Ultra-processed foods and added sugars in the Chilean diet (2010)

The possible role of increased consumption of ultra-processed food products in the development of frailty: a threat for healthy ageing?

Frailty, a multifactorial ageing-related syndrome characterised by reduced resistance to stressors and possibly associated with low-grade systemic inflammation, results in negative health outcomes and compromises healthy ageing. There is a growing body of evidence on the relationship between dietary habits, low-grade systemic inflammation and the risk of frailty. Consumption of dietary ultra-processed products (UPP) could negatively contribute to these conditions. In this article, we intend to (i) discuss the role that UPP might have on the development of frailty considering the inflammatory potential of this type of food and (ii) to raise awareness on deleterious effects of excess UPP intake in the development of adverse health outcomes, in particular, frailty and compromised healthy ageing. UPP are industrial formulations whose nutrient profile has been associated with inflammation and altered gut microbiota. Besides, diets with a greater presence of unprocessed foods and antioxidants have been linked to the reduction of oxidative stress and the expression of inflammatory biomarkers. Because inflammation is believed to be a contributing factor in the development of frailty, it is possible that UPP would contribute to the onset or increase of this condition. Importantly, the increasing consumption of UPP in younger populations might pose a greater risk to the development of compromised healthy ageing in the long term.

Three decades of household food availability according to NOVA - Brazil, 1987-2018

OBJECTIVE

To evaluate the trend of household food acquisition according to the NOVA classification in Brazil between 1987-1988 and 2017-2018.

METHODS

We used household food acquisition data from five editions of the Pesquisas de Orçamentos Familiares (Household Budget Surveys), conducted by the Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics), in the years 1987-1988, 1995-1996, 2002-2003, 2008-2009, and 2017-2018. All reported foods were categorized according to the NOVA classification. The household availability of food groups and subgroups was expressed through their share (%) in total calories, for all Brazilian families, by household situation (urban or rural), for each of the five geographic regions of the country, by fifths of the household income per capita distribution (2002-2003, 2008-2009 and 2017-2018 surveys), and for the 11 main urban regions of the country (1987-1988, 1995-1996, 2002-2003, 2008-2009 and 2017-2018 surveys). Linear regression models were used to assess the trend of increasing or decreasing food purchases.

RESULTS

The diet of the Brazilian population is still composed predominantly of foods in natura or minimally processed and processed culinary ingredients. However, our findings point to trends of increasing share of ultra-processed foods in the diet. This increase of 0.4 percentage points per year between 2002 and 2009 slowed down to 0.2 percentage points between 2008 and 2018. The consumption of ultra-processed food was higher among households with higher income, in the South and Southeast regions, in urban areas, and in metropolitan regions.

CONCLUSION

Our results indicate an increase in the share of ultra-processed foods in the diet of Brazilians. This is a worrisome scenario, since the consumption of such foods is associated with the development of diseases and the loss of nutritional quality of the diet.

Geographical and Temporal Variability of Ultra-Processed Food Consumption in the Spanish Population: Findings from the DRECE Study

The consumption of ultra-processed foods (UPFs) has increased in recent decades, worldwide. Evidence on the negative impacts of food processing on health outcomes has also been steadily increasing. The aim of this study is to describe changes in consumption patterns of ultra-processed foods in the Spanish population over time and their geographical variability. Data from four representative cohorts of the Spanish population were used (1991−1996−2004−2008). Dietary information was collected using a validated frequency questionnaire and categorized using the NOVA classification. A total increase of 10.8% in UPF consumption between 1991 and 2008 was found in Spain (p-value < 0.001). The products contributing most to UPF consumption were sugar-sweetened beverages, processed meats, dairy products, and sweets. Those who consumed more ultra-processed foods were younger (p-value < 0.001) and female (p-value = 0.01). Significant differences between the different geographical areas of Spain were found. The eastern part of Spain was the area with the lowest UPF consumption, whereas the north-western part was the area with the highest increase in UPF consumption. Given the negative effect that the consumption of ultra-processed foods has on health, it is necessary to implement public health policies to curb this increase in UPF consumption.

Quality of the diet during the COVID-19 pandemic in 11 Latin-American countries

BACKGROUND AND OBJECTIVES

The confinement by COVID-19 has affected the food chain and environments, which added to factors such as anxiety, frustration, fear and stress have modified the quality of the diet in the population around the world. The purpose of this study was to explore diet quality during the COVID-19 pandemic in 11 Latin American countries.

METHODOLOGY

Multicentric, cross-sectional study. An online survey was applied to residents of 11 Latin-American countries, during April and May 2020, when confinement was mandatory. Diet quality was evaluated using a validated questionnaire.

RESULT

10,573 people participated in the study. The quality of the food by country shows that Colombia presented the best quality, while Chile and Paraguay presented the lowest. When comparing the overall results of diet quality by gender, schooling and age, women, people with more schooling and people under 30 years of age, presented better diet quality. The regression model showed that the variables associated with diet quality were: age (df = 3, F = 4. 57, p < 0.001), sex (df = 1, F = 131.01, p < 0.001), level of education (df = 1, F = 38.29, p < 0.001), perception of weight change (df = 2, F = 135.31, p < 0.001), basis services (df = 1, F = 8.63, p = 0.003), and quarantine (df = 1, F = 12.14, p = 0.001).

CONCLUSION

It is necessary for governments to intervene to reverse these indicators, considering that inadequate feeding favors the appearance of no communicable diseases, which favor a higher risk of infection and worse prognosis with COVID-19.

Phosphate intake, hyperphosphatemia, and kidney function

Phosphate is essential in living organisms and its blood levels are regulated by a complex network involving the kidneys, intestine, parathyroid glands, and the skeleton. The crosstalk between these organs is executed primarily by three hormones, calcitriol, parathyroid hormone, and fibroblast growth factor 23. Largely due to a higher intake of ultraprocessed foods, dietary phosphate intake has increased in the last decades. The average intake is now about twice the recommended dietary allowance. Studies investigating the side effect of chronic high dietary phosphate intake suffer from incomplete dietary phosphate assessment and, therefore, often make data interpretation difficult. Renal excretion is quickly adapted to acute and chronic phosphate intake. However, at the high ends of dietary intake, renal adaptation, even in pre-existing normal kidney function, apparently is not perfect. Experimental intervention studies suggest that chronic excess of dietary phosphate can result in sustained higher blood phosphate leading to hyperphosphatemia. Evidence exists that the price of the homeostatic response (phosphaturia in response to phosphate loading/hyperphosphatemia) is an increased risk for declining kidney function, partly due by intraluminal/tubular calcium phosphate particles that provoke renal inflammation. High dietary phosphate intake and hyperphosphatemia are progression factors for declining kidney function and are associated with higher cardiovascular disease and mortality risk. This is best established for pre-existing chronic kidney disease, but epidemiological and experimental data strongly suggest that this holds true for subjects with normal renal function as well. Here, we review the latest advances in phosphate intake and kidney function decline.

Dissecting ultra-processed foods and drinks: Do they have a potential to impact the brain?

Ultra-processed foods and drinks (UPF) are formulation of ingredients, mostly of exclusive industrial use, that result from a series of industrial processes. They usually have a low nutrient but high energy density, with a high content of saturated and trans fats, and added sugars. In addition, they have characteristic organoleptic properties, and usually contain sophisticated additives, including artificial sweeteners, to intensify their sensory qualities and imitate the appearance of minimally processed foods. In addition, recent research has warned about the presence of chemicals (e.g., bisphenol) and neo-formed contaminants in these products. UPF production and consumption growth have been spectacular in the last decades, being specially consumed in children and adolescents. UPF features have been associated with a range of adverse health effects such as overeating, the promotion of inflammatory and oxidative stress processes, gut dysbiosis, and metabolic dysfunction including problems in glucose regulation. The evidence that these UPF-related adverse health effects may have on the neural network implicated in eating behavior are discussed, including the potential impact on serotonergic and dopaminergic neurotransmission, brain integrity and function. We end this review by placing UPF in the context of current food environments, by suggesting that an increased exposure to these products through different channels, such as marketing, may contribute to the automatic recruitment of the brain regions associated with food consumption and choice, with a detrimental effect on inhibitory-related prefrontal cortices. While further research is essential, preliminary evidence point to UPF consumption as a potential detrimental factor for brain health and eating behavior.

Food processing groups and colorectal cancer risk in Morocco: evidence from a nationally representative case-control study

OBJECTIVE

The aim of this study was to investigate the association between the consumption of foods and drinks from different food processing categories using the NOVA classification and CRC risk among Moroccan adults.

METHODS

1453 cases and 1453 matched controls aged at least 18 years and recruited from the 5 greater Moroccan regions were interviewed by trained investigators about their habitual diet using a standardized food frequency questionnaire (FFQ). Foods were categorized according to their degree of processing by the NOVA classification. Intakes of each food processing group were categorized into tertiles based on the distribution of controls with the lowest tertile considered as the reference category. Multivariable conditional logistic regression models were used to assess the association between each group and CRC risk (Odds Ratio (OR) and 95% Confidence Intervals (CI)), taking relevant confounders into account.

