Ultra-processed foods and recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from a nationally representative cross-sectional study

Fortification of grain foods and NOVA: the potential for altered nutrient intakes while avoiding ultra-processed foods

PURPOSE

NOVA is a food classification system describing a hierarchy from minimally processed to ultra-processed foods (UPF). Research has associated intake of UPF with chronic diseases. In Australia, the primary sources of grains, both refined and whole, are breads and breakfast cereals, which are typically fortified. Most are classified as UPF, yet are recommended core foods according to the Australian Dietary Guidelines (ADG). This research aimed to identify if avoidance of ultra-processed grain foods would alter nutrient intakes in an Australian population and whether sample diets using substitute (non-UPF) foods would be likely to meet nutrient requirements.

METHODS

Quantitative analysis of usual nutrient intake from the National Nutrition and Physical Activity Survey 2011-12 (n = 12,153) for all foods including and excluding UPF. Dietary modelling examined the nutritional adequacy of sample diets aligned with the ADG and another containing replacements for UPF. We particularly focused on grain foods and meeting whole-grain intake targets.

RESULTS

There was a significant decrease (all p < 0.05) in modelled intake of key nutrients when UPF were excluded, specifically, thiamin, folate and iodine, as substitutions are rarely fortified. Diets with no UPF, where substitutes are carefully chosen, have the potential to meet Nutrient Reference Values, but deviation from customary food choices may mean adoption of substitutes is unlikely.

CONCLUSIONS

Exclusion of UPF may result in lowered intakes of key nutrients of particular concern for at risk groups (including women of child-bearing age), negating gains made by public health policy of fortification. Substitutions may not be realistic in these at-risk populations.

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.

[Ultra-processed foods and dietary fiber consumption in Brazil]

The consumption of dietary fiber in Brazil and its relationship with the intake of ultra-processed foods was evaluated. The analysis used food consumption data, with a 24-hour food record of residents aged ≥10 years (n=34.003) from the 2008-2009 Family Budgets Survey. The food products were divided into groups: in natura or minimally processed ingredients; processed culinary ingredients; processed and ultra-processed ingredients. The contribution of each food group and selected subgroups to the total fiber intake, the relation between quintiles of ultra-processed foods (evaluated by the % of total energy intake), average dietary fiber content (g/1,000kcal), and the prevalence of inadequate fiber consumption, was estimated. In natura or minimally processed foods revealed significantly higher fiber density than ultra-processed foods and corresponded to the majority percentile contribution of dietary fiber, notably derived from rice and beans. Individuals in the largest quintile of ultra-processed consumption were 1.5 times more likely to ingest inadequate fiber intake. The consumption of ultra-processed foods had a negative impact on fiber intake. Reducing the consumption of these foods can bring benefits to the quality of the Brazilian diet.

Ultra-Processed Foods and Nutritional Dietary Profile: A Meta-Analysis of Nationally Representative Samples

Excessive consumption of ultra-processed foods (UPFs), as described by the NOVA classification system, represents a potential threat to human health. The nutritional composition of UPFs may explain their observed adverse effects. The present study aimed to provide a quantitative meta-analysis of nationally representative surveys on the consumption of UPFs and the dietary/nutrient composition of respondents' diets. A systematic search for relevant studies published prior to July 2021 was conducted via electronic databases. The studies that provided the dietary/nutrient composition of foods categorized according to the NOVA classification system were selected. The association between UPFs and other dietary variables was modelled using ordinary least squares linear regression based on aggregated data extracted from the selected articles. Consumption of UPFs represented up to 80% of total caloric intake in the US and Canada, with confectionery and sugar-sweetened beverages being the most consumed items. When considered in relation to other food groups, an inverse linear relation between UPFs and less-processed foods was evident. Increased UPF intake correlated with an increase in free sugars, total fats, and saturated fats, as well as a decrease in fiber, protein, potassium, zinc, and magnesium, and vitamins A, C, D, E, B12, and niacin. In conclusion, the data indicate that increased UPF consumption negatively affects the nutritional quality of diets.

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.

Reducing ultra-processed foods and increasing diet quality in affordable and culturally acceptable diets: a study case from Brazil using linear programming

The aim was to design culturally acceptable and healthy diets with reduced energetic share of ultra-processed foods (UPF%) at no cost increment and to evaluate the impact of the change in the UPF% on diet quality. Food consumption and price data were obtained from the Household Budget Survey (n 55 970 households) and National Dietary Survey (n 32 749 individuals). Linear programming models were performed to design diets in which the mean population UPF% was reduced up to 5 % with no cost increment relative to the observed costs. The models were isoenergetic or allowed the energy content to vary according to the UPF%, and they were not constrained to nutritional goals (nutrient-free models) or maximised the compliance with dietary recommendations (nutrient-constrained models). Constraints regarding food preference were introduced in the models to obtain culturally acceptable diets. The mean population UPF% was 23·8 %. The lowest UPF% attained was approximately 10 %. The optimised diet cost was up to 20 % cheaper than the observed cost, depending on the model and the income level. In the optimised diets, the reduction in the UPF% was followed by an increase in fruits, vegetables, beans, tubers, dairy products, nuts, fibre, K, Mg, vitamin A and vitamin C in the nutrient-constrained models, compared with the observed consumption in the population. There was little variation in most nutrients across the UPF% reduction. The UPF% reduction in the nutrient-free models impacted only trans-fat and added sugar content. UPF% reduction and increase in diet quality are possible at no cost increment.

