Ultraprocessed Food Versus Diet Quality in Relation to Cardiometabolic Health and All-Cause Mortality: NHANES 1999-2018

Objectives. To examine associations of ultraprocessed foods (UPFs, defined by Nova) with cardiometabolic risk factors, prevalent conditions, and mortality, before and after comprehensively adjusting for nutritional quality. Methods. We analyzed data from 47 999 adults in the National Health and Nutrition Examination Survey (NHANES) 1999-2018. Survey-weighted, multivariable adjusted linear or logistic regression evaluated cross-sectional associations with risk factors and disease prevalence, and Cox models evaluated prospective associations with all-cause mortality. Models were compared before and after adjustment for each individual's Food Compass Score (i.FCS) to test independence from nutritional quality. Results. Every 10% of energy supplied from UPFs was associated with higher body mass index, HbA1c, diastolic blood pressure, total-to-high-density lipoprotein cholesterol (HDL-C); lower HDL-C and low-density lipoprotein cholesterol (LDL-C); greater prevalence of metabolic syndrome (odds ratio [OR] = 1.07; 95% confidence interval [CI] = 1.05, 1.09), diabetes (OR = 1.03; 95% CI = 1.00, 1.07), and cancer (OR = 1.05; 95% CI = 1.02, 1.08); and higher risk of all-cause mortality (hazard ratio = 1.04; 95% CI = 1.02, 1.07). When we adjusted for i.FCS, associations were only partly attenuated, remaining significant. By comparison, adjustment for saturated fat, added sugar, or sodium had little effect. Findings were consistent in population subgroups, except for stronger associations among lower-income adults. Conclusions. UPF consumption is associated with adverse risk factors, disease conditions, and all-cause mortality, only partly explained by nutritional quality. (Am J Public Health. 2026;116(7):1015-1024. https://doi.org/10.2105/AJPH.2026.308499).