RESULTS

High consumption of unprocessed or minimally processed foods (NOVA group 1) was significantly inversely (OR = 0.82, 95%CI = 0.72-0.93), while high consumption of ultra-processed foods and drink products (NOVA group 4) was significantly positively (OR = 1.40, 95% CI = 1.22-1.61) associated with CRC risk as compared to the lowest intake group. These results were similar for colon and rectum sub-sites.

CONCLUSION

This is the first study to evaluate the association between the NOVA classification groups and CRC risk in an African country. Our results suggest that the consumption of ultra-processed foods and drink products may be associated with an increased risk of developing CRC, but longitudinal studies are needed to confirm these results.

Gender and socio-economic stratification of ultra-processed and deep-fried food consumption among rural adolescents: A cross-sectional study from Bangladesh

Background

Although consumption of ultra-processed and deep-fried foods among adolescents is a global health concern, little is known about its gender and socio-economic stratification in rural settings of low- and middle-income countries. We, thus, aimed to describe ultra-processed and deep-fried food consumption among rural adolescents by gender and socio-economic factors, and to explore their relative importance in shaping consumption.

Methods

This cross-sectional study drew on data from a household survey in Matlab, a rural sub-district in Bangladesh. The analytic sample comprised 2463 adolescents. We assessed consumption of four ultra-processed food groups: ready-to-eat or “instant” foods; confectionery, sweets and similar packaged products; savory snacks; sugar-sweetened beverage; and of deep-fried foods with a 24-hour, qualitative recall. Asset scores were constructed. Proportion of consumption was calculated and compared by gender and household wealth. Logistic regression models were fitted to isolate socio-demographic variables associated with consumption.

Results

Approximately 83% (81.5–84.4) adolescents consumed at least one ultra-processed or deep-fried item. Confectioneries were the most consumed (53.5%), whereas sugar-sweetened beverage was the least consumed (12%) group. Boys had greater odds of consumption than girls for all food groups. The association was strongest for sugar-sweetened beverage (adjusted odds ratio = 2.57; 95% CI: 1.97, 3.37), followed by deep-fried foods (adjusted odds ratio = 1.96; 95% CI: 1.66, 2.32) and ready-to-eat foods (adjusted odds ratio = 1.85; 95% CI: 1.45, 2.38). Belonging to the richest households was associated with ready-to-eat food consumption (adjusted odds ratio = 1.55; 95% CI: 1.12, 2.16). Adolescents with higher educational attainment had lower odds of consuming sugar-sweetened beverage (adjusted odds ratio = 0.73; 95% CI: 0.54, 0.98).

Conclusion

Consumption of packaged confectioneries, savory snacks, and deep-fried foods appeared common, while SSB consumption was relatively low. Role of gender was pre-eminent as consumption was more likely among boys across the food groups. This may disproportionately expose them to the risk of diet-related non-communicable diseases.

[Intake of energy and critical nutrients according to the NOVA classification in Argentina, time trend and differences according to income]

Growing evidence of the global transition in food systems exists, affecting the availability, accessibility, affordability, and convenience of highly processed foods. This study aimed to evaluate the apparent consumption of energy, saturated fat, added sugars, and sodium according to the degree of food processing in Argentina from 1996 to 2018 and according to income level. This is a descriptive and cross-sectional study with data on food and beverage expenditures and income from the National Household Expenditure Survey for years 1996-1997, 2004-2005, 2012-2013, and 2017-2018, including more than 20,000 households in each period. The apparent daily consumption of energy, saturated fat, added sugars, and sodium per adult for: (1) minimally processed foods; (2) processed culinary ingredients; (3) processed foods; and (4) ultra-processed products, was calculated for each period and according to per capita income quintile in each household. Descriptive statistical analysis was performed. Reductions in the proportion of energy and all nutrients evaluated from minimally processed foods, culinary ingredients and processed foods were observed, as well as an increase in the consumption of ultra-processed products. One also observes a greater share from ultra-processed foods as household income increases but with decreasing differences over time. Therefore, future strategies in Argentina should promote the consumption of minimally processed foods and discourage the availability and accessibility of ultra-processed ones, especially for the most vulnerable groups.

Changes in Obesity Prevalence Attributable to Ultra-Processed Food Consumption in Brazil Between 2002 and 2009

Objectives: To quantify the impact of temporal changes in the consumption of ultra-processed foods on obesity trends in Brazil between 2002 and 2009. Methods: We analyzed data from two Household Budget Surveys carried out in 2002/2003 (n = 182,333) and 2008/2009 (n = 190,159), which provided information on household food acquisition and individuals' weight and height. We examined the association between ultra-processed foods consumption and obesity and quantified the fraction of increase in obesity prevalence attributable to the rise in the consumption of ultra-processed foods. Results: From 2002 to 2009, there was an increase in the obesity prevalence from 9.9% (95% CI 9.3; 10.4) to 13.2% (12.8; 13.7) while the contribution of ultra-processed foods to total energy consumption raised from 14.3% (13.4; 15.1) to 17.3% (16.5; 18.1). Ultra-processed foods consumption was positively associated with obesity prevalence. More than one quarter (28.6%) of the increase in obesity prevalence was attributable to the rise in the consumption of ultra-processed foods in the period. Conclusion: We found that the rise in the consumption of ultra-processed foods played a major role on the increase of obesity epidemic in Brazil.

Consumption of processed and ultra-processed foods by patients with stomach adenocarcinoma: a multicentric case-control study in the Amazon and southeast regions of Brazil

PURPOSE

There is limited information about the dietary habits associated with stomach adenocarcinoma in the Brazilian population, so our purpose is to analyze the consumption of processed and ultra-processed foods by patients with stomach adenocarcinoma in Brazil.

METHODS

A multicentric hospital-based case-control study was conducted in São Paulo (southeastern region) and Belém (Amazon region) of Brazil with 1,045 individuals, both sexes, between 18 and 75 years old. In São Paulo, there were 214 cases with stomach adenocarcinoma and 150 controls patients submitted to stomach endoscopy named as Group I (without any pre-malignant gastric disease) and the Healthy Controls (Group 2) comprised 401 individuals matched by age and sex from the prevention unit at A.C .Camargo Cancer Center. In Belém, it has two groups one are cases 140 and second 140 hospital controls, recruited in outpatient clinics. Lifestyle and food frequency questionnaires (FFQ) were administered in cases and controls in both places. Univariate and multivariable binomial logistic regression analyses were performed.

RESULTS

In São Paulo, cases reported two times greater consumption of processed meat (adjusted OR 2.56, 95% CI 1.32-4.96) and of sweets (≥ 80 g/day) than Group 1 (endoscopic controls) (adjusted OR 2.25, 95% CI 1.21-4.18). Compared with Group 2, processed food consumption (≥ 44 g/day) as well as ≥ 44 g/day of salted bread increased the odds of having stomach adenocarcinoma (adjusted OR 2.96, 95% CI 1.82-4.81 and adjusted OR 2.03, 95% CI 1.30-3.18), respectively. In Belém, individuals who reported consuming ≥ 166 g/day of fried and roasted meat and fish were more likely to have stomach adenocarcinoma (adjusted OR 2.21, 95% CI 1.13-4.30).

CONCLUSIONS

In both cities, consumption of processed and ultra-processed foods, especially salted bread, yellow cheese, fried and roasted meats, fish fried, processed meat, and sweets, was independently associated with the chance of having stomach adenocarcinoma.

Potential impacts of policies to reduce purchasing of ultra-processed foods in Mexico at different stages of the social transition: an agent-based modelling approach

OBJECTIVES

To develop a simulation framework for assessing how combinations of taxes, nutrition warning labels and advertising levels could affect purchasing of ultra-processed foods (UPF) in Latin American countries and to understand whether policies reinforce or reduce pre-existing social disparities in UPF consumption.

DESIGN

We developed an agent-based simulation model using international evidence regarding the effect of price, nutrition warning labels and advertising on UPF purchasing.

SETTING

We estimated policy effects in scenarios representing two stages of the 'social transition' in UPF purchasing: (1) a pre-transition scenario, where UPF purchasing is higher among high-income households, similar to patterns in Mexico; and (2) a post-transition scenario where UPF purchasing is highest among low-income households, similar to patterns in Chile.

PARTICIPANTS

A population of 1000 individual agents with levels of age, income, educational attainment and UPF purchasing similar to adult women in Mexico.

RESULTS

A 20 % tax would decrease purchasing by 24 % relative to baseline in both the pre- and post-transition scenarios, an effect that is similar in magnitude to that of a nutrition warning label policy. A 50 % advertising increase or decrease had a comparatively small effect. Nutrition warning labels were most effective among those with higher levels of educational attainment. Labelling reduced inequities in the pre-transition scenario (i.e. highest UPF purchasing among the highest socio-economic group) but widened inequities in the post-transition scenario.