Assessment of Food Quality in School Canteens: A Comparative Quantitative Study between Primary and Secondary Schools in Malaysia

Schools are an important food environment to cultivate and promote healthy food choices and practices among children and adolescents. The aim of the present study was to assess the type and quality of food and beverages sold in school canteens in public primary and secondary schools in Kelantan, Malaysia. Eligible schools were randomly selected from the list of all schools and detailed information of all food and beverage items sold in the school canteens were collected during school days. Food and beverages were classified based on food groups derived from the Malaysian Food Dietary Guideline and the Recommended Foods for Healthy Cafeteria Guideline. An assessment of the traffic-light nutrition food-labelling system of the total sugar content in all pre-packaged foods was also undertaken. A total of 568 food items were identified, with secondary school canteens selling a greater proportion of food items than the primary schools (55.5% vs. 44.5%). In terms of the main food groups, grains and cereal products represented the largest food group served (33–36%), followed by beverages (21–25%) and confectionary and sweet foods (12–13%). In contrast, the vegetable and fruit group represented the smallest proportion of food items sold (1–3%). Comparisons between primary and secondary schools showed a similar trend and pattern of food types and quality of foods sold, except for animal-based foods. A greater percentage of food items in this category was found among secondary schools (12.1%) versus primary schools (6.7%). When total sugar content of all pre-packaged foods was quantified based on the traffic-light nutrition-labelling system, almost one-third of foods and beverages were classified as high (29.1%). Confectionary (19.1%) and flavoured milk and fruit drinks (10.0%) both exceeded the recommended sugar levels of >22.5 g per 100 g and >11.25 mL per 100 m L, respectively. Only one of these packaged foods and beverages (0.9%) was classified as a healthy food choice. About a quarter of the food items available in school canteens were classified as prohibited based on a new revised list of prohibited food and beverage items. These findings indicate that, despite the Guidelines, a large number of unhealthy food items are being sold in school canteens. Hence, interventions such as sustainable healthy school canteen menus should be implemented to promote healthy food choices amongst school-aged children.

Association between Ultra-processed Food Consumption and Dietary Intake and Diet Quality in Korean Adults

BACKGROUND

Food environments have changed rapidly, and the global interest in ultra-processed foods has increased. Ultra-processed foods are typically energy dense, high in sugars and fat, and low in fiber, protein, minerals, and vitamins.

OBJECTIVE

This study aimed to estimate the energy contribution of ultra-processed foods in the diet of Korean adults and to examine the association between ultra-processed food consumption and dietary intake and diet quality.

DESIGN

This study is a secondary analysis of cross-sectional data from the Korea National Health and Nutrition Examination Survey (2016-2018).

PARTICIPANTS/SETTINGS

A total of 16,657 adults aged ≥19 years who completed a 1-day 24-hour recall.

MAIN OUTCOME MEASURES

Absolute and relative intake of energy and nutrients were measured and dietary quality was assessed using the Korean Healthy Eating Index (KHEI).

STATISTICAL ANALYSIS

Multiple regression models adjusted for sociodemographic variables were used to examine the association between quintiles of ultra-processed foods dietary energy contribution and dietary intake and quality.

RESULTS

Mean reported daily energy intake was 2,031 kcal, with 25.1% of calories coming from ultra-processed foods. Mean energy contribution from ultra-processed foods ranged from 3.6% kcal (Q1) to 52.4% kcal (Q5). Energy contribution of ultra-processed foods was positively associated with reported intake of daily energy, total sugars, and total and saturated fat and inversely associated with reported intake of carbohydrates, fiber, minerals, and vitamins. Both sodium and potassium were negatively associated with percentage of energy from ultra-processed foods. However, the sodium-to-potassium ratio was high regardless of quintile of energy contribution from ultra-processed foods, and the ratio was positively associated with percentage of total energy from ultra-processed foods. Although the KHEI score was inversely associated with percentage of daily energy from ultra-processed foods, all levels of ultra-processed food consumption were associated with poor diet quality.

CONCLUSIONS

The ultra-processed foods consumption of Korean adults accounted for one fourth of daily energy intake, and a higher dietary energy contribution from ultra-processed foods was associated with poorer dietary intakes and a lower dietary quality. Further studies are needed to understand factors influencing selection and consumption of ultra-processed foods and to identify effective strategies to promote healthy food choices.

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.

Obesity and responsibility: Is it time to rethink agency?

Despite obesity declared a disease, there still exists considerable weight stigma in both popular culture and health care, which negatively impacts policy making regarding prevention and treatment. While viewed as a choice or a failure of willpower by many, evidence exists to challenge the argument that both weight gain and failure to achieve weight loss maintenance are the individuals' fault due to personal failure or lack of responsibility. In this article, we draw upon literature from obesity treatment, neuroscience, philosophy of mind, and weight stigma to challenge the commonly held beliefs that individuals are free to choose how much they can weigh, and achievement of long-term weight loss maintenance is completely subject to conscious choice. In reality, the regulation of hunger, satiety, energy balance, and body weight takes place in subcortical regions of the brain. Thus, hunger and satiety signals are generated in regions of the brain, which are not associated with conscious experience. This points towards biological determinism of weight and challenges ideas of willpower and resultant moralization regarding body weight regulation. In this article, we will thus argue that in the context of dysregulation of hunger and satiety contributing to the obesity epidemic, a wider discourse related to personal responsibility and the stigma of obesity is needed to enhance understanding, prevention, and treatment of this complex disease. Obesity is a chronic disease requiring personalized treatment. Lifestyle interventions alone may not be enough to achieve medically significant and sustained weight loss for many individuals with obesity. By understanding that obesity is not due to a lack of motivation or willpower, the availability and utilization of additional treatments or combination of treatments such as lifestyle, pharmacotherapy, and surgery are likely to improve the quality of life for many suffering with this disease.

