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. 2023 Jul 1;46(7):1335-1344.
doi: 10.2337/dc22-1993.

Ultra-Processed Food Consumption and Risk of Type 2 Diabetes: Three Large Prospective U.S. Cohort Studies

Zhangling Chen  1   2 , Neha Khandpur  1   3   4 , Clémence Desjardins  5   6 , Lu Wang  7 , Carlos A Monteiro  3   4 , Sinara L Rossato  1   8 , Teresa T Fung  1   9 , JoAnn E Manson  10   11 , Walter C Willett  1   10   11   12 , Eric B Rimm  1   10   12 , Frank B Hu  1   10   11   12 , Qi Sun  1   10   12   13 , Jean-Philippe Drouin-Chartier  5   6
Affiliations

Ultra-Processed Food Consumption and Risk of Type 2 Diabetes: Three Large Prospective U.S. Cohort Studies

Zhangling Chen et al. Diabetes Care. .

Abstract

Objective: We examined the relationship between ultra-processed food (UPF) intake and type 2 diabetes (T2D) risk among 3 large U.S. cohorts, conducted a meta-analysis of prospective cohort studies, and assessed meta-evidence quality.

Research design and methods: We included 71,871 women from the Nurses' Health Study, 87,918 women from the Nurses' Health Study II, and 38,847 men from the Health Professional Follow-Up Study. Diet was assessed using food frequency questionnaires and UPF was categorized per the NOVA classification. Associations of total and subgroups of UPF with T2D were assessed using Cox proportional hazards models. We subsequently conducted a meta-analysis of prospective cohort studies on total UPF and T2D risk, and assessed meta-evidence quality using the NutriGrade scoring system.

Results: Among the U.S. cohorts (5,187,678 person-years; n = 19,503 T2D cases), the hazard ratio for T2D comparing extreme quintiles of total UPF intake (percentage of grams per day) was 1.46 (95% CI 1.39-1.54). Among subgroups, refined breads; sauces, spreads, and condiments; artificially and sugar-sweetened beverages; animal-based products; and ready-to-eat mixed dishes were associated with higher T2D risk. Cereals; dark and whole-grain breads; packaged sweet and savory snacks; fruit-based products; and yogurt and dairy-based desserts were associated with lower T2D risk. In the meta-analysis (n = 415,554 participants; n = 21,932 T2D cases), each 10% increment in total UPF was associated with a 12% (95% CI 10%-13%) higher risk. Per NutriGrade, high-quality evidence supports this relationship.

Conclusions: High-quality meta-evidence shows that total UPF consumption is associated with higher T2D risk. However, some UPF subgroups were associated with lower risk in the U.S. cohorts.

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Conflict of interest statement

Duality of Interest. J.-P.D.-C. received speaker and consulting honoraria from the Dairy Farmers of Canada in 2016, 2018, and 2021, outside of the submitted work. No other potential conflicts of interest relevant to this article were reported.

Figures

None
Graphical abstract
Figure 1
Figure 1
Associations of subgroups of UPFs and risk of T2D. Results were obtained from the pooled multivariable model 2 (final multivariable model) stratified by calendar time (in 2-year intervals) and cohort (sex), and adjusted for age, race/ethnicity (White/other), family history of diabetes (yes/no), history of hypercholesterolemia at baseline (yes/no), history of hypertension at baseline (yes/no), baseline BMI (kg/m2: <21.0, 21.0–22.9, 23.0–24.9, 25.0–26.9, 27.0–29.9, 30.0–34.9, ≥35.0), smoking status (never, past, current), physical activity (MET-hours/week: <3.0, 3.0–8.9, 9.0–17.9, 18.0–26.9, ≥27.0), oral contraceptive use (in NHSII only: never, former, current), postmenopausal hormone use (in NHS and NHSII only: premenopausal, never, former, current), physical examination in the past 2 years (yes/no), neighborhood income (quintiles), total energy (kcal/day; quintiles), and total alcohol consumption (g/day; quintiles). All covariables (except race/ethnicity, family history of diabetes, baseline hypercholesterolemia, hypertension, and BMI) were updated every 2 years. The UPF groups (or subgroups) were included simultaneously in the models as distinct covariables. The CHISQ.DIST.RT function was used to calculate P value for likelihood ratio test. All P values were <0.0001 for likelihood ratio tests and indicated that heterogeneity in the associations with risk of T2D among subgroups of UPFs was significant.
Figure 2
Figure 2
Meta-analyses of the association of total UPF consumption (in percentage of grams of UPF per day) with risk of T2D. A: Meta-analysis of high versus low total UPF intakes, using random effects meta-analyses. B: Meta-analysis for 10% increment in total UPF intake, using random-effects meta-analyses. C: Dose-response meta-analysis for UPFs and risk of T2D using restricted cubic splines (Pnonlinearity = 0.90). A and B: Weights of each of the studies are represented by the size of the square. Black diamonds represent the individual study effects, and black lines represent the 95% CIs. The overall effect estimates and 95% CIs are represented by the hollow diamond. DL, DerSimonian and Laird method.
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