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[7 min read] Ultra-processed food consumption and all-cause mortality

[Nutrition Research Review] Ultra-processed food consumption is associated with increased risk of all-cause mortality and cardiovascular mortality in the Moli-sani Study.

Worldwide, the consumption of processed foods is on the rise, leading to a range of health implications. It is well evidenced that a healthier diet is one that is based on whole foods and foods which are minimally processed, as opposed to one that relies heavily on processed foods.

Food processing exists along a continuum from whole foods to minimally processed foods right through to those which are ultra-processed. Ultra-processed foods (UPF) are described in the NOVA Classification, which is a classification tool used to distinguish foods based on the extent and purpose of processing, rather than nutrient content.1 UPF do not contain significant amounts of whole or minimally processed foods, instead being comprised of a combination of substances that are derived from foods and additives. They are hyper-palatable, highly convenient, highly profitable for food manufacturers and displace less processed foods and whole foods in consumers’ diets.1

To understand the health implications of UPF consumption, Bonaccio et al. explored the association between UPF and mortality risk in a large sample of the Italian adult population drawn from the prospective, population-based Moli-sani Study cohort.2 In addition to mortality, the researchers tested which nutritional factors (sugar, saturated fats, dietary cholesterol, sodium and energy content) were potential mediators of this relationship, and which known cardiovascular disease (CVD) risk factors were likely to be on the pathway between UPF and mortality.

Drawing from 24,475 subjects, data from a validated Food Frequency Questionnaire (measuring food intake in the year before enrolment) and the Mediterranean Diet Score (MDS) (measuring adherence to the traditional Mediterranean diet)3 were analysed. Based on the FFQ, the NOVA classification1 was used to identify UPF foods and intake was calculated and divided into quartiles using a weight ratio.

Biomarkers of renal function, glucose metabolism, lipid metabolism and inflammatory markers were tested as possible mediators of the mortality risk associated with UPF consumption. Median follow up was 8.6 years and 1,216 all-cause deaths occurred.

The results of this analysis confirmed the detrimental impact of increasing UPF consumption on CV health. Specifically, results included:

  • Median intake of UPF was 10% (IQR 6.6%-14.6%) of dietary intake as UPF.
  • High consumers of UPF (>14.6% food consumed) were more likely to be women, younger, more educated and reported fewer risk factors and chronic diseases as baseline than people who consumed lower levels of UPF.
  • As UPF intake increased, adherence with the Mediterranean diet and intake of dietary fibre decreased, while energy, fat, sodium, sugar and dietary cholesterol intakes increased.
  • There was a direct linear relationship between a 5% increase in the proportion of UPF in the diet and risk of all-cause and CVD mortality. Higher UPF consumption was associated with a 58% increased risk of CVD mortality and a 52% higher risk of dying from IHD/CV causes, and that this was independent of known risk factors, including adherence to the Mediterranean diet.
  • No direct association was found between BMI and UPF intake.
  • High risk individuals (with CVD or T2DM) were more sensitive to higher UPF intakes in terms of CVD mortality risk.
  • Sugar explained nearly 40% of the association of UPF and IHD/CV mortality. Other studied nutrients only partially accounted for the adverse relationship between UPF and mortality risk, which may indicate that nutrient composition alone is unable to fully explain the increased mortality risk associated with UPF consumption.
  • Biomarkers of renal function were found to be likely mediators of the increased mortality associated with higher UPF consumption. Similarly, all CVD risk factors were significantly associated with the excess of all-cause and CVD mortality risk linked to UPF intake.

The important take home message from this research is that higher intakes of UPF are associated with increased all-cause and CVD mortality in this large sample of Mediterranean adults. This finding gives weight to the argument for ongoing public health actions that support all people to have access to, and choose, a diet in line with national dietary guidelines that is based on whole and minimally processed foods, with minimal UPF.

See the full article here.

Anna Millichamp, APD, Bond University

Learn more in the online Professional Diploma of Medical Nutrition Management.


  1. Monteiro C, Cannon G, Levy R, Moubarac JC & Jaime P, al A. NOVA. The star shines bright. Position paper 2. World Nutrition. 2016;7:28-38. Accessed 23rd March 2021, URL: https://www.researchgate.net/publication/315378059_NOVA_The_star_shines_bright_Position_paper_2
  2. Bonaccio M, Di Castelnuovo A, Costanzo S, De Curtis A, Persichillo M, Sofi F, Cerletti C, Donati MB, de Gaetano G, Iacoviello L. Ultra-processed food consumption is associated with increased risk of all-cause and cardiovascular mortality in the Moli-sani Study. Am J Clin Nutr. 2021 Feb 2;113(2):446-455. doi: 10.1093/ajcn/nqaa299. PMID: 33333551.
  3. Trichopoulou A, Costacou T, Bamia C, Trichopoulous D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl. J Med. 2003;348:2599-608. Accessed 24th March 2021. URL: https://www.nejm.org/doi/full/10.1056/nejmoa025039

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