Associations of Processed Meat, Unprocessed Red Meat, Poultry, or Fish Intake With Incident Cardiovascular Disease and All-Cause Mortality

Abstract

Importance: Although the associations between processed meat intake and cardiovascular disease (CVD) and all-cause mortality have been established, the associations of unprocessed red meat, poultry, or fish consumption with CVD and all-cause mortality are still uncertain.

Objective: To identify the associations of processed meat, unprocessed red meat, poultry, or fish intake with incident CVD and all-cause mortality.

Design, setting, and participants: This cohort study analyzed individual-level data of adult participants in 6 prospective cohort studies in the United States. Baseline diet data from 1985 to 2002 were collected. Participants were followed up until August 31, 2016. Data analyses were performed from March 25, 2019, to November 17, 2019.

Exposures: Processed meat, unprocessed red meat, poultry, or fish intake as continuous variables.

Main outcomes and measures: Hazard ratio (HR) and 30-year absolute risk difference (ARD) for incident CVD (composite end point of coronary heart disease, stroke, heart failure, and CVD deaths) and all-cause mortality, based on each additional intake of 2 servings per week for monotonic associations or 2 vs 0 servings per week for nonmonotonic associations.

Results: Among the 29 682 participants (mean [SD] age at baseline, 53.7 [15.7] years; 13 168 [44.4%] men; and 9101 [30.7%] self-identified as non-white), 6963 incident CVD events and 8875 all-cause deaths were adjudicated during a median (interquartile range) follow-up of 19.0 (14.1-23.7) years. The associations of processed meat, unprocessed red meat, poultry, or fish intake with incident CVD and all-cause mortality were monotonic (P for nonlinearity ≥ .25), except for the nonmonotonic association between processed meat intake and incident CVD (P for nonlinearity = .006). Intake of processed meat (adjusted HR, 1.07 [95% CI, 1.04-1.11]; adjusted ARD, 1.74% [95% CI, 0.85%-2.63%]), unprocessed red meat (adjusted HR, 1.03 [95% CI, 1.01-1.06]; adjusted ARD, 0.62% [95% CI, 0.07%-1.16%]), or poultry (adjusted HR, 1.04 [95% CI, 1.01-1.06]; adjusted ARD, 1.03% [95% CI, 0.36%-1.70%]) was significantly associated with incident CVD. Fish intake was not significantly associated with incident CVD (adjusted HR, 1.00 [95% CI, 0.98-1.02]; adjusted ARD, 0.12% [95% CI, -0.40% to 0.65%]). Intake of processed meat (adjusted HR, 1.03 [95% CI, 1.02-1.05]; adjusted ARD, 0.90% [95% CI, 0.43%-1.38%]) or unprocessed red meat (adjusted HR, 1.03 [95% CI, 1.01-1.05]; adjusted ARD, 0.76% [95% CI, 0.19%-1.33%]) was significantly associated with all-cause mortality. Intake of poultry (adjusted HR, 0.99 [95% CI, 0.97-1.02]; adjusted ARD, -0.28% [95% CI, -1.00% to 0.44%]) or fish (adjusted HR, 0.99 [95% CI, 0.97-1.01]; adjusted ARD, -0.34% [95% CI, -0.88% to 0.20%]) was not significantly associated with all-cause mortality.

Conclusions and relevance: These findings suggest that, among US adults, higher intake of processed meat, unprocessed red meat, or poultry, but not fish, was significantly associated with a small increased risk of incident CVD, whereas higher intake of processed meat or unprocessed red meat, but not poultry or fish, was significantly associated with a small increased risk of all-cause mortality. These findings have important public health implications and should warrant further investigations.

Figure 1.. Associations of Meat, Poultry, or Fish Intake With Incident Cardiovascular Disease (CVD) and All-Cause Mortality

Cohort-stratified cause-specific hazard models for incident CVD and cohort-stratified standard proportional hazards models for all-cause mortality were applied. The models were further stratified by age groups, sex, and race/ethnicity for panel E and by sex for panel F, to satisfy proportional hazards assumption. The dotted vertical line indicates the 95th percentile cutoff. The distribution is shown up to the 99th percentile. All panels were created with the fully adjusted models specified in the Methods. P values for the quadratic term of the food intake were P = .006 for A, P = .35 for B, P = .62 for C, P = .25 for D, P = .36 for E, P = .57 for F, P = .63 for G, and P = .48 for H.

Figure 2.. Associations of Meat, Poultry, or Fish Intake With Incident Cardiovascular Disease (CVD)

All models were stratified by cohort. Model 1 was adjusted for age, sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, Chinese, or other), and educational level (less than high school, high school, or some college or higher). Model 2 was adjusted for model 1 variables plus total energy, smoking status (current, former, or never), smoking pack-years (0, 0.1-4.9, 5.0-9.9, 10-19.9, 20-29.9, 30-39.9, or ≥40), cohort-specific physical activity z score, alcohol intake (grams), and hormone therapy (yes or no). Model 3 was adjusted for model 2 variables plus fruits, legumes, potatoes, other vegetables excluding legumes and potatoes, nuts and seeds, whole grains, refined grains, low-fat dairy products, high-fat dairy products, sugar-sweetened beverages, eggs, and 3 of the 4 food types (processed meat, unprocessed red meat, poultry, and fish); a term of processed meat squared was also included. HR indicates hazard ratio.

Figure 3.. Associations of Meat, Poultry, or Fish Intake With All-Cause Mortality

All models were stratified by cohort. Model 1 was adjusted for age, sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, Chinese, or other), and educational level (less than high school, high school, or some college or higher). Model 2 was adjusted for model 1 variables plus total energy, smoking status (current, former, or never), smoking pack-years (0, 0.1-4.9, 5.0-9.9, 10-19.9, 20-29.9, 30-39.9, or ≥40), cohort-specific physical activity z score, alcohol intake (grams), and hormone therapy (yes or no). Model 3 was adjusted for model 2 variables plus fruits, legumes, potatoes, other vegetables excluding legumes and potatoes, nuts and seeds, whole grains, refined grains, low-fat dairy products, high-fat dairy products, sugar-sweetened beverages, eggs, and 3 of the 4 food types (processed meat, unprocessed red meat, poultry, and fish). HR indicates hazard ratio.