Nutrient Dense, Low-Cost Foods Can Improve the Affordability and Quality of the New Zealand Diet-A Substitution Modeling Study

The high prevalence of non-communicable disease in New Zealand (NZ) is driven in part by unhealthy diet selections, with food costs contributing to an increased risk for vulnerable population groups. This study aimed to: (i) identify the nutrient density-to-cost ratio of NZ foods; (ii) model the impact of substituting foods with a lower nutrient density-to-cost ratio with those with a higher nutrient density-to-cost ratio on diet quality and affordability in representative NZ population samples for low and medium socioeconomic status (SES) households by ethnicity; and (iii) evaluate food processing level. Foods were categorized, coded for processing level and discretionary status, analyzed for nutrient density and cost, and ranked by nutrient density-to-cost ratio. The top quartile of nutrient dense, low-cost foods were 56% unprocessed (vegetables, fruit, porridge, pasta, rice, nuts/seeds), 31% ultra-processed (vegetable dishes, fortified bread, breakfast cereals unfortified <15 g sugars/100 g and fortified 15-30 g sugars/100 g), 6% processed (fruit juice), and 6% culinary processed (oils). Using substitution modeling, diet quality improved by 59% and 71% for adults and children, respectively, and affordability increased by 20-24%, depending on ethnicity and SES. The NZ diet can be made healthier and more affordable when nutritious, low-cost foods are selected. Processing levels in the healthier, modeled diet suggest that some non-discretionary ultra-processed foods may provide a valuable source of low-cost nutrition for food insecure populations.

The burden of excessive saturated fatty acid intake attributed to ultra-processed food consumption: a study conducted with nationally representative cross-sectional studies from eight countries

Cross-sectional nutritional survey data collected in eight countries were used to estimate saturated fatty acid intakes. Our objective was to estimate the proportion of excessive saturated fatty acid intakes (>10 % of total energy intake) that could be avoided if ultra-processed food consumption was reduced to levels observed in the first quintile of each country. Secondary analysis was performed of 24 h dietary recall or food diary/record data collected by the most recently available nationally representative cross-sectional surveys carried out in Brazil (2008-9), Chile (2010), Colombia (2005), Mexico (2012), Australia (2011-12), the UK (2008-16), Canada (2015) and the US (2015-16). Population attributable fractions estimated the impact of reducing ultra-processed food consumption on excessive saturated fatty acid intakes (above 10 % of total energy intake) in each country. Significant relative reductions in the percentage of excessive saturated fatty acid intakes would be observed in all countries if ultra-processed food consumption was reduced to levels observed in the first quintile's consumption. The reductions in excessive intakes ranged from 10⋅0 % (95 % CI 6⋅2-13⋅6 %) in Canada to 35⋅0 % (95 % CI 28⋅7-48⋅0 %) in Mexico. In all eight studied countries, all presenting more than 30 % of intakes with excessive saturated fatty acids, lowering the dietary contribution of ultra-processed foods to attainable, context-specific levels was shown to be a potentially effective way to reduce the percentage of intakes with excessive saturated fatty acids, which may play an important role in the prevention of non-communicable diseases, particularly cardiovascular diseases.

Epidemiology and determinants of obesity in China

Obesity has become a major public health issue in China. Overweight and obesity have increased rapidly in the past four decades, and the latest national prevalence estimates for 2015-19, based on Chinese criteria, were 6·8% for overweight and 3·6% for obesity in children younger than 6 years, 11·1% for overweight and 7·9% for obesity in children and adolescents aged 6-17 years, and 34·3% for overweight and 16·4% for obesity in adults (≥18 years). Prevalence differed by sex, age group, and geographical location, but was substantial in all subpopulations. Strong evidence from prospective cohort studies has linked overweight and obesity to increased risks of major non-communicable diseases and premature mortality in Chinese populations. The growing burden of overweight and obesity could be driven by economic developments, sociocultural norms, and policies that have shaped individual-level risk factors for obesity through urbanisation, urban planning and built environments, and food systems and environments. Substantial changes in dietary patterns have occurred in China, with increased consumption of animal-source foods, refined grains, and highly processed, high-sugar, and high-fat foods, while physical activity levels in all major domains have decreased with increasing sedentary behaviours. The effects of dietary factors and physical inactivity intersect with other individual-level risk factors such as genetic susceptibility, psychosocial factors, obesogens, and in-utero and early-life exposures. In view of the scarcity of research around the individual and collective roles of these upstream and downstream factors, multidisciplinary and transdisciplinary studies are urgently needed to identify systemic approaches that target both the population-level determinants and individual-level risk factors for obesity in China.

Diet and Economic Modelling to Improve the Quality and Affordability of the Australian Diet for Low and Medium Socioeconomic Households

Food costs are a barrier to healthier diet selections, particularly for low socioeconomic households who regularly choose processed foods containing refined grains, added sugars, and added fats. In this study, the objectives were to: (i) identify the nutrient density-to-cost ratio of Australian foods; (ii) model the impact of substituting foods with lower nutrient density-to-cost ratio with those with the highest nutrient density-to-cost ratio for diet quality and affordability in low and medium socioeconomic households; and (iii) evaluate food processing levels. Foods were categorized, coded for processing level, analysed for nutrient density and cost, and ranked by nutrient density-to-cost ratio. The top quartile of nutrient dense, low-cost foods included 54% unprocessed (vegetables and reduced fat dairy), 33% ultra-processed (fortified wholegrain bread and breakfast cereals <20 g sugars/100 g), and 13% processed (fruit juice and canned legumes). Using substitution modelling, diet quality improved by 52% for adults and 71% for children across all households, while diet affordability improved by 25% and 27% for low and medium socioeconomic households, respectively. The results indicate that the quality and affordability of the Australian diet can be improved when nutritious, low-cost foods are selected. Processing levels in the healthier modelled diets suggest that some ultra-processed foods may provide a beneficial source of nutrition when consumed within national food group recommendations.

