Abstract
Background
Consumption of ultra‐processed food, which is manufactured food that is high in additives and sparse in intact foods, is adversely associated with cardiovascular health, primarily in non‐US study populations. We aimed to estimate the association between ultra‐processed food consumption and incident hypertension in middle‐aged adults in the United States.
Methods and Results
We included 8923 ARIC (Atherosclerosis Risk in Communities) study participants who were hypertension free at baseline and had complete dietary, covariate, and hypertension data from visit 1 (1987–1989). Over a median (25th, 75th percentile) follow‐up of 13 (6–21) years, 79% of participants developed hypertension. Participants in the highest quartile of ultra‐processed food consumption had 15% higher risk of incident hypertension than those in the lowest quartile (hazard ratio [HR], 1.15 [95% CI, 1.08–1.23]). Participants in the highest quartile of consumption of sugar‐sweetened beverages, red and processed meat, and margarine had 16% (HR, 1.16 [95% CI, 1.08–1.24]; p‐trend <0.001), 10% (HR, 1.10 [95% CI, 1.03–1.19]; P trend = 0.005), and 6% (HR, 1.06 [95% CI, 0.99, 1.45]; P trend = 0.045) higher risk of incident hypertension, respectively, when compared with the lowest quartiles of consumption. Each additional serving of minimally or unprocessed food was associated with a 2% lower risk of incident hypertension (HR, 0.98 [95% CI, 0.98, 0.99], P<0.001).
Conclusions
High consumption of ultra‐processed foods, specifically of sugar‐sweetened beverages, red and processed meat, and margarine, was associated with a higher incidence of hypertension, whereas minimally or unprocessed food consumption was associated with lower hypertension risk.
Keywords: Atherosclerosis Risk in Communities study, diet and nutrition, hypertension, nova classification, ultra‐processed foods
Subject Categories: Diet and Nutrition
Nonstandard Abbreviations and Acronyms
- ARIC
Atherosclerosis Risk in Communities
- IU
international units
- UPF
ultra‐processed food
Research Perspective.
What Is New?
In middle‐aged Black and White women and men, higher intake of ultra‐processed food, specifically red and processed meat and sugar‐sweetened beverages, was associated with higher risk of new‐onset hypertension, whereas consumption of minimally processed or unprocessed food was associated with lower risk of hypertension.
What Question Should Be Addressed Next?
Future research is needed to better understand the mechanisms underlying the observed association between ultra‐processed food and hypertension risk and disentangle the multifaceted harmful effects of ultra‐processed food beyond nutritional characteristics, such as the influence of artificial additives and food matrix degradation.
Ultra‐processed food (UPF) is manufactured food that is sparse in whole foods and contains ingredients extracted from foods as well as artificial substances. 1 UPF is typically nutrient poor, low in fiber, and high in refined carbohydrates, added sugar, sodium, and preservatives. Over the past 2 decades, consumption of UPF in the United States has increased substantially. 2 , 3 , 4 In the United States, approximately half of total energy intake comes from UPF. 3 Furthermore, because of its easy accessibility and palatability, dietary intake of UPF is becoming more common worldwide. 4
A growing body of literature has shown that consumption of UPF is adversely associated with a wide range of cardiometabolic health consequences. 5 Studies conducted in Brazil, Spain, and Canada indicate that people in the highest versus lowest level of UPF intake have ≈30% higher risk of incident hypertension after accounting for confounding factors. 6 , 7 , 8 , 9 Smilijanec et al. found that higher UPF consumption was associated with higher systolic and diastolic blood pressure levels in 40 young adults from the United States. 10 Beyond this study, there is limited evidence from US. populations on the impact of UPF consumption on hypertension risk.
We aimed to examine the prospective association between UPF overall, as well as specific sources of UPF and minimally/unprocessed food, and risk of incident hypertension in a large, biracial sample of adults from geographically dispersed centers across the US in the ARIC (Atherosclerosis Risk in Communities) study.
Methods
Study Population and Design
Due to the sensitive nature of the data collected for this study, requests to access the data set from qualified researchers trained in human subject confidentiality protocols may be sent to the ARIC study Collaborative Studies Coordinating Center at csccmail@unc.edu or to the National Heart, Lung, and Blood Institute Biologic Specimen and Data Repository Information Coordinating Center at https://biolincc.nhlbi.nih.gov/home/. We followed the Strengthening the Reporting of Observational Studies in Epidemiology cohort reporting guidelines. 11
The ARIC study is a prospective cohort containing 15 792 middle‐aged adults aged 45 to 64 years recruited from 4 US communities (Minneapolis, Minnesota; Jackson, Mississippi; Forsyth County, North Carolina; Washington County, Maryland). For the current study, we used data from visit 1 (1987–1989) as the baseline visit and followed participants for the development of hypertension through visit 7 (2018–2019). A total of 7 visits occurred during the study period: visit 1 (1987–1989), visit 2 (1990–1992), visit 3 (1993–1995), visit 4 (1996–1998), visit 5 (2011–2013), visit 6 (2016–2017), and visit 7 (2018–2019). We excluded participants based on the following criteria: 364 who were missing either 10 or more items on the food frequency questionnaires or nutritional data; 13 participants who had implausible caloric intake (<500 or >3500 kcal/day for women and <600 or >4500 kcal/day for men); 310 who were missing data on covariates; 5235 participants who had prevalent hypertension at baseline; and 947 participants who were missing hypertension diagnoses at baseline, resulting in an analytical sample of 8923 (Figure 1).
