Emulsifiers and heart health: a prospective cohort study reveals associations

In a recent study published in BMJ, researchers examined the relationships between the intake of food emulsifiers and cardiovascular disease (CVD) risk.

Food additive emulsifiers and risk of cardiovascular disease in the NutriNet-Santé cohort: prospective cohort study
Study: Food additive emulsifiers and risk of cardiovascular disease in the NutriNet-Santé cohort: prospective cohort study. Image Credit: New Africa/Shutterstock.com


Emulsifiers are substances added to industrially processed food products to enhance texture and lengthen shelf life. Studies conducted on healthy individuals have reported detrimental impacts of food emulsifiers on the gut microbiome and metabolome, which can result in chronic inflammation in the gut and increase CVD and cancer risk.

About the study

In the present prospective cohort study, researchers investigated whether consuming food emulsifiers could affect cardiovascular well-being.

Data from participants in the NutriNet-Santé trial, conducted between 2009 and 2021, were analyzed. The study population comprised adult individuals without prevalent cardiovascular diseases who completed three or more 24-hour diet records within the initial two years of follow-up or through October 5, 2021, whichever occurred first.

The outcome measures were relationships between exposure to food emulsifiers [continuous (mg/day)] and risk of cerebrovascular disease, coronary artery disease, and cardiovascular disease, characterized by multivariate proportional hazard Cox modeling to calculate hazard ratios (HRs).

The team recruited individuals from the general French population through media campaigns and, upon enrolment, completed five questionnaires.

These were related to their diet, health (e.g., family and personal medical history, medications), anthropometric measures (such as weight and height), physical fitness (one-week evaluation using the International Physical Activity Questionnaire [IPAQ]), and sociodemographic and lifestyle measures (such as birth date, sex, educational attainment, number of offsprings, profession, and smoking status).

Regular dietary consumption was assessed at study initiation and then semi-annually using three, online one-day diet records, assigned randomly over 14 days. The records included details such as brands and commercial names of industrial food products to calculate the intake of each additive. Portion sizes were estimated based on the volume or weight of food consumed using validated containers or photographs.

In addition, a food intake database in France was reviewed to estimate the mean daily consumption of micronutrients, macronutrients, alcohol, and energy. To assess dietary quality, the food items consumed were matched with three databases: OQALI, Open Food Facts, and the Mintel Global New Products Database. In addition, study data were linked to the National Health Insurance database and the national cause-specific mortality registry of France.

Respondents underreporting their total calorie intake were excluded from the analysis. Individual emulsifiers with similar chemical structures were grouped as phosphates, lactylates, fatty acid polyglycerol esters, fatty acid monoglycerides and diglycerides, celluloses, carrageenans, modified starches, and alginates.


Of 127,826 individuals with two or more valid dietary records at baseline, 21,708 were excluded due to under-reported calorie intake, 1,890 were excluded due to prevalent cardiovascular disease at baseline, and 8,786 were excluded since they provided less than three one-day diet records.

As a result, 95,442 eligible individuals were included, among whom 79% (n=75,390) were female, and the mean participant age was 43 years.

At study initiation, in comparison to individuals with the lowest intake of food emulsifiers, those who consumed emulsifiers the most showed an increased likelihood of being younger non-smokers with higher body mass index (BMI) values, educational attainment, and physical fitness.

In addition, individuals with increased emulsifier intake showed tendencies to consume more calories, sodium, saturated fats, fiber, and sugars.

Food additive emulsifiers were mostly detected in processed fruits and vegetables (such as dehydrated soups, 19%), biscuits and cakes (15%), and dairy (10%). Among the food emulsifiers quantified using the dietary records of the participants, 61 food emulsifiers were identified as emulsifying salts or emulsifiers.

During the median follow-up of 7.4 years, 1,995, 1,044, and 974 new-onset cardiovascular diseases, coronary artery diseases, and cerebrovascular diseases, respectively, were diagnosed.

Increased cellulose intake was positively correlated with higher CVD risks and coronary artery disease. In particular, increased E460 cellulose consumption was associated with elevated risks of cardiovascular disease and coronary artery disease, and increased carboxymethylcellulose intake was linked to higher coronary artery disease and CVD risks.

In addition, increased consumption of fatty acid monoglyceride and diglyceride compounds was linked to elevated CVD risks.

Among the food additives, citric acid esters of fatty acid monoglycerides, as well as diglycerides, were linked to increased risks of cardiovascular disease and coronary artery disease. In addition, lactic esters of fatty acid monoglyceride and diglyceride compounds were linked to increased risks of cardiovascular disease and cerebrovascular illness. Increased trisodium phosphate consumption was linked to a higher coronary artery disease risk. Sensitivity analyses yielded similar results.

Overall, the study findings showed positive relationships between cardiovascular disease risk and consumption of food emulsifier groups (celluloses and fatty acid monoglyceride and diglyceride compounds) and individual food additive emulsifiers (E4-60, 66, 72b, 72c) used widely in industrial foods.

Journal reference:
Pooja Toshniwal Paharia

Written by

Pooja Toshniwal Paharia

Pooja Toshniwal Paharia is an oral and maxillofacial physician and radiologist based in Pune, India. Her academic background is in Oral Medicine and Radiology. She has extensive experience in research and evidence-based clinical-radiological diagnosis and management of oral lesions and conditions and associated maxillofacial disorders.


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