Pepperoni: one 1988 trial on the sausage, everything else is processed meat

The only trial that fed people pepperoni itself is from 1988. Twelve healthy adults aged 24 to 43 ate a pepperoni pizza at noon and in the evening. Endoscopy about 12 hours later showed a median gastric damage score of 0, the same as after a bland meal. On the aspirin day, 1950 mg of it left erosions in 11 of the 12. That is the whole of the direct evidence, and it says nothing about years of eating. Everything else on this page is about processed meat as a class, which IARC defines to include fermented and cured sausages. In 20 healthy men, 2 weeks of 240 g a day of red and processed meat raised faecal genotoxicity and nitroso compound excretion, and the same weight of mycoprotein lowered both. In volunteers eating 180 g of cured meat a day for 4 days, faecal nitroso compounds and lipid peroxidation rose, and calcium carbonate brought both back to normal, in a trial whose abstract does not say how many people took part. Those are markers in stool over days. The cancer numbers come from cohorts. Pooled prospective cohorts to 2011 link each extra 50 g of processed meat a day to a colorectal cancer relative risk of 1.18 (95 percent CI 1.10 to 1.28), and the IARC Group 1 label rests on an analysis of the same kind. Group 1 describes how sure the evidence is, not how large the risk is. Across 31 cohorts with 1.97 million adults followed for a median 10 years, each 50 g a day carried a type 2 diabetes hazard ratio of 1.15 (1.11 to 1.20).

The numbers, per 100 g

How much is actually in it

• Pooling 99 laboratory experiments from 43 articles, cutting or replacing sodium chloride in dry-fermented sausages raised moisture, water activity, lactic acid bacteria and tyramine content, while Enterobacteriaceae still did not grow. — 43 articles with 99 product experiments on dry-fermented sausages with reduced or replaced NaCl versus conventional salt (n = 99 experiments) Evidence D source
  Higher moisture, water activity, redness, lactic acid bacteria and tyramine (P = 0.001 for tyramine); lower lightness, staphylococci and resilience; Enterobacteriaceae did not grow

What it does to your health

• In human volunteers eating 180 g of cured meat a day for 4 days in a crossover design, faecal nitroso compounds and lipid peroxidation rose, and adding calcium carbonate brought both markers back to normal. — human volunteers, crossover, 180 g/d cured meat for 4 d with or without calcium or tocopherol; parallel rat carcinogenesis experiments Evidence B source
  Cured meat increased faecal nitroso compounds and lipoperoxidation (both P < 0.05); calcium normalised both in human faeces; tocopherol reduced lipoperoxidation only
• In 20 healthy men, 2 weeks of 240 g a day of red and processed meat raised faecal genotoxicity and nitroso compound excretion, while the same weight of mycoprotein lowered both. — 20 healthy male adults, investigator-blind randomised crossover, 240 g/day red and processed meat vs 240 g/day mycoprotein, 2 weeks each with 4-week washout (n = 20) Evidence B source
  Meat diet increased faecal genotoxicity and nitroso compound excretion; mycoprotein decreased both and raised short chain fatty acid excretion
• Pooled prospective cohorts to March 2011 link each extra 50 g of processed meat a day to an 18% higher colorectal cancer risk, with risk rising roughly linearly up to about 140 g a day of red and processed meat combined. — prospective cohort studies identified in PubMed until March 2011, dose-response meta-analysis Evidence C source
  Processed meat RR 1.18 (95% CI 1.10-1.28) per 50 g/day; red and processed meat RR 1.14 (1.04-1.24) per 100 g/day; plateau near 140 g/day
• Across 31 cohorts with 1.97 million adults and 107 271 new cases over a median 10 years, each 50 g a day of processed meat was associated with a 15% higher incidence of type 2 diabetes. — 1 966 444 adults in 31 cohorts from 20 countries (InterConnect), median follow-up 10 years, 107 271 incident type 2 diabetes cases (n = 1 966 444) Evidence C source
  HR 1.15 (95% CI 1.11-1.20) per 50 g/day processed meat (I2 59%); unprocessed red meat HR 1.10 (1.06-1.15) per 100 g/day; poultry HR 1.08 (1.02-1.14) per 100 g/day
• In a 2026 meta-analysis of 31 observational studies, processed meat intake was associated with a 65% higher risk of colorectal polyps but not with colorectal adenomas. — 31 observational studies published to 31 December 2024, adults with precancerous colorectal lesions Evidence C source
  Colorectal polyps RR 1.65 (95% CI 1.05-2.61); colorectal adenomas RR 1.14 (0.93-1.41), not significant
• A 2026 umbrella review of 54 meta-analyses found each 50 g a day of processed meat associated with a 17% higher colorectal cancer risk and a 72% higher gastric cancer risk, all rated low to very low certainty by GRADE. — 34 articles and 54 meta-analyses of observational studies on processed meat, searched to May 2025 Evidence C source
  Per 50 g/day: gastric cancer +72%, colorectal cancer +17%, prostate cancer +4%, COPD +8%; certainty low to very low

