Associations of Ultra-Processed Food Intake with the Incidence of Cardiometabolic and Mental Health Outcomes Go Beyond Specific Subgroups-The Brazilian Longitudinal Study of Adult Health

Abstract

Background/Objectives: Avoidance of ultra-processed foods (UPFs) has been recommended to achieve a healthy diet, but whether it applies equally to all UPFs is uncertain. We evaluated individual UPF subgroups in the prediction of cardiometabolic and mental health outcomes. Methods: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is an occupational cohort study of 15,105 adults (35-74 years) recruited in 2008-2010. We followed participants up to 2018 to ascertain elevated weight and waist gains and the onset of metabolic syndrome, hypertension, metabolic dysfunction-associated steatotic liver disease, diabetes, common mental disorders, depressive episodes, and anxiety disorders. Results: In adjusted robust Poisson regression, greater overall UPF intake at the baseline predicted all studied outcomes. Various subgroups of UPF, most frequently processed meat and sweetened beverages, individually conferred a greater risk, and nearly all predicted at least one studied outcome. Considering all subgroups and outcomes, a broad pattern of overall risk was present. When subgroups not individually predictive of these outcomes were aggregated, increased risk (for a one-standard deviation change) was observed for elevated weight (RR = 1.05; 95% CI 1.01-1.11) and waist (RR = 1.05; 95% CI 1.00-1.10) gains, and for the incidence of common mental (RR = 1.06; 95% CI 1.01-1.12), and anxiety (RR = 1.09; 95% CI 1.02-1.16) disorders. Conclusions: UPFs overall and their subgroups predicted future cardiometabolic and mental health outcomes. The pattern of individual UPF subgroup associations varied across outcomes, and the aggregate of subgroups not individually predicting risk also predicted large gains in overall and central adiposity and the incidence of mental health disorders. While additional studies investigating other outcomes are needed, these findings justify avoidance of overall UPF intake in health promotion and disease prevention.

Keywords: cardiometabolic risk factors; epidemiology; foods; mental disorders; processed meat; sugar-sweetened beverages; weight gain.

Figure 1

ELSA-Brasil food groups, according to the Nova classification, are based on the degree of industrial processing of food. The ultra-processed food group (Group 3) was divided into prespecified subgroups based on similarities in nutritional content or purpose.

Figure 2

Heat map of the association of UPF subgroups and the nine outcomes. Red = risk (RR > 1); Green = protection (RR < 1); White = no association (RR = 1); Darker colors = statistical significance; GM/DAY % = Percent of total dietary intake of UPFs in grams/day; WEIGHT = elevated weight gain; WAIST = elevated waist gain; METSYN = metabolic syndrome; HPT = hypertension; MASLD = metabolic dysfunction-associated steatotic liver disease; T2DM = diabetes; CMD = common mental disorders; DEPR = depressive episodes; and ANX = anxiety disorders.

Figure 3

Associations of cardiometabolic and mental health outcomes for a one-standard deviation difference in (1) overall ultra-processed food (UPF) intake; (2) the aggregate of UPF intake remaining after removal of UPF subgroups presenting statistically significant associations; and (3) this aggregate, now additionally adjusted for the individually associated subgroups. Analyses are conducted independently for each outcome. All models are adjusted for age, sex, race/color, school achievement, per capita family income, smoking, physical activity, and alcohol consumption using robust Poisson regression.