10.4081/btvb.2023.91
Not available. 
application/pdf
2785-5309
91
3
en
Maria Benedetta Donati
https://creativecommons.org/licenses/by-nc/4.0
Bleeding, Thrombosis and Vascular Biology
venous thromboembolism
It’s definitely time to consider diet in its ultra-processing form as a major risk factor for thrombotic vascular disorders
Text.Serial.Journal
https://www.btvb.org/btvb
2
Invited Editorials
2023-08-03
2023-07-11
2023-07-31
2023-11-15
Bleed Thromb Vascul Biol
Maria Benedetta Donati
2023/08/03
10.4081/btvb.2023.91
Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli
2785-5309
3
venous thromboembolism
en
de Oliveira PG, de Sousa JM, Assunção DGF, et al. Impacts of consumption of ultra-processed foods on the maternal-child health: a systematic review. Front Nutr 2022;9:821657.
It’s definitely time to consider diet in its ultra-processing form as a major risk factor for thrombotic vascular disorders
https://www.btvb.org/btvb/article/download/91/79
2
                                                                                                            INVITED EDITORIAL

It’s definitely time to consider diet in its ultra-processing form
as a major risk factor for thrombotic vascular disorders
Marialaura Bonaccio1, Licia Iacoviello1,2, Maria Benedetta Donati1

Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli; 2Department of Medicine and Surgery, Research Center in
1

Epidemiology and Preventive Medicine (EPIMED), University of Insubria, Varese, Italy




    Shuai Yuan et al. recently examined whether ultra-                        son-years in Europe and the USA, respectively, varying widely
processed food (UPF) intake is associated with an increased                   by age, sex, race and medical conditions.2
risk of venous thromboembolism (VTE).1 To accomplish this,                         Unprovoked VTE, which occurs in the absence of trigger-
they longitudinally analysed data on 186,323 participants free                ing factors such as immobilization, trauma, surgery, cancer
of VTE at baseline from the larger UK Biobank cohort, with a                  or hospitalization,2 could be theoretically avoided through
total of 4235 incident VTE cases recorded after a 10.5-year fol-




                                                                                                         ly
                                                                              lifestyle choices, such as absence of smoking and having a
low-up. After adjusting for known risk factors, results showed                healthy body weight.3




                                                                                                 on
that a higher UPF intake was associated with 10% to 21% in-                        A number of studies have also examined the potential role
creased risk of VTE.                                                          of diet quality on VTE risk, but failed to provide robust evi-
    In most countries, VTE is one of the most common vascular                 dence;4 some randomized controlled trials and cohort studies in-




                                                                                           e
diseases, and its incidence is estimated to be ~1-2 per 1000 per-             dicated that diets rich in fruits and vegetables, moderate alcohol,

                                                                                   us
                                                                              vitamin E, vitamin B6, and fibre are possibly associated with a
                                                                              reduced VTE risk.2 Lack of convincing evidence on the impact
                                                                              of diet on VTE could be possibly due to the fact that traditional
                                                                              al
                                                                              approaches to the diet-disease relationship have been mainly tar-
    Correspondence: Marialaura Bonaccio, Department of Epidemiol-             geted to the nutritional quality assessment, regardless of food
                                                                    ci

    ogy and Prevention, IRCCS Neuromed, Via Atinense 18, 86077
                                                                              processing. However, it is largely acknowledged that the nutri-
    Pozzilli (IS), Italy.
                                                                              tional composition alone does not exhaustively explain the over-
                                                                  er


    E-mail: marialaura.bonaccio@moli-sani.org
                                                                              all food health potential, and that other non-nutritional factors
                                                                              could be equally relevant to human health.5
                                                                 m



    Citation: Bonaccio M, Iacoviello L, Donati MB. It’s definitely time
    to consider diet in its ultra-processing form as a major risk factor           In order to adequately capture all dimensions of food,
    for thrombotic vascular disorders. Bleeding, Thrombosis, and Vas-
                                                      om




