Ultraprocessed foods (UPF) are widespread in Western diets. Their consumption has been associated in recent prospective studies with increased risks of all-cause mortality and chronic diseases such ...as cancer, cardiovascular diseases, hypertension, and dyslipidemia; however, data regarding diabetes are lacking.
To assess the associations between consumption of UPF and risk of type 2 diabetes (T2D).
In this population-based prospective cohort study, 104 707 participants aged 18 years or older from the French NutriNet-Santé cohort (2009-2019) were included. Dietary intake data were collected using repeated 24-hour dietary records (5.7 per participant on average), designed to register participants' usual consumption for more than 3500 different food items. These were categorized according to their degree of processing by the NOVA classification system.
Associations between UPF consumption and risk of T2D were assessed using cause-specific multivariable Cox proportional hazard models adjusted for known risk factors (sociodemographic, anthropometric, lifestyle, medical history, and nutritional factors).
A total of 104 707 participants (21 800 20.8% men and 82 907 79.2% women) were included. Mean (SD) baseline age of participants was 42.7 (14.5) years. Absolute T2D rates in the lowest and highest UPF consumers were 113 and 166 per 100 000 person-years, respectively. Consumption of UPF was associated with a higher risk of T2D (multi-adjusted hazard ratio HR for an absolute increment of 10 in the percentage of UPF in the diet, 1.15; 95% CI, 1.06-1.25; median follow-up, 6.0 years; 582 252 person-years; 821 incident cases). These results remained statistically significant after adjustment for several markers of the nutritional quality of the diet, for other metabolic comorbidities (HR, 1.13; 95% CI, 1.03-1.23), and for weight change (HR, 1.13; 95% CI, 1.01-1.27). The absolute amount of UPF consumption (grams per day) was consistently associated with T2D risk, even when adjusting for unprocessed or minimally processed food intake (HR for a 100 g/d increase, 1.05; 95% CI, 1.02-1.08).
In this large observational prospective study, a higher proportion of UPF in the diet was associated with a higher risk of T2D. Even though these results need to be confirmed in other populations and settings, they provide evidence to support efforts by public health authorities to recommend limiting UPF consumption.
ClinicalTrials.gov Identifier: NCT03335644.
AbstractObjectiveTo assess the prospective associations between consumption of ultra-processed foods and risk of cardiovascular diseases.DesignPopulation based cohort study.SettingNutriNet-Santé ...cohort, France 2009-18.Participants105 159 participants aged at least 18 years. Dietary intakes were collected using repeated 24 hour dietary records (5.7 for each participant on average), designed to register participants’ usual consumption of 3300 food items. These foods were categorised using the NOVA classification according to degree of processing.Main outcome measuresAssociations between intake of ultra-processed food and overall risk of cardiovascular, coronary heart, and cerebrovascular diseases assessed by multivariable Cox proportional hazard models adjusted for known risk factors.ResultsDuring a median follow-up of 5.2 years, intake of ultra-processed food was associated with a higher risk of overall cardiovascular disease (1409 cases; hazard ratio for an absolute increment of 10 in the percentage of ultra-processed foods in the diet 1.12 (95% confidence interval 1.05 to 1.20); P<0.001, 518 208 person years, incidence rates in high consumers of ultra-processed foods (fourth quarter) 277 per 100 000 person years, and in low consumers (first quarter) 242 per 100 000 person years), coronary heart disease risk (665 cases; hazard ratio 1.13 (1.02 to 1.24); P=0.02, 520 319 person years, incidence rates 124 and 109 per 100 000 person years, in the high and low consumers, respectively), and cerebrovascular disease risk (829 cases; hazard ratio 1.11 (1.01 to 1.21); P=0.02, 520 023 person years, incidence rates 163 and 144 per 100 000 person years, in high and low consumers, respectively). These results remained statistically significant after adjustment for several markers of the nutritional quality of the diet (saturated fatty acids, sodium and sugar intakes, dietary fibre, or a healthy dietary pattern derived by principal component analysis) and after a large range of sensitivity analyses.ConclusionsIn this large observational prospective study, higher consumption of ultra-processed foods was associated with higher risks of cardiovascular, coronary heart, and cerebrovascular diseases. These results need to be confirmed in other populations and settings, and causality remains to be established. Various factors in processing, such as nutritional composition of the final product, additives, contact materials, and neoformed contaminants might play a role in these associations, and further studies are needed to understand better the relative contributions. Meanwhile, public health authorities in several countries have recently started to promote unprocessed or minimally processed foods and to recommend limiting the consumption of ultra-processed foods.Study registrationClinicalTrials.gov NCT03335644.
