiovascular outcomes.

Relevance: Table 3 strengthens the findings presented in Table 2 by pooling data from the three cohorts, providing a more robust estimate of the association between total UPF intake and cardiovascular outcomes. The pooled analysis confirms the adverse effects of high UPF consumption on CVD and CHD risk.

Critique
Visual Aspects
  • The table is well-organized, with clear headings and consistent formatting, making it easy to compare pooled HRs across outcomes.
  • The use of shading to distinguish between different models (age- and energy-adjusted vs. fully-adjusted) improves readability and helps readers focus on the key findings.
  • The table could benefit from visual cues, such as bolding or asterisks, to highlight statistically significant associations.
Analytical Aspects
  • The table presents both age- and energy-adjusted and fully-adjusted pooled models, allowing readers to assess the impact of confounder adjustment on the associations.
  • The inclusion of p-values for trend across quintiles provides a clear indication of the dose-response relationship between UPF intake and cardiovascular outcomes in the pooled analysis.
  • The table presents I2 statistics for heterogeneity, indicating the degree of variability in HRs across the three cohorts. This information is crucial for interpreting the pooled estimates.
Numeric Data
  • Pooled HR for CVD (Q5 vs. Q1): 1.11
  • Pooled HR for CHD (Q5 vs. Q1): 1.16
  • Pooled HR for stroke (Q5 vs. Q1): 1.04
  • p-value for trend (CVD): 0.0001
  • I2 for heterogeneity (CVD): 55.2 %
Figure 1

Figure 1, titled 'Association between UPF intake (highest vs. lowest quintile) and cardiovascular disease in three US cohorts, excluding liquors, yoghurt, sugar-sweetened beverages, and processed meats,' presents pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD, CHD, and stroke, comparing the highest to the lowest quintile of UPF intake, after excluding specific food groups from the analysis. The figure shows that the associations for total CVD and CHD persist after removing hard liquors and yoghurt. However, removing sugar-sweetened beverages and processed meats attenuates the risk estimates for CVD and CHD and changes the directionality of the stroke estimate.

First Mention

Text: "The associations for total CVD and CHD persisted after removing hard liquors and yoghurt from the analysis (Fig. 1)."

Context: This sentence, found in the third paragraph of the Results section, describes the findings of a sensitivity analysis where specific food groups were excluded from the definition of total UPF intake.

Relevance: Figure 1 illustrates the robustness of the associations between total UPF intake and CVD/CHD risk by demonstrating that the associations persist even after excluding specific food groups. The figure also highlights the potential differential impact of specific UPF groups on cardiovascular outcomes.

Critique
Visual Aspects
  • The figure is clear and concise, with distinct panels for each outcome (CVD, CHD, and stroke) and clear labeling of the excluded food groups.
  • The use of a forest plot format effectively displays the HRs and CIs, allowing for easy comparison across different exclusion scenarios.
  • The figure could benefit from a legend explaining the symbols used (e.g., squares for HRs, diamonds for pooled estimates) and the meaning of the error bars (95% CIs).
Analytical Aspects
  • The figure presents a well-designed sensitivity analysis, systematically excluding specific food groups to assess their impact on the overall associations.
  • The findings suggest that the associations between total UPF intake and CVD/CHD risk are not solely driven by the consumption of hard liquors, yoghurt, sugar-sweetened beverages, or processed meats.
  • The figure does not present information on the statistical significance of the differences in HRs between exclusion scenarios. Including p-values for these comparisons would enhance the analytical value of the figure.
Numeric Data
  • HR for CVD (Q5 vs. Q1), excluding hard liquors and yoghurt: 1.1
  • HR for CHD (Q5 vs. Q1), excluding hard liquors and yoghurt: 1.17
  • HR for stroke (Q5 vs. Q1), excluding sugar-sweetened beverages and processed meats: 0.92
Figure 2

Figure 2, titled 'Association between group-specific UPF intake (highest vs. lowest quintile) and cardiovascular disease in three US cohorts,' presents pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD, CHD, and stroke, comparing the highest to the lowest quintile of intake for each of the ten UPF groups. The figure shows that processed meats and sugar-sweetened beverages are significantly associated with a higher risk of all three outcomes. Conversely, savory snacks and yoghurt/dairy-based desserts are inversely associated with total CVD and CHD risks. A higher total intake of bread and cereals is associated with lower stroke risk.

First Mention

Text: "Among UPF groups (Fig. 2; Supplementary Table S10), processed meats and sugar-sweetened beverages (Q5 vs. Q1) were significantly associated with a higher risk of the three outcomes."

Context: This sentence, found in the fourth paragraph of the Results section, introduces the findings regarding the associations between specific UPF groups and cardiovascular outcomes.