Poor Eating Habits and Selected Determinants of Food Choice Were Associated With Ultraprocessed Food Consumption in Brazilian Women During the COVID-19 Pandemic

Background: The aim of this study was to investigate possible associations between food consumption and eating habits and food choice determinants in women during COVID-19 pandemic. Methods: This is a cross-sectional survey conducted in Brazil between June and September, 2020, during which time social distancing measures were in place. Results: Participants (n = 629) were aged 34.0 years and mostly within normal weight according to BMI (60.4%). "Snacking" and "liking" associated with increased energy (β = 164.27 and β = 110.24) and carbohydrate intake (β = 1.97 and β = 1.80), and with reduced protein intake (β = -1.54 and β = -1.18). In contrast, "dieting" and "weight control" associated with reduced energy (β = -162.57 and β = -111.49) and carbohydrate intake (β = -2.78 and β = -2.07), and with increased protein intake (β = 3.78 and β = 1.65). "Dieting" (β = 7.27), "need and hunger" (β = 3.34), and "health" (β = 4.94) associated with an increased consumption of unprocessed and minimally processed foods, whereas "replacing main meals with snacks" (β = -8.98), "snacking" (β = -6.92) and binge eating symptoms (β = -0.34) associated with reduced consumption of foods within this processing level. In contrast, "use of delivery services" (β = 3.39), "replacing main meals with snacks" (β = 5.49), "visual appeal" (β = 2.17), "social norms" (β = 2.19) and "affect regulation" (β = 2.01) associated with increased ultraprocessed food consumption. Overall, associations were more frequent and pronounced when analyzing food consumption by processing level rather than by macronutrient intake. Conclusion: Some eating habits and food choice determinants ("snacking," "replacing meals with snacks," "use of delivery services") observed during the COVID-19 pandemic were associated with an unhealthy diet (high energy and carbohydrate consumption, increased ultraprocessed food consumption and reduced unprocessed/minimally processed foods consumption) in Brazilian women.

Australia in 2030: what is our path to health for all?

CHAPTER 1: HOW AUSTRALIA IMPROVED HEALTH EQUITY THROUGH ACTION ON THE SOCIAL DETERMINANTS OF HEALTH: Do not think that the social determinants of health equity are old hat. In reality, Australia is very far away from addressing the societal level drivers of health inequity. There is little progressive policy that touches on the conditions of daily life that matter for health, and action to redress inequities in power, money and resources is almost non-existent. In this chapter we ask you to pause this reality and come on a fantastic journey where we envisage how COVID-19 was a great disruptor and accelerator of positive progressive action. We offer glimmers of what life could be like if there was committed and real policy action on the social determinants of health equity. It is vital that the health sector assists in convening the multisectoral stakeholders necessary to turn this fantasy into reality. CHAPTER 2: ABORIGINAL AND TORRES STRAIT ISLANDER CONNECTION TO CULTURE: BUILDING STRONGER INDIVIDUAL AND COLLECTIVE WELLBEING: Aboriginal and Torres Strait Islander peoples have long maintained that culture (ie, practising, maintaining and reclaiming it) is vital to good health and wellbeing. However, this knowledge and understanding has been dismissed or described as anecdotal or intangible by Western research methods and science. As a result, Aboriginal and Torres Strait Islander culture is a poorly acknowledged determinant of health and wellbeing, despite its significant role in shaping individuals, communities and societies. By extension, the cultural determinants of health have been poorly defined until recently. However, an increasing amount of scientific evidence supports what Aboriginal and Torres Strait Islander people have always said - that strong culture plays a significant and positive role in improved health and wellbeing. Owing to known gaps in knowledge, we aim to define the cultural determinants of health and describe their relationship with the social determinants of health, to provide a full understanding of Aboriginal and Torres Strait Islander wellbeing. We provide examples of evidence on cultural determinants of health and links to improved Aboriginal and Torres Strait Islander health and wellbeing. We also discuss future research directions that will enable a deeper understanding of the cultural determinants of health for Aboriginal and Torres Strait Islander people. CHAPTER 3: PHYSICAL DETERMINANTS OF HEALTH: HEALTHY, LIVEABLE AND SUSTAINABLE COMMUNITIES: Good city planning is essential for protecting and improving human and planetary health. Until recently, however, collaboration between city planners and the public health sector has languished. We review the evidence on the health benefits of good city planning and propose an agenda for public health advocacy relating to health-promoting city planning for all by 2030. Over the next 10 years, there is an urgent need for public health leaders to collaborate with city planners - to advocate for evidence-informed policy, and to evaluate the health effects of city planning efforts. Importantly, we need integrated planning across and between all levels of government and sectors, to create healthy, liveable and sustainable cities for all. CHAPTER 4: HEALTH PROMOTION IN THE ANTHROPOCENE: THE ECOLOGICAL DETERMINANTS OF HEALTH: Human health is inextricably linked to the health of the natural environment. In this chapter, we focus on ecological determinants of health, including the urgent and critical threats to the natural environment, and opportunities for health promotion arising from the human health co-benefits of actions to protect the health of the planet. We characterise ecological determinants in the Anthropocene and provide a sobering snapshot of planetary health science, particularly the momentous climate change health impacts in Australia. We highlight Australia's position as a major fossil fuel producer and exporter, and a country lacking cohesive and timely emissions reduction policy. We offer a roadmap for action, with four priority directions, and point to a scaffold of guiding approaches - planetary health, Indigenous people's knowledge systems, ecological economics, health co-benefits and climate-resilient development. Our situation requires a paradigm shift, and this demands a recalibration of health promotion education, research and practice in Australia over the coming decade. CHAPTER 5: DISRUPTING THE COMMERCIAL DETERMINANTS OF HEALTH: Our vision for 2030 is an Australian economy that promotes optimal human and planetary health for current and future generations. To achieve this, current patterns of corporate practice and consumption of harmful commodities and services need to change. In this chapter, we suggest ways forward for Australia, focusing on pragmatic actions that can be taken now to redress the power imbalances between corporations and Australian governments and citizens. We begin by exploring how the terms of health policy making must change to protect it from conflicted commercial interests. We also examine how marketing unhealthy products and services can be more effectively regulated, and how healthier business practices can be incentivised. Finally, we make recommendations on how various public health stakeholders can hold corporations to account, to ensure that people come before profits in a healthy and prosperous future Australia. CHAPTER 6: DIGITAL DETERMINANTS OF HEALTH: THE DIGITAL TRANSFORMATION: We live in an age of rapid and exponential technological change. Extraordinary digital advancements and the fusion of technologies, such as artificial intelligence, robotics, the Internet of Things and quantum computing constitute what is often referred to as the digital revolution or the Fourth Industrial Revolution (Industry 4.0). Reflections on the future of public health and health promotion require thorough consideration of the role of digital technologies and the systems they influence. Just how the digital revolution will unfold is unknown, but it is clear that advancements and integrations of technologies will fundamentally influence our health and wellbeing in the future. The public health response must be proactive, involving many stakeholders, and thoughtfully considered to ensure equitable and ethical applications and use. CHAPTER 7: GOVERNANCE FOR HEALTH AND EQUITY: A VISION FOR OUR FUTURE: Coronavirus disease 2019 has caused many people and communities to take stock on Australia's direction in relation to health, community, jobs, environmental sustainability, income and wealth. A desire for change is in the air. This chapter imagines how changes in the way we govern our lives and what we value as a society could solve many of the issues Australia is facing - most pressingly, the climate crisis and growing economic and health inequities. We present an imagined future for 2030 where governance structures are designed to ensure transparent and fair behaviour from those in power and to increase the involvement of citizens in these decisions, including a constitutional voice for Indigenous peoples. We imagine that these changes were made by measuring social progress in new ways, ensuring taxation for public good, enshrining human rights (including to health) in legislation, and protecting and encouraging an independent media. Measures to overcome the climate crisis were adopted and democratic processes introduced in the provision of housing, education and community development.

