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Association between consumption of ultra-processed foods and all cause mortality: SUN prospective cohort study

BMJ 2019; 365 doi: (Published 29 May 2019) Cite this as: BMJ 2019;365:l1949

Linked Research

Ultra-processed food intake and risk of cardiovascular disease

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Ultra-processed food and adverse health outcomes

  1. Anaïs Rico-Campà, researcher12,
  2. Miguel A Martínez-González, professor1234,
  3. Ismael Alvarez-Alvarez, postdoctoral researcher1,
  4. Raquel de Deus Mendonça, postdoctoral researcher15,
  5. Carmen de la Fuente-Arrillaga, research dietitian123,
  6. Clara Gómez-Donoso, doctoral student1,
  7. Maira Bes-Rastrollo, professor123
  1. 1Department of Preventive Medicine and Public Health, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain
  2. 2Biomedical Research Centre Network on Obesity and Nutrition (CIBERobn), Spanish National Institute of Health Carlos III, Madrid, Spain
  3. 3IDISNA, Navarra Institute for Health Research, Pamplona, Spain
  4. 4Harvard TH Chan School of Public Health, Boston, MA, USA
  5. 5Department of Nutrition, School of Nursing, Federal University of Minas Gerais, Belo Horizonte, Brazil
  1. Correspondence to: M Bes-Rastrollo mbes{at}
  • Accepted 23 April 2019


Objective To evaluate the association between consumption of ultra-processed foods and all cause mortality.

Design Prospective cohort study.

Setting Seguimiento Universidad de Navarra (SUN) cohort of university graduates, Spain 1999-2018.

Participants 19 899 participants (12 113 women and 7786 men) aged 20-91 years followed-up every two years between December 1999 and February 2014 for food and drink consumption, classified according to the degree of processing by the NOVA classification, and evaluated through a validated 136 item food frequency questionnaire.

Main outcome measure Association between consumption of energy adjusted ultra-processed foods categorised into quarters (low, low-medium, medium-high, and high consumption) and all cause mortality, using multivariable Cox proportional hazard models.

Results 335 deaths occurred during 200 432 persons years of follow-up. Participants in the highest quarter (high consumption) of ultra-processed foods consumption had a higher hazard for all cause mortality compared with those in the lowest quarter (multivariable adjusted hazard ratio 1.62, 95% confidence interval 1.13 to 2.33) with a significant dose-response relation (P for linear trend=0.005). For each additional serving of ultra-processed foods, all cause mortality relatively increased by 18% (adjusted hazard ratio 1.18, 95% confidence interval 1.05 to 1.33).

Conclusions A higher consumption of ultra-processed foods (>4 servings daily) was independently associated with a 62% relatively increased hazard for all cause mortality. For each additional serving of ultra-processed food, all cause mortality increased by 18%.

Study registration NCT02669602.


  • Contributors: AR-C, MAM-G, and MB-R conceived and designed the study. AR-C, IA-A, MAM-G, and MB-R analysed the data. CF-A and RDM acquired and analysed the data. MAM-G and MB-R obtained funding. AR-C and CG-D drafted the manuscript. AR-C, MAM-G, IA-A, RDM, CF-A, CG-D, and MB-R critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of the work ensuring integrity and accuracy. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. MB-R is the guarantor.

  • Funding: The SUN Project is supported by the Spanish Government-Instituto de Salud Carlos III, and the European Regional Development Fund (FEDER) (RD 06/0045, PI14/01798, PI14/01764, PI17/01795), Navarra Regional Government, and the University of Navarra. The funding sources had no role in the design, execution, analyses, and interpretation of the data or decision to submit the results of this study.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The protocol was written in accordance with the principles of the Declaration of Helsinki and was approved by the University of Navarra institutional review board.

  • Data sharing: No additional data available.

  • Transparency: The manuscript’s guarantor (MB-R) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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