CONCLUSIONS

Effective policy levers are available to reduce UPF purchasing, but policymakers should anticipate that equity impacts will differ depending on existing social patterns in UPF purchasing.

Exploring ways to respond to rising obesity and diabetes in the Caribbean using a system dynamics model

Diabetes and obesity present a high and increasing burden of disease in the Caribbean that have failed to respond to prevention policies and interventions. These conditions are the result of a complex system of drivers and determinants that can make it difficult to predict the impact of interventions. In partnership with stakeholders, we developed a system dynamics simulation model to map the system driving diabetes and obesity prevalence in the Caribbean using Jamaica as a test case. The study aims to use the model to assess the magnitude changes necessary in physical activity and dietary intake to achieve global targets set by the WHO Global Action plan and to test scenarios for interventions to reduce the burden of diabetes and obesity. Continuing current trends in diet, physical activity, and demographics, the model predicts diabetes in Jamaican adults (20+ years) to rise from 12% in 2018 to 15.4% in 2030 and 20.9% by 2050. For obesity, it predicts prevalence to rise from 28.6% in 2018 to 32.1% by 2030 and 39.2% by 2050. The magnitude change necessary to achieve the global targets set by the World Health Organization is so great as to be unachievable. However, a combination of measures both upstream (including reducing the consumption of sugar sweetened beverages and ultra processed foods, increasing fruit and vegetable intake, and increasing moderate-to-vigorous activity) at the population level, and downstream (targeting people at high risk and with diabetes) can significantly reduce the future burden of diabetes and obesity in the region. No single intervention reduces the prevalence of these conditions as much as a combination of interventions. Thus, the findings of this model strongly support adopting a sustained and coordinated approach across various sectors to synergistically maximise the benefits of interventions.

Impacts of Consumption of Ultra-Processed Foods on the Maternal-Child Health: A Systematic Review

Background and Aims

Changes in eating patterns have been leading to an increase in the consumption of ultra-processed foods (UPF), negatively impacting the quality of the diet and generating risk of harm to the health of the adult population, however, there is no systematized evidence of the impact of UPF in maternal-child health. Thus, in this study we aimed to evaluated the association between UPF consumption and health outcomes in the maternal-child population.

Methods

Systematic review registered on the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021236633), conducted according to the PRISMA diagram in the following databases: PubMed, Medline, Scopus, Web of Science, Scielo, and CAPES thesis and dissertation directory. We included original cross-sectional, case-control and cohort studies in any language. Eligibility criteria were (a) food consumption assessment by the NOVA classification, (b) health outcome (nutritional or diseases), and (c) maternal-child population (pregnant, lactating women and infants/children). All data were analyzed and extracted to a spreadsheet structured by two independent reviewers. We evaluated the methodological quality of the studies included using the Newcastle-Otawa Scale and RoB 2.

Results

Searches retrieved 7,801 studies and 15 contemplated the eligibility criteria. Most studies included were cohort studies (n = 8, 53%), had children as their population (n = 9, 60%) and only one study evaluated UPF consumption in infants and lactating women. Panoramically, we observed that a higher participation of UPF in children’s diet has been associated with different maternal-child outcomes, such as increase of weight gain, adiposity measures, overweight, early weaning, lower diet quality, metabolic alterations, diseases, and consumption of plastic originated from packaging. Only one of the studies included did not present high methodological quality.

Conclusion

Despite the limited literature on UPF consumption and health outcomes in the maternal-child population, the highest UPF consumption negatively impacted nutrition and disease development indicators in pregnant, lactating women and children. Considering the expressive participation of these foods in the diet, other studies should be conducted to further investigate the impact of UPF consumption on different health indicators, especially in the lactation phase for this was the one to present the most important knowledge gap.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021236633], identifier [CRD42021236633].

Score of ultra-processed food consumption and its association with sociodemographic factors in the Brazilian National Health Survey, 2019

This is a cross-sectional population-based study that describes the score of ultra-processed food consumption, applied in the Brazilian National Health Survey performed in 2019, and its association with sociodemographic factors in Brazilian adults (18 years or older). The score of ultra-processed food consumption was calculated by adding up the positive answers about the consumption on the previous day of 10 subgroups of ultra-processed foods frequently consumed in Brazil. The distribution of the score in the population was presented as a count. Poisson regression models were used to evaluate the crude and adjusted associations of scores equal to or higher than five subgroups of ultra-processed foods with urban/rural area, geographic region, sex, age group, schooling level, and wealth index. About 15% of the Brazilian adults reached scores equal to or higher than five. After adjustment for confounders, the prevalence of consuming five or more subgroups of ultra-processed foods decreased linearly with age, increased linearly with wealth quintiles and it was higher in urban areas, in the Southeast and South regions (compared to the others) and in men. Public policies that reduce the consumption of ultra-processed foods with emphasis on strata of the population at the greatest risk are essential and monitoring the score of ultra-processed food consumption across studies and populations will be important to assess the success of these policies.

Evaluation of foods, drinks and diets in the Netherlands according to the degree of processing for nutritional quality, environmental impact and food costs

OBJECTIVE

This study investigates nutritional quality, environmental impact and costs of foods and drinks and their consumption in daily diets according to the degree of processing across the Dutch population.

DESIGN

The NOVA classification was used to classify the degree of processing (ultra-processed foods (UPF) and ultra-processed drinks (UPD)). Food consumption data were derived from the Dutch National Food Consumption Survey 2012-2016. Indicators assessed were nutritional quality (saturated fatty acids (SFA), sodium, mono and disaccharides (sugar), fibre and protein), environmental impact (greenhouse gas (GHG) emissions and blue water use) and food costs.

SETTING

The Netherlands.

PARTICIPANTS

Four thousand three hundred thirteen Dutch participants aged 1 to 79 years.

RESULTS

Per 100 g, UPF were more energy-dense and less healthy than unprocessed or minimally processed foods (MPF); UPF were associated with higher GHG emissions and lower blue water use, and were cheaper. The energy and sugar content of UPD were similar to those of unprocessed or minimally processed drinks (MPD); associated with similar GHG emissions but blue water use was less, and they were also more expensive. In the average Dutch diet, per 2000 kcal, ultra-processed foods and drinks (UPFD) covered 29% (456 g UPF and 437 g UPD) of daily consumption and 61% of energy intake. UPFD consumption was higher among children than adults, especially for UPD. UPFD consumption determined 45% of GHG emissions, 23% of blue water use and 39% of expenses for daily food consumption. UPFD consumption contributed 54% to 72% to daily sodium, sugar and SFA intake.

CONCLUSIONS

Compared with unprocessed or minimally processed foods and drinks, UPF and UPD were found to be less healthy considering their high energy, SFA, sugar and sodium content. However, UPF were associated higher GHG emissions and with less blue water use and food costs. Therefore daily blue water use and food costs might increase if UPF are replaced by those unprocessed or minimally processed. As nutritional quality, environmental impacts and food costs relate differently to the NOVA classification, the classification is not directly applicable to identify win-win-wins of nutritional quality, environmental impact and costs of diets.

Modelling the Impact of Reducing Ultra-Processed Foods Based on the NOVA Classification in Australian Women of Reproductive Age

Women of reproductive age have a high proportion of overweight/obesity and an overall poor nutritional intake and diet quality. Nutritional modelling is a method to forecast potential changes in nutrition composition that may offer feasible and realistic changes to dietary intake. This study uses simulation modelling to estimate feasible population improvements in dietary profile by reducing ultra-processed food (UPF) consumption in Australian women of reproductive age. The simulation used weighted data from the most recent 2011-2012 National Nutrition and Physical Activity Survey. A total of 2749 women aged 19-50 years was included, and 5740 foods were examined. The highest daily energy, saturated fat, and added sugar and sodium came from UPF. Reducing UPF by 50% decreased energy intake by 22%, and saturated fat, added sugar, sodium, and alcohol by 10-39%. Reducing UPF by 50% and increasing unprocessed or minimally processed foods by 25% led to a lower estimated reduction in energy and greater estimated reductions in saturated fat and sodium. Replacement of 50% UPF with 75% of unprocessed or minimally processed foods led to smaller estimated reductions in energy and nutrients. Our results provide insight as to the potential impact of population reductions in UPF, but also increasing intake of unprocessed or minimally processed foods, which may be the most feasible strategy for improved nutritional intake.

A Semi-quantitative Food Frequency Questionnaire Has Relative Validity to Identify Groups of NOVA Food Classification System Among Mexican Adults

Background

Ultra-processed foods are recognized as indicators of an unhealthy diet in epidemiological studies. In addition to ultra-processed foods, the NOVA food classification system identifies three other groups with less processing. Unprocessed foods that, together with minimally processed foods (MPF), make NOVA group 1, NOVA group 2 is processed culinary ingredients, and NOVA group 3 is processed foods.

Objective

To assess the relative validity of the semi-quantitative food frequency questionnaire (SFFQ) to estimate the energy intake for each group NOVA classification system by comparing it with two 24 h-dietary-recall (24DRs) Mexican adults.