To study the associations between artificial sweeteners from all dietary sources (beverages, but also table top sweeteners, dairy products, etc), overall and by molecule (aspartame, acesulfame ...potassium, and sucralose), and risk of cardiovascular diseases (overall, coronary heart disease, and cerebrovascular disease).
Population based prospective cohort study (2009-21).
France, primary prevention research.
103 388 participants of the web based NutriNet-Santé cohort (mean age 42.2±14.4, 79.8% female, 904 206 person years). Dietary intakes and consumption of artificial sweeteners were assessed by repeated 24 h dietary records, including brand names of industrial products.
Associations between sweeteners (coded as a continuous variable, log10 transformed) and cardiovascular disease risk, assessed by multivariable adjusted Cox hazard models.
Total artificial sweetener intake was associated with increased risk of cardiovascular diseases (1502 events, hazard ratio 1.09, 95% confidence interval 1.01 to 1.18, P=0.03); absolute incidence rate in higher consumers (above the sex specific median) and non-consumers was 346 and 314 per 100 000 person years, respectively. Artificial sweeteners were more particularly associated with cerebrovascular disease risk (777 events, 1.18, 1.06 to 1.31, P=0.002; incidence rates 195 and 150 per 100 000 person years in higher and non-consumers, respectively). Aspartame intake was associated with increased risk of cerebrovascular events (1.17, 1.03 to 1.33, P=0.02; incidence rates 186 and 151 per 100 000 person years in higher and non-consumers, respectively), and acesulfame potassium and sucralose were associated with increased coronary heart disease risk (730 events; acesulfame potassium: 1.40, 1.06 to 1.84, P=0.02; incidence rates 167 and 164; sucralose: 1.31, 1.00 to 1.71, P=0.05; incidence rates 271 and 161).
The findings from this large scale prospective cohort study suggest a potential direct association between higher artificial sweetener consumption (especially aspartame, acesulfame potassium, and sucralose) and increased cardiovascular disease risk. Artificial sweeteners are present in thousands of food and beverage brands worldwide, however they remain a controversial topic and are currently being re-evaluated by the European Food Safety Authority, the World Health Organization, and other health agencies.
ClinicalTrials.gov NCT03335644.
Epidemiological and experimental evidence support a protective effect of dietary polyphenols on chronic diseases, but high quality longitudinal data are needed, including details on categories of ...polyphenols. Our objective was to investigate the prospective association between total and individual classes and subclasses of dietary polyphenols and the risk of major cardiovascular disease in the NutriNet-Santé cohort.
A total of 84,158 participants, who completed at least three 24 h dietary records, were included between May 2009 and June 2017. Individual polyphenols intakes were obtained by matching food consumption data from the 24 h dietary records with the Phenol-Explorer polyphenol composition database. Multivariable Cox proportional hazards models were used to characterize the associations between dietary polyphenols and the incidence of cardiovascular diseases, comparing tertile T3 vs. T1 of classes and subclasses of polyphenols.
Over a median of 4.9 years of follow-up, 602 major cardiovascular events were diagnosed. Intakes of anthocyanins, catechins, and flavonols were strongly inversely associated with cardiovascular disease risk (anthocyanins: Hazard Ratio (HR)
= 0.98 (0.96⁻0.99,
= 0.03, HR
= 0.66 (0.52⁻0.83),
= 0.0003; catechins: HR
= 0.98 (0.96⁻0.99),
= 0.02, HR
= 0.74 (0.60⁻0.91),
= 0.004; flavonols: HR
= 0.94 (0.90⁻0.99),
= 0.02, HR
= 0.75 (0.61⁻0.94),
= 0.006). Intakes of dihydrochalcones, proanthocyaninidins, dihydroflavonols, hydroxybenzoic acids, and stilbenes were also associated with a decrease (13%, 19%, 24%, 24%, and 27%, respectively) in cardiovascular disease risk, when comparing tertile T3 to T1.
Higher intakes of polyphenols, especially of anthocyanins, catechins, and flavonols, were associated with a statistically significant decreased cardiovascular disease risk.
