Ultra-processed food intake and long-term risk of cardiovascular disease mortality among myocardial infarction patients: A prospective analysis of the Alpha Omega Cohort

Background The impact of a diet high in ultra-processed foods (UPF) on mortality risk in patients with cardiovascular disease (CVD) remains unclear. Objective We examined the diet quality of a high UPF diet and its association with risk of total CVD mortality, ischemic heart disease (IHD) mortality, and stroke mortality in post- myocardial infraction (MI) patients. Methods We analyzed data from 4,365 post-MI patients in the Alpha Omega Cohort (79% men). Dietary intake at baseline was collected using a 203-item FFQ. Diet quality was assessed using the Dutch Healthy Diet Index adapted for CVD patients (DHD-CVD, range 0-160). UPF were identified and categorized according to the Nova classification system. Q1 and Q4 of %g/day of UPF represented a low and a high ultra-processed diet, respectively. HRs for CVD, IHD and stroke mortality were obtained from multivariable Cox regression models. Results Mean UPF contribution to the diet was 18%g/day (Q1 vs Q4=9 vs 29%g/day). Compared to Q1, patients in Q4 had higher intakes of total energy, and lower intakes of fruit and vegetables. DHD-CVD scores decreased slightly across quartiles (Q1 vs Q4=95 vs 82). Over a median follow-up of 14 years, 1,012 patients died from CVD (659 from IHD, 208 from stroke). Compared to Q1, a high ultra-processed diet was not consistently or significantly associated with CVD and IHD mortality. However, it was associated with a higher risk of stroke mortality (HR per10% point increase : 1.21, 95% CI: 1.02-1.42). This association was stronger in older patients, women, and those with a higher BMI, lower physical activity levels, and lower socio-economic status and robust to sensitivity analysis. Conclusions In post-MI patients, a high UPF diet was lower in whole, cardio-protective foods. Our study highlights the adverse association of a high UPF diet with stroke mortality risk among patients that have previously experienced an MI.