Methods

We analyzed dietary information from 226 adults included <60 and ≥60 years with complete SFFQ and two 24DRs from the National Health and Nutrition Survey 2012. We reported mean differences, Spearman correlation coefficients, intra-class correlations coefficients, Bland–Altman plots, and weighted kappa between measures.

Results

The percentage energy intake from unprocessed and minimally processed foods group, Spearman correlation coefficients was 0.54 in adults <60 years and 0.42 in adults ≥60 years, while ultra-processed foods group was 0.67 and 0.48, respectively. The intra-class correlation coefficients in the unprocessed and minimally processed foods group was 0.51 in adults <60 years and 0.46 in adults ≥60 years, and for the ultra-processed foods group were 0.71 and 0.50, respectively. Bland–Altman plots indicated reasonably consistent agreement for unprocessed and minimally processed foods group and ultra-processed foods group in adults <60 years and adults in the ≥60 age group. Weighted kappa was 0.45 in the ultra-processed foods group to adults <60 years and was 0.36–≥60 years.

Conclusion

The SFFQ had acceptable validity to rank the percentage of energy intake from unprocessed and minimally processed foods group and ultra-processed foods group in Mexican adults, both in adults under 60 years and who were 60 years old or older.

Adaption and reliability of the Nutrition Environment Measures for stores (NEMS-S) instrument for use in urban areas of Chile

Objective

To adapt and assess reliability of the Chilean version of Nutritional Environment Measurement for Stores (NEMS-S-CHILE) to measure the food environment of stores in urban areas.

Design

NEMS-S-CHILE was the NEMS-S tool adapted to the Chilean food patterns; foods were grouped according to level of processing in (a) unprocessed or minimally processed foods, (b) processed culinary ingredients, (c) processed foods, and (d) ultra-processed foods, and scored according to NEMS-S-CHILE tool. Reliability inter evaluators was measured.

Setting

City of Concepción, Bio-Bio region, Chile.

Participants

Seventeen of a total of 25 supermarkets, and 9 out of 10 street markets according to the municipal registry and the street market trade unions, representing 74.3% of both types of food premises in Concepción.

Results

Reliability inter evaluators was measured by the following aspects: product availability, price, quality, and variety, through the intraclass correlation coefficient (ICC), percent agreement, and Cohen’s kappa analysis. Reliability was high for availability, where the kappa index and ICC were acceptable, ranging from moderate to high (0.42 to 1.00 for the kappa coefficient and 0.65 to 1.00 for ICC), as well as for prices (ICC: 0.65-1.00 ), variety (kappa: 0.76-1.00) and quality (percent agreement: 68.2- 100%).

Conclusions

The adapted instrument, NEMS-S-CHILE, has a high reliability inter evaluators and can be useful to measure the availability of foods by the level of processing according to the prevalent food system in developing countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12651-w.

Consumption of Ultraprocessed Foods and Diet Quality Among U.S. Children and Adults

INTRODUCTION

Consumption of ultraprocessed foods has been linked with higher intake of added sugars, sodium, and unhealthful fats, but the associations of ultraprocessed foods with overall diet quality and major food groups are not well known.

METHODS

Data were derived from the National Health and Nutrition Examination Survey (2015-2018), including 9,758 adults (aged ≥20 years) and 5,280 children (aged 2-19 years) with 24-hour dietary recalls (≥1), with analysis performed in 2020. Ultraprocessed foods were identified using the NOVA classification, with intake (% energy) assessed in quintiles. Diet quality was assessed using the validated American Heart Association 2020 continuous primary and secondary diet scores and Healthy Eating Index 2015. Poor diet was defined as <40% adherence to the American Heart Association secondary score. Generalized linear regressions estimated relationships between ultraprocessed food intake and diet quality.

RESULTS

Compared with the lowest quintile of ultraprocessed food consumption (<39.1% energy), the American Heart Association primary score in adults was progressively lower in Quintile 2 (-1.99, 95% CI= -2.73, -1.25), Quintile 3 (-3.60, 95% CI= -4.47, -2.72), Quintile 4 (-5.29, 95% CI= -6.28, -4.30), and Quintile 5 (-7.24, 95% CI= -8.13, -6.36; >70.7% energy). Corresponding values in children were -2.05 (95% CI= -3.01, -1.09), -2.97 (95% CI= -4.16, -1.79), -3.82 (95% CI= -5.20, -2.44), and -6.22 (95% CI= -7.20, -5.25; >79.0% energy). The estimated proportion of children having poor diet progressively increased from 31.3% (95% CI=26.2%, 36.5%) in Quintile 1 up to 71.6% (95% CI=68.1%, 75.1%) in Quintile 5. Corresponding proportions of adults having poor diet increased from 18.1% (95% CI=14.3%, 22.0%) in Quintile 1 up to 59.7% (95% CI=55.3%, 64.1%) in Quintile 5. Findings were similar using the American Heart Association secondary score and Healthy Eating Index 2015 score.

CONCLUSIONS

Higher ultraprocessed food consumption is associated with substantially lower diet quality among children and adults.

Integrative development of a short screening questionnaire of highly processed food consumption (sQ-HPF)

BACKGROUND

Recent lifestyle changes include increased consumption of highly processed foods (HPF), which has been associated with an increased risk of non-communicable diseases (NCDs). However, nutritional information relies on the estimation of HPF consumption from food-frequency questionnaires (FFQ) that are not explicitly developed for this purpose. We aimed to develop a short screening questionnaire of HPF consumption (sQ-HPF) that integrates criteria from the existing food classification systems.

METHODS

Data from 4400 participants (48.1% female and 51.9% male, 64.9 ± 4.9 years) of the Spanish PREDIMED-Plus ("PREvention with MEDiterranean DIet") trial were used for this analysis. Items from the FFQ were classified according to four main food processing-based classification systems (NOVA, IARC, IFIC and UNC). Participants were classified into tertiles of HPF consumption according to each system. Using binomial logistic regression, food groups associated with agreement in the highest tertile for at least two classification systems were chosen as items for the questionnaire. ROC analysis was used to determine cut-off points for the frequency of consumption of each item, from which a score was calculated. Internal consistency of the questionnaire was assessed through exploratory factor analysis (EFA) and Cronbach's analysis, and agreement with the four classifications was assessed with weighted kappa coefficients.

RESULTS

Regression analysis identified 14 food groups (items) associated with high HPF consumption for at least two classification systems. EFA showed that items were representative contributors of a single underlying factor, the "HPF dietary pattern" (factor loadings around 0.2). We constructed a questionnaire asking about the frequency of consumption of those items. The threshold frequency of consumption was selected using ROC analysis. Comparison of the four classification systems and the sQ-HPF showed a fair to high agreement. Significant changes in lifestyle characteristics were detected across tertiles of the sQ-HPF score. Longitudinal changes in HPF consumption were also detected by the sQ-HPF, concordantly with existing classification systems.

CONCLUSIONS

We developed a practical tool to measure HPF consumption, the sQ-HPF. This may be a valuable instrument to study its relationship with NCDs.

TRIAL REGISTRATION

Retrospectively registered at the International Standard Randomized Controlled Trial Registry ( ISRCTN89898870 ) on July 24, 2014.

Decision flowchart for food classification by the extension and purpose of industrial processing: update and practical application

ABSTRACT Objective To describe the development and update of an instrument for food categorisation according to the extension and purpose of industrial processing, and to test its practical application. Methods After updating the instrument based on a recent publication on the NOVA classification, it was applied by five researchers to a database of 108 food items. These items are part of a database of foods announced in the health-related sections of supermarket promotional circulars. The Cohen’s weighted kappa coefficient was calculated to determine intra-rater agreement; Fleiss’ kappa and Kendall’s coefficient were applied to determine inter-rater agreement. Results In the updated version, two classes of additives and eight substances considered by the most recent publication as specific to ultra-processed foods were added. The intra-rater agreement was 100% (p<0.001), indicating an “almost perfect” agreement; Fleiss’ agreement among all raters ranged from 74% to 97% (p<0.001), which represents an agreement that ranged from “strong” to “almost perfect”; Kendall’s W was higher than 0.93 (p<0.001) among all raters. Conclusion The updated instrument showed high agreement and proved to be a methodologically sound and applicable tool for the purpose of classifying foods by the extension and purpose of industrial processing.

Ultra-processed foods and total sugars intake in Korea: evidence from the Korea National Health and Nutrition Examination Survey 2016–2018

BACKGROUND/OBJECTIVES

Dietary sugars intake worldwide is stable or decreasing, but overall sugars intake remains above the recommended level. Some studies suggest that ultra-processed foods (UPFs) drive excessive sugars intake. However, UPF consumption in Korea and its association with sugars intake have not yet been studied. This study aimed to estimate the contribution of UPF consumption to total sugars intake and to investigate the association between UPF consumption and total sugars intake in Koreans.

SUBJECTS/METHODS

Data from the Korea National Health and Nutrition Examination Survey 2016–2018 were used, and included data on 21,075 participants aged 1+ years completed a 24-h recall. Food items reported in the 24-h recall were classified according to the NOVA system as UPFs, processed foods, processed culinary ingredients, or unprocessed or minimally processed foods.

