Does Regular Consumption of Ultraprocessed Foods Raise the Risk for CV Events and Mortality?

A line of soda bottles in various flavors
A line of soda bottles in various flavors
Using data from the second generation of the ongoing prospective Framingham Heart Study cohort, the Framingham Offspring Cohort, researchers sought to examine the relationship between ultra-processed foods and CVD incidence and mortality.

Regular consumption of a wide range of ultraprocessed foods is associated with an increased risk for cardiovascular (CV) events and mortality, independent of other CV risk factors, according to research published in the Journal of the American College of Cardiology.

Using data from the second generation of the ongoing prospective Framingham Heart Study cohort, the Framingham Offspring Cohort, researchers sought to examine the relationship between ultra-processed foods and cardiovascular disease (CVD) incidence and mortality.

Dietary intake at baseline was assessed via mail, using the validated, 131-item Harvard semiquantitative food frequency questionnaire. Questionnaire food items were classified into 5 mutually exclusive categories, ranging from unprocessed or minimally processed foods to ultraprocessed foods, with the addition of culinary preparations to include mixed dishes that were presumed to be homemade.

Outcome data were gathered from the Framingham Offspring Cohort to confirm incident CVD deaths, CVD-related deaths, and total mortality.

At baseline, participants (55.1% women) were middle aged and overweight (mean age, 53.5 years; mean body mass index [BMI], 27.3 kg/m2). Most participants (52.9%) reported a high level of physical activity. Across quintiles of ultraprocessed foods, mean age, BMI, and waist circumference increased. In contrast, higher consumption of ultraprocessed foods was inversely associated with physical activity and education levels.

Of participants, 5.8% had diabetes and 19.0% had hypertension, with a higher prevalence among high consumers of ultraprocessed foods vs low consumers (quintile 5 vs quintile 1).

Over a mean follow-up period of 18 years (53,933.3 person-years), investigators noted a total of 648 incident CVD events, including 251 cases of hard CVD and 163 cases of hard coronary heart disease (CHD). Participants with the highest intake of ultraprocessed foods experienced the highest incidence rates per 1000 person-years of hard CVD and hard CHD (3.36 vs 6.64, respectively).

After controlling for age, sex, education level, smoking status, alcohol intake, and physical activity, investigators identified a 1 standard deviation increase in ultraprocessed food intake (2.9 servings) associated with a 22% and 30% increased risk for hard CVD and hard CHD, respectively; each ultraprocessed food serving was associated with a 7% increase in hard CVD risk (hazard ratio [HR], 1.07; 95% CI, 1.03-1.12) and a 9% increase in hard CHD risk (HR, 1.09; 95% CI, 1.10-3.28).

Additional adjustments for total energy intake, diet quality, waist circumference, BMI, systolic blood pressure, and current treatment with hypertension or lipid-lowering medication “did not meaningfully change the associations” between consumption of ultraprocessed food and CVD outcomes.

Consumption of ultraprocessed foods was also associated with an increased risk for overall CVD and CVD mortality (multivariable-adjusted HRs, 1.05; 95% CI, 1.02-1.08 and 1.09; 95% CI, 1.02-1.16, respectively), but not with total mortality (multivariable-adjusted HR, 1.01; 95% CI, 0.99-1.04). Mean follow-up for mortality analyses occurred over a 20.2-year period, representing 60,598.7 person-years).

Bread intake was associated with an increased risk of incident hard CVD, hard CHD, and overall CVD; ultraprocessed meat intake, however, was associated with an increased risk for both hard and overall CVD, but not hard CHD. Salty snack foods were associated an increased risk for incident hard CVD and CHD, but not with overall CVD, compared with intake of low-calorie soft drinks, which were associated with an increased overall CVD risk.

Finally, results of age-adjusted models indicated that each additional daily serving of minimally processed foods was associated with a 3% lower risk for incident overall CVD (HR, 0.97; 95% CI, 0.95-0.99). This association, though, was not statistically significant in multivariable-adjusted models (HR, 0.98; 95% CI, 0.96-1.01).

Study limitations include the inherent measurement errors typical of dietary assessment questionnaires, potential under- and overestimation of ultraprocessed food intake due to misclassification, and an inability to determine causality due to the observational study design.

“From a clinical practice perspective, our findings provide support to current American College of Cardiology/American Heart Association Guideline[s] on the Primary Prevention of Cardiovascular Disease, which recommends minimizing intake of processed red meats and refined carbohydrates,” the researchers wrote. “Our study further expands the evidence base, by recognizing the clinical importance of a broader range of ultraprocessed foods.”

“Careful nutrition counseling is needed to design individualized, patient-centered, heart-healthy diets,” the study authors concluded.


Juul F, Vaidean G, Lin Y, Deierlein AL, Parekh N. Ultra-processed foods and incident cardiovascular disease in the Framingham Offspring Study. J Am Coll Cardiol. 2021;77(12):1520-1531. doi:10.1016/j.jacc.2021.01.047