Daily eating/fasting cycles synchronise circadian peripheral clocks, involved in the regulation of the cardiovascular system. However, the associations of daily meal and fasting timing with ...cardiovascular disease (CVD) incidence remain unclear. We used data from 103,389 adults in the NutriNet-Santé study. Meal timing and number of eating occasions were estimated from repeated 24 h dietary records. We built multivariable Cox proportional-hazards models to examine their association with the risk of CVD, coronary heart disease and cerebrovascular disease. In this study, having a later first meal (later than 9AM compared to earlier than 8AM) and last meal of the day (later than 9PM compared to earlier than 8PM) was associated with a higher risk of cardiovascular outcomes, especially among women. Our results suggest a potential benefit of adopting earlier eating timing patterns, and coupling a longer nighttime fasting period with an early last meal, rather than breakfast skipping, in CVD prevention.
Organic food (OF) consumption has substantially increased in high income countries, mostly driven by environmental concerns and health beliefs. Lower exposure to synthetic pesticides has been ...systematically documented among consumers of organic products compared to non-consumers. While experimental studies suggest that pesticides currently used in food production may be associated with type 2 diabetes (T2D), no well-conducted prospective studies have investigated the potential association between consumption of organic products and the risk of T2D, controlling for potential confounding factors. The objective of this prospective study was to estimate the association between OF consumption and the risk of T2D.
A total of 33,256 participants (76% women, mean (SD) age: 53 years (14)) of the French NutriNet-Santé prospective cohort study who completed the organic food frequency questionnaire were included (2014-2019). The proportion of OF in the diet (as weight without drinking water) was computed. The associations between the proportion of OF in the diet (as 5% increment and as quintiles) and the risk of T2D were estimated using multivariable Hazard Ratio (HR) and 95% confidence interval (95% CI) derived from proportional hazards models adjusted for confounders (sociodemographic, anthropometric, lifestyle, medical and nutritional factors).
During follow-up (mean = 4.05 y, SD = 1.03 y, 134,990 person-years), 293 incident cases of T2D were identified. After adjustment for confounders including lifestyle (physical activity, smoking status, alcohol consumption) and nutritional quality of the diet assessed by the adherence to the French food-based dietary guidelines, OF consumption was associated with a lower risk of T2D. Participants with the highest quintile of OF consumption, compared with those with the lowest quintile, had 35% lower risk of T2D (95% CI = 0.43-0.97). Each increment of 5% in the proportion of OF in the diet was associated with 3% lower risk of T2D (HR 0.97, 95% CI = 0.95-0.99).
In this large prospective cohort study, OF consumption was inversely associated with the risk of T2D. Further experimental and prospective studies should be conducted to confirm these observations.
The study was registered at ClinicalTrials.gov ( NCT03335644 ).
Obesity has been linked to poor access to medical care. Although scientific evidence suggest that kidney transplantation improves survival and quality of life in obese patients with end-stage renal ...disease (ESRD), few data exist on the impact of obesity on access to kidney transplantation in this population.
We aimed to characterize the relationships between body mass index (BMI) at the start of dialysis, changes in BMI after the start of dialysis, and either access to kidney transplantation or overall mortality in dialysis or transplantation among ESRD patients.
Between 2002 and 2011, 19524 dialysis patients with ESRD were included in the study via the French nationwide Renal Epidemiology and Information Network. Data on sociodemographic factors, comorbidities and laboratory test results were recorded upon entry into the registry. BMI were obtained at the start of dialysis and then yearly. Cubic spline regression analyses provided a graphic evaluation of the relationships between BMI at the start of dialysis and outcomes. Joint models were used to evaluate the association between the change over time in BMI and outcomes.
During a median follow-up of 20.3 months, 6634 patients underwent kidney transplantation. A BMI >31 kg/m2 at the start of the dialysis was associated with a lower likelihood of receiving a kidney transplant, and the likelihood decreased even further with higher BMI values. For patients with BMI ≥30kg/m2 at the start of the dialysis, a 1 kg/m2 decrease in BMI during follow-up was associated with a 9% to 11% increase in the likelihood of receiving a transplant. There was an L-shaped relationship between BMI at the start of dialysis and overall mortality. We showed that obese patients with ESRD face barriers to the receipt of a kidney transplant without valid reasons.
Greater attention to this issue would improve the fairness of the organ allocation process and might improve outcomes for obese patients with ESRD.