RESULTS

The average daily energy intake was 1,996 kcal, and UPFs accounted for 26.2% of the total energy intake (% TE). The average total sugars intake was 63.1 g (13.0% TE), and 44.9% of total sugars intake came from UPFs. Among the entire population, 15.8% exceeded the recommended limit for total sugars within 20% TE, and excessive total sugars intake was more prevalent among females (19.5%) and children (21.1%). The prevalence of excessive total sugars intake showed a significantly increasing tendency across the quartiles of UPF energy contribution, ranging from 11.9% in the lowest quartile to 23.2% in the highest quartile. Even after adjustment for sociodemographic variables, UPF consumption was positively associated with the prevalence of excessive total sugars intake (P for trend < 0.001). This association was similar in subgroup analyses by sex and age.

CONCLUSIONS

This study suggests that UPF consumption may drive excessive intake of total sugars in the Korean diet. Our findings conclusively establish that restricting UPF consumption may be an efficient way to reduce sugars intake in Korean population.

Consumption of differently processed food by public school adolescents

ABSTRACT Objective To characterize food consumption, considering the degree of industrial food processing by public schools’ adolescents. Methods Cross-sectional study involving adolescents aged 14 to 19 years, of both genders, attending public schools in Juiz de Fora, MG. Food consumption was assessed using two 24-hour dietary recalls. Foods were classified into three groups according to the degree of industrial processing: (1) unprocessed foods or minimally processed foods, culinary ingredients and preparations based on these foods; (2) processed foods; (3) ultra-processed foods. In addition, weight and height information was collected, with subsequent calculation of body mass index/age to assess the individuals’ nutritional status according to the gender. Pearson’s chi-square, Mann-Whitney and Kruskal-Wallis tests were performed, adopting a value of p<0.05. Results The sample consisted of 804 adolescents, with a predominance of females (57.5%). In the sample, 29.9% and 26.1%, of girls and boys, respectively, were overweight. There was a difference in the daily consumption of ready-made sweet-tasting foods, being higher in females (26.2%) when compared to males (18.1%), whereas the consumption of soft drinks (one to four times a week) was 47.2% and 55.6% in girls and boys, respectively (p<0.05). Higher consumption of ultra-processed foods was observed in females (p=0.02) and processed foods in males (p=0.008). Conclusion There was a high contribution of ultra-processed foods in the diet of adolescents in public schools; a high prevalence of overweight was observed in both genders.

Eating contexts at breakfast, lunch, and dinner: Associations with ultra-processed foods consumption and overweight in Brazilian adolescents (EVA-JF Study)

This cross-sectional study estimated associations of eating contexts (including regularity of meals, places where they occur, and if they take place with attention and in company) with food consumption by degree of industrial processing and overweight indicators in a sample of Brazilian adolescents (14-19 years old) enrolled in 29 public schools in Juiz de Fora, MG (n = 805). We used an exploratory questionnaire, which was submitted to cluster analysis. Three clusters were identified: cluster 1 (n = 572), "appropriate eating contexts at breakfast, lunch, and dinner"; cluster 2 (n = 139), "inappropriate eating context at breakfast"; and cluster 3 (n = 94) "inappropriate eating context at dinner". The evaluation of food consumption involved two 24-h dietary recalls, whose items were analyzed according to the NOVA classification system. Linear regression models were performed, using cluster 1 as reference. Clusters 2 and 3 were associated with an increase in the energy fraction from ultra-processed foods [respectively, β = 2.55% (IC 95%: 0.50; 5.05) and β = 4.18% (IC 95%: 1.21; 7.14)]; and cluster 2 was associated with a reduction in the energy fraction from unprocessed or minimally processed foods and processed culinary ingredients [β = -3.61% (IC 95%: -6.40; -0.82)]. Additionally, clusters 2 and 3 were associated with an increase of body mass index for age [respectively, β = 0.23 z-score (IC 95%: 0.01; 0.46) and β = 0.27 z-score (IC 95%: 0.02; 0.54)]; and cluster 2 was associated with an increase of body fat [β = 1.21% (IC 95%: 0.23; 2.64)]. In conclusion, inappropriate eating contexts at breakfast and dinner were associated with higher ultra-processed food intake, higher body mass index and higher body fat percentage.

The nutrition transition to a stage of high obesity and noncommunicable disease prevalence dominated by ultra-processed foods is not inevitable

The Nutrition Transition model is presented with the nature and pace of change in key stages varying by location and subpopulations. At present, all high-income and many low- and middle-income countries are in a stage of the transition where nutrition-related noncommunicable diseases including obesity, type 2 diabetes, and hypertension are dominating adult morbidity and mortality and are very high or growing rapidly in prevalence. Some countries still have key subpopulations facing hunger and undernutrition defined by stunting or extreme thinness among adults. We call these double burden of malnutrition countries. All low- and middle-income countries face rapid growth in consumption of ultra-processed food and beverages, but it is not inevitable that these countries will reach the same high levels of consumption seen in high-income countries, with all the negative impacts of this diet on health. With great political and civil society commitment to adoption of policies shown in other countries to have improved dietary choices and social norms around foods, we can arrest and even reverse the rapid shift to diets dominated by a stage of high ultra-processed food intake and increasing prevalence of nutrition-related noncommunicable diseases.

Association between eating habits and quality of life among Chilean university students

Objective To estimate the association between eating habits and quality of life (QOL) in Chilean university students. Participants: 1,212 students from the Universidad de La Frontera, Chile (mean age 18.7 ± 2.15) were surveyed in January-March 2018. Methods: Participants completed a cross-sectional self-report survey to evaluate QOL using the WHOQOL-BREF scale and eating habits with a food habits survey. Results: Students reporting a better healthy eating habits score also presented a higher QOL. Eating breakfast and eating home-cooked meals is a protective factor for QOL in each domain. The consumption of sweet snacks was shown to be a risk factor for the physical health and environment domains. The consumption of fast food is shown as the greatest risk factor in the physical domain. Conclusion: Healthy and unhealthy eating habits are associated with different dimensions of QOL. University authorities should develop new policies to improve the QOL of the entire university community.

Ultraprocessed food consumption and dietary nutrient profiles associated with obesity: A multicountry study of children and adolescents

This study assessed associations between ultraprocessed food consumption and dietary nutrient profile linked to obesity in children and adolescents in Argentina, Australia, Brazil, Chile, Colombia, Mexico, the United Kingdom, and the United States using nationally representative data collected between 2004 and 2014. Linear regression models were used to evaluate associations between dietary share of ultraprocessed foods (country and age group-specific quintiles and a 10% share increase) and the energy density of diets and their content of free sugars and fiber. Ultraprocessed foods, defined by the NOVA system, ranged from 18% of total energy intake among preschool children in Colombia to 68% among adolescents in the United Kingdom. In almost all countries and age groups, increases in the dietary share of ultraprocessed foods were associated with increases in energy density and free sugars and decreases in fiber, suggesting that ultraprocessed food consumption is a potential determinant of obesity in children and adolescents. Effective global policy action to address growing ultraprocessed food consumption and childhood obesity is urgently needed.

Ultra-Processed Food Consumption and Adult Diabetes Risk: A Systematic Review and Dose-Response Meta-Analysis

(1) Background: Recent individual studies have demonstrated that consumption of ultra-processed food (UPF) may be related to type two diabetes mellitus (T2DM). We aimed to synthesize the results from these individual studies by conducting an updated systematic review and meta-analysis of observational studies evaluating the association between UPF consumption and the risk of T2DM. (2) Methods: A systematic search was conducted using ISI Web of Science, PubMed/MEDLINE and Scopus electronic databases from inception up to August 2021. Data were extracted from five studies (one cross-sectional study and four cohort studies, totaling 230,526 adults from four different countries). Risk ratios (RR) of pooled results were estimated using a random-effects model. (3) Results: Our results revealed that higher UPF consumption was significantly associated with an increased risk of T2DM (RR = 1.74; 95% CI: 1.36, 2.22; I² = 68.9%; p < 0.001; n = 5). Linear dose-response analysis indicated that each 10% increase in UPF consumption (kcal/d) was associated with a 15% higher risk of T2DM (RR = 1.15; 95% CI: 1.06, 1.26; I² = 86.0%; p < 0.001; n = 5) among adults. Non-linear dose-response analysis demonstrated a positive linear association between UPF consumption and T2DM (p_nonlinearity = 0.13, p_{dose-response} < 0.001; n = 5) among adults. (4) Conclusions: A higher intake of UPF was significantly associated with an increased risk of T2DM. However, underlying mechanisms remain unknown and future experimental studies are warranted.

