Diabetes Distilled: ESC consensus on ultra-processed foods and cardiovascular disease

Ultra-processed foods (UPFs) are increasingly replacing healthier whole food intake. UPFs can be defined as “cheap industrial ingredients, additives and neo-formed compounds, with little or no nutritional value” (Guasti et al, 2026). Flavourings, colourings, sweeteners, emulsifiers and other additives are added to make the foods look and taste appealing and to improve consistency and mouth-feel, and these are widely believed to contribute to the addictive qualities of these foods.

Usually, the Nova classification, as developed by Monteiro (2009), is used to divide foods into four categories: unprocessed or minimally processed; processed culinary ingredients; processed foods; and UPFs. Examples of foods which would typically be placed in each of these groups is shown in Figure 1.

Consumption of UPFs is growing across Europe, and in 2016 UK intake was amongst the highest across Europe, with an average of 141 kg per person per annum, representing an average of 54% of total calories (Vandevijvereet al, 2019).

Growing evidence links dietary UPF intake to cardiometabolic risk and, although lifestyle counselling is often undertaken in those with cardiovascular disease (CVD) or at high risk of developing it, this does not usually include discussion of UPFs.

ESC consensus on UPFs

The European Society of Cardiology (ESC) has published the present consensus document in the European Heart Journal (Guasti et al, 2026). Although the consensus aims to provide actionable guidance primarily to cardiologists, it is equally applicable to us in primary and community care teams.

The relationship between UPFs and CVD is complex and multifaceted, and the consensus makes it clear that dietary UPF exposure contributes to the development of cardiometabolic risk factors such as obesity, hypertension, dyslipidaemia and insulin resistance, which indirectly contribute to adverse cardiovascular outcomes (Table 1), as well as some foods being more directly associated with cardiovascular morbidity and mortality.

Direct relationships between UPFs and cardiovascular disease

According to the evidence reviewed in the consensus statement, mainly from observational studies, UPF consumption is associated with increased cardiovascular morbidity and mortality. Associations are less clear between UPFs and atrial fibrillation or heart failure, and further studies are needed. However, the authors warn that residual confounding and reverse causation cannot be excluded, and call for larger and longer randomised controlled trials with hard clinical endpoints.

UPF foods are usually high in saturated and trans-fats and added sugar, all of which can increase the risk of type 2 diabetes, endothelial dysfunction and atherosclerosis. Processing may alter more than just the nutritional content of foods, changing the structure; forming advanced glycation end-products, acrylamide and trans-fatty acids; adding flavourings, additives, emulsifiers and contaminants; and placing food in direct contact with often toxic packaging chemicals that can leach out into the food. UPFs can also crowd out healthier foods which would have protective benefits on cardiovascular risk.

The authors conclude that since the UPF category of foods is broad and heterogeneous, many foods may be misclassified. Other studies have suggested that UPFs which do not have significant amounts of fat, salt and sugar may be less damaging, provided they do not have significant additives. Since most of the current evidence is based around cohort studies, further research is needed, ideally including randomised controlled trials.

In a study recently published in the European Heart Journal involving more than 112000 participants in the NutriNet-Santé cohort in France, Hasenböhler et al (2026) used repeated 24-hour dietary records to explore the impact of exposure to preservative food additives. This identified that total preservative intake, total non-antioxidant preservatives, sorbates, potassium sorbate (E202), potassium metabisulfite (E224), total nitrites, sodium nitrite (E250), total ascorbates, ascorbic acid (E300), sodium ascorbate (E301), total erythorbates, sodium erythorbate (E316), citric acid (E330) and extracts of rosemary (E392) were all associated with hypertension. Total non-oxidant preservatives, total ascorbates, ascorbic acid (E300), total erythorbates, and sodium erythorbate (E316) were associated with CVD, with around 16% of the CVD incidence mediated by hypertension.

Implications for practice

The people we support with type 2 diabetes, metabolic dysfunction-associated steatotic liver disease (MASLD) and/or chronic kidney disease are at increased risk of CVD. Although targeted at cardiologists, this consensus is equally relevant and important to us in primary care. The consensus provides practical guidance and a framework to follow, starting with brief screening of UPF intake followed by individualised, concise communication and advice on food substitutes, integrated into acute or chronic care alongside other lifestyle counselling (e.g. smoking cessation), and reinforced at each consultation. Tailoring education and counselling to the individual sitting beside us can make it more impactful.

Discussing the benefits of whole and unprocessed foods, and encouraging batch cooking to ensure healthy food is always available, may help reduce UPF intake on busy days. Undertaking a similar audit of our own food intake is likely to flag up where UPFs are creeping in, and provide encouragement to change – the food additives highlighted in the NutriNet-Santé study are everywhere and I suspect we largely ignore them, thinking that substances such as vitamin C (ascorbic acid) must be beneficial.

A useful free UPF calculator, which offers people the option to estimate their UPF intake and provides guidance on healthy swaps specific to the UPFs consumed, is available for free at: https://dietplanner.io/ultra-processed-food-calculator/. This can help clinicians support increases in whole foods and reductions in UPFs without needing extensive nutritional knowledge and education. The consensus is open-access and provides a detailed list of practical do’s and don’ts, facilitating dietary counselling where we do not have access to a dietitian.

Key messages regarding eating more natural foods (“real foods”), gradually reducing UPF intake and combining this with slowly increasing fibre intake, aiming for 30 g daily and 30 different fruits, vegetables, nuts, seeds, herbs and spices weekly, as well as optimising protein intake (usually aiming for up to 1 g per kg of body weight per day), can help with satiety provided there are no renal contraindications.

For most of us, access to dietetic support is very limited. Since UPFs are now known to contribute to most long-term health conditions, this consensus will hopefully provide a framework to allow us to make every contact count, however short our time.