                                                                              Brazilian researchers conceptualized and developed the Nova
    cular Biology 2023;2:91.                                                  classification.6 This classification was originally proposed as a
                                                                              novel way to look at foods based on the degree of processing of
    Key words: diet, thrombotic risk, venous thromboembolism.
                                               -c




                                                                              foods rather than on their nutritional composition, postulating
    Contributions: the authors contributed equally.                           that processing may be as relevant to health as food composition,
                                      on




                                                                              possibly through mechanisms that are triggered by non-nutri-
    Conflict of interest: the authors declare no potential conflict of in-    tional components of these foods, such as degradation and arti-
    terest.                                                                   ficialization of the food matrix, cosmetic additives, food contact
                                N




                                                                              materials, or neo-formed compounds (Figure 1).5-8
    Ethical approval and consent to participate: not applicable.                   The term ultra-processed foods indicates industrially man-
                                                                              ufactured ready-to-eat or ready-to-heat formulations made
    Received: 10 July 2023.
    Accepted: 20 July 2023.                                                   mostly or entirely from substances extracted from foods or de-
                                                                              rived from food constituents often containing added flavours,
    Publisher’s note: all claims expressed in this article are solely those   colours, emulsifiers and other cosmetic additives;6,8 most impor-
    of the authors and do not necessarily represent those of their affili-    tantly, UPFs are intentionally produced to be hyper-palatable
    ated organizations, or those of the publisher, the editors and the re-    and attractive, with long shelf-life, and able to be consumed any-
    viewers. Any product that may be evaluated in this article or claim       where at any time, and their formulation, presentation and mar-
    that may be made by its manufacturer is not guaranteed or endorsed        keting often promote overconsumption.9
    by the publisher.                                                              Examples of typical UPFs are carbonated drinks, fruit yo-
                                                                              gurt, fruit drinks, sweet or savoury packaged snacks, ice-cream,
    ©
     Copyright: the Author(s), 2023
    Licensee PAGEPress, Italy                                                 chocolate, candies (confectionery), mass-produced packaged
    Bleeding, Thrombosis and Vascular Biology 2023; 2:91                      breads and buns, and many others.6
    doi:10.4081/btvb.2023.91                                                       In the last decade, the number of studies examining the re-
                                                                              lationship of UPF and health has dramatically increased, due to
    This work is licensed under a Creative Commons Attribution-               the fact that consumption of highly processed food is on the rise
    NonCommercial 4.0 International License (CC BY-NC 4.0).                   globally. Actually, UPFs have progressively displaced un-
                                                                              processed or minimally processed foods and traditional cooking


                                                Bleeding, Thrombosis and Vascular Biology 2023; 2:91
        It’s definitely time to consider diet in its ultra-processing form as a major risk factor for thrombotic vascular disorders     11




                                                                                            ly
                                                                                    on
                                                                              e
                                                                         us
Figure 1. The Nova food classification. Reprinted from de Oliveira PG et al.27
                                                                    al
                                                     ci

in the diet worldwide, and now constitute more than half of the              In light of this, the relationship between dietary habits and
                                                   er


total calories eaten daily in many high-income Countries.10              VTE, as well as other blood clotting-related diseases, will likely
     In Mediterranean Countries such as Spain and Italy, the pro-        benefit from a paradigm shift aimed to examine the overall food
                                                  m




portion of food that is ultra-processed among adults is about            health potential rather than the nutritional composition alone.
                                       om




