Consumption of ultra-processed foods and health outcomes: a systematic review of recent evidence

INTRODUCTION

The escalating global consumption of ultra-processed foods (UPFs) has emerged as a critical public health concern in the 21st century. UPFs are industrial food formulations manufactured predominantly from substances extracted or derived from foods, combined with additives, preservatives, colorants, and flavor enhancers rarely used in home cooking (Monteiro et al., 2019). Classified under the NOVA food system into four groups based on the extent and purpose of industrial processing, UPFs encompass a wide range of products including packaged snacks, sugary beverages, instant noodles, reconstituted meat products, and ready-to-eat meals (Chen et al., 2020). Over recent decades, UPFs have come to dominate dietary patterns in high-income countries, accounting for more than half of total daily energy intake in nations such as the United States, United Kingdom, Canada, and Australia, while their consumption is rapidly rising in low- and middle-income countries as well (Marino et al., 2021). This shift in dietary behavior, driven largely by urbanization, food industry marketing, and the convenience these products offer, has prompted urgent scientific inquiry into their consequences for human health (Srour et al., 2022). Given the scale and pace of this dietary transition, systematic assessment of the cumulative evidence linking UPF consumption to adverse health outcomes is both timely and necessary.

A substantial and growing body of epidemiological evidence links UPF consumption to a broad spectrum of non-communicable diseases (NCDs). Systematic reviews and meta-analyses have consistently demonstrated that higher UPF intake is associated with significantly elevated risks of obesity, type 2 diabetes mellitus, hypertension, and dyslipidemia (Pagliai et al., 2021; Khandpur et al., 2023). With respect to cardiometabolic health, prospective cohort investigations have reported that each incremental increase in UPF consumption corresponds to measurable increases in cardiovascular disease incidence and related mortality (Bonaccio et al., 2021; Mendoza et al., 2024). Chen et al. (2023) further confirmed, across three large prospective U.S. cohort studies, that UPF consumption was independently and significantly associated with increased risk of type 2 diabetes, even after adjustment for overall diet quality. An umbrella review by Lane et al. (2024), encompassing data from nearly ten million participants, identified robust associations between UPF exposure and 32 distinct adverse health outcomes, underscoring the breadth of harm attributable to these dietary patterns. Furthermore, Cordova et al. (2023) demonstrated in a multinational cohort study that higher UPF intake was linked to an elevated risk of multimorbiditythe co-occurrence of cancer and cardiometabolic diseaseshighlighting the systemic nature of UPF-related health consequences. These findings collectively signal that UPF consumption represents a modifiable dietary risk factor of substantial public health significance.

Beyond cardiometabolic outcomes, recent evidence has illuminated the role of UPFs in mental health, neurological function, and cancer risk. Lane et al. (2022) conducted a systematic review and meta-analysis of observational studies and reported that UPF consumption was significantly associated with increased prevalence of depression, anxiety, and common mental health disorders. Grosso et al. (2023) further documented that elevated UPF intake was associated with depressive symptomatology in a Mediterranean cohort, suggesting that the neuroinflammatory and gut-brain axis dysregulation induced by UPF additives may underlie these psychiatric associations. With regard to oncological outcomes, Kliemann et al. (2023) analyzed data from the prospective EPIC cohort and reported that UPF consumption was positively associated with cancer risk across multiple anatomical sites, a finding corroborated by the broader umbrella review literature. Research has also implicated UPFs in cognitive decline, with Li et al. (2022) reporting in a prospective cohort study that higher ultraprocessed food intake was associated with increased risk of incident dementia. Mechanistically, Srour et al. (2022) proposed that these diverse health harms stem from both the nutritional characteristics of UPFshigh in sodium, saturated fats, added sugars, and low in fiberand non-nutritional factors such as food additives, contaminants generated during high-temperature processing, and disruption of the gut microbiome.

Despite the mounting evidence, several critical gaps remain in the literature. Existing systematic reviews have often been restricted in scope, focusing on single health outcomes or specific population subgroups, without providing a comprehensive synthesis across the full spectrum of health outcomes associated with UPF consumption (Pagliai et al., 2021; Zhang & Giovannucci, 2023). Methodological heterogeneity in the operationalization of UPF intakeincluding variability in dietary assessment instruments, NOVA classification application, and study population characteristicshas introduced inconsistencies that complicate the interpretation of findings across studies (Astrup & Monteiro, 2022). Rauber et al. (2021) highlighted that prospective cohort evidence from diverse geographic and demographic contexts is still limited, particularly in low- and middle-income country settings where UPF consumption is rising most rapidly. Moreover, while umbrella reviews and meta-analyses have demonstrated associations, dose-response relationships and the strength of evidence across specific disease categories remain insufficiently characterized (Wang et al., 2022; Taneri et al., 2022). The present systematic review therefore aims to address these gaps by synthesizing recent epidemiological and experimental evidence on UPF consumption and health outcomes published from 2020 onward, applying rigorous inclusion criteria and quality appraisal to produce an updated, comprehensive, and methodologically transparent evidence base to inform dietary guidelines and public health policy.

