Food consumption by degree of food processing and risk of type 2 diabetes mellitus: a prospective cohort analysis of the European Prospective Investigation into Cancer and Nutrition (EPIC)

Samuel J Dicken; Christina C Dahm; Daniel B Ibsen; Anja Olsen; Anne Tjønneland; Mariem Louati-Hajji; Claire Cadeau; Chloé Marques; Matthias B Schulze; Franziska Jannasch; Ivan Baldassari; Luca Manfredi; Maria Santucci de Magistris; Maria-Jose Sánchez; Carlota Castro-Espin; Daniel Rodríguez Palacios; Pilar Amiano; Marcela Guevara; Yvonne T van der Schouw; Jolanda M A Boer; W M Monique Verschuren; Stephen J Sharp; Nita G Forouhi; Nicholas J Wareham; Eszter P Vamos; Kiara Chang; Paolo Vineis; Alicia K Heath; Marc J Gunter; Geneviève Nicolas; Elisabete Weiderpass; Inge Huybrechts; Rachel L Batterham

doi:10.1016/j.lanepe.2024.101043

Food consumption by degree of food processing and risk of type 2 diabetes mellitus: a prospective cohort analysis of the European Prospective Investigation into Cancer and Nutrition (EPIC)

Lancet Reg Health Eur. 2024 Sep 16:46:101043. doi: 10.1016/j.lanepe.2024.101043. eCollection 2024 Nov.

Authors

Samuel J Dicken¹, Christina C Dahm², Daniel B Ibsen^{2

3

4}, Anja Olsen^{2

5}, Anne Tjønneland^{5

6}, Mariem Louati-Hajji⁷, Claire Cadeau⁷, Chloé Marques⁷, Matthias B Schulze^{8

9

10}, Franziska Jannasch⁸, Ivan Baldassari¹¹, Luca Manfredi¹², Maria Santucci de Magistris¹³, Maria-Jose Sánchez^{14

15

16}, Carlota Castro-Espin^{17

18}, Daniel Rodríguez Palacios^{19

20}, Pilar Amiano^{21

22}, Marcela Guevara^{23

16

24}, Yvonne T van der Schouw²⁵, Jolanda M A Boer²⁶, W M Monique Verschuren^{25

26}, Stephen J Sharp²⁷, Nita G Forouhi²⁷, Nicholas J Wareham²⁷, Eszter P Vamos²⁸, Kiara Chang²⁸, Paolo Vineis²⁹, Alicia K Heath²⁹, Marc J Gunter^{29

30}, Geneviève Nicolas³⁰, Elisabete Weiderpass³¹, Inge Huybrechts³⁰, Rachel L Batterham^{1

32

33}

Affiliations

¹ Centre for Obesity Research, Department of Medicine, University College London (UCL), London WC1E 6JF, UK.
² Department of Public Health, Aarhus University, Aarhus, Denmark.
³ Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark.
⁴ Department of Nutrition, Sports and Exercise, University of Copenhagen, Frederiksberg, Denmark.
⁵ Danish Cancer Institute, Copenhagen, Denmark.
⁶ Department of Public Health, University of Copenhagen, Denmark.
⁷ Paris-Saclay University, UVSQ, Inserm, Gustave Roussy, CESP, Villejuif, France.
⁸ Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany.
⁹ German Center for Diabetes Research (DZD), Neuherberg, Germany.
¹⁰ Institute of Nutritional Science, University of Potsdam, Nuthetal, Germany.
¹¹ Department of Epidemiology and Data Science, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan 20133, Italy.
¹² Centre for Biostatistics, Epidemiology, and Public Health (C-BEPH), Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano (TO), Italy.
¹³ A.O.U. Federico II, Naples, Italy.
¹⁴ Escuela Andaluza de Salud Pública (EASP), Granada 18011, Spain.
¹⁵ Instituto de Investigación Biosanitaria ibs.GRANADA, Granada 18012, Spain.
¹⁶ Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid 28029, Spain.
¹⁷ Unit of Nutrition and Cancer, Catalan Institute of Oncology-ICO, L'Hospitalet de Llobregat, Barcelona, Spain.
¹⁸ Nutrition and Cancer Group, Epidemiology, Public Health, Cancer Prevention and Palliative Care Program, Bellvitge Biomedical Research Institute-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
¹⁹ Department of Epidemiology, Murcia Regional Health Council-IMIB, Murcia, Spain.
²⁰ CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
²¹ Ministry of Health of the Basque Government, Sub Directorate for Public Health and Addictions of Gipuzkoa, San Sebastian, Spain.
²² BioGipuzkoa (BioDonostia) Health Research Institute, Epidemiology of Chronic and Communicable Diseases Group, San Sebastián, Spain.
²³ Instituto de Salud Pública y Laboral de Navarra, Pamplona 31003, Spain.
²⁴ Navarra Institute for Health Research (IdiSNA), Pamplona 31008, Spain.
²⁵ Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
²⁶ National Institute for Public Health and the Environment, Bilthoven, the Netherlands.
²⁷ Medical Research Council Epidemiology Unit, Institute of Metabolic Science, University of Cambridge Clinical School, Cambridge, UK.
²⁸ Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London W12 0BZ, UK.
²⁹ Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
³⁰ Nutrition and Metabolism Branch, International Agency for Research on Cancer, World Health Organization (IARC-WHO), Lyon, France.
³¹ International Agency for Research on Cancer, World Health Organization, Lyon, France.
³² Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital (UCLH), London NW1 2BU, UK.
³³ National Institute for Health Research, Biomedical Research Centre, University College London Hospital (UCLH), London W1T 7DN, UK.

Abstract

Background: It is unknown whether the association between ultra-processed food (UPF) intake and type 2 diabetes mellitus differs from other degrees of food processing. We examined the association between degree of food processing and incident type 2 diabetes mellitus.

Methods: This was a prospective cohort analysis of the European Prospective Investigation into Cancer and Nutrition (EPIC). Dietary intake was assessed at baseline using dietary questionnaires and classified according to the Nova classification into unprocessed/minimally processed food (MPF), processed culinary ingredients (PCI), processed food (PF) and UPF. Type 2 diabetes mellitus cases were verified through multiple methods. Cox regression and statistical substitution analysis was used to estimate associations between MPF + PCI, PF and UPF intake and incident type 2 diabetes mellitus. To investigate heterogeneity in the association between UPF and incident type 2 diabetes mellitus, UPF sub-group analysis was conducted. Different reference groups were used in each analysis.

Findings: Over an average 10.9 years follow-up of 311,892 individuals, 14,236 type 2 diabetes mellitus cases were identified. Each 10% increment of total daily food intake from UPF (%g/day) was associated with 17% (95% confidence interval (95%CI): 1.14-1.19) higher incident type 2 diabetes mellitus. Each 10% increment in MPF + PCI or PF intake was associated with lower incident type 2 diabetes mellitus (MPF + PCI hazard ratio: 0.94 (95%CI: 0.92-0.96); PF hazard ratio: 0.92 (95%CI: 0.89-0.95)). Replacing UPF with MPF + PCI or PF was associated with lower incident type 2 diabetes mellitus. However, heterogeneity was observed across UPF sub-groups, with breads, biscuits and breakfast cereals, sweets and desserts, and plant-based alternatives associated with lower incident type 2 diabetes mellitus.

Interpretation: These findings support recommendations to focus on reducing intake of specific UPF for lowering type 2 diabetes mellitus risk.

Funding: International Agency for Research on Cancer.

Keywords: Diet; Europe; Food processing; Nova classification; Type 2 diabetes mellitus; Ultra-processed food.