UPFs with heart benefits?
A review of the evidence
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Welcome to the second of our four-part blog series, where we will explore essential dietary interventions for achieving optimal blood lipids.
Ultra-processed foods (UPFs) are frequently cited as having adverse health effects1,2. This is true for many processed foods high in saturated fat, salt, and/or sugars. However, not all UPFs have a negative nutritional profile. Some, like spreads rich in unsaturated fat and wholemeal bread high in fibre, are associated with positive cardiovascular and other health outcomes3,4. As Dr Thomas Butler and Lynne Garton discuss in our Diet and Lipid Network Meeting, demonising food solely based on its level of processing is neither productive nor beneficial for cardiovascular or other health outcomes. The nutritional quality of food plays a crucially greater role in determining health outcomes3,4.
This 2024 publication examines this complex issue by focusing on plant-based meat alternatives (PBMA) and their effects on cardiovascular risk factors and cardiovascular disease (CVD) outcomes5.
Why focus on plant-based meat alternatives?
Meat and meat products are among the top contributors to saturated fat intake in the UK diet6, which remains above recommendations7. Additionally, meat consumption per se has been associated with poorer cardiovascular disease outcomes8-10. Therefore, reducing meat and meat products and replacing them with healthier plant proteins is a key dietary strategy for managing blood cholesterol and improving cardiovascular health11. Healthful plant-based diets, including those that include some meat, have been proven to be cardioprotective12.
From a behavioural strategy perspective, PBMA products are more likely to appeal to meat consumers than other plant proteins, such as beans and tofu, which have little similarity to meat's characteristics. However, PBMA are classified as UPFs, which can lead to the presumption that they are unhealthy and may deter people from consuming or recommending them.
What the study investigated
This study reviews current evidence on the impact of PBMA on cardiovascular outcomes, and examines whether their classification as UPFs is relevant to health outcomes. Given the variation in PBMA, the authors also investigated the influence of their protein sources and overall nutritional profiles5.
Studies selected
Prospective cohort studies and randomised controlled trials (RCTs) comparing the impact of PBMA versus meat consumption and common PBMA ingredients on cardiovascular outcomes were included.
A re-cap on UPFsUPFs are part of the Brazilian NOVA food classification system, which places foods into one of four categories based on their level of processing13:
The system discourages consumption of Group 4 foods (UPFs) and encourages more foods from Groups 1 and 2. This classification conflicts with established evidence on foods' impact on cardiovascular and other health outcomes. For example, high saturated fat foods like butter, lard, and fatty meat (in Groups 1 and 2) are known to increase blood cholesterol, while replacing saturated fats with unsaturated fat spreads (in Group 4) lowers cholesterol3,4,14,15. Another anomaly is the significant heterogeneity within Group 4, where doughnuts and chocolates are grouped with wholemeal bread and fortified high-fibre cereals. Moreover, we typically do not consume individual ingredients. Even when cooking at home, it is common to add ingredients such as oils and stock cubes, making the NOVA system challenging to apply in practice. |
Key outcomes
The authors identified differences in salt, saturated fatty acids (SFA), polyunsaturated fatty acids (PUFA), and fibre content across various PBMA. Overall, the studies demonstrated that PBMA consumption produces more favourable cardiovascular outcomes compared to meat consumption.
PBMA's superior nutritional profile
Compared to meat, PBMA tended to be lower in SFA, energy density, and protein, while higher in PUFA and fibre.
Only 14% of PBMA were classified as unhealthy versus 44% of comparative meat products. Unhealthy PBMA were typically higher in salt and, if containing coconut fat, significantly higher in SFA.
PBMA improve blood lipids
Various RCTs reviewed consistently demonstrated that replacing meat with PBMA in the diet results in lower total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), and Apo-B, even when macronutrient profiles of the diets were controlled.
PBMA and CVD
The authors felt the evidence was too limited to form accurate conclusions. However, they emphasise that meta-analyses of large cohort studies have repeatedly shown a significant reduction in CVD events with higher plant protein consumption.
PBMA and their protein ingredients
The publication highlights that many PBMA protein sources are associated with improved CVD outcomes and blood lipids:
- Soya: Extensively researched, shown to lower serum LDL-C and improve other cardiovascular risk factors, associated with reduced risk of CVD, coronary heart disease (CHD), strokes, and cancers.
- Legumes: Greater intake is associated with improved blood lipids and a 6% reduction in CVD and 10% reduction in CHD.
- Mycoproteins: RCTs have demonstrated improved lipid profiles when mycoprotein replaces meat in the diet.
In summary
PBMA vary in their makeup and nutritional profile, particularly concerning salt and saturated fat when tropical (coconut and palm) oils are used. However, compared to meat, PBMA generally have a superior nutritional profile for cardiovascular outcomes: lower in SFA, higher in PUFA, and fibre.