24% and 17%, respectively,11,12 probably because home cooking            This would possibly help clarifying the role of diet (as a broader
is still part of a traditional Mediterranean diet.                       concept) to the pathogenesis of these diseases and also con-
     Robust and well-conducted cohort studies worldwide found            tribute to the reduction of their burden globally.
that a larger dietary share of UPF is associated with shorter survival
                                 -c




and an increased risk of non-communicable diseases,13 including
                         on




cardiovascular disease (CVD),14 type 2 diabetes,15 and cancer.16         References
     Analyses from the Moli-sani Study in Italy have shown that
UPF intake is an independent risk factor for mortality not only           1. Yuan S, Chen J, Fu T, et al. Ultra-processed food intake and
                    N




in the general population, but also among participants with pre-             incident venous thromboembolism risk: Prospective cohort
existing CVD.17                                                              study. Clin Nutr 2023;42:1268-75.
     Potential mechanisms linking UPFs to cardiovascular health           2. Lutsey PL, Zakai NA. Epidemiology and prevention of ve-
include, among others, altered low-grade inflammation - possi-               nous thromboembolism. Nat Rev Cardiol 2023;20:248-62.
bly triggered by contaminants (e.g., phthalates, bisphenols that          3. Gregson J, Kaptoge S, Bolton T, et al. Emerging Risk Fac-
migrate from contact packaging to foods),10,18,19 altered food ma-           tors Collaboration. Cardiovascular Risk Factors Associated
trix, and food additives - that is a major risk factor for cardio-           With Venous Thromboembolism. JAMA Cardiol 2019;4:
vascular disease,20 and VTE.21                                               163-73.
     Also, higher intake of UPF has been associated with im-              4. Varraso R, Kabrhel C, Goldhaber SZ, et al. Prospective
paired renal function and obesity,17,22,23 which have been report-           study of diet and venous thromboembolism in US women
edly linked to increased VTE risk in prior cohort studies.24-26              and men. Am J Epidemiol 2012;175:114-26.
     Interestingly, most of the reported associations between UPF         5. Fardet A, Rock E, Bassama J, et al. Current food classifica-
intake and adverse health outcomes were independent of the                   tions in epidemiological studies do not enable solid nutri-
overall diet quality; this means that the poor diet quality of this          tional recommendations for preventing diet-related chronic
foods (e.g. high in sugar, salt, cholesterol, and low in fibre, min-         diseases: the impact of food processing. Adv Nutr 2015;6:
erals and vitamins) only partially accounts for the excess of                629-38.
death or disease associated with UPF consumption,17 and this              6. Monteiro CA, Cannon G, Levy RB, et al. NOVA. The star
may explain the weak associations between diet quality and                   shines bright. World Nutr 2016;7:28-38.
VTE observed so far.                                                      7. Fardet A, Rock E. Chronic diseases are first associated with


                                           Bleeding, Thrombosis and Vascular Biology 2023; 2:91
12                                                           M. Bonaccio et al.




      the degradation and artificialization of food matrices rather      18. Juul F, Vaidean G, Parekh N. Ultra-processed foods and car-
      than with food composition: calorie quality matters more               diovascular diseases: potential mechanisms of action. Adv
      than calorie quantity. Eur J Nutr 2022;61:2239-53.                     Nutr 2021;12:1673-80.
 8.   Monteiro CA. Nutrition and health. The issue is not food,          19. Mignogna C, Costanzo S, Di Castelnuovo A, et al. The in-
      nor nutrients, so much as processing. Public Health Nutr               flammatory potential of the diet as a link between food pro-
      2009;12:729-31.                                                        cessing and low-grade inflammation: an analysis on 21,315
 9.   Monteiro CA, Cannon G, Moubarac JC, et al. The UN Decade               participants to the Moli-sani study. Clin Nutr 2022;41:
      of Nutrition, the NOVA food classification and the trouble             2226-34.
      with ultra-processing. Public Health Nutr 2018;21:5-17.
                                                                         20. Danesh J, Whincup P, Walker M, et al. Low grade inflam-
10.   Srour B, Kordahi MC, Bonazzi E, et al. Ultra-processed
                                                                             mation and coronary heart disease: prospective study and
      foods and human health: from epidemiological evidence to
                                                                             updated meta-analyses. BMJ 2000;321:199-204.
      mechanistic insights. Lancet Gastroenterol Hepatol 2022;7:
      1128-40.                                                           21. Evensen LH, Folsom AR, Pankow JS, et al. Hemostatic fac-
11.   Blanco-Rojo R, Sandoval-Insausti H, López-Garcia E, et al.             tors, inflammatory markers, and risk of incident venous
      Consumption of Ultra-Processed Foods and Mortality: A                  thromboembolism: the multi-ethnic study of atherosclerosis.
      National Prospective Cohort in Spain. Mayo Clin Proc 2019;             J Thromb Haemost 2021;19:1718-28.
      94:2178-88.                                                        22. Bonaccio M, Di Castelnuovo A, Costanzo S, et al. Ultra-
12.   Ruggiero E, Esposito S, Costanzo S, et al. Ultra-processed             processed food consumption is associated with increased