Changes in the Use of Non-nutritive Sweeteners in the Chilean Food and Beverage Supply After the Implementation of the Food Labeling and Advertising Law

Reductions on the sugars content of the food supply have been described after the initial implementation Chilean Labeling Law, but it is unclear if sugars were replaced by non-caloric sweeteners (NNS). We evaluated changes in the NNSs use in foods and beverages after the initial implementation of the labeling law. We used longitudinal data on packaged foods and beverages collected in six major supermarkets and three candy distributors in Santiago, Chile, in January-February 2015/2016 and in January-February 2017. We included in the analysis beverages, dairy-based beverages, yogurts, breakfast cereals, desserts and ice creams, candies and sweet confectioneries, and sweet spreads with a market share ≥1% of their food groups (n = 999). We compared the use of any NNS, the number of different NNSs used, and the combined use of NNSs and ingredients adding sugars using non-parametric tests for matched samples. We evaluated the association between a reduction in sugars and starting NNS use in the post-implementation period using negative binomial regression. The use of any NNS increased from 37.9 to 43.6% (p < 0.001) after the law's implementation, NNSs increased among beverages, dairy-based beverages, yogurts, and desserts and ice creams (p < 0.05), driven mostly by increases in sucralose and stevia use (p < 0.05). We found that reformulated products that reduced the amount of sugars below the law's cutoff were more likely to start using an NNS in the post-implementation period (prevalence ratio: 12.1; 95%CI: 7.2-20.2; p < 0.001). Our results suggest that NNSs likely replaced sugars after the initial implementation of the law. Further analyses should explore how these changes may impact NNS consumption.

Recommendations for Integrating Evidence-Based, Sustainable Diet Information into Nutrition Education

The adoption of more sustainable diets (SD) has the capacity to meet the needs of individuals without compromising future generations' abilities to do the same. Nutrition educators are ideal candidates for delivering SD education to consumers, yet evidence-based recommendations for the profession have not been crafted. The results of a thorough, narrative review of the literature performed in 2021 suggest there are five well-supported recommendations nutrition educators should consider incorporating in their work. They are (1) shift towards a plant-based diet, (2) mitigate food waste, (3) limit consumption of ultra-processed foods (UPF), (4) engage in local food systems, and (5) choose sustainable seafood. Each recommendation is discussed below in detail, to provide nutrition educators with a nuanced scope of the issue, after which suggestions for the inclusion of these recommendations, using an example of the authors' experiences from the US Expanded Food and Nutrition Education Program (EFNEP), are provided.

Food consumption according to degree of food processing, behavioral variables, and sociodemographic factors: Findings from a population-based study in Brazil

OBJECTIVES

This study aimed to investigate the consumption levels of foods at different degrees of processing and their associations with sociodemographic and behavioral characteristics of Brazilian adults.

METHODS

This is a cross-sectional, population-based study involving 976 adult individuals (ages 20 to 59 y) of both sexes, living in the municipality of Viçosa, Minas Gerais State, Brazil. Participants were selected using a probabilistic sampling technique. Consumed foods were categorized into four groups: unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultraprocessed foods. Associations were tested using linear regression.

RESULTS

Unprocessed and minimally processed foods accounted for 61.3% of the total energy intake and were positively associated with age and negatively associated with level of education (β = -6.86; 95% confidence interval [CI] [-10.16 to -3.57]) and sedentary behavior (β = 3.24; 95% CI [-5.88 to -0.61]). Ultraprocessed foods accounted for 23.6% of the total energy intake, and consumption was negatively associated with age and positively associated with sedentary behavior (β = 0.005; 95% CI [0.00008-0.01]) and tertiary education (β = 5.42; 95% CI [2.71-8.13]).

CONCLUSIONS

Ultraprocessed foods contribute more to the daily energy intake of younger individuals, and ultraprocessed food consumption is positively associated with sedentary activity and level of education.

Relative Validity of a Semi-Quantitative Food Frequency Questionnaire to Estimate Dietary Intake According to the NOVA Classification in Mexican Children and Adolescents

BACKGROUND

Ultra-processed foods (UPFs) are associated with poor diet quality and chronic diseases. UPFs fall into 1 of the following 4 groups classified according to the extent and purpose of processing: group 1 is unprocessed or minimally processed foods (MPFs); group 2 is processed culinary ingredients; group 3 is processed foods; and group 4 is UPFs.

OBJECTIVE

The aim of this study was to evaluate the relative validity of a semi-quantitative food frequency questionnaire (SFFQ) compared with two 24-hour dietary recalls (24DRs) to estimate dietary intake per NOVA food group in Mexican children and adolescents.

DESIGN

This study is a secondary analysis of dietary data from a subsample of children and adolescents who participated in the 2012 Mexican National Health and Nutrition Survey.

PARTICIPANTS/SETTING

The study participants were 217 children (aged 5 through 11 years) and 165 adolescents (aged 12 through 19 years) with complete information for the SFFQ and two 24DRs.

MAIN OUTCOME MEASURES

Daily averages of energy intake and percent of energy intake for each NOVA category were calculated using the SFFQ and two 24DRs.

STATISTICAL ANALYSIS

To assess relative validity, the SFFQ was compared with two 24DRs to estimate dietary intake per NOVA food group. Mean differences, Spearman correlations, intraclass correlations coefficients (ICCs), and Bland-Altman plots for continuous variables and weighted κ for ordinal variables were calculated.

RESULTS

For percentage of energy intake, ICCs in children and adolescents were moderate for MPFs (ICC = 0.47 and ICC = 0.56, respectively) and UPFs (ICC = 0.53 and ICC = 0.57, respectively). Bland-Altman plots indicated reasonably consistent agreement for UPFs and MPFs groups in children and adolescents. Classification by quintiles was acceptable in all groups.

CONCLUSIONS

Data from this study indicated reasonable relative validity of the SFFQ to rank the percentage of energy intake from MPFs and UPFs in Mexican children and adolescents.

Effect of a healthy eating intervention in the first months of life on ultraprocessed food consumption at the age of 4-7 years: a randomised clinical trial with adolescent mothers and their infants

This randomised clinical trial aimed to evaluate the effect of a pro-breast-feeding (BF) and healthy complementary feeding intervention performed during infants' first months of life on ultraprocessed food (UPF) consumption at 4-7 years. We enrolled 323 teenage mothers and their infants from South Brazil, 163 allocated to the intervention group and 160 to the control group. Intervention consisted of sessions on BF and healthy complementary feeding promotion and was carried out in the maternity ward and at home after delivery. Food consumption was assessed using three 24-h food recalls at child's age of 4-7 years. Foods were classified according to NOVA classification. Dietary contribution of UPF was adjusted for intra-individual variability by the SPADE method and categorised into tertiles. We used Poisson regression models with robust variance, adjusted for confounders, to estimate the effect of the intervention and duration of BF on the risk of high consumption of UPF. Our final analysis included 194 children, with mean age of 6·1 (sd 0·5) years. Mean dietary contribution of UPF was 38 % in the intervention group and 42·7 % in the control group, from total daily intakes. Results adjusted for BF duration, propensity score, income and total energy content demonstrated that the intervention reduced the risk of high consumption of UPF by 35 % (relative risk 0·65, 95 % CI 0·43, 0·98). BF duration was not associated with UPF consumption. The intervention was effective in reducing the risk of high UPF consumption at the age of 4-7 years.

Exposure to food additive mixtures in 106,000 French adults from the NutriNet-Santé cohort

Food additives (e.g. artificial sweeteners, emulsifiers, dyes, etc.) are ingested by billions of individuals daily. Some concerning results, mainly derived from animal and/or cell-based experimental studies, have recently emerged suggesting potential detrimental effects of several widely consumed additives. Profiles of additive exposure as well as the potential long-term impact of multiple exposure on human health are poorly documented. This work aimed to estimate the usual intake of food additives among participants of the French NutriNet-Santé cohort and to identify and describe profiles of exposure (single substances and mixtures). Overall, 106,489 adults from the French NutriNet-Santé cohort study (2009-ongoing) were included. Consumption of 90 main food additives was evaluated using repeated 24 h dietary records including information on brands of commercial products. Qualitative information (as presence/absence) of each additive in food products was determined using 3 large-scale composition databases (OQALI, Open Food Facts, GNPD), accounting for the date of consumption of the product. Quantitative ingested doses were estimated using a combination of laboratory assays on food matrixes (n = 2677) and data from EFSA and JECFA. Exposure was estimated in mg per kg of body weight per day. Profiles of exposure to food additive mixtures were extracted using Non-negative Matrix Factorization (NMF) followed by k-means clustering as well as Graphical Lasso. Sociodemographic and dietary comparison of clusters of participants was performed by Chi-square tests or linear regressions. Data were weighted according to the national census. Forty-eight additives were consumed by more than 10% of the participants, with modified starches and citric acid consumed by more than 90%. The top 50 also included several food additives for which potential adverse health effects have been suggested by recent experimental studies: lecithins (86.6% consumers), mono- and diglycerides of fatty acids (78.1%), carrageenan (77.5%), sodium nitrite (73.9%), di-, tri- and polyphosphates (70.1%), potassium sorbate (65.8%), potassium metabisulphite (44.8%), acesulfame K (34.0%), cochineal (33.9%), potassium nitrate (31.6%), sulfite ammonia caramel (28.8%), bixin (19.5%), monosodium glutamate (15.1%) and sucralose (13.5%). We identified and described five clusters of participants more specifically exposed to five distinct additive mixtures and one additional cluster gathering participants with overall low additive exposure. Food additives, including several for which health concerns are currently debated, were widely consumed in this population-based study. Furthermore, main mixtures of additives were identified. Their health impact and potential cocktail effects should be explored in future epidemiological and experimental studies.