Safety, limits and interactions

• In pooled prospective cohorts, each 50 g a day of processed meat was associated with a 42% higher risk of coronary heart disease. The roughly 400% higher sodium content of processed meat was modelled to explain about two-thirds of its extra risk over unprocessed meat. — prospective cohort studies of unprocessed red and processed meat, adults, updated evidence review to 2012 Evidence C source
  CHD RR 1.42 (95% CI 1.07-1.89) per 50 g/day processed meat; diabetes RR 1.51 (1.25-1.83) per 50 g/day; unprocessed red meat: smaller or no CHD risk
• WHO's IARC classified processed meat, which by its definition includes fermented and cured sausages such as pepperoni, as Group 1, carcinogenic to humans, citing an estimate that every 50 g eaten daily raises colorectal cancer risk by about 18%. — IARC Monographs Working Group evaluation, 26 October 2015, based on more than 800 studies Evidence E source
  Group 1 classification for processed meat; about 18% higher colorectal cancer risk per 50 g/day (from an analysis of 10 studies)
• In a 1999 Canadian outbreak, 143 people were infected with E. coli O157:H7 over 12 weeks, and a matched case-control study tied illness to one company's dry fermented salami, which tested positive for the outbreak strain. — 143 laboratory-confirmed cases with one PFGE pattern in British Columbia, 12 weeks, matched case-control study (n = 143) Evidence C source
  Matched odds ratio 10.0 (95% CI 1.4-434, P=0.01) for eating Company A salami; salami positive for the outbreak strain; national recall
• A 2009-2010 US outbreak of Salmonella Montevideo with 272 cases in 44 states was traced to ready-to-eat salami, with the outbreak strain isolated from the salami, from the plant and from sealed containers of black and red pepper at the facility. — 272 cases in 44 states, illness onset 1 July 2009 to 14 April 2010, matched case-control study (n = 272) Evidence C source
  Matched odds ratio 8.5 (95% CI 2.1-75.9) for eating ready-to-eat salami; outbreak strain isolated from salami, plant environment and sealed pepper containers
• Listeria monocytogenes was found in 22.7% of 1020 Italian dry salami samples taken at 17 plants before sale in 2002-2003, but always below 10 CFU per gram. — 1020 salami samples from 17 Italian plants, autumn 2002 to summer 2003, sampled before sale (n = 1020) Evidence C source
  Prevalence 22.7% (range 1.6-58.3% by plant); contamination level under 10 CFU/g; serotypes 1/2c, 1/2a, 1/2b, 4b
• Dry sausage sits on the high-risk tyramine list given to patients starting monoamine oxidase inhibitors, and in a survey of 139 psychiatric patients more than half ate dry sausage, corned beef, yeast products or beer at least monthly before such treatment. — 139 psychiatric inpatients and outpatients not yet on MAOIs, self-report questionnaire of MAOI-diet items (n = 139) Evidence C source
  Dry sausage, corned beef, yeast products, broad beans, sauerkraut and beer used at least monthly by more than 50% of patients; hard cheese used daily or weekly by 90%
• WHO's 2012 sodium guideline names processed meats among the processed foods that often carry high amounts of sodium, alongside breads, crackers and snack foods. — WHO guideline for adults and children, 2012 Evidence E source
  Processed meats listed as a high-sodium food group; WHO recommends under 2 g sodium per day for adults (elsewhere in the guideline)