                                                                                                   ly
      food consumption and its correlates among Italian children,            risk of all-cause and cardiovascular mortality in the Moli-




                                                                                           on
      adolescents and adults from the Italian Nutrition & Health             sani study. Am J Clin Nutr 2021;113:446-55.
      Survey (INHES) cohort study. Public Health Nutr 2021;24:           23. Mambrini SP, Menichetti F, Ravella S, et al. Ultra-processed
      6258-71.                                                               food consumption and incidence of obesity and cardiometa-




                                                                                      e
13.   Pagliai G, Dinu M, Madarena MP, et al. Consumption of                  bolic risk factors in adults: a systematic review of prospec-
      ultra-processed foods and health status: a systematic review

14.
      and meta-analysis. Br J Nutr 2021;125:308-18.
      Juul F, Vaidean G, Lin Y, et al. Ultra-processed foods and
                                                                                  us
                                                                             tive studies. Nutrients 2023;15:2583.
                                                                         24. Wattanakit K, Cushman M, Stehman-Breen C, et al. Chronic
                                                                             kidney disease increases risk for venous thromboembolism.
      incident cardiovascular disease in the Framingham Off-
                                                                        al
                                                                             J Am Soc Nephrol 2008;19:135-40.
      spring study. J Am Coll Cardiol 2021;77:1520-31.
                                                                         25. Mahmoodi BK, Gansevoort RT, Næss IA, et al. Association
                                                           ci

15.   Llavero-Valero M, Escalada-San Martín J, Martínez-
                                                                             of mild to moderate chronic kidney disease with venous
      González MA, et al. Ultra-processed foods and type-2 dia-
                                                         er


                                                                             thromboembolism: pooled analysis of five prospective gen-
      betes risk in the SUN project: a prospective cohort study.
      Clin Nutr 2021;40:2817-24.                                             eral population cohorts. Circulation 2012;126:1964-71.
                                                        m




16.   Fiolet T, Srour B, Sellem L, et al. Consumption of ultra-          26. Caiano LM, Costanzo S, Panzera T, et al. Association be-
      processed foods and cancer risk: results from NutriNet-                tween body mass index, waist circumference, and relative
                                               om




      Santé prospective cohort. BMJ 2018;360:k322.                           fat mass with the risk of first unprovoked venous throm-
17.   Bonaccio M, Costanzo S, Di Castelnuovo A, et al. Ultra-                boembolism. Nutr Metab Cardiovasc Dis 2021;31:3122-30.
      processed food intake and all-cause and cause-specific mor-        27. de Oliveira PG, de Sousa JM, Assunção DGF, et al. Impacts
                                         -c




      tality in individuals with cardiovascular disease: the                 of consumption of ultra-processed foods on the maternal-
      Moli-sani Study. Eur Heart J 2022;43:213-24.                           child health: a systematic review. Front Nutr 2022;9:821657.
                                 on
                            N




                                          Bleeding, Thrombosis and Vascular Biology 2023; 2:91