Figure 1. Flow chart of study participant selection in the ARIC study.
*Number of participants excluded for each covariate: age (n=0), race (n=0), sex (n=0), body mass index (n=11), physical activity level (n=44), smoking status (n=12), education level (n=18), diabetes status (n=129), and hypertension status (n=68), estimated glomerular filtration rate (n=28). ARIC indicates Atherosclerosis Risk in Communities.
The study protocol was approved by the institutional review board at each study site, and informed consent was provided by all participants at each study visit.
Dietary Assessment
Dietary intake was assessed using a semiquantitative 66‐item food frequency questionnaire, which was modified from the Willett food frequency questionnaire. 12 , 13 Participants reported their usual intake of food items of a specified portion size during the preceding year. The food frequency questionnaire was administered at baseline (visit 1) and visit 3 (1993–1995) by trained interviewers. Baseline dietary data were used for participants who were classified as hypertensive or administratively censored between baseline and visit 3. Otherwise, we used the mean of dietary data from visits 1 and 3 for those who were followed for the development of incident hypertension after visit 3. We averaged the participant's dietary data to improve the precision of our estimation of dietary intake per food item. 14 Dietary intake of UPF was lower by 0.1 servings/day at visit 3 (5.8 servings/day) compared with visit 1 (5.9 servings/day), and intake of minimally processed and unprocessed food was higher by 0.3 servings/day at visit 3 (9.3 servings/day) compared with visit 1 (9.0 servings/day).
Nutrient intake was derived by multiplying the daily servings of each food item by its nutrient content, which was obtained from US Department of Agriculture sources.
Classification of Ultra‐Processed Food
All food items on the food frequency questionnaire were categorized into 1 of 4 groups representing processing level according to the Nova food classification system. 15 , 16 Category 1 is unprocessed or minimally processed foods, consisting of foods that are fresh or slightly modified by methods such as flash‐freezing, drying, or pasteurization, without adding culinary ingredients. Category 2 is processed culinary ingredients, which includes substances extracted from natural foods or by natural processes that were used in culinary preparations, such as salt, sugar, vegetable oils, and fats. Category 3 is processed foods, which includes products that have undergone preparation or preservation with the use of culinary ingredients to make them last longer or taste better. Category 4 is UPFs, which are defined as products made entirely or mostly from industrial formulations with artificial additives such as sweeteners and preservatives. We adjusted total daily consumption of each food processing category by total energy intake using the residual method and divided intake of UPF into quartiles for analysis. 17
Ascertainment of Incident Hypertension
Incident hypertension cases were ascertained both at study visits and through follow‐up calls. Cases were defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or use of antihypertensive medication from baseline (1987–1989) until administrative censoring at the end of participant's visit 7. Similar definitions of incident hypertension have been used previously in the ARIC study. 18 , 19 , 20 Blood pressure was measured 3 times at all study visits except study visit 4 where it was measured twice. Measurements were taken by trained technicians using a random zero sphygmomanometer after participants rested for 5 minutes in a seated position, and the average of the last 2 readings was recorded. Participants self‐reported physician diagnosis of hypertension, and all medications were also transcribed during the visit. Additionally, semiannual follow‐up telephone interviews have been conducted since study visit 4 to collect information about participants' health status, including self‐reported hypertension diagnosis and antihypertensive medication use. Active surveillance was used to ascertain vital status through linkage to the National Death Index, hospital discharge records, obituaries, and telephone calls with proxies. Vital status was used to censor participants in survival analysis of incident hypertension.
Measurement of Covariates
Socioeconomic and demographic covariates (age, sex, race, center, education level) were collected via questionnaire administered by trained staff. Smoking status was categorized into current, former, or never smoker. Physical activity level was calculated using information on frequency, duration, and intensity of leisure‐time physical activity collected with the Baecke questionnaire, and was scored on a scale of 1 (low) to 5 (high). 21 Body mass index was calculated using participants' weight and height measured at baseline and categorized as normal weight or underweight (body mass index <25 kg/m2), overweight (body mass index 25 to <30 kg/m2), and obese (body mass index ≥30 kg/m2). Creatinine was measured by the modified kinetic Jaffé method in serum specimens from study visit 1. Estimated glomerular filtration rate was calculated using the 2021 Chronic Kidney Disease Epidemiology Collaboration race‐free creatinine equation. 22 Diabetes status was defined as self‐reported physician diagnosis of diabetes, self‐reported diabetes medication usage within 2 weeks before the visit, nonfasting blood glucose ≥200 mg/dL, or fasting blood glucose ≥126 mg/dL.
