Ultra-processed foods and mortality: analysis from the Prospective Urban and Rural Epidemiology study

Prospective Urban Rural Epidemiology (PURE) study investigators

Research output: Contribution to journalArticlepeer-review

17 Citations (Scopus)


Background: Higher intake of ultra-processed foods (UPFs) has been associated with increased risk of CVD and mortality in observational studies from Western countries but data from non-Western countries are limited. Objectives: We aimed to assess the association between consumption of UPFs and risk of mortality and major CVD in a cohort from multiple world regions. Design: This analysis includes 138,076 participants without a history of CVD between the ages of 35 and 70 y living on 5 continents, with a median follow-up of 10.2 y. We used country-specific validated food-frequency questionnaires to determine individuals’ food intake. We classified foods and beverages based on the NOVA classification into UPFs. The primary outcome was total mortality (CV and non-CV mortality) and secondary outcomes were incident major cardiovascular events. We calculated hazard ratios using multivariable Cox frailty models and evaluated the association of UPFs with total mortality, CV mortality, non-CV mortality, and major CVD events. Results: In this study, 9227 deaths and 7934 major cardiovascular events were recorded during the follow-up period. We found a diet high in UPFs (≥2 servings/d compared with 0 intake) was associated with higher risk of mortality (HR: 1.28; 95% CI: 1.15, 1.42; P-trend < 0.001), CV mortality (HR: 1.17; 95% CI: 0.98, 1.41; P-trend = 0.04), and non-CV mortality (HR: 1.32; 95% CI 1.17, 1.50; P-trend < 0.001). We did not find a significant association between UPF intake and risk of major CVD. Conclusions: A diet with a high intake of UPFs was associated with a higher risk of mortality in a diverse multinational study. Globally, limiting the consumption of UPFs should be encouraged.

Original languageEnglish
Pages (from-to)55-63
Number of pages9
JournalAmerican Journal of Clinical Nutrition
Issue number1
Publication statusPublished - Jan 2023


  • NOVA classification
  • major cardiovascular disease
  • minimally processed foods
  • mortality
  • ultra-processed foods


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