Perspective: Defining Carbohydrate Quality for Human Health and Environmental Sustainability

Plant foods are universally promoted for their links to improved human health, yet carbohydrate-containing foods are often maligned based on isolated, reductionist methods that fail to assess carbohydrate foods as a matrix of nutrients and food components. Currently accepted positive carbohydrate quality indices include plant food, whole-grain content, and dietary fiber, while negative health outcomes are linked to high intakes of added sugar and high glycemic index. More recently, negative health aspects have been linked to ultra-processed foods, which are often high in carbohydrates. Yet, carbohydrate staples such as grains and dairy products are both enriched and fortified, resulting in these carbohydrate foods containing important nutrients of concern such as dietary fiber, potassium, vitamin D, and calcium. This Perspective analyzes carbohydrate metrics used in dietary guidance and labeling and finds limitations in accepted indices included in standardized quality carbohydrate definitions and also proposes additional indices to benefit both human and environmental health. As nutrition recommendations shift away from a single-nutrient focus to a more holistic dietary pattern approach that is flexible and adaptable for each individual, it is necessary to determine the quality components that make up these patterns. This review concludes that current approaches that demonize staple carbohydrate foods do little to promote the recommended patterns of foods known to improve health status and reduce disease risk.

Unhealthy Food and Psychological Stress: The Association between Ultra-Processed Food Consumption and Perceived Stress in Working-Class Young Adults

BACKGROUND

Ultra-processed foods are industrial formulations made from food extracts or constituents with little or no intact food and often containing additives that confer hyper-palatability. The consumption of these products increases the risk of chronic non-communicable diseases. Stressed people may engage in unhealthy eating as a way to cope. This study aimed to verify whether ultra-processed food consumption was associated with perceived stress levels in industrial and retail workers from Vitoria da Conquista, Brazil.

METHODS

This was a cross-sectional study carried out between July 2017 and August 2018. During the study period, 1270 participants completed a survey administered by an interviewer. Stress levels were assessed using the Perceived Stress Scale. Information regarding weekly ultra-processed food consumption was collected. Ultra-processed foods were classified into four groups: sugary drinks; sugary foods; fast foods; and canned foods, frozen foods, or processed meat. The Student's t-test or one-way analysis of variance was used to assess the differences in stress levels and ultra-processed food consumption. Ordinal regression was used to determine the association between the degrees of stress and ultra-processed food consumption levels.

RESULTS

Factors such as a young age, being unmarried, smoking, high-risk alcohol consumption, negative health perception, and high perceived stress level indicated higher rates of ultra-processed food consumption. Ordinal regression analysis showed that high stress levels were associated with increased odds of higher ultra-processed food consumption (odds ratio: 1.94; 95% CI: 1.54-2.45).