METHODS

This chapter presents the methodological framework guiding the systematic identification, appraisal, and synthesis of evidence on ultra-processed food (UPF) consumption and health outcomes. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and was prospectively registered in PROSPERO to ensure transparency and reproducibility across all stages of the review process.

Search Strategy

A systematic literature search was conducted across PubMed/MEDLINE, Scopus, Web of Science, CINAHL, and the Cochrane Library, covering studies published from January 2020 to December 2024. Search terms were developed in consultation with the PICOS framework and combined using Boolean operators. The primary search string integrated terms such as "ultra-processed food," "NOVA classification," "food processing," paired with health outcome terms including "cardiovascular disease," "diabetes," "obesity," "cancer," "mental health," and "mortality." Search filters were applied to restrict results to peer-reviewed, English-language publications. No geographic restrictions were imposed, ensuring global representativeness of the evidence base. Reference lists of all included studies and relevant systematic reviews were hand-searched to capture any additional eligible studies not retrieved through the database search. The complete search strategies for each database were documented and are available as supplementary material.

RESULTS

This chapter presents the findings of the systematic review organized according to the study's specific objectives. Following database searches and application of eligibility criteria, a total of 87 studies met the inclusion requirements and were retained for synthesis. Results are presented thematically across four objective-aligned sections, each accompanied by a summary table.

The findings in Table 1 reveal a globally pervasive pattern of high UPF consumption across diverse populations and geographic settings. Evidence consistently shows that UPFs contribute disproportionately large shares of daily energy intake, particularly in high-income nations. Juul et al. (2021) reported that UPFs accounted for 57% of total daily energy in the United States, while Seferidi et al. (2020) documented a comparable 56.8% contribution in the United Kingdom, with the greatest burden concentrated among lower-income households. Ruggiero et al. (2021) identified children as the highest UPF consumers in Italy at 43% energy contribution, signaling early dietary risk socialization. Vandevijvere et al. (2021) further demonstrated that UPF sales are expanding most rapidly in low- and middle-income countries, particularly across Southeast Asia and Sub-Saharan Africa, indicating that the global dietary transition is accelerating beyond wealthy nations. Cediel et al. (2021) confirmed adolescents in Chile as the highest consumers domestically, while Dicken et al. (2023) established through a multi-national systematic review that younger age, urban residence, and unmarried status consistently predicted higher UPF intake across 34 nationally representative surveys. Collectively, these findings demonstrate that UPF consumption is a structural, cross-cultural dietary phenomenon requiring population-wide public health intervention rather than individual behavioral correction alone.

The evidence presented in Table 2 establishes a broad and consistent pattern of adverse health associations attributable to elevated UPF consumption across multiple disease categories, with findings drawn from prospective cohorts, cross-sectional surveys, and systematic reviews spanning fifteen studies across twelve countries. The strength, consistency, and breadth of these associations collectively reinforce the classification of UPF consumption as a significant and modifiable dietary risk factor for non-communicable disease. Srour et al. (2022) reported that each 10% increase in UPF intake was independently associated with a 12% higher risk of cardiovascular disease in a large French prospective cohort, a finding corroborated by Zhong et al. (2021), who demonstrated that the highest tertile of UPF consumption in a multicenter American cohort carried significantly greater cardiovascular mortality risk. With respect to metabolic outcomes, Delpino et al. (2022) confirmed through a meta-analysis of 373,124 participants that each 10% increment in UPF consumption significantly elevated type 2 diabetes incidence, while Lv et al. (2021) established a 7% increase in hypertension prevalence per daily UPF serving in a large Chinese cross-sectional study. Canhada et al. (2020) demonstrated a 27% greater obesity risk among the highest UPF quintile in Brazil over eight years. Mental health outcomes were equally implicated, with Gomez-Donoso et al. (2020) and Adjibade et al. (2021) both documenting significant positive associations between UPF intake and depression incidence and depressive symptom scores respectively. Rico-Campà et al. (2021) established that each additional daily UPF serving was associated with an 18% increase in all-cause mortality risk, reinforcing the systemic and cumulative nature of UPF-related health harm.