Replacing meat with PBMA has been shown in numerous RCTs to lower serum TC, LDL-C, TG, and Apo-B. Although direct evidence linking PBMA to CVD outcomes is limited, extensive evidence associates the protein ingredients in PBMA with reduced CVD events.
The evidence shows that replacing meat with PBMA, despite being classified as UPFs, do not negatively impact cardiovascular health. In fact, due to their positive nutrition profile, they improve blood lipids and potentially reduce CVD risk. This highlights that focusing on nutritional quality is a better indicator of health outcomes than relying solely on the NOVA classification, which only considers the degree of processing.
References
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Mambrini SP, Menichetti F, Ravella S, et al. Ultra-Processed Food Consumption and Incidence of Obesity and Cardiometabolic Risk Factors in Adults: A Systematic Review of Prospective Studies. Nutrients. 2023;15(11):2583. doi: 10.3390/nu15112583.
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Lane MM, Gamage E, Du S, et al. Ultra-processed food exposure and adverse health outcomes: umbrella review of epidemiological meta-analyses. BMJ. 2024;384:e077310. doi: 10.1136/bmj-2023-077310.
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Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice: Developed by the Task Force for cardiovascular disease prevention in clinical practice with representatives of the European Society of Cardiology and 12 medical societies With the special contribution of the European Association of Preventive Cardiology (EAPC). European Heart Journal. 2021;42(34):3227-3337. doi:10.1093/eurheartj/ehab484
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Feingold KR. The Effect of Diet on Cardiovascular Disease and Lipid and Lipoprotein Levels. In: Feingold KR, Anawalt B, Blackman MR, et al., eds. Endotext. MDText.com, Inc.; 2000. Accessed January 3, 2024. http://www.ncbi.nlm.nih.gov/books/NBK570127/
- Nagra M, Tsam F, Ward S, Ur E. Review: Animal vs Plant-Based Meat: A Hearty Debate. Canadian J Cardiol. 2024;40:1198e1209. https://onlinecjc.ca/article/S0828-282X(23)01882-2/fulltext.
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PHE. NDNS: results from years 9 to 11 (2016 to 2017 and 2018 to 2019). GOV.UK. Published December 11, 2020. Accessed January 3, 2024. https://www.gov.uk/government/statistics/ndns-results-from-years-9-to-11-2016-to-2017-and-2018-to-2019
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PHE. Government Dietary Recommendations: Government Recommendations for Energy and Nutrients for Males and Females Aged 1 – 18 Years and 19+ Years. PHE; 2016:12. https://assets.publishing.service.gov.uk/media/5a749fece5274a44083b82d8/government_dietary_recommendations.pdf
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Al-Shaar L, Satija A, Wang DD, et al. Red meat intake and risk of coronary heart disease among US men: prospective cohort study. BMJ 2020;371:m4141 http://dx.doi.org/10.1136/bmj.m4141
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Guasch-Ferré M, Satija A, Blondin SA, et al. Meta-Analysis of Randomized Controlled Trials of Red Meat Consumption in Comparison With Various Comparison Diets on Cardiovascular Risk Factors. Circulation. 2019;139:1828–1845. DOI: 10.1161/CIRCULATIONAHA.118.035225
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Papier K, Knuppel A, Syam N, et al. Meat consumption and risk of ischemic heart disease: A systematic review and meta-analysis, Critical Reviews in Food Sci Nutr. 2023;63(3):426-437. https://doi.org/10.1080/10408398.2021.1949575
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HEART UK. Healthy Protein Recommendations. https://www.heartuk.org.uk/healthy-protein/healthy-protein-recommendations
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HEART UK. Dietary Recommendations, Dietary Patterns: Plant-based diets. 2024. https://heartuk.org.uk/dietary-patterns/plant-based-diets
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EduChange with guidance from NUPENS (Sao Paulo). The NOVA Food Classification System. EduChange; 2018. https://ecuphysicians.ecu.edu/wp-content/pv-uploads/sites/78/2021/07/NOVA-Classification-Reference-Sheet.pdf
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Mensink RP, World Health Organization. Effects of Saturated Fatty Acids on Serum Lipids and Lipoproteins: A Systematic Review and Regression Analysis. World Health Organization; 2016. Accessed October 16, 2023. https://iris.who.int/handle/10665/246104
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Christensen JJ, Arnesen EK, Rundblad A, et al. Dietary fat quality, plasma atherogenic lipoproteins, and atherosclerotic cardiovascular disease: An overview of the rationale for dietary recommendations for fat intake. Atherosclerosis. 2024;389:117433. doi:10.1016/j.atherosclerosis.2023.117433
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Published: 2nd August 2024