Dietary share of ultra-processed foods and metabolic syndrome in the US adult population
Introduction
Metabolic syndrome (MetS) is a complex of multiple, interrelated risk factors for cardiovascular disease (CVD) and diabetes which occur more often together than by chance alone and for which the cause is often uncertain (Alberti et al., 2009). MetS is not an absolute risk indicator, as it does not contain many of the factors that determine absolute risk, such as age, sex, cigarette smoking, and low-density lipoprotein cholesterol levels (Alberti et al., 2009). However, evidence exists that people affected by MetS are at twice the risk of developing CVD over the next 5 to 10 years and have a 5-fold risk of type 2 diabetes mellitus compared to unaffected individuals (Alberti et al., 2009).
In the last decades, worldwide prevalence of MetS has risen dramatically, presumably due to increasing obesity and lifestyle risk factors (Alberti et al., 2009), including poor diet (Martínez-González and Martín-Calvo, 2013). Still, the most appropriate diet for prevention and treatment of MetS remains uncertain (Pérez-Martínez et al., 2017). Recent studies suggest that using overall dietary patterns rather than isolated nutrients may better appraise the association between diet and MetS (Martínez-González and Martín-Calvo, 2013). In this sense, evidence is supportive of a beneficial effect on MetS of the adherence to “a priori defined” Mediterranean dietary pattern (Martínez-González and Martín-Calvo, 2013; Pérez-Martínez et al., 2017; Kastorini et al., 2011; Gouveri and Diamantopoulos, 2015; Babio et al., 2014) and also, though studies are scarce (Pérez-Martínez et al., 2017), to the DASH diet or Northern Europe dietary pattern (Calton et al., 2014; Azadbakht et al., 2005; Adamsson et al., 2012). Conversely, other studies including two recent meta-analyses (Martínez-González and Martín-Calvo, 2013; Rodríguez-Monforte et al., 2017; Shab-Bidar et al., 2018; Agodi et al., 2018; Esmaillzadeh et al., 2007; Heidemann et al., 2011) have confirmed that greater adherence to “a posteriori-defined” Western dietary pattern is associated with an increased risk for MetS, while prudent/traditional dietary patterns are associated with a lower prevalence of MetS.
Highly present in Western dietary patterns, ultra-processed foods (UPF) are formulations of many ingredients, mostly of exclusive industrial use, that result from a sequence of industrial processes (hence ultra-processed) (Monteiro et al., 2019). Evidence exists that global food supplies are increasingly dominated by UPF (Moodie et al., 2013; Ultra-processed food and drink products in Latin America: Trends, impact on obesity, policy implications, 2015; Stuckler et al., 2012; Monteiro and Cannon, 2012; Monteiro et al., 2013). Nationally representative studies carried out in the US (Martínez Steele et al., 2017; Martínez Steele and Monteiro, 2017; Martinez Steele et al., 2016), Canada (Moubarac et al., 2017; Moubarac et al., 2012) and other countries (Rauber et al., 2018; Julia et al., 2018; Cediel et al., 2018; Latasa et al., 2017; Louzada et al., 2015a, Louzada et al., 2015b, Louzada et al., 2018; Monteiro et al., 2010) have shown that high dietary contribution of UPF renders nutritionally unbalanced diets. Large, population-based cross-sectional and cohort studies support that the consumption of these foods is associated with overweight and obesity (Julia et al., 2018; Juul et al., 2018; Mendonça et al., 2016; Louzada et al., 2015; Canella et al., 2014), dyslipidemia (Rauber et al., 2015), hypertension (Mendonça et al., 2017) and abdominal obesity (Juul et al., 2018). Two small cross-sectional studies found an association between UPF consumption and MetS in Brazilian adolescents (Tavares et al., 2012) and among Indigenous Cree (Eeyouch) from northern Québec (Lavigne-Robichaud et al., 2018).
The aim of the current study was to examine whether a relationship exists between the dietary share of UPF and MetS among a representative sample of US adults.
Section snippets
Data source, population and sampling
We used nationally representative data from National Health and Nutrition Examination Survey (NHANES, n.d.) 2009–2014 (three 2-year cycles). NHANES is a continuous, nationally representative, cross-sectional survey of the non-institutionalized, civilian US residents conducted by The Centers for Disease Control and Prevention (Johnson et al., n.d.). Participants were recruited using a four-stage sample design based on the selection of counties, blocks, households, and the number of people within
UPF consumption and prevalence of metabolic syndrome according to sociodemographic and life-style variables
Among US adults aged 20 years or above who met the eligibility criteria (n = 6385), the mean dietary contribution of UPF was 55.5% (95% CI 54.6, 56.4) of total energy intake and decreased with age (p for linear trend<0.001) (Table 3). UPF consumption was lowest among Other Hispanic and Other race, intermediate among Mexican American, and highest among Non-Hispanic White and Black (p < 0.05). Individuals with income-to-poverty ratio < 3.5 and 12 years of education presented the highest UPF
Discussion
Findings from this nationally representative study of US adults show that higher dietary contribution of UPF is associated with higher prevalence of MetS. The association was especially strong among young adults (between 20 and 39 years) and grew weaker with age.
A positive association between UPF consumption and MetS has been reported in small studies carried out in Brazil (Tavares et al., 2012) and Canada (Lavigne-Robichaud et al., 2018). Our results are also consistent with evidence linking
Acknowledgments
Not applicable.
Author contributions
EMS and CAM conceived and designed the study including statistical analysis; EMS performed the statistical analyses; EMS and CAM analyzed and interpreted the data; EMS took the lead in writing the manuscript; FJ, FR, DN and CAM revised the manuscript for important intellectual content. All authors approved the final manuscript and take full responsibility for the final content.
Funding
This work was supported by the CNPq [Processo CNPq n° 150888/2017-1] and the Sao Paulo Research Foundation (FAPESP) [Processo 2018/17972-9; 2016/25853-4; 2016/14302-7; 2015/14900-9].
Declaration of competing interest
The authors declare no conflict of interest.
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