Relevance: Figure 2 provides crucial evidence for the divergent associations of different UPF groups with cardiovascular risk. The figure supports the notion that UPF is not a homogeneous entity and that specific groups within this category may have distinct effects on cardiovascular health.

Critique
Visual Aspects
  • The figure is well-organized, with distinct panels for each outcome (CVD, CHD, and stroke) and clear labeling of the UPF groups.
  • The use of a forest plot format effectively displays the HRs and CIs, allowing for easy comparison across different UPF groups.
  • The figure could benefit from a legend explaining the symbols used (e.g., squares for HRs, diamonds for pooled estimates) and the meaning of the error bars (95% CIs).
Analytical Aspects
  • The figure presents a comprehensive analysis of the associations between specific UPF groups and cardiovascular outcomes, providing valuable insights into the heterogeneity within the UPF category.
  • The findings highlight the importance of considering the specific composition of UPF intake when assessing its impact on cardiovascular health.
  • The figure does not present information on the statistical significance of the differences in HRs between UPF groups. Including p-values for these comparisons would enhance the analytical value of the figure.
Numeric Data
  • HR for CVD (Q5 vs. Q1), processed meats: 1.23
  • HR for CHD (Q5 vs. Q1), sugar-sweetened beverages: 1.24
  • HR for stroke (Q5 vs. Q1), savory snacks: 0.95
Figure 3

Figure 3, titled 'Random-effects meta-analyses of prospective cohort studies on the association of total UPF consumption (high vs. low) with CVD, CHD, and stroke risk,' presents forest plots summarizing the results of meta-analyses of prospective cohort studies investigating the association between total UPF consumption and cardiovascular outcomes. The figure shows that high UPF consumption is associated with a 17% (95% CI: 11-24%) higher risk of CVD, a 23% (95% CI: 12-34%) higher risk of CHD, and a 9% (95% CI: 3-15%) higher risk of stroke. The figure also presents I2 statistics for heterogeneity, indicating substantial variability in effect sizes across studies.

First Mention

Text: "In meta-analyses comparing the highest vs. lowest total UPF intake (Fig. 3), the pooled HRs for CVD, CHD, and stroke were 1.17 [95% CI: 1.11–1.24; I2: 76.4%; s-value > 13.3], 1.23 [95% CI: 1.12–1.34; I2: 79.8%; s-value > 13.3], and 1.09 [95% CI: 1.03–1.15; I2: 9.8%; s-value > 13.3], respectively."

Context: This sentence, found in the fifth paragraph of the Results section, summarizes the findings of the meta-analyses investigating the association between total UPF intake and cardiovascular outcomes.

Relevance: Figure 3 provides external validation for the findings observed in the three US cohorts by summarizing the results of meta-analyses of prospective cohort studies from multiple countries. The figure strengthens the evidence for the adverse effects of high UPF consumption on CVD, CHD, and stroke risk.

Critique
Visual Aspects
  • The figure is well-organized, with distinct panels for each outcome (CVD, CHD, and stroke) and clear labeling of the studies included in the meta-analyses.
  • The use of a forest plot format effectively displays the HRs and CIs for each study, as well as the pooled estimates and their confidence intervals.
  • The figure could benefit from a legend explaining the symbols used (e.g., squares for HRs, diamonds for pooled estimates) and the meaning of the error bars (95% CIs).
Analytical Aspects
  • The figure presents a comprehensive meta-analysis, including a large number of prospective cohort studies, providing a robust estimate of the association between total UPF intake and cardiovascular outcomes.
  • The inclusion of I2 statistics for heterogeneity allows readers to assess the variability in effect sizes across studies, providing context for interpreting the pooled estimates.
  • The figure does not present information on the potential sources of heterogeneity or conduct subgroup analyses to explore factors that might explain the variability in effect sizes.
Numeric Data
  • Pooled HR for CVD (high vs. low UPF intake): 1.17
  • Pooled HR for CHD (high vs. low UPF intake): 1.23
  • Pooled HR for stroke (high vs. low UPF intake): 1.09
  • I2 for heterogeneity (CVD): 76.4 %
  • I2 for heterogeneity (CHD): 79.8 %

Discussion

Overview

This section discusses the study's key findings regarding the association between ultra-processed food (UPF) consumption and cardiovascular disease (CVD) risk. It highlights the adverse association of total UPF intake with CVD and CHD risk, consistent with findings from previous studies. The authors emphasize the divergent associations of different UPF groups with cardiovascular risk, suggesting the need for a nuanced understanding of UPF's impact on health. The section also addresses the study's strengths, limitations, and implications for future research and public health recommendations.

Key Aspects

Strengths

Suggestions for Improvement

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