Statistical Analysis
We reported descriptive statistics for participant and nutritional characteristics and tested for differences across quartiles of UPF using Pearson's chi‐square test for categorical variables and ANOVA for continuous variables.
We used progressively adjusted multivariable regression models to examine the association between UPF consumption and incident hypertension. Model 1 adjusted for demographic characteristics (age, sex, race, study center) and total energy intake. Model 2 was considered the main model and adjusted for the covariates listed in model 1 as well as socioeconomic status (education level) and health behaviors (smoking status, physical activity level). Model 3 adjusted for the covariates from model 2 as well as the potential mediators (body mass index, diabetes status, and estimated glomerular filtration rate). We tested for trend across quartiles using the median values of each UPF consumption quartile. Survival analysis (Cox proportional hazards regression models) was used to evaluate the prospective association between UPF consumption and risk of hypertension. Hazard ratios (HRs) for incident hypertension were calculated according to quartiles of UPF consumption using quartile 1 as the reference group. We also analyzed UPF as a continuous variable and expressed results per one additional serving of UPF per day.
We tested for interaction by sex, race, diabetes, and body mass index categories using likelihood ratio tests and stratified the analysis by these factors, as they are considered important risk factors for hypertension that may modify the association between UPF and risk of incident hypertension.
We also performed a secondary analysis of categories of food classified as ultra‐processed, and, separately, an analysis of unprocessed and minimally processed food associated with incident hypertension. We used restricted cubic splines to explore nonlinear associations between UPF consumption and hypertension and between unprocessed and minimally processed food consumption and hypertension.
Results
Participants had a mean age of 53 years, 54% were female, 18% were Black, mean body mass index was 27 kg/m2, 41% reported having never smoked, and 49% had more than a high school education. The mean UPF consumption was 8.3 servings/day in the highest quartile and 3.7 servings/day in the lowest quartile (Table 1). Participants in the highest quartile of UPF consumption were more likely to be White, obese, and less physically active than participants in the lowest quartile of UPF consumption. Participants in the highest quartile of UPF consumption ate more total fat and less protein than those in the lowest quartile (Table 2). Participants in the highest quartile of UPF consumption also had lower intake of micronutrients including fiber, potassium, and vitamins.
Table 1.
Baseline Characteristic by Quartile of Ultra‐Processed Food Consumption in the ARIC Study*
| Characteristic | Quartile 1 (n=2231) | Quartile 2 (n=2231) | Quartile 3 (n=2231) | Quartile 4 (n=2230) | P value† |
|---|---|---|---|---|---|
| Energy adjusted ultra‐processed food intake, servings/day | 3.7±1.0 | 5.3±0.3 | 6.3±0.3 | 8.3±1.7 | <0.001 |
| Energy adjusted minimally or unprocessed food intake, servings/day | 10.4±3.0 | 9.2±2.5 | 8.6±2.6 | 8.0±3.1 | <0.001 |
| Adjusted ultra‐processed food intake, range per quartile | 0.1–4.7 | 4.8–5.7 | 5.7–6.8 | 6.9–14.2 | |
| Age, y | 54±5.7 | 53±5.7 | 53±5.6 | 53±5.6 | <0.001 |
| Female sex | 1214 (54) | 1282 (58) | 1210 (54) | 1126 (51) | <0.001 |
| Black race | 491 (22) | 497 (22) | 370 (17) | 216 (10) | <0.001 |
| Study center | |||||
| Minneapolis, Minnesota | 549 (25) | 535 (24) | 671 (30) | 893 (40) | <0.001 |
| Jackson, Mississippi | 407 (18) | 438 (20) | 339 (15) | 178 (8) | |
| Washington County, Maryland | 549 (25) | 573 (26) | 597 (27) | 644 (29) | |
| Forsyth County, North Carolina | 726 (33) | 685 (31) | 624 (28) | 515 (23) | |
| Education | |||||
| <High school degree | 413 (19) | 420 (19) | 392 (18) | 382 (17) | <0.001 |
| High school degree | 637 (29) | 756 (34) | 781 (35) | 769 (35) | |
| >High school degree | 1181 (53) | 1055 (47) | 1058 (47) | 1079 (48) | |
| Smoking status | |||||
| Former | 626 (28) | 585 (26) | 573 (26) | 579 (26) | 0.08 |
| Current | 692 (31) | 707 (32) | 712 (32) | 773 (35) | |
| Never | 913 (41) | 939 (42) | 946 (42) | 878 (39) | |
| Physical activity score‡ | 2.5±0.8 | 2.5±0.8 | 2.5±0.8 | 2.5±0.8 | 0.04 |
| Diabetes | 108 (5) | 103 (5) | 131 (6) | 127 (6) | 0.16 |
| Estimated glomerular filtration rate (mL/min/1.73 m2) | 104±11 | 104±11 | 104±11 | 104±11 | 0.90 |
| Body mass index category, kg/m2 | |||||
| <25 | 929 (42) | 937 (42) | 904 (41) | 812 (36) | <0.001 |
| ≥25–<30 | 898 (40) | 871 (39) | 901 (40) | 921 (41) | |
| ≥30 | 404 (18) | 423 (19) | 426 (19) | 497 (22) | |
ARIC indicates Atherosclerosis Risk in Communities.