The findings summarized in Table 3 provide compelling evidence that the relationship between UPF consumption and adverse health outcomes follows a consistent, linear dose-response gradient, strengthening the causal inference that can be drawn from the predominantly observational evidence base. Suksatan et al. (2022) demonstrated through a dose-response meta-analysis of 207,291 participants that each 10% increase in UPF intake raised all-cause mortality risk by 21% and cardiovascular disease mortality by 50%, with a linear response curve confirmed across the full distribution of UPF intake. Taneri et al. (2022) corroborated these findings in a larger pooled sample of 521,120 participants, establishing that the highest UPF tertile carried a 26% greater all-cause mortality risk compared to the lowest. Yuan et al. (2023) further quantified that each 10% increase in UPF consumption was associated with a 6% higher risk of cardiovascular events. For cancer outcomes, Fiolet et al. (2020) and Chang et al. (2023) both confirmed dose-dependent increases in cancer incidence and mortality respectively, with 10% UPF increments linked to 12% and 2% higher cancer risks. Moradi et al. (2021) established an equivalent 15% rise in type 2 diabetes incidence per 10% UPF increase. Mental health outcomes similarly demonstrated graded associations, with Gomez-Donoso et al. (2020) and Adjibade et al. (2021) confirming stepwise increases in depression risk and depressive symptom burden across UPF consumption tertiles. Lavigne-Robichaud et al. (2023) extended these findings to cognitive outcomes, documenting accelerating cognitive decline across higher UPF tertiles in a Canadian cohort. The consistency of dose-response gradients across such diverse outcomes, populations, and methodological approaches substantially reinforces the public health urgency of reducing population-level UPF consumption.

The methodological quality assessment presented in Table 4 reveals that the evidence base underpinning this systematic review is predominantly of moderate to high quality, providing reasonable confidence in the reported associations between UPF consumption and health outcomes, while simultaneously highlighting several persistent and important gaps that limit the certainty and generalizability of current findings. Among the systematic reviews and meta-analyses appraised using AMSTAR-2, Lane et al. (2024), Pagliai et al. (2021), Suksatan et al. (2022), and Khandpur et al. (2023) all received high quality ratings, reflecting pre-registered protocols, comprehensive database searches, formal risk of bias assessments, and application of GRADE evidence certainty frameworks. The large prospective cohort studies by Srour et al. (2022) and Chang et al. (2023) scored 8 out of 9 on the Newcastle-Ottawa Scale, reflecting strong methodological rigor including validated dietary assessment instruments and comprehensive covariate adjustment. However, several critical gaps were identified consistently across studies. First, the overwhelming dominance of observational study designs across the evidence base means that causal directionality cannot be definitively established, as confounding by broader lifestyle factors, socioeconomic status, and overall diet quality remains a persistent limitation even in the most rigorously adjusted analyses. Second, geographic representation is heavily skewed toward high-income European and North American populations, with Khandpur et al. (2023) and Dicken et al. (2023) both explicitly noting the scarcity of high-quality data from low- and middle-income countries. Third, heterogeneity in dietary assessment methods and NOVA classification application across studies complicates cross-study comparisons, as noted by Taneri et al. (2022). These gaps collectively underscore the urgent need for longitudinal, interventional, and geographically diverse research to strengthen causal evidence and inform equitable global dietary policy.

DISCUSSION

The findings of this systematic review provide a comprehensive and multi-dimensional account of the relationship between ultra-processed food consumption and a wide spectrum of adverse health outcomes, drawing on evidence from 87 studies spanning 24 countries and multiple study designs. The results consistently demonstrated that UPF consumption is positively and dose-dependently associated with increased risks of cardiovascular disease, type 2 diabetes, obesity, mental health disorders, cancer, and all-cause mortality, corroborating and extending the conclusions of prior landmark reviews including Lane et al. (2024) and Pagliai et al. (2021). The breadth and consistency of these associations across geographically, demographically, and methodologically diverse studies strengthens the inference that UPF consumption represents a genuinely independent and modifiable dietary determinant of non-communicable disease burden at the population level. The following discussion contextualizes these findings within the existing literature, examining the epidemiological evidence, biological mechanisms, and population-level implications identified across the review.

CONCLUSION

Strong and consistent evidence indicates that ultra-processed food consumption is an independent, dose-dependent risk factor for multiple non-communicable diseases, including cardiovascular disease, type 2 diabetes, obesity, cancer, mental health disorders, and all-cause mortality. Across 87 studies from 24 countries, higher intake of ultra-processed foods contributes substantially to total energy consumption worldwide, influenced by broader sociodemographic and commercial forces beyond individual control. Dose-response relationships across outcomes, together with mechanistic findings involving gut microbiome disruption, systemic inflammation, and food additive toxicity, strengthen causal inference. The burden is disproportionately higher among children, adolescents, and lower-income populations, reflecting structural inequalities in food environments. Although the evidence base is largely of moderate to high quality, gaps remain in low- and middle-income country data and randomized trials. Overall findings support urgent, coordinated public health action to reduce ultra-processed food consumption and mitigate its growing global disease burden.

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