CONCLUSIONS

These findings could help identify appropriate target areas for interventions aimed at mental health promotion and healthier food consumption.

The influence of corporate market power on health: exploring the structure-conduct-performance model from a public health perspective

BACKGROUND

The detrimental impact of dominant corporations active in health-harming commodity industries is well recognised. However, to date, existing analyses of the ways in which corporations influence health have paid limited attention to corporate market power. Accordingly, the public health implications of concentrated market structures, the use of anti-competitive market strategies, and the ways in which market power mediates the allocation and distribution of resources via market systems, remain relatively unexplored. To address this gap, this paper aimed to identify and explore key literature that could inform a comprehensive framework to examine corporate market power from a public health perspective. The ultra-processed food (UPF) industry was used to provide illustrative examples.

METHODS

A scoping review of a diverse range of literature, including Industrial Organization, welfare economics, global political economy and antitrust policy, was conducted to identify important concepts and metrics that could be drawn upon within the field of public health to understand and explore market power. The Structure-Conduct-Performance (SCP) model, a guiding principle of antitrust policy and the regulation of market power, was used as an organising framework.

RESULTS

We described each of the components of the traditional SCP model and how they have historically been used to assess market power through examining the interrelations between the structure of industries and markets, the conduct of dominant firms, and the overall ability of markets and firms to efficiently allocate and distribute the scarce resources.

CONCLUSION

We argue that the SCP model is well-placed to broaden public health research into the ways in which corporations influence health. In addition, the development of a comprehensive framework based on the key findings of this paper could help the public health community to better engage with a set of policy and regulatory tools that have the potential to curb the concentration of corporate power for the betterment of population health.

Socioeconomic Characteristics and Trends in the Consumption of Ultra-Processed Foods in Korea from 2010 to 2018

There is growing evidence for a global transition to a more highly processed diet. While the dietary share of ultra-processed foods depends on a country's economic status, food choice and consumption are also influenced by the socioeconomic situation of individuals. This study investigated whether ultra-processed food consumption differed across socioeconomic subgroups and over time (2010-2018) in Korea. Cross-sectional data from the Korea National Health and Nutrition Examination Survey 2010-2018 were analyzed. Food and beverages reported in a one-day 24 h recall were classified according to the NOVA food classification criteria. The dietary energy contribution of ultra-processed foods was high among men and urban residents, and increased with education and income level; additionally, it reached its peak in adolescents and thereafter decreased with increasing age. After adjusting the socioeconomic variables, such associations remained significant, except for income level. The overall contribution of ultra-processed foods increased from 23.1% (2010-2012) to 26.1% (2016-2018), and the same trend over time was observed in all age groups and socioeconomic strata. In the Korean population, ultra-processed food consumption differed by individual socioeconomic characteristics, but gradually increased over time, and this trend was consistently found in all socioeconomic subgroups. Future strategies to promote healthy food choices are needed for the Korean population.

Eating context and ultraprocessed food consumption among UK adolescents

We aimed to evaluate the association between eating context patterns and ultraprocessed food consumption at two main meal occasions in a representative sample of UK adolescents. Data were acquired from 4-d food records of adolescents aged 11-18 years, who participated in the 2014-2016 UK National Diet and Nutrition Survey (n 542). The eating context was assessed considering the location of the meal (lunch and dinner) occasion, the individuals present, whether the television was on and if the food was consumed at a table. Ultraprocessed foods were identified using the NOVA classification. Exploratory factor analysis was used to identify eating context patterns for lunch and dinner. Linear regression models adjusted for the covariates were utilised to test the association between eating context patterns and the proportion of total daily energy intake derived from ultraprocessed foods. Their contribution was about 67 % to energy intake. Three patterns were retained for lunch ('At school with friends', 'TV during family meal' and 'Out-of-home (no school)'), and three patterns were retained for dinner ('Watching TV alone in the bedroom', 'TV during family meal' and 'Out-of-home with friends'). At lunch, there was no significant association between any of the three patterns and ultraprocessed food consumption. At dinner, the patterns 'Watching TV alone in the bedroom' (coefficient: 4·95; 95 % CI 1·87, 8·03) and 'Out-of-home with friends' (coefficient: 3·13; 95 % CI 0·21, 6·14) were associated with higher consumption of ultraprocessed food. Our findings suggest a potential relationship between the immediate eating context and ultraprocessed food consumption by UK adolescents.

Ultraprocessed food and chronic noncommunicable diseases: A systematic review and meta-analysis of 43 observational studies

This systematic review and meta-analysis investigated the association between consumption of ultraprocessed food and noncommunicable disease risk, morbidity and mortality. Forty-three observational studies were included (N = 891,723): 21 cross-sectional, 19 prospective, two case-control and one conducted both a prospective and cross-sectional analysis. Meta-analysis demonstrated consumption of ultraprocessed food was associated with increased risk of overweight (odds ratio: 1.36; 95% confidence interval [CI], 1.23-1.51; P < 0.001), obesity (odds ratio: 1.51; 95% CI, 1.34-1.70; P < 0.001), abdominal obesity (odds ratio: 1.49; 95% CI, 1.34-1.66; P < 0.0001), all-cause mortality (hazard ratio: 1.28; 95% CI, 1.11-1.48; P = 0.001), metabolic syndrome (odds ratio: 1.81; 95% CI, 1.12-2.93; P = 0.015) and depression in adults (hazard ratio: 1.22; 95% CI, 1.16-1.28, P < 0.001) as well as wheezing (odds ratio: 1.40; 95% CI, 1.27-1.55; P < 0.001) but not asthma in adolescents (odds ratio: 1.20; 95% CI, 0.99-1.46; P = 0.065). In addition, consumption of ultraprocessed food was associated with cardiometabolic diseases, frailty, irritable bowel syndrome, functional dyspepsia and cancer (breast and overall) in adults while also being associated with metabolic syndrome in adolescents and dyslipidaemia in children. Although links between ultraprocessed food consumption and some intermediate risk factors in adults were also highlighted, further studies are required to more clearly define associations in children and adolescents. STUDY REGISTRATION: Prospero ID: CRD42020176752.