Baseline characteristics are expressed as n (%) for categorical variables and mean±SD for continuous variables.
P values are calculated from Pearson's chi‐square test for categorical variables and analysis of variance for continuous variables.
Physical activity score is for sport‐related exercise during leisure time. Scores range from 1 (poor) to 5 (high).
Table 2.
Nutritional Characteristic by Quartiles of Ultra‐Processed Food Consumption in the ARIC Study*
| Nutritional characteristic | Quartile 1 (n=2231) | Quartile 2 (n=2231) | Quartile 3 (n=2231) | Quartile 4 (n=2230) | P value† |
|---|---|---|---|---|---|
| Total energy intake (kcal) | 1741.1±610.1 | 1520.9±559.7 | 1526.0±558.4 | 1724.1±643.7 | <0.001 |
| Macronutrients | |||||
| Protein (% total energy) | 19.4±3.9 | 18.7±3.5 | 17.6±3.4 | 16.5±3.6 | <0.001 |
| Carbohydrate (% total energy) | 49.1±9.0 | 48.9±8.0 | 49.3±8.3 | 49.1±8.8 | 0.63 |
| Total fat (% total energy) | 31.1±6.7 | 32.4±5.8 | 33.1±5.9 | 34.1±6.2 | <0.001 |
| Saturated fat (% total energy) | 11.4±3.0 | 11.8±2.6 | 12.0±2.6 | 12.2±2.6 | <0.001 |
| Monounsaturated fat (% total energy) | 11.9±3.0 | 12.6±2.6 | 12.9±2.6 | 13.3±2.7 | <0.001 |
| Polyunsaturated fat (% total energy) | 4.6±1.2 | 4.9±1.1 | 5.1±1.2 | 5.4±1.4 | <0.001 |
| Sugar intake (g/1000 calories) | 65.0±21.7 | 66.7±20.2 | 68.9±23.0 | 70.2±26.8 | <0.001 |
| Micronutrients | |||||
| Cholesterol (mg/1000 calories) | 159.5±57.4 | 159.2±51.2 | 151.6±49.7 | 141.5±48.2 | <0.001 |
| Folate (μg/1000 calories) | 153.8±49.0 | 152.9±50.2 | 149.4±52.2 | 141.5±55.3 | <0.001 |
| Niacin (mg/1000 calories) | 12.5±2.8 | 12.4±2.8 | 11.8±2.7 | 11.2±2.8 | <0.001 |
| Fiber (g/1000 calories) | 12.2±4.4 | 11.3±3.7 | 10.5±3.3 | 9.7±3.0 | <0.001 |
| Vitamin A (IU/1000 calories) | 6928.8±4658.5 | 6392.7±3944.4 | 5671.9±3578.6 | 4866.2±3060.8 | <0.001 |
| Vitamin B6 (mg/1000 calories) | 1.2±0.3 | 1.2±0.3 | 1.1±0.3 | 1.0±0.3 | <0.001 |
| Vitamin B12 (μg/1000 calories) | 4.8±2.2 | 4.8±2.3 | 4.5±2.2 | 4.0±2.0 | <0.001 |
| Vitamin C (mg/1000 calories) | 74.4±37.6 | 76.7±36.7 | 77.6±40.3 | 74.0±43.4 | 0.005 |
| Vitamin E (mg/1000 calories) | 3.2±1.4 | 3.2±1.5 | 3.1±1.6 | 2.9±1.3 | <0.001 |
| Sodium (mg/1000 calories) | 940.1±193.2 | 930.8±174.0 | 919.8±178.3 | 917.5±180.9 | <0.001 |
| Calcium (mg/1000 calories) | 454.3±185.5 | 424.8±171.8 | 399.1±145.8 | 385.6±147.6 | <0.001 |
| Iron (mg/1000 calories) | 7.2±2.0 | 7.2±2.2 | 7.2±2.3 | 6.9±2.3 | <0.001 |
| Phosphorus (mg/1000 calories) | 723.2±146.6 | 689.5±146.2 | 658.6±140.4 | 647.6±155.6 | <0.001 |
| Magnesium (mg/1000 calories) | 174.9±37.2 | 165.9±38.1 | 157.7±35.8 | 150.0±35.4 | <0.001 |
| Zinc (mg/1000 calories) | 6.8±1.5 | 6.7±1.5 | 6.7±1.5 | 6.6±1.7 | 0.003 |
| Potassium (mg/1000 calories) | 1795.8±377.6 | 1736.7±387.9 | 1658.9±363.7 | 1556.1±360.4 | <0.001 |
| Food consumption | |||||
| Fruits (servings/day) | 1.9±1.7 | 1.4±1.1 | 1.3±1.1 | 1.2±1.0 | <0.001 |
| Vegetables (servings/day) | 2.2±1.5 | 1.8±1.1 | 1.6±1.0 | 1.5±1.0 | <0.001 |
| Red meat (servings/day) | 1.3±1.0 | 1.2±0.9 | 1.3±0.8 | 1.4±1.0 | <0.001 |
| All meat (servings/day) | 1.9±1.0 | 1.7±0.9 | 1.7±0.8 | 1.7±0.9 | <0.001 |
| Coffee (servings/day) | 2.1±2.3 | 2.0±2.1 | 2.0±2.1 | 2.0±2.2 | 0.013 |
| Sugar‐sweetened beverages (servings/day) | 0.6±0.7 | 0.7±0.8 | 1.0±1.0 | 1.8±1.8 | <0.001 |
| Dairy (servings/day) | 2.4±1.8 | 1.9±1.5 | 1.8±1.3 | 2.0±1.5 | <0.001 |
| Alcohol (g/day) | 7.1±14.7 | 4.9±10.3 | 5.0±9.9 | 6.1±12.4 | <0.001 |
ARIC indicates Atherosclerosis Risk in Communities.
