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Association Between Ultra-processed Food Consumption and Mortality Among US Adults: Prospective Cohort Study of the National Health and Nutrition Examination Survey, 2003-2018

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Wang, Lu, Steele, Euridice Martínez, Du, Mengxi, Luo, Hanqi, Zhang, Xuehong, Mozaffarian, Dariush, Zhang, Fang Fang·2025·Journal of the Academy of Nutrition and Dietetics
DOI 10.1016/j.jand.2024.11.014PMC PMC12104482
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Abstract

Background Intake of ultra-processed foods (UPF) provides more than half of the daily energy US adults consume. Still, the prospective association of UPF consumption with mortality in the general US population remains understudied. Objective To investigate the prospective association of UPF consumption with mortality in a nationally representative sample of US adults. Design A prospective cohort analysis was conducted by linking baseline measurement from the National Health and Nutrition Examination Survey with mortality information from the National Death Index. The percentage of total energy consumed from UPF, defined by the Nova classification system, was computed based on dietary data collected using 24-hour diet recalls. Participants/setting This study included 38 148 nationally representative US adults aged 20 years and older who participated in National Health and Nutrition Examination Survey between 2003-2004 and 2017-2018 and provided dietary intake data, with linkage to mortality data. Main outcome measures Information on all-cause and cause-specific mortality was obtained from linkage to the National Death Index through December 31, 2019. Statistical analysis performed Cox proportional hazard models estimated the multivariable-adjusted hazard ratios and 95% CIs for the association between UPF intake and mortality. Results During a median follow-up of 8.0 years, 4611 deaths were confirmed, including 2064 deaths from cardiometabolic disorders and 1046 deaths from cancer. After multivariable adjustments, each 10-point increment in usual percentage of total energy from UPF was associated with a 9% higher risk of all-cause mortality (hazard ratio 1.09, 95% CI 1.04 to 1.14). The association remained significant after adjusting for the overall diet quality measured by the Health Eating Index 2015 (hazard ratio 1.06, 95% CI 1.00 to 1.11; P < .05). Among subgroups, sugar-sweetened beverages, ready-to-eat or -heat mixed dishes, ultra-processed dairy products, and ultra-processed oil/fat, condiments, and sauces were associated with an increased risk of all-cause or cause-specific mortality. Ultra-processed vegetables and legumes were associated with a reduced risk. Conclusions In this nationally representative study of US adults, higher consumption of UPF was associated with a higher risk of all-cause mortality, and this association was not fully explained by overall diet quality.

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  • Avoiding ultraprocessed foods is generally advisable, although certain subcategories may have neutral or net positive health effects depending on ingredients, processing, and additives.

    “Avoiding these foods is generally advisable, although certain subcategories of ultraprocessed foods may have neutral or net positive health effects (e.g., those rich in whole grains, fruit, yogurts, or seafood), depending on their ingredients, processing, and additives [300, 301].”

    From Nutritional priorities to support <scp>GLP</scp> ‐1 therapy for obesity: A joint Advisory from the American College of Lifestyle Medicine, the American Society for Nutrition, the Obesity Medicine Association, and The Obesity Society (2025) · cites this paper as [300]

    The Introduction and Discussion (page unavailable) associate higher ultra-processed-food consumption with poorer diet quality and higher mortality, while noting that health implications vary by subgroup. The Discussion reports reduced mortality risk for ultra-processed vegetable and legume products and a possible, non-significant benefit for whole-grain foods. It does not establish the cited examples of fruit, yogurt, or seafood as beneficial; it associates ultra-processed dairy products with increased mortality risk. (LLM, conf=0.85)

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Cited by

Sorted by citations

Authors
Wang, L., Steele, E. M., Du, M., Luo, H., Zhang, X., Mozaffarian, D., & Zhang, F. F.
Affiliations
  • Tufts University (US)
  • Emory University (US)
  • Harvard University (US)
Corresponding author
Zhang, Fang Fang
ORCID
Venue
Journal of the Academy of Nutrition and Dietetics
Publisher
Elsevier BV
Published
2025-07
Volume
125
Issue
7
Pages
875-887.e7
ISSN
2212-2672 (ISSN-L)
DOI
10.1016/j.jand.2024.11.014
PMC
PMC12104482
OpenAlex
W4404734886
Cited by
16
References
9
Citations by year
2026: 6 · 2025: 10
FWCI
6.63
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the Academy of Nutrition and Dietetics (acceptedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (publishedVersion)
Funders
  • American Diabetes Association (1-24-INI-04)
  • Fundação de Amparo à Pesquisa do Estado de São Paulo
  • National Institutes of Health (2018/17972-9)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Consumer Attitudes and Food Labeling
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
  • Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Global Public Health Policies and Epidemiology
Keywords
ultra-processed foods, mortality, all-cause mortality, cancer mortality, NOVA classification, sugar-sweetened beverages, diet quality, energy intake, United States adults, NHANES, National Death Index linkage, prospective cohort
MeSH terms
Food, Processed, Adult, Aged, Cause of Death, Diet, Female, Humans, Male, Middle Aged, Mortality, Nutrition Surveys, Prospective Studies, Risk Factors, United States, Proportional Hazards Models, Young Adult, Fast Foods

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