Ultraprocessed food consumption is associated with all-cause and cardiovascular mortality in participants with type 2 diabetes independent of diet quality: a prospective observational cohort study

Background: Nutritional strategies for prevention and management of type 2 diabetes traditionally emphasize dietary patterns reflecting nutrient goals, but the health implications of ultraprocessed food (UPF) for patients with type 2 diabetes remain unknown.Objectives: This study aimed to evaluate the association of UPF intake with all-cause and cardiovascular disease (CVD) mortality among participants with type 2 diabetes from the Moli-sani Study in Italy (enrollment 2005-2010).Methods: This was a prospective observational cohort study on 1065 individuals with type 2 diabetes at baseline, followed up for 11.6 y (median). Food intake was assessed by a 188-item food-frequency questionnaire. UPF was defined following the Nova classification and calculated as the ratio (weight ratio; %) between UPF (g/d) and total food eaten (g/d). Overall diet quality was assessed through the Mediterranean Diet Score (MDS). Multivariable-adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality. Results: The average UPF consumption was 7.4% (+/- 5.0%). In multivariable-adjusted Cox analyses, greater UPF intake (Q4, >10.5% and >= 9% of total food eaten for females and males, respectively), as opposed to the lowest (Q1, UPF <4.7% and <3.7% for females and males, respectively), was associated with higher hazards of both all-cause (HR: 1.70; 95% CI: 1.25, 2.33) and CVD mortality (HR: 2.64; 95% CI: 1.59, 4.40); inclusion of the MDS into the model did not substantially alter the magnitude of these associations (HR: 1.64; 95% CI: 1.19, 2.25 and HR: 2.55; 95% CI: 1.53, 4.24 for all-cause and CVD mortality, respectively). A linear dose-response relationship of UPF intake with both all-cause and CVD mortality was also observed.Conclusions: In participants with type 2 diabetes at study entry, higher UPF consumption was associated with reduced survival and higher CVD mortality rate, independent of diet quality. Besides prioritizing the adoption of a diet based on nutritional requirements, dietary guidelines for the management of type 2 diabetes should also recommend limiting UPF.