Higher Ultra-Processed Food Consumption Is Associated with Increased Risk of Incident Coronary Artery Disease in the Atherosclerosis Risk in Communities Study

Abstract

Background: Higher ultra-processed food intake has been linked with several cardiometabolic and cardiovascular diseases. However, prospective evidence from US populations remains scarce.

Objectives: To test the hypothesis that higher intake of ultra-processed foods is associated with higher risk of coronary artery disease.

Methods: A total of 13,548 adults aged 45-65 y from the Atherosclerosis Risk in Communities study were included in the analytic sample. Dietary intake data were collected through a 66-item FFQ. Ultra-processed foods were defined using the NOVA classification, and the level of intake (servings/d) was calculated for each participant and divided into quartiles. We used Cox proportional hazards models and restricted cubic splines to assess the association between quartiles of ultra-processed food intake and incident coronary artery disease.

Results: There were 2006 incident coronary artery disease cases documented over a median follow-up of 27 y. Incidence rates were higher in the highest quartile of ultra-processed food intake (70.8 per 10,000 person-y; 95% CI: 65.1, 77.1) compared with the lowest quartile (59.3 per 10,000 person-y; 95% CI: 54.1, 65.0). Participants in the highest compared with lowest quartile of ultra-processed food intake had a 19% higher risk of coronary artery disease (HR: 1.19; 95% CI: 1.05, 1.35) after adjusting for sociodemographic factors and health behaviors. An approximately linear relation was observed between ultra-processed food intake and risk of coronary artery disease.

Conclusions: Higher ultra-processed food intake was associated with a higher risk of coronary artery disease among middle-aged US adults. Further prospective studies are needed to confirm these findings and to investigate the mechanisms by which ultra-processed foods may affect health.

Keywords: ARIC; NOVA classification; cardiovascular disease; coronary artery disease; diet and nutrition; epidemiology; ultra-processed foods.

FIGURE 1

Proportion (%) of each food group contributing to the frequency (servings/d) of ultra-processed food consumption in the Atherosclerosis Risk in Communities Study. Dairy products: ice cream; fats and oils: margarine; meats: hamburgers, hot dogs, processed meats (sausage, salami, bologna), beef, pork, or lamb in dishes; sugary products: chocolate bars or pieces (Hershey's, plain M&M's, Snickers, Reese's), candy without chocolate; bakery goods: ready-made pie, donuts, biscuits, or cornbread; Danish pastry, sweet roll, coffee cake, croissant, cookies, cake, or brownie; cereals: cold breakfast cereal; fried foods: potato chips or corn chips, French fried potatoes, food fried away from home; beverages: orange or grapefruit juice, low calorie and regular soft drinks, fruit-flavored punch or noncarbonated beverages (lemonade, Kool-Aid, Hawaiian Punch); liquor: hard liquor.

FIGURE 2

Kaplan-Meier estimate of cumulative incidence of coronary artery disease according to quartile of ultra-processed food consumption over 32 y of follow-up in the Atherosclerosis Risk in Communities Study.

FIGURE 3

Partial hazard and 95% CIs for incident coronary artery disease according to intake of ultra-processed food/d using a restricted cubic spline in the Atherosclerosis Risk in Communities Study.¹ The gray histogram shows the distribution of ultra-processed food consumption. The black solid line represents the partial hazard for incident coronary artery disease, modeled using restricted cubic splines with 4 knots at the 5th, 35th, 65th, and 95th percentiles. The reference level was set at the 25th percentile (4.02 servings/d). The black dashed lines represent 95% CIs. Partial hazard was adjusted for age, sex, race-center, total energy intake, education level, smoking and alcohol drinking status, and physical activity score.

FIGURE 4

Subgroup analyses for the association between ultra-processed food consumption and incident coronary artery disease in the Atherosclerosis Risk in Communities Study.¹ The model was adjusted for age, sex, race–center, total energy intake, education level, smoking and alcohol drinking status, and physical activity score. CAD, coronary artery disease.