What people believe that the data does not support

• In 12 healthy adults, a pepperoni pizza meal eaten at lunch and dinner left a median endoscopic gastric damage score of 0 about 12 hours later, the same as a bland steak meal, while 1950 mg of aspirin produced multiple erosions in 11 of 12. — 12 healthy adults (8 men, 4 women, aged 24 to 43), randomised crossover, four test meals each given at noon and evening, endoscopy about 12 h after (n = 12) Evidence B source
  Median Lanza-type score 0 after pepperoni pizza, Mexican meal and bland meal; single erosion in single cases after pizza and Mexican meals; aspirin meal: erosions in 11/12 (median score C, severe)
• A 2019 systematic review of 55 cohorts with over 4 million participants rated the evidence that cutting processed meat by 3 servings a week lowers mortality, stroke, heart attack and diabetes risk as low certainty, with very small absolute effects. — 61 articles on 55 cohort studies with more than 4 million adults, searched to 2018-2019 Evidence C source
  Very small decrease in risk for all-cause mortality, cardiovascular mortality, stroke, MI and type 2 diabetes per 3 fewer servings/week of processed meat; low-certainty evidence

Who this works differently for

• In 50 people with type 2 diabetes and 50 healthy adults, a processed hamburger meat meal produced a larger 3-hour rise in blood lipids than an isocaloric vegan meal in both groups and persistent hyperinsulinaemia in the diabetic group. — 50 patients with type 2 diabetes and 50 healthy subjects, randomised crossover, two 3-hour meal tolerance tests (n = 100) Evidence B source
  Higher postprandial lipids after the meat meal in both groups (p<0.001); persistent postprandial hyperinsulinaemia in T2D (p<0.001); larger lipoperoxidation rise in T2D (p<0.05)
• In a 2010 Danish outbreak of Salmonella Typhimurium, 20 people fell ill, half of them children aged 10 or younger, and a matched case-control study linked illness to one salami product with a matched odds ratio of 150. — 20 cases in the greater Copenhagen area, April to June 2010, 3 hospitalised, matched case-control study (n = 20) Evidence C source
  Matched odds ratio 150 (95% CI 19-1600) for eating the salami; microbiological confirmation in food not obtained
• Across cohort, case-control and cross-sectional studies, people who eat raw or undercooked meat, including sausages and salamis, have 1.2 to 1.3 times the risk and 1.7 to 3.0 times the odds of Toxoplasma gondii infection. — observational studies of T. gondii seroprevalence by raw or undercooked meat consumption, any animal species, pooled by design Evidence C source
  Risk ratio 1.2-1.3 (cohort); odds ratio 1.7-3.0 (case-control and cross-sectional); seroprevalence 1.3-88.6% across studies

The bottom line

Per 100 g, USDA lists sliced beef and pork pepperoni at 1582 mg of sodium, 46.3 g of fat and 17.7 g of saturated fat. That is per 100 g of sausage, and we have no card on how much of it lands on one pizza, so scale from the label. WHO's 2012 sodium guideline names processed meats among the foods that often carry high amounts of sodium. A 2012 review of prospective cohorts gives processed meat a coronary heart disease relative risk of 1.42 per 50 g a day, with a wide interval of 1.07 to 1.89. The same review models the roughly 400 percent higher sodium of processed meat as explaining about two-thirds of its gap to unprocessed meat. That share is a model, not a trial. In 50 people with type 2 diabetes and 50 healthy adults, a processed hamburger meat meal gave a larger 3-hour lipid rise than an isocaloric vegan meal in both groups and persistent hyperinsulinaemia in those with diabetes. The meat there was hamburger, and the comparator differed in carbohydrate too. How sure any of this is depends on who grades it. A 2019 review of 55 cohorts with over 4 million adults rated the evidence that cutting processed meat by 3 servings a week lowers mortality, stroke, heart attack and diabetes as low certainty with very small absolute effects. Its authors list inadequate confounder adjustment among the reasons. A 2026 umbrella review of 54 meta-analyses reports 17 percent higher colorectal and 72 percent higher gastric cancer risk per 50 g a day, all low to very low certainty on GRADE. A 2026 meta-analysis of 31 observational studies found a colorectal polyp relative risk of 1.65 (1.05 to 2.61) and an adenoma estimate of 1.14 (0.93 to 1.41) that did not reach significance. The direction is consistent across all of them, and every one of them is observational. The sharper cautions concern the sausage as a raw fermented product. Three outbreaks sit on this page. In British Columbia in 1999, 143 people were infected with E. coli O157:H7 over 12 weeks, tied to one company's dry salami that tested positive for the strain, at a matched odds ratio of 10.0 with a confidence interval from 1.4 to 434. In 2009 to 2010, 272 Salmonella Montevideo cases in 44 US states were traced to ready-to-eat salami, and the strain was isolated from the salami and from sealed containers of black and red pepper at the plant. In Copenhagen in 2010, 20 Salmonella Typhimurium cases, half of them children aged 10 or younger, were linked to one salami at a matched odds ratio of 150, with no isolate obtained from the product. Listeria monocytogenes was found in 22.7 percent of 1020 Italian dry salami samples taken before sale, always under 10 CFU per gram, and whether counts that low make anyone ill is unresolved. Across observational studies, people who eat raw or undercooked meat, a habit the authors say includes sausages and salamis, have 1.2 to 1.3 times the risk and 1.7 to 3.0 times the odds of Toxoplasma gondii infection, with no estimate specific to fermented sausage. This page has no card on Toxoplasma or Listeria in pregnancy, so the low Listeria counts above are not a reassurance for anyone pregnant. Dry sausage is on the tyramine diet list handed to patients starting monoamine oxidase inhibitors, and in a survey of 139 psychiatric patients more than half ate dry sausage, corned beef, yeast products or beer at least monthly before such treatment. Pooled laboratory experiments, 99 of them, found that cutting or replacing salt in dry-fermented sausage raised its tyramine content, which is the substance that list exists for. We have no card on allergy to pepperoni.

