“Avoiding both extremes, the Tathagata has realized the Middle Path: It gives vision, it gives knowledge, and it leads to calm, to insight, to enlightenment, and to Nirvana.”
— The Buddha
One of the first things we were taught in medical school was that “The poison’s in the dose.” It was the practical application of something known as a “therapeutic window.” Applied particularly to drugs like antibiotics, it refers to the fact that below a certain level, the effect of the drug (in the case of an antibiotic, to get rid of an infection) fails to occur. However, above a certain dose, the side effects (which can include an increasing risk of mortality) begin to outweigh the benefits. In medicine, “more” is often not only not better, but it can be lethal.
Even the necessities of life, administered in excess – particularly in times of vulnerability – can be toxic. For decades, cardiologists believed that giving additional oxygen to all patients having a heart attack, even those with normal oxygen levels, was beneficial. However, it turns out that administering supplemental oxygen to those patients having a heart attack but who have normal oxygen levels increases the size of the heart attack and potentially increases their risk of dying[1].
The rule applies not only to illness but to everyday living. The consumption of completely natural, wholesome, and organic foodstuffs is not immune from the consequences of excess. For example, bitter almonds (which are often used in the production of almond-flavored extracts) must be processed to remove the cyanide present; otherwise, the consumption of even a few kernels could prove fatal – unlike sweet almonds (that are the kind sold for direct consumption) which would require the consumption of thousands of nuts to induce toxicity.
All of this served to pique my curiosity when I came across a headline proclaiming that “Ultra-Processed Doesn’t Always Mean Bad — Here’s How to Tell.” Their takeaway was that “[C]ereals, savory snacks, and yogurt and dairy-based desserts were linked to a lower risk of these [cardiovascular disease and coronary heart] diseases.[2]”
Certainly, some of this makes sense on the surface. Even using the NOVA classification to parse out ultra-processed foods (UPFs) as a distinct category meeting specific criteria, it is a massive group of highly diverse manufactured constituents. There is certainly every reason to believe that, as a group, the effects are more shades of gray than simply black or white. But as I was also taught in my medical training, someone else’s summation is convenient and nice, but there is no substitute for examining the data yourself, especially when the study in question drew a much less sensational conclusion by observing that “Total UPF intake was adversely associated with CVD and CHD risk in US adults…Nutritional advice for cardiovascular health should consider differential consequences of group-specific UPF.”
- The study used the data from three prior US studies (the Nurses’ Health Study (NHS; n = 75,735), Nurses’ Health Study II (NHSII; n = 90,813), and the Health Professionals Follow-Up Study (HPFS; n = 40,409).
- The food data from these studies was obtained through the use of a food frequency questionnaire every 2-4 years.
- The study also contained a meta-analysis involving 19 cohort studies examining ultra-processed food intake and cardiovascular disease risk.
- UPF consumption was divided into quintiles, and an analysis was performed comparing the highest consumers (Q5) to the lowest (Q1).
- The top 3 UPF categories of consumption were bread and cereals (6.4–7.4%), sweet snacks and desserts (4.5–6.3%), and ready-to-eat/heat-mixed dishes (3.9–5.8%).
- Higher total UPF intake was associated with a higher risk of CVD and CHD.
- An increased risk of developing CVD was associated with the consumption of processed meats and artificial and sugar-sweetened beverages.
- A decreased risk of developing CVD was associated with the consumption of cold cereal, hard liquor, savory snacks, and yogurt and dairy-based desserts.
- A decreased risk of developing stroke was associated with increased bread and cereal consumption.
The Caveat:
Multiple studies from Europe, the United States, and other areas around the world have demonstrated a clear link between the consumption of ultra-processed food and the risk of developing chronic disability and disease, particularly obesity, hypertension, type II diabetes, and cardiovascular disease.
A previous study examining the risk of developing type II diabetes that was published in 2023 showed that, as a group, ultra-processed foods increased the risk of developing type II diabetes[3]. However, unlike many previous studies, this study broke down the risk by specific types of ultra-processed food. They found cereals, dark breads, and whole grain breads served to decrease the risk of developing type II diabetes. A similar decrease in diabetes risk was associated with packaged sweet and savory snacks and fruit-based products. Yogurt and dairy-based desserts were the final group of ultra-processed foods that decreased the risk of developing type II diabetes.
The current study seemed to echo these findings with respect to the risk of cardiovascular disease (CVD). Given that type II diabetes is a well-known and highly predictive risk factor for the subsequent development of CVD, these findings are not unexpected, especially in light of the fact that the current study utilized exactly the same cohort groups as the diabetic study published in 2023 (NHS, NHSII, and HPFS). Given the dataset and the known linkage between type II diabetes and cardiovascular disease, I believe this study should be viewed in the context of adding incremental as opposed to new and substantial evidence.
The authors themselves note that “[T]he inverse association of hard liquors with CHD aligns with existing evidence. Moderate alcohol consumption, regardless of beverage type [i.e., fermented (processed products: beer and wine) or distilled (UPF: spirits)], has been associated with lower CHD risk in some studies. Also, modest ethanol intake is associated with increased high-density lipoprotein-cholesterol, insulin sensitivity, and modulation of inflammation.”
They also acknowledged that “Our results of lower CVD risk for yoghurt/dairy-based desserts agree with [existing] evidence suggesting neutral or positive cardiovascular benefit from dairy products not always meeting UPF characteristics, especially fermented plain yoghurt.” The caveat lies in the admission that the researchers were unable to differentiate ultra-processed yogurt from non-ultra-processed yogurt due to food frequency questionnaire limitations.
The conclusion that ultra-processed foods should be further categorized and further subgroup analysis performed makes logical sense. However, the importance of analyzing overall dietary patterns, a somewhat more holistic approach, should not be neglected. It should be remembered that we don’t sit down at the table and order nutrients; we eat foods in the form of meals, always best served with a side of gratitude.
[1] (Stub, 2015)
[2] (Wairimu, 2024)
[3] (Chen, 2023)
The Study:
Additional resources:
Yuan L, Hu H, Li T, et al. Dose-response meta-analysis of ultraprocessed food with the risk of cardiovascular events and all-cause mortality: evidence from prospective cohort studies. Food Funct. 2023;14(6):2586–2596. https://doi.org/10.1039/d2fo02628g. Zhong GC, Gu HT, Peng Y, et al. Association of ultra-processed food consumption with cardiovascular mortality in the US population: long-term results from a large prospective multicenter study. Int J Behav Nutr Phys Activ. 2021;18(1):1–14. https://doi.org/10.1186/s12966-021-01081-3.
