Consumption of ultra-processed foods and risk of multimorbidity of cancer and cardiometabolic diseases: a multinational cohort study

Abstract

Background: It is currently unknown whether ultra-processed foods (UPFs) consumption is associated with a higher incidence of multimorbidity. We examined the relationship of total and subgroup consumption of UPFs with the risk of multimorbidity defined as the co-occurrence of at least two chronic diseases in an individual among first cancer at any site, cardiovascular disease, and type 2 diabetes.

Methods: This was a prospective cohort study including 266,666 participants (60% women) free of cancer, cardiovascular disease, and type 2 diabetes at recruitment from seven European countries in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Foods and drinks consumed over the previous 12 months were assessed at baseline by food-frequency questionnaires and classified according to their degree of processing using Nova classification. We used multistate modelling based on Cox regression to estimate cause-specific hazard ratios (HR) and their 95% confidence intervals (CI) for associations of total and subgroups of UPFs with the risk of multimorbidity of cancer and cardiometabolic diseases.

Findings: After a median of 11.2 years of follow-up, 4461 participants (39% women) developed multimorbidity of cancer and cardiometabolic diseases. Higher UPF consumption (per 1 standard deviation increment, ∼260 g/day without alcoholic drinks) was associated with an increased risk of multimorbidity of cancer and cardiometabolic diseases (HR: 1.09, 95% CI: 1.05, 1.12). Among UPF subgroups, associations were most notable for animal-based products (HR: 1.09, 95% CI: 1.05, 1.12), and artificially and sugar-sweetened beverages (HR: 1.09, 95% CI: 1.06, 1.12). Other subgroups such as ultra-processed breads and cereals (HR: 0.97, 95% CI: 0.94, 1.00) or plant-based alternatives (HR: 0.97, 95% CI: 0.91, 1.02) were not associated with risk.

Interpretation: Our findings suggest that higher consumption of UPFs increases the risk of cancer and cardiometabolic multimorbidity.

Funding: Austrian Academy of Sciences, Fondation de France, Cancer Research UK, World Cancer Research Fund International, and the Institut National du Cancer.

Keywords: Cancer; Cardiovascular diseases; Diabetes; Diet; Multimorbidity; Ultra-processed foods.

Fig. 1

Transitions from baseline to cancer, cardiovascular disease, type 2 diabetes, and subsequent cancer-cardiometabolic multimorbidity. Cancer refers to first malignant tumour at any site excl. non-melanoma skin cancer. Deaths were censored and not modelled as a separate outcome. State-specific number of events is reported in boxes, and transition-specific number of events and incidence rates per 1000 person-years (within brackets) are reported on arrows. Abbreviations: CVD, cardiovascular disease; T2D, type 2 diabetes.

Fig. 2

Associations between ultra-processed food consumption^aand risk of cancer, cardiovascular disease, type 2 diabetes, and subsequent cancer-cardiometabolic multimorbidity. Cancer refers to first malignant tumour at any site excl. non-melanoma skin cancer. ^aEnergy-adjusted baseline UPF without alcoholic drinks (g/day) using residual method. Standardized residuals were computed by a linear regression of baseline UPF (g/day) adjusted for energy intake and center. Cox proportional hazard model, stratified by age at inclusion (1-year categories), sex, center, and transition in a clock forward multi-state analysis with age as primary time variable. Models were adjusted for total energy intake (continuous, kcal/day), baseline alcohol intake (g/day), height (cm), smoking status (never, former, current), the Cambridge physical activity index (inactive, moderately inactive, moderately active, active), highest attained educational level (none, primary completed, technical/professional, longer education including university degree), plausibility of dietary energy reporting (under-reporter, acceptable, over-reporter), and the modified relative Mediterranean Diet Score (mrMDS), post-menopause hormone therapy (yes, no), and menopausal status (premenopausal, perimenopausal, postmenopausal, surgical) in women. Abbreviations: CVD, cardiovascular disease; T2D, type 2 diabetes; BMI, body mass index; HR, hazard ratio; CI, confidence interval; SD, standard deviation.

Fig. 3

Associations between subgroups of ultra-processed food consumption^aand risk of cancer-cardiometabolic multimorbidity. Cancer refers to first malignant tumour at any site excl. non-melanoma skin cancer. ^aEnergy-adjusted subgroups of baseline UPF without alcoholic drinks (g/day) using residual method. Standardized residuals were computed by a linear regression of subgroups of baseline UPF (g/day) adjusted for energy intake and center. Cox proportional hazard model, stratified by age at inclusion (1-year categories), sex, center, and transition in a clock forward multi-state analysis with age as primary time variable. Subgroups were simultaneously added in the model as distinct covariables. Models were adjusted for total energy intake (continuous, kcal/day), baseline alcohol intake (g/day), height (cm), smoking status (never, former, current), the Cambridge physical activity index (inactive, moderately inactive, moderately active, active), highest attained educational level (none, primary completed, technical/professional, longer education including university degree), plausibility of dietary energy reporting (under-reporter, acceptable, over-reporter), and the modified relative Mediterranean Diet Score (mrMDS), post-menopause hormone therapy (yes, no), and menopausal status (premenopausal, perimenopausal, postmenopausal, surgical) in women. Abbreviations: HR, hazard ratio; CI, confidence interval; SD, standard deviation.