Sources

1. pepp-v1-18 · pooled laboratory experiments
   The literature search yielded 549 citations and 43 scientific articles with 99 experiments, which were included in the meta-analysis...Pool estimation showed that NaCl reduction and/or replacement in dry-fermented sausages increased moisture, water activity, redness (a* value), lactic acid bacteria count, and tyramine content...The safety of sausages with NaCl reduction and/or replacement was not compromised, as Enterobacteriaceae did not grow, compared to conventional sausages.
   Meat Sci, 2025 · checked 2026-09-23
2. pepp-v1-02 · RCT
   cured meat, with or without calcium or tocopherol, was given to dimethylhydrazine-initiated rats (47% meat diet for 100 d) and to human volunteers in a crossover study (180 g/d for 4 d)...Cured meat increased nitroso compounds and lipoperoxidation in human stools (both P < 0.05). Calcium normalized both biomarkers in rats and human feces
   Am J Clin Nutr, 2013 · checked 2026-09-23
3. pepp-v1-03 · RCT
   Twenty healthy male adults were randomised to consume 240 g day-1 red and processed meat for 2 weeks, with crossover to 2 weeks 240 g day-1 mycoprotein, separated by a 4-week washout period...The meat diet increased faecal genotoxicity and nitroso compound excretion, whereas the weight-matched consumption of mycoprotein decreased faecal genotoxicity and nitroso compounds.
   Eur J Nutr, 2023 · checked 2026-09-23
4. pepp-v1-05 · meta-analysis of cohorts
   Non-linear dose-response meta-analyses revealed that colorectal cancer risk increases approximately linearly with increasing intake of red and processed meats up to approximately 140 g/day, where the curve approaches its plateau...processed meat (RR (for 50 g/day increase)...1.18, 95% CI...1.10-1.28).
   PLoS One, 2011 · checked 2026-09-23
5. pepp-v1-06 · meta-analysis of cohorts
   Among 1 966 444 adults eligible for participation, 107 271 incident cases of type 2 diabetes were identified during a median follow-up of 10 (IQR 7-15) years...1·15 (1·11-1·20) per 50 g/day of processed meat (I2=59%)
   Lancet Diabetes Endocrinol, 2024 · checked 2026-09-23
6. pepp-v1-09 · meta-analysis of observational studies
   Thirty-one observational studies were ultimately included...Processed meat consumption was correlated with increased colorectal polyp risk (1.65; 1.05, 2.61) but not colorectal adenoma risk (1.14; 0.93, 1.41).
   Nutr Rev, 2026 · checked 2026-09-23
7. pepp-v1-10 · umbrella review
   A total of 34 articles and 54 meta-analyses were included in the review...Dose-response analysis revealed that an increase in PM consumption of 50 g/day was associated with a 72% higher risk of gastric cancer, 17% higher risk of colorectal cancer, 4% higher risk of prostate cancer, and an 8% higher risk of chronic obstructive pulmonary disease (COPD). All the above dose-response associations are based on low to very low certainty evidence as assessed by the GRADE system.
   Front Public Health, 2026 · checked 2026-09-23
8. pepp-v1-07 · meta-analysis of cohorts
   In meta-analyses of prospective cohorts, higher risk of CHD is seen with processed meat consumption (RR per 50 g: 1.42, 95 %CI = 1.07-1.89), but a smaller increase or no risk is seen with unprocessed meat consumption. Differences in sodium content (~400 % higher in processed meat) appear to account for about two-thirds of this risk difference.
   Curr Atheroscler Rep, 2012 · checked 2026-09-23
9. pepp-v1-11 · agency document
   Processed meat was classified as Group 1, carcinogenic to humans....An analysis of data from 10 studies estimated that every 50 gram portion of processed meat eaten daily increases the risk of colorectal cancer by about 18%.
   WHO, Cancer: Carcinogenicity of the consumption of red meat and processed meat (Q&A), 26 October 2015 · checked 2026-09-23
10. pepp-v1-12 · case-control