Nutritional characteristics are expressed as mean±SD and P values are calculated from analysis of variance.
P values are calculated from analysis of variance for continuous variables.
Over a median follow‐up of 13 years (25th–75th percentile: 6–21 years), there were 7018 cases of incident hypertension (79% of the total population). The incidence rate of the highest quartile is 57 cases per 1000 person‐years comparing to 54 cases per 1000 person‐years in the lowest quartile. After adjusting for age, sex, race, study center, and total energy intake (model 1), those in the highest quartile of UPF consumption had an 18% higher risk of incident hypertension than those in the lowest quartile of UPF consumption (HR, 1.18 [95% CI, 1.10–1.26]; P trend<0.001). In the main model (model 2), after additionally adjusting for smoking, physical activity, and education, participants in the highest quartile of UPF consumption had a 15% higher risk of incident hypertension than participants in the lowest quartile (HR, 1.15 [95% CI, 1.08–1.23]; P trend<0.001). After accounting for mediators in model 3 (body mass index, diabetes status, estimated glomerular filtration rate), the association was attenuated, those in the highest quartile of UPFs had a 12% higher risk of incident hypertension compared with those in the lowest quartile (HR, 1.12 [95% CI, 1.04–1.20]; P trend = 0.001; Table 3). When examining the consumption of UPFs in servings per day, a linear relationship was observed between higher consumption of UPFs and an increased risk of incident hypertension at >4 servings per day (25th percentile; Figure 2). There was a 2% higher risk of hypertension for each additional serving of UPF intake per day (HR, 1.02 [95% CI, 1.01–1.03]; P=0.001).
Table 3.
Risk of Incident Hypertension by Quartile of Ultra‐Processed Food Consumption in the Atherosclerosis Risk in Communities Study
| Quartile 1 (n=2231) | Quartile 2 (n=2231) | Quartile 3 (n=2231) | Quartile 4 (n=2230) | P trend | |
|---|---|---|---|---|---|
| Energy adjusted ultra‐processed food intake, servings/day | 3.7±1.0 | 5.3±0.3 | 6.3±0.3 | 8.3±1.7 | <0.001 |
| Incident hypertension cases, n (%) | 1723 (77) | 1747 (78) | 1772 (79) | 1776 (80) | |
| Incidence rate per 1000 person‐years, 95% CI | 54 (51.6–56.7) | 54 (51.9–57.0) | 54 (51.7–56.7) | 57 (54.9–60.2) | |
| Model 1* | 1 (Reference) | 1.03 (0.96–1.10) | 1.05 (0.98–1.12) | 1.18 (1.10–1.26) | <0.001 |
| Model 2† | 1 (Reference) | 1.01 (0.95–1.08) | 1.03 (0.96–1.10) | 1.15 (1.08–1.23) | <0.001 |
| Model 3‡ | 1 (Reference) | 1.01 (0.94–1.08) | 1.01 (0.95–1.08) | 1.12 (1.04–1.20) | 0.001 |
Model 1 was adjusted for: age, sex, race, study center, and energy intake.
Model 2 (main model) was adjusted for: Model 1 covariates and smoking status, physical activity level, and education level.
Model 3 (mediator model) was adjusted for: Model 2 covariates and body mass index, diabetes status, and estimated glomerular filtration rate.
Figure 2. Adjusted hazard ratios and 95% CIs for incident hypertension according to level of ultra‐processed food consumption modeled with restricted cubic spline.
Data were truncated to the 1st and 99th percentiles of ultra‐processed food consumption. The reference point is 4.0 servings of ultra‐processed food consumption per day (25th percentile). The four knots were located at the 5th, 35th, 65th, and 95th percentiles representing 2.3, 4.5, 6.4, and 11.1 servings of ultra‐processed food per day, respectively. Multivariable regression models were adjusted for age, sex, race, study center, total energy intake, smoking status, physical activity level, and education level.
Results were not statistically different in subgroups defined by sex (P interaction = 0.40), race (P interaction = 0.15), diabetes (P interaction = 0.41), and body mass index category (P interaction = 0.69; Figure 3).
Figure 3. Subgroup analysis of the association between ultra‐processed food consumption and incident hypertension.