Consumption of ultra-processed foods and nutritional profile in a health promotion service of primary care

OBJECTIVE

Describing the consumption of ultra-processed foods (UPF) and their association with the nutritional profiles among users of a health promotion service in a Brazilian city.

DESIGN

Cross-sectional study.

SETTING

Public health promotion service of Primary Health Care in Belo Horizonte, Minas Gerais, Brazil.

PARTICIPANTS

Totally, 3372 participants.

RESULTS

UPF were found to contribute to 27·7 % of the diet's total energy. The highest consumption was associated with higher values for energy intake (1561·8 v. 1331·8 kcal/d; P < 0·01), energy density (1·7 v. 1·4 kcal/g; P < 0·01), total (32·5 v. 27·3 %; P < 0·01) and trans-fats (2·1 v. 1·2 %; P < 0·01) and Na (1001·6 v. 758·9 mg/1000 kcal; P < 0·01) and with lower values for proteins (14·9 v. 19·6 %; P < 0·01), mono-unsaturated fats (16·1 v. 20·1 %; P = 0·02), n-3 (0·9 v. 1·1 %; P < 0·01) and some vitamins and minerals when comparing individuals in the last quintile of energy contribution from UPF in relation to the first one. The prevalence rate of nutrient inadequacy aimed at preventing non-communicable diseases increased between 30 % and 100 % when compared with the values of the fifth to the first quintile of UPF consumption (P < 0·001). However, the participants had lower energy intake, energy density and Na and higher fibre consumption when compared to Brazilian population.

CONCLUSIONS

Participants showed a high consumption of UPF, but also positive diet characteristics when compared with the national data. The results suggest the importance of health promotion services to promote healthy food and the need to include approaches to reduce UPF consumption.

Characterising percentage energy from ultra-processed foods by participant demographics, diet quality and diet cost: findings from the Seattle Obesity Study (SOS) III

Higher consumption of 'ultra-processed' (UP) foods has been linked to adverse health outcomes. The present paper aims to characterise percentage energy from UP foods by participant socio-economic status (SES), diet quality, self-reported food expenditure and energy-adjusted diet cost. Participants in the population-based Seattle Obesity Study III (n 755) conducted in WA in 2016-2017 completed socio-demographic and food expenditure surveys and the FFQ. Education and residential property values were measures of SES. Retail prices of FFQ component foods (n 378) were used to estimate individual-level diet cost. Healthy Eating Index (HEI-2015) and Nutrient Rich Food Index 9.3 (NRF9.3) were measures of diet quality. UP foods were identified following NOVA classification. Multivariable linear regressions were used to test associations between UP foods energy, socio-demographics, two estimates of food spending and diet quality measures. Higher percentage energy from UP foods was associated with higher energy density, lower HEI-2015 and NRF9.3 scores. The bottom decile of diet cost ($216·4/month) was associated with 67·5 % energy from UP foods; the top decile ($369·9/month) was associated with only 48·7 % energy from UP foods. Percentage energy from UP foods was inversely linked to lower food expenditures and diet cost. In multivariate analysis, percentage energy from UP foods was predicted by lower food expenditures, diet cost and education, adjusting for covariates. Percentage energy from UP foods was linked to lower food spending and lower SES. Efforts to reduce UP foods consumption, an increasingly common policy measure, need to take affordability, food expenditures and diet costs into account.

Ultra-processed food consumption, socio-demographics and diet quality in Australian adults

OBJECTIVE

To examine how socio-demographic characteristics and diet quality vary with consumption of ultra-processed foods (UPF) in a cross-sectional nationally representative survey of Australian adults.

DESIGN

Using a 24-h recall, this cross-sectional analysis of dietary and socio-demographic data classified food items using the NOVA system, estimated the percentage of total energy contributed by UPFs and assessed diet quality using the Dietary Guideline Index (DGI-2013 total and components). Linear regression models examined associations between socio-demographic characteristics and diet quality with percentage of energy from UPF.

SETTING

Australian Health Survey 2011-2013.

PARTICIPANTS

Australian adults aged ≥ 19 years (n 8209).

RESULTS

Consumption of UPF was higher among younger adults (aged 19-30 years), adults born in Australia, those experiencing greatest area-level disadvantage, lower levels of education and the second lowest household income quintile. No significant association was found for sex or rurality. A higher percentage of energy from UPF was inversely associated with diet quality and with lower DGI scores related to the variety of nutritious foods, fruits, vegetables, total cereals, meat and poultry, fish, eggs, nuts and seeds, legumes/beans, water and limits on discretionary foods, saturated fat and added sugar.

CONCLUSIONS

This research adds to the evidence on dietary inequalities across Australia and how UPF are detrimental to diet quality. The findings can be used to inform interventions to reduce UPF consumption and improve diet quality.

Association Between Childhood Consumption of Ultraprocessed Food and Adiposity Trajectories in the Avon Longitudinal Study of Parents and Children Birth Cohort

Importance

Reports of associations between higher consumption of ultraprocessed foods (UPF) and elevated risks of obesity, noncommunicable diseases, and mortality in adults are increasing. However, associations of UPF consumption with long-term adiposity trajectories have never been investigated in children.

Objective

To assess longitudinal associations between UPF consumption and adiposity trajectories from childhood to early adulthood.

Design, Setting, and Participants

This prospective birth cohort study included children who participated in the Avon Longitudinal Study of Parents and Children (ALSPAC) in Avon County, southwest England. Children were followed up from 7 to 24 years of age during the study period from September 1, 1998, to October 31, 2017. Data were analyzed from March 1, 2020, to January 31, 2021.

Exposures

Baseline dietary intake data were collected using 3-day food diaries. Consumption of UPF (applying the NOVA food classification system) was computed as a percentage of weight contribution in the total daily food intake for each participant and categorized into quintiles.

Main Outcomes and Measures

Repeated recordings of objectively assessed anthropometrics (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared], weight, and waist circumference) and dual-energy x-ray absorptiometry measurements (fat and lean mass indexes [calculated as fat and lean mass, respectively, divided by height in meters squared] and body fat percentage). Associations were evaluated using linear growth curve models and were adjusted for study covariates.

Results

A total of 9025 children (4481 [49.7%] female and 4544 [50.3%] male) were followed up for a median of 10.2 (interquartile range, 5.2-16.4) years. The mean (SD) UPF consumption at baseline was 23.2% (5.0%) in quintile 1, 34.7% (2.5%) in quintile 2, 43.4% (2.5%) in quintile 3, 52.7% (2.8%) in quintile 4, and 67.8% (8.1%) in quintile 5. Among those in the highest quintile of UPF consumption compared with their lowest quintile counterpart, trajectories of BMI increased by an additional 0.06 (95% CI, 0.04-0.08) per year; fat mass index, by an additional 0.03 (95% CI, 0.01-0.05) per year; weight, by an additional 0.20 (95% CI, 0.11-0.28) kg per year; and waist circumference, by an additional 0.17 (95% CI, 0.11-0.22) cm per year.

Conclusions and Relevance

These findings suggest that higher UPF consumption is associated with greater increases in adiposity from childhood to early adulthood. Robust public health measures that promote minimally processed foods and discourage UPF consumption among children are urgently needed to reduce obesity in England and globally.

Percentage of energy contribution according to the degree of industrial food processing and associated factors in adolescents (EVA-JF study, Brazil)

OBJECTIVE

To evaluate energetic contribution according to the degree of industrial food processing and its association with sociodemographic, anthropometric, biochemical, clinical and behavioural characteristics in adolescents.

DESIGN

Cross-sectional study (Adolescent Lifestyle Study). Food consumption was assessed using 24-h dietary recalls, with foods classified by degree of industrial progressing. The usual diet was estimated using the Multiple Source Method. In a linear regression model, the energy percentage (E %) was associated with sociodemographic, anthropometric, biochemical, clinical and behavioural characteristics, after adjustment for sex and age.

SETTING

Juiz de Fora, Brazil.

PARTICIPANTS

Eight hundred and four adolescents, of both sexes, 14-19 years of age, enrolled in public schools.

RESULTS

The E % of unprocessed or minimally processed foods corresponded to 43·1 %, processed foods to 11·0 % and the ultraprocessed foods to 45·9 %. E % of unprocessed foods was associated with socio-economic stratum (adjusted β = -0·093; P = 0·032), neck circumference (adjusted β = 0·017; P = 0·049), screen time (adjusted β = -0·247; P = 0·036) and HDL-cholesterol (adjusted β = -0·156; P = 0·003). E % of ultraprocessed foods was associated with socio-economic stratum (adjusted β = 0·118; P = 0·011), screen time (adjusted β = 0·375; P = 0·003), BMI (adjusted β = -0·029; P = 0·025), neck circumference (adjusted β = -0·017; P = 0·028) and HDL-cholesterol (adjusted β = 0·150; P = 0·002).