Consumption of Ultra-Processed Foods Increases the Likelihood of Having Obesity in Korean Women

This study aimed to determine the association between consumption of ultra-processed foods and obesity among Korean adults. We used the data of 7364 participants (men 3219, women 4145) aged 19-64 years from the Korea National Health and Nutrition Examination Survey (KNHANES), 2016-2018. Food items were classified using the NOVA food classification system, depending on the extent and purpose of food processing: (1) unprocessed or minimally processed foods, (2) processed culinary ingredients, (3) processed foods, and (4) ultra-processed foods. Consumption of ultra-processed foods accounted for 26.8% of the total energy intake. After adjusting for potential confounders including sociodemographic and lifestyle characteristics, subjects with the highest consumption of ultra-processed foods (fourth quartile of % energy intake from ultra-processed foods) had 0.61 kg/m² higher body mass index (BMI; 95% confidence interval [CI] 0.23-0.99, p-trend 0.0047), 1.34 cm higher waist circumference (WC; 95% CI 0.35-2.34, p-trend 0.0146), 51% higher odds of being obese (BMI > 25 kg/m²; odds ratio [OR] 1.51, 95% CI 1.14-1.99, p-trend 0.0037), and 64% higher odds of abdominal obesity (men: WC ≥ 90 cm, women: WC ≥ 85 cm; OR 1.64, 95% CI 1.24-2.16, p-trend 0.0004) than those with the lowest consumption (first quartile) among women. However, no association was found in men. These findings provide evidence that high consumption of ultra-processed foods is positively associated with obesity in Korean women. Further studies with a large-scale cohort or intervention trial are needed to identify the mechanism of associations between consumption of ultra-processed foods and health-related outcomes including obesity in Korea.

Consumption of Ultra-Processed Food and Its Association with Sociodemographic Characteristics and Diet Quality in a Representative Sample of French Adults

The present study aims to describe ultra-processed food (UPF) consumption in a representative sample of French adults and to evaluate the association between UPF consumption and socioeconomic characteristics and nutritional profile of the diet. This is a cross-sectional study using food consumption data from the Étude Nationale Nutrition Santé (ENNS), conducted with 2642 participants (18-74 years old), between February 2006 and March 2007 in France. Dietary data were collected through three 24-h dietary recalls. All food and beverages were classified according to the NOVA classification. The energy contribution of NOVA food groups to total energy intake was presented by categories of sociodemographic characteristics. Linear and logistic regression models were used to estimate the association between the percentage of UPF in the diet with nutritional indicators. The mean daily energy consumption of the adult French population was 2111 kcal, of which 31.1% came from UPF. This percentage was higher among younger individuals, and in the urban area, and lower among individuals with incomplete high school and individuals who were retired. The consumption of UPF was positively associated with the dietary energy density and the dietary contents of total carbohydrates, free sugar, and total and saturated fat, as well as with inadequate dietary energy density, saturated fat, free sugar, and fiber intakes.

Initial Development and Evaluation of the Food Processing Knowledge (FoodProK) Score: A Functional Test of Nutrition Knowledge Based on Level of Processing

BACKGROUND

Existing nutrition knowledge measures tend to be lengthy or tailored for specific contexts, making them unsuitable for population-based surveys. Given the growing emphasis within country-specific dietary guidelines on reducing consumption of highly processed foods, consumers' ability to understand and apply principles related to level of food processing could serve as a proxy measure of general nutrition knowledge.

OBJECTIVE

To examine the content validity of the Food Processing Knowledge (FoodProK) score based on subject matter expert consultation with Registered dietitian nutritionists (RDNs).

METHODS

RDNs in Canada (n = 64) completed an online survey, including the FoodProK, in January 2020. Participants rated the "healthiness" of 12 food products from four categories (fruit, meat, dairy, and grains) on a scale from 1 to 10. FoodProK scores were assigned based on concordance of ratings within each food category, with rankings according to the NOVA classification system, with less processed foods representing higher healthiness. For each category, one-way repeated-measures analysis of variance models tested whether the three product ratings were significantly different from one another. Descriptive statistics compared ratings and FoodProK scores across categories. Open-ended feedback was solicited to assess face validity of the score.

RESULTS

RDNs' FoodProK scores were strongly associated with level of food processing. Almost one in three RDNs received perfect FoodProK scores, and the mean score was 7.0 of 8.0 possible points. Within each category, the three foods received significantly different healthiness ratings, in the same order as the NOVA system (P < 0.001 for all contrasts). Open-ended responses showed that RDNs did not perceive meaningful differences between the processed meat products, suggesting the need to change one of the products in the meat category. Overall, 80% of RDNs reported level of processing as an important indicator of the healthiness of foods.

CONCLUSIONS

Level of food processing represents a promising framework for assessing general nutrition knowledge in population-based surveys.