Results presented were adjusted for age, sex, race, study center, total energy intake, smoking status, physical activity level, and education level. There was no statistical evidence of interaction of the association between ultra‐processed food and incident hypertension by sex (P=0.40), race (P=0.15), diabetes (P=0.41), and body mass index (P=0.69).
Participants in the highest quartile of dietary intake of sugar‐sweetened beverages, red and processed meat, and margarine had a 16% higher (95% CI, 1.08–1.24; P trend<0.001), 10% higher (95% CI, 1.03–1.19; P trend = 0.005), and 6% higher (95% CI, 0.99–1.13; P trend = 0.045) respectively, risk of incident hypertension compared with the lowest quartile (Table 4). Conversely, those in the highest quartile of intake of cold breakfast cereal and dairy had a 10% lower (95% CI, 0.84–0.96; P trend = 0.008) and 11% lower (95% CI, 0.82–0.95; P trend = 0.001) risk of incident hypertension compared with the lowest quartiles.
Table 4.
Risk of Incident Hypertension by Quartile of Foods Classified as Ultra‐Processed in the Atherosclerosis Risk in Communities Study*
| Quartile 1 (n=2231) | Quartile 2 (n=2231) | Quartile 3 (n=2231) | Quartile 4 (n=2230) | P trend | |
|---|---|---|---|---|---|
| Sugar‐sweetened beverages† | 1 (Reference) | 1.03 (0.97–1.11) | 1.09 (1.02–1.17) | 1.16 (1.08–1.24) | <0.001 |
| Margarine | 1 (Reference) | 0.97 (0.90–1.03) | 1.12 (1.05–1.20) | 1.06 (0.99–1.13) | 0.045 |
| Baked goods‡ | 1 (Reference) | 0.95 (0.88–1.02) | 0.93 (0.86–1.01) | 0.93 (0.85–1.01) | 0.125 |
| Red and processed meat§ | 1 (Reference) | 1.01 (0.94–1.08) | 1.02 (0.95–1.10) | 1.10 (1.03–1.19) | 0.005 |
| Cold breakfast cereal | 1 (Reference) | 0.93 (0.87–0.99) | 0.92 (0.86–0.98) | 0.90 (0.84–0.96) | 0.008 |
| Fried foodsǁ | 1 (Reference) | 1.03 (0.96–1.11) | 1.05 (0.98–1.13) | 1.03 (0.96–1.11) | 0.689 |
| Sugary snacks# | 1 (Reference) | 0.94 (0.87–1.01) | 1.00 (0.92–1.08) | 1.01 (0.93–1.10) | 0.528 |
| Alcohol | 1 (Reference) | 0.95 (0.87–1.02) | 0.99 (0.90–1.09) | 0.99 (0.91–1.07) | 0.113 |
| Dairy** | 1 (Reference) | 0.95 (0.89–1.03) | 0.94 (0.88–1.02) | 0.89 (0.82–0.95) | 0.001 |
Results presented were adjusted for age, sex, race, study center, total energy intake, smoking status, physical activity level, and education level.
Sugar‐sweetened beverages include fruit juice from concentrate, diet sodas, regular sodas, and artificially flavored beverages.
Baked goods include chocolate bars and pieces, nonchocolate candies, premade pies, donuts, biscuits and cornbread, danishes, cake and brownies, and cookies.
Red and processed meat include hamburgers, hot dogs, processed and deli meats, beef, pork, and lamb.
Fried foods include potato and corn chips, French fried potatoes, and foods fried away from home.
Sugary snacks include chocolate bars or pieces (Hershey's, plain M&M's, Snickers, Reese's), candy without chocolate.
Dairy includes ice cream.
Participants in the highest quartile of minimally or unprocessed food consumption had a 9% lower (HR, 0.91 [95% CI, 0.85–0.97]) risk of incident hypertension compared with those in the lowest quartile after adjusting for age, sex, race, study center, and total energy intake in model 1 (P trend <0.010; Table 5). The association was not significant after additional adjustment for smoking status, physical activity level, and education level in model 2 (P trend = 0.234) but became significant after adjusting for potential mediators in model 3 (P‐trend = 0.048). Each additional serving of minimally or unprocessed food was associated with a 2% lower risk of incident hypertension (HR, 0.98 [95% CI, 0.98–0.99], P<0.001). Higher intake of minimally or unprocessed food was approximately linearly associated with a lower risk of incident hypertension before 11 servings per day (Figure 4).
Table 5.