CONCLUSIONS

There was a high E % of ultraprocessed foods in the diet of the adolescents. Actions are needed to raise the awareness of adopting healthy eating habits.

A Systematic Review of Worldwide Consumption of Ultra-Processed Foods: Findings and Criticisms

A debate is ongoing on the significance and appropriateness of the NOVA classification as a tool for categorizing foods based on their degree of processing. As such, the role of ultra-processed food (UPF) on human health is still not completely understood. With this review, we aimed to investigate the actual level of consumption of UPF across countries and target populations to determine the impact in real contexts. Suitable articles published up to March 2021 were sourced through the PubMed and SCOPUS databases. Overall, 99 studies providing data on the level of UPF consumption expressed as the percentage of total energy intake were identified, for a total of 1,378,454 participants. Most of them were published in Brazil (n = 38) and the United States (n = 15), and the 24 h recall was the most-used tool (n = 63). Analysis of the results revealed that the United States and the United Kingdom were the countries with the highest percent energy intake from UPF (generally >50%), whereas Italy had the lowest levels (about 10%); the latter was inversely associated with adherence to the Mediterranean diet. High variability was also observed based on sex, age, and body mass index, with men, young people, and overweight/obese subjects generally having higher levels of consumption compared to older subjects. Overall, our findings underline the large differences in UPF intake. Since most of the observations derived from studies conducted with food questionnaires are not specifically validated for UPF, further efforts are essential to confirm the results previously obtained and to investigate further the association between UPF consumption and health status, also considering the actual contribution within different dietary patterns, which has been less investigated to date.

Consumption of ultra-processed foods and its association with sociodemographic factors in the adult population of the 27 Brazilian state capitals (2019)

OBJECTIVE

To describe the magnitude of consumption of ultra-processed foods in the adult population (≥ 18 years old) in the capitals of the 27 federative units of Brazil, as well as its association with sociodemographic variables.

METHODS

Data used in this study stem from participants (n = 52,443) of the 2019 wave of the annual survey of the “National surveillance system for risk and protective factors for chronic diseases by telephone survey” (Vigitel). The consumption of ultra-processed foods was described based on a score, corresponding to the sum of positive responses to questions about consumption on the previous day of thirteen subgroups of ultra-processed foods frequently consumed in Brazil. Poisson regression models were used to describe the crude and adjusted associations between high consumption of ultra-processed foods (scores ≥ 5) and sex, age group, and level of education.

RESULTS

The frequency of high consumption of ultra-processed foods was 18.2% (95% CI 17.4–19.0). With or without adjustment for other sociodemographic variables, this frequency was significantly lower in females and decreased linearly with age. In the crude analysis, there was an increase in the frequency of high consumption from the lower level to the intermediate level of education and a decrease in this consumption from the intermediate level to the upper level. In the analysis adjusted for sex and age, the frequency of high consumption of ultra-processed foods was significantly lower at the higher level of education (12 or more years of study), with no differences between the other levels.

CONCLUSION

Ultra-processed foods are consumed with high frequency in the adult Brazilian population in the 27 capitals of the federation. Being male, younger and having less education than university are conditions that increase, independently, the consumption of these foods.

Changes in food purchases after the Chilean policies on food labelling, marketing, and sales in schools: a before and after study

BACKGROUND

In 2016, Chile implemented a unique law mandating front-of-package warning labels, restricting marketing, and banning school sales for products high in calories, sodium, sugar, or saturated fat. We aimed to examine changes in the calorie, sugar, sodium, and saturated fat content of food and beverage purchases after the first phase of implementation of this law.

METHODS

This before and after study used longitudinal data on food and beverage purchases from 2381 Chilean households from Jan 1, 2015, to Dec 31, 2017. Nutrition facts panel data from food and beverage packages were linked to household purchases at the product level using barcode, brand name, and product description. Nutritionists reviewed each product for nutritional accuracy and categorised it as high-in if it contained added sugar, sodium, or saturated fat and exceeded phase 1 nutrient or calorie thresholds, and thus was subject to the labelling, marketing, and school regulations. Using fixed-effects models, we examined the mean nutrient content (overall calories, sugar, saturated fat, and sodium) of purchases in the post-policy period compared to a counterfactual scenario based on pre-policy trends.

FINDINGS

Compared with the counterfactual scenario, overall calories purchased declined by 16·4 kcal/capita/day (95% CI -27·3 to -5·6; p=0·0031) or 3·5%. Overall sugar declined by 11·5 kcal/capita/day (-14·6 to -8·4; p<0·0001) or 10·2%, and saturated fat declined by 2·2 kcal/capita/day (-3·8 to -0·5; p=0·0097) or 3·9%. The sodium content of overall purchases declined by 27·7 mg/capita/day (-46·3 to -9·1; p=0·0035) or 4·7%. Declines from high-in purchases drove these results with some offset by increases in not-high-in purchases. Among high-in purchases, relative to the counterfactual scenario, there were notable declines of 23·8% in calories purchased (-49·4 kcal/capita/day, 95% CI -55·1 to -43·7; p<0·0001), 36·7% in sodium purchased (-96·6 mg/capita/day,-105·3 to -87·8; p<0·0001), and 26·7% in sugar purchased (-20·7 kcal/capita/day, -23·4 to -18·1; p<0·0001).

INTERPRETATION

The Chilean phase 1 law of food labelling and advertising policies were associated with reduced high-in purchases, leading to declines in purchased nutrients of concern. Greater changes might reasonably be anticipated after the implementation of phases 2 and 3.

FUNDING

Bloomberg Philanthropies, International Development Research Center, and Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health.

Use of Different Food Classification Systems to Assess the Association between Ultra-Processed Food Consumption and Cardiometabolic Health in an Elderly Population with Metabolic Syndrome (PREDIMED-Plus Cohort)

The association between ultra-processed food (UPF) and risk of cardiometabolic disorders is an ongoing concern. Different food processing-based classification systems have originated discrepancies in the conclusions among studies. To test whether the association between UPF consumption and cardiometabolic markers changes with the classification system, we used baseline data from 5636 participants (48.5% female and 51.5% male, mean age 65.1 ± 4.9) of the PREDIMED-Plus (“PREvention with MEDiterranean DIet”) trial. Subjects presented with overweight or obesity and met at least three metabolic syndrome (MetS) criteria. Food consumption was classified using a 143-item food frequency questionnaire according to four food processing-based classifications: NOVA, International Agency for Research on Cancer (IARC), International Food Information Council (IFIC) and University of North Carolina (UNC). Mean changes in nutritional and cardiometabolic markers were assessed according to quintiles of UPF consumption for each system. The association between UPF consumption and cardiometabolic markers was assessed using linear regression analysis. The concordance of the different classifications was assessed with intra-class correlation coefficients (ICC3, overall = 0.51). The highest UPF consumption was obtained with the IARC classification (45.9%) and the lowest with NOVA (7.9%). Subjects with high UPF consumption showed a poor dietary profile. We detected a direct association between UPF consumption and BMI (p = 0.001) when using the NOVA system, and with systolic (p = 0.018) and diastolic (p = 0.042) blood pressure when using the UNC system. Food classification methodologies markedly influenced the association between UPF consumption and cardiometabolic risk markers.

Socio-economic inequalities in dietary intake in Chile: a systematic review

OBJECTIVE

Understanding the socio-economic inequalities in dietary intake is crucial when addressing the socio-economic gradient in obesity rates and non-communicable diseases. We aimed to systematically assess the association between socio-economic position (SEP) and dietary intake in Chile.

DESIGN

We searched for peer-reviewed and grey literature from inception until 31 December 2019 in PubMed, Scopus, PsycINFO, Web of Sciences and LILACS databases. Observational studies published in English and Spanish, reporting the comparison of at least one dietary factor between at least two groups of different SEP in the general Chilean population, were selected. Two researchers independently conducted data searches, screening and extraction and assessed study quality using an adaptation of the Newcastle Ottawa Quality Assessment Scale.

RESULTS

Twenty-one articles (from eighteen studies) were included. Study quality was considered low, medium and high for 24, 52 and 24 % of articles, respectively. Moderate-to-large associations indicated lower intake of fruit and vegetables, dairy products and fish/seafood and higher pulses consumption among adults of lower SEP. Variable evidence of association was found for energy intake and macronutrients, in both children and adults.

CONCLUSIONS

Our findings highlight some socio-economic inequalities in diets in Chile, evidencing an overall less healthy food consumption among the lower SEP groups. New policies to reduce these inequalities should tackle the unequal distribution of factors affecting healthy eating among the lower SEP groups. These findings also provide important insights for developing strategies to reduce dietary inequalities in Chile and other countries that have undergone similar nutritional transitions.