    A total of 143 cases were identified over a 12-week period with the same pulsed-field gel electrophoresis (PFGE) pattern. The case-control study found that Company A salami was significantly associated with illness (Mantel-Haenszel matched odds ratio 10.0%, 95% CI 1.4-434, P=0.01).
    Epidemiol Infect, 2004 · checked 2026-09-23
11. pepp-v1-14 · case-control
    We identified 272 cases in 44 states with illness onset dates ranging from 1 July 2009 to 14 April 2010...Ready-to-eat salami consumption was significantly associated with illness (matched odds ratio 8·5, 95% confidence interval 2·1-75·9). The outbreak strain was isolated from company A salami products from an environmental sample from one manufacturing plant, and sealed containers of black and red pepper at the facility.
    Epidemiol Infect, 2013 · checked 2026-09-23
12. pepp-v1-15 · cross-sectional
    We analyzed 1,020 samples taken during the autumn and winter 2002 and spring and summer 2003 periods and immediately before selling...L. monocytogenes was found in 22.7% of samples, but the contamination level was less than 10 CFU/g.
    J Food Prot, 2006 · checked 2026-09-23
13. pepp-v1-17 · cross-sectional
    We conducted a survey of 139 psychiatric patients admitted to either an inpatient unit specializing in the treatment of mood disorders or an outpatient anxiety disorders clinic specializing in the treatment of social phobia...Yeast products, dry sausage, corned beef, broad beans, sauerkraut, and beer were used at least monthly by more than 50% of patients.
    J Clin Psychiatry, 1995 · checked 2026-09-23
14. pepp-v1-19 · agency document
    It is often found in high amounts in processed foods such as breads, crackers, processed meats and snack foods (23-26).
    WHO, Guideline: Sodium intake for adults and children, 2012 · checked 2026-09-23
15. pepp-v1-01 · RCT
    Twelve subjects (eight men and four women, aged 24 to 43 years) were studied in a randomized, crossover trial with the test meal given at the noon and evening meals; each subject received all four test meals...In contrast, the median endoscopic score for the other three meals was 0. Single cases of a single erosion were present after the Mexican meals and after the pizza meals.
    JAMA, 1988 · checked 2026-09-23
16. pepp-v1-08 · meta-analysis of cohorts
    Of 61 articles reporting on 55 cohorts with more than 4 million participants, none addressed quality of life or satisfaction with diet...Likewise, low-certainty evidence was found that a reduction in processed meat intake of 3 servings per week is associated with a very small decrease in risk for all-cause mortality, cardiovascular mortality, stroke, MI, and type 2 diabetes.
    Ann Intern Med, 2019 · checked 2026-09-23
17. pepp-v1-04 · RCT
    In a randomized crossover study, 50 patients suffering from type 2 diabetes (T2D) and 50 healthy subjects underwent two 3-h meal tolerance tests...The M-meal resulted in a higher postprandial increase in lipids in both groups (p<0.001) and persistent postprandial hyperinsulinemia in patients with diabetes (p<0.001).
    PLoS One, 2014 · checked 2026-09-23
18. pepp-v1-13 · case-control
    The outbreak involved twenty cases, primarily living within the greater Copenhagen area. Half of the cases were children aged ten years or younger...matched odds ratio(mOR):150, confidence interval (CI): 19–1,600.
    Euro Surveill, 2011 · checked 2026-09-23
19. pepp-v1-16 · meta-analysis of observational studies
    Our results suggest that individuals who eat raw or undercooked meat have, respectively, 1.2-1.3 times the risk and 1.7-3.0 times the odds of T. gondii infection compared to those who thoroughly cook meat, regardless of the animal species they consume...These numbers reflect various preferences with regard to eating meat (i.e., eating tartar, sausages, or salamis)
    Vector Borne Zoonotic Dis, 2021 · checked 2026-09-23