Risk of Incident Hypertension by Quartile of Minimally and Unprocessed Food Consumption in the Atherosclerosis Risk in Communities Study
| Quartile 1 (n=2231) | Quartile 2 (n=2231) | Quartile 3 (n=2231) | Quartile 4 (n=2230) | P trend | |
|---|---|---|---|---|---|
| Energy‐adjusted minimally or unprocessed food intake, servings/day* , † | 5.7±1.2 | 7.9±0.5 | 9.7±0.6 | 12.9±2.2 | <0.001 |
| Incident hypertension cases, n (%) | 1756 (79) | 1760 (79) | 1762 (79) | 1740 (78) | |
| Incidence rate per 1000 person‐years, 95% CI | 59 (56.0–61.5) | 55 (52.5–57.6) | 54 (51.2–56.2) | 53 (50.6–55.6) | |
| Model 1‡ | 1 (Reference) | 0.93 (0.87–0.99) | 0.91 (0.85–0.97) | 0.91 (0.85–0.97) | 0.010 |
| Model 2§ | 1 (Reference) | 0.95 (0.89–1.01) | 0.95 (0.89–1.01) | 0.95 (0.89–1.02) | 0.234 |
| Model 3ǁ | 1 (Reference) | 0.94 (0.88–1.01) | 0.94 (0.88–1.01) | 0.93 (0.87–0.99) | 0.048 |
Expressed as mean±SD.
Participants were categorized into ultra‐processed food consumption quartiles based on averaged dietary intake from food frequency questionnaires administered at visits 1 and 3.
Model 1 was adjusted for age, sex, race, study center, and energy intake.
Model 2 (main model) was adjusted for Model 1 covariates and smoking status, physical activity level, and education level.
Model 3 (mediator model) was adjusted for Model 2 covariates and body mass index, diabetes status, and estimated glomerular filtration rate.
Figure 4. Adjusted hazard ratios and 95% CIs for incident hypertension according to level of minimally or unprocessed food consumption modeled with restricted cubic spline.
Data were truncated at the 1st and 99th percentiles of minimally or unprocessed food consumption. The reference point is 6.6 servings of minimally or unprocessed food consumption per day (25th percentile). The four knots are located at the 5th, 35th, 65th, and 95th percentiles representing 4.2, 7.4, 10.0, and 15.3 servings of minimally or unprocessed food per day, respectively. Multivariable regression models were adjusted for age, sex, race, study center, total energy intake, smoking status, physical activity level, and education level.
Discussion
In this study of 8923 middle‐aged US adults, there was a 15% higher risk of incident hypertension among those in the highest versus lowest quartile of UPF consumption after controlling for sociodemographic characteristics, total energy intake, and health behaviors. Higher dietary intake of red and processed meat, sugar‐sweetened beverages, and margarine, as separate food groups classified as ultra‐processed, were associated with higher risk of incident hypertension. In contrast, dietary intake of cold breakfast cereal and dairy were inversely associated with hypertension risk. Results were consistent within subgroups of the study population defined by sex, race, diabetes, and body mass index. Furthermore, higher intake of minimally or unprocessed food was associated with lower risk of incident hypertension.
Our study findings were consistent with previous research. In a meta‐analysis of 9 studies consisting of 111 594 adults, higher consumption of UPF were associated with a 23% higher risk of hypertension (odds ratio, 1.23 [95% CI, 1.11–1.37]; P value: 0.034). 23 In 13 608 Canadian adults, those in the highest versus lowest tertile of UPF consumption had a 60% greater odds of hypertension. 6 In 14 790 Spanish adults, highest versus lowest tertile of UPF consumption was associated with 21% higher risk of hypertension. 7 In 8754 Brazilian adults enrolled in the Brazilian Longitudinal Study of Adult Health, individuals in the highest tertile of UPF consumption had a 23% higher risk of developing hypertension than those in the lowest tertile of UPF consumption. 8
The magnitude of the associations between UPF consumption and risk of hypertension varied between studies and was not as strong in the present study relative to previous research. The differences in the magnitude of association may be explained by differences in timing and methodology of data collection (ie, 24‐hour dietary recall, food diary, or food frequency questionnaire), duration of follow‐up, geographic location of study populations, quantiles used to classify UPF (tertiles, quartiles, or quintiles), and the evolving nature of processed food in the food supply over time. Using a food frequency questionnaire to categorize foods according to processing level in our study may have resulted in misclassification of exposure and potentially an underestimate of the association between UPF consumption and incident hypertension. However, despite these potential differences, the direction of the association remained consistent across studies. This indicates that UPFs are associated with incident hypertension despite methodological differences and should be considered a concern for cardiovascular health globally, given the consistency of findings from epidemiologic studies. For future research, it would be helpful to expand on this strong evidence base by exploring aspects of UPF that may explain the adverse impact on hypertension risk, such as additives and degradation in the food matrix.