Abstract Background In France, the implementation of a front-of-pack (FOP) nutrition label–the 5-Colour Nutrition Label (5-CNL) is currently under consideration as a strategic tool to allow consumers ...making healthier food choices. This FOP label is based on the British Food Standards Agency Nutrient Profiling System (FSA-NPS), reflecting the overall nutritional quality of foods. At the individual level, an energy-weighted mean of all FSA-NPS scores of foods usually consumed has been elaborated (FSA-NPS DI). Our objective was to investigate the prospective association between the FSA-NPS DI and cardiovascular disease (CVD) risk. Methods 75,801 participants to the NutriNet-Santé cohort, who completed at least three 24 h dietary records during the first 2 y of the follow-up, were followed between 2009 and 2016. Multivariable Cox proportional hazards models were used to characterize the associations between FSA-NPS DI and the incidence of CVDs. Results 509 major cardiovascular events were diagnosed (262 coronary heart diseases and 247 strokes). A higher FSA-NPS DI, characterizing lower dietary quality, was associated with increased CVD risk (HRfor a 1-point increment = 1.08 (1.03–1.13); HRQ4vs.Q1 = 1.40 (1.06–1.84), Ptrend Q4-Q1 = 0.01). This association tended to be stronger in overweight subjects (HRfor a 1-point increment = 1.12 (1.04–1.19); Pinteraction = 0.003). Conclusions These results suggest that lower dietary quality, as reflected by a higher FSA-NPS DI, may be associated with a significant increase in cardiovascular risk, especially in at-risk individuals (overweight population). They support the public health relevance of developing a front-of-pack nutrition label based on this score.
In the ongoing debate about front-of-package (FOP) nutrition labels, little data exist regarding nutritionally at-risk populations, although they are critical targets of prevention programs. This ...study aimed to compare the impact of FOP labels on the ability to rank products according to their nutritional quality among French adults potentially at risk of poor dietary quality (N = 14,230). Four labels were evaluated: Guideline Daily Amounts (GDA), Multiple Traffic Lights (MTL), 5-Color Nutrition Label (5-CNL), Green Tick (Tick), along with a reference without label. Mixed models were used to assess how individual characteristics and FOP labels were associated with the ability to rank products. Older participants and those with a lower educational level, income, nutritional knowledge, and likelihood of reading nutrition facts were less skilled at ranking food products according to nutritional quality. Compared with individual characteristics, nutrition labels had an increased impact on food product ranking ability. Overall, 5-CNL corresponded to the highest rate of correct responses, followed by MTL, GDA, and Tick (p < 0.0001). The strongest impact of 5-CNL was observed among individuals with no nutritional knowledge (odds ratio (OR): 20.24; 95% confidence interval (CI): 13.19-31.06). Therefore, 5-CNL appeared to be effective at informing consumers, including those who are nutritionally at-risk, about the nutritional quality of food products.
Studies focusing on dietary pesticides in population-based samples are scarce and little is known about potential mixture effects. We aimed to assess associations between dietary pesticide exposure ...profiles and Type 2 Diabetes (T2D) among NutriNet-Santé cohort participants.
Participants completed a Food Frequency Questionnaire at baseline, assessing conventional and organic food consumption. Exposures to 25 active substances used in European Union pesticides were estimated using the Chemisches und Veterinäruntersuchungsamt Stuttgart residue database accounting for farming practices. T2D were identified through several sources. Exposure profiles were established using Non-Negative Matrix Factorization (NMF), adapted for sparse data. Cox models adjusted for known confounders were used to estimate hazard ratios (HR) and 95% confidence interval (95% CI), for the associations between four NMF components, divided into quintiles (Q) and T2D risk.
The sample comprised 33,013 participants aged 53 years old on average, including 76% of women. During follow-up (median: 5.95 years), 340 incident T2D cases were diagnosed. Positive associations were detected between NMF component 1 (reflecting highest exposure to several synthetic pesticides) and T2D risk on the whole sample: HR
= 1.47, 95% CI (1.00, 2.18). NMF Component 3 (reflecting low exposure to several synthetic pesticides) was associated with a decrease in T2D risk, among those with high dietary quality only (high adherence to French dietary guidelines, including high plant foods consumption): HR
= 0.31, 95% CI (0.10, 0.94).
These findings suggest a role of dietary pesticide exposure in T2D risk, with different effects depending on which types of pesticide mixture participants are exposed to. These associations need to be confirmed in other types of studies and settings, and could have important implications for developing prevention strategies (regulation, dietary guidelines).
This study is registered in ClinicalTrials.gov ( NCT03335644 ).
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