The observed association of UPF and hypertension may in part be explained by the low fiber content of a diet that is high in UPF, as demonstrated in our study. Higher dietary intake of fiber has previously been shown to be associated with lower blood pressure in adults. 24 , 25 Fiber consumption improves insulin sensitivity. Diets rich in dietary fiber help prevent hyperinsulinism, which has been suggested to be another underlying cause of hypertension. 26 Also, people who have switched to diets high in dietary fiber have been observed to have reductions in plasma cholesterol levels, which mediates vasoconstriction. 25 The inverse association that we observed between cold breakfast cereal consumption and hypertension may be attributed to the high content of fiber and whole grains in some cereals, which have been associated with lower risk of hypertension. 27 Consuming breakfast cereal could also be indicative of differences in dietary behaviors such as eating breakfast rather than skipping breakfast. In the NHANES (National Health and Nutrition Examination Survey), skipping breakfast was associated with higher risk of cardiovascular mortality in US adults. 28 Skipping breakfast and an extended period of fasting can lead to higher circulating cortisol levels and elevated blood pressure. 29
We also found that participants who had diets high in red and processed meats had a higher risk of developing hypertension. This association may be explained by the consumption of nitrates and nitrites commonly used to preserve meats. Among 106 288 participants in the French NutriNet cohort, those who consumed additive‐originated nitrites from their foods had a 19% higher risk of hypertension compared with nonconsumers (HR, 1.19 [95% CI, 1.08–1.32]; P value = 0.001). 30 Another potential mechanism is inflammation, which leads to atherosclerosis and the development of hypertension. 31 In the Multiethnic Cohort Study, higher consumption of red and processed meat was associated with higher serum levels of C‐reactive protein in women. 32
In our study, we found that participants in the highest quartile of sugar‐sweetened beverage consumption had higher risk of developing hypertension compared with individuals in the lowest quartile. Our findings are consistent with 2 meta‐analyses which found an association between sugar‐sweetened beverages and hypertension. 33 , 34 In NHANES, higher consumption of sugar‐sweetened beverages was cross‐sectionally associated with higher blood levels of C‐reactive protein, an inflammatory biomarker associated with higher risk of hypertension. 35 One possible explanation is related to the fructose content of sugar‐sweetened beverages. Fructose consumption has been linked to higher circulating levels of inflammation biomarkers, including interleukin‐6, C‐reactive protein, and tumor necrosis factor‐α. Fructose is also linked to uric acid production, which causes sodium retention, alterations in renal microvascularization, and dysfunction in endothelial tissues. 36
There are many noteworthy strengths of our study. Our study leverages a richly phenotyped, geographically and demographically diverse, prospective cohort study conducted in the United States. The present study enriches the overall literature on this topic which has been predominantly conducted outside of the United States. Study data were rigorously collected by standardized procedures and trained staff. The prospective study design allowed us to establish temporality between dietary intake and the onset of hypertension. The large sample size and extended duration of follow‐up yielded robust and precise estimates.
There are some limitations that should be considered when interpreting our findings. First, the food frequency questionnaire is subject to measurement error and recall biases. However, we used a validated food frequency questionnaire administered by trained staff. Second, exposure misclassification of food processing level using the Nova classification system is possible. We may have underestimated UPF intake due to less detailed information assessed on the food frequency questionnaire compared with other assessment tools (eg, 24‐hour dietary recalls). However, the Nova food classification is widely used for epidemiological studies examining the association between UPF consumption and health outcomes. Third, residual confounding due to unmeasured or incorrectly measured covariates cannot be ruled out because of the nature of observational studies. However, an extensive list of relevant covariates assessing sociodemographic characteristics, health behaviors, and health status were obtained by trained staff and included in multivariable regression models. Finally, the dietary data collected at visits 1 (1987–1989) and 3 (1993–1995) may not reflect the current dietary consumption of UPFs, and dietary intake can change over time. However, we found that there was minimal change on average in consumption of UPF, minimally processed, and unprocessed food.
Conclusions
Our findings have important public health implications. Replacing UPF with minimally processed or unprocessed food could help to reduce the risk of developing hypertension, such as replacing sugar‐sweetened beverages with water and replacing red and processed meat with plant sources of protein (eg, beans, nuts). Implementing changes in dietary behavior on an individual level can be challenging, time intensive, and potentially costly. Larger‐scale interventions, such as reducing the cost of fresh produce and increasing regulations for the food industry to minimize the use of harmful additives, could be helpful for reducing intake of UPF on the population level.
In conclusion, UPF consumption is significantly associated with elevated risk of incident hypertension in US middle‐aged adults. Our findings strengthen the growing body of evidence on the adverse cardiovascular health consequences of UPF consumption. Encouraging the replacement of UPF, and specifically red and processed meat, sugar‐sweetened beverages, and margarine, with unprocessed or minimally processed food may be helpful for reducing the risk of developing hypertension.
Sources of Funding
The Atherosclerosis Risk in Communities study has been funded in whole or in part with federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, US Department of Health and Human Services (75N92022D00001, 75N92022D00002, 75N92022D00003, 75N92022D00004, 75N92022D00005). Casey M. Rebholz was supported by a grant from the National Heart, Lung, and Blood Institute (R01 HL153178). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Disclosures
None.
Acknowledgments
The authors thank the staff and participants of the ARIC study for their important contributions. Author Contributions: Nikolaos Rivera and Casey M. Rebholz designed the study; Nikolaos Rivera and Shutong Du conducted data analysis; Nikolaos Rivera drafted the article; Shutong Du, Lauren Bernard, Hyunju Kim, Kunihiro Matsushita, and Casey M. Rebholz revised the article; Nikolaos Rivera had primary responsibility for final content. All authors have read and approved the final article.
This article was sent to Tochukwu M. Okwuosa, DO, Associate Editor, for review by expert referees, editorial decision, and final disposition.
For Sources of Funding and Disclosures, see page 11.
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