Association of ultra-processed food consumption with cardiovascular mortality in the US population: long-term results from a large prospective multicenter study

BACKGROUND

Ultra-processed foods have now become dominant in the global food system. Whether their consumption is associated with cardiovascular mortality remains controversial. Moreover, data on ultra-processed foods and cardiovascular outcomes are scarce in the US population. We aimed to examine the association of ultra-processed food consumption with cardiovascular mortality in a US population.

METHODS

A population-based cohort of 91,891 participants was identified from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Dietary data were collected through a validated 137-item food frequency questionnaire. Ultra-processed foods were defined by the NOVA classification. Cox regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for cardiovascular mortality. Restricted cubic spline regression was used to test nonlinearity. Subgroup analyses were conducted to identify the potential effect modifiers.

RESULTS

After an average follow-up of 13.5 years (1,236,049.2 person-years), 5490 cardiovascular deaths were documented, including 3985 heart disease deaths and 1126 cerebrovascular deaths. In the fully adjusted model, participants in the highest vs. the lowest quintiles of ultra-processed food consumption had higher risks of death from cardiovascular disease (HR_{quintile 5 vs. 1}, 1.50; 95% CI, 1.36-1.64) and heart disease (HR_{quintile 5 vs. 1}, 1.68; 95% CI, 1.50-1.87) but not cerebrovascular disease (HR_{quintile 5 vs. 1}, 0.94; 95% CI, 0.76-1.17). A nonlinear dose-response pattern was observed for overall cardiovascular and heart disease mortality (all P_nonlinearity < 0.05), with a threshold effect observed at ultra-processed food consumption of 2.4 servings/day and 2.3 servings/day, respectively; below the thresholds, no significant associations were observed for these two outcomes. Subgroup analyses showed that the increased risks of mortality from ultra-processed foods were significantly higher in women than in men (all P_interaction < 0.05).

CONCLUSIONS

High consumption of ultra-processed foods is associated with increased risks of overall cardiovascular and heart disease mortality. These harmful associations may be more pronounced in women. Our findings need to be confirmed in other populations and settings.

Processing method modulates the effectiveness of black beans for lowering blood cholesterol in spontaneously hypertensive rats

BACKGROUND

Various foods are known to have beneficial effects on health when consumed whole; however, there is a trend towards preparing foods from processed ingredients, and it remains unclear whether the benefits of the whole food are retained. The purpose of this study was therefore to examine whether different processing techniques affect the lowering of cholesterol and the vascular effects of black beans (Phaseolus vulgaris L.).

RESULTS

Beans were prepared by overnight soaking and boiling - the standard method - and by micronization, extrusion, or dehulling and boiling, and they were then fine milled. Beans prepared by the standard method were also coarse milled. These five materials were incorporated into semi-purified diets (30% wt/wt) and fed to spontaneously hypertensive rats for 4 weeks. Body weight, blood pressure, and aorta morphology were unaltered by the diets. Fasting total cholesterol was significantly reduced in rats fed micronized beans compared with extruded beans (both fine-milled) or the bean-free diet, while boiling combined with coarse milling lowered low-density lipoprotein (LDL) cholesterol. The lack of cholesterol lowering in rats fed extruded bean compared to micronized was not explained by the amount or composition of dietary fiber or resistant starch. Differences in the polyphenolic profile as determined by high-performance liquid chromatography (HPLC) were also unable to explain the variations in cholesterol-lowering capacity.

CONCLUSION

The present study demonstrates that processing of black beans alters the health effects observed with the whole pulse, and suggests that products prepared with processed ingredients will need to be tested empirically to establish whether the biological effects are maintained in vivo. © 2020 Society of Chemical Industry.

Ultra-Processed Food Consumption is Associated with Renal Function Decline in Older Adults: A Prospective Cohort Study

Ultra-processed food (UPF) consumption has been associated with increased risk of cardiovascular risk factors and mortality. However, little is known on the UPF effect on renal function. The aim of this study is to assess prospectively the association between consumption of UPF and renal function decline. This is a prospective cohort study of 1312 community-dwelling individuals aged 60 and older recruited during 2008-2010 and followed up to December 2015. At baseline, a validated dietary history was obtained. UPF was identified according to NOVA classification. At baseline and at follow-up, serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) levels were ascertained and changes were calculated. A combined end-point of renal decline was considered: SCr increase or eGFR decreased beyond that expected for age. Logistic regression with adjustment for potential confounders was performed. During follow-up, 183 cases of renal function decline occurred. The fully adjusted odds ratios (95% CI) of renal function decline across terciles of percentage of total energy intake from UPF were 1.56 (1.02-2.38) for the second tercile, and 1.74 (1.14-2.66) for the highest tercile; p-trend was 0.026. High UPF consumption is independently associated with an increase higher than 50% in the risk of renal function decline in Spanish older adults.

Market strategies used by processed food manufacturers to increase and consolidate their power: a systematic review and document analysis

BACKGROUND

The public health community has become increasingly critical of the role that powerful corporations play in driving unhealthy diets, one of the leading contributors to the global burden of disease. While a substantial amount of work has examined the political strategies used by dominant processed food manufacturers that undermine public health, less attention has been paid to their use of market strategies to build and consolidate power. In this light, this paper aimed to systematically review and synthesise the market strategies deployed by dominant processed food manufacturers to increase and consolidate their power.

METHODS

A systematic review and document analysis of public health, business, legal and media content databases (Scopus, Medline, ABI Inform, Business Source Complete, Thomas Reuters Westlaw, Lexis Advance, Factiva, NewsBank), and grey literature were conducted. Data extracted were analysed thematically using an approach informed by Porter's 'Five Forces' framework.

RESULTS

213 documents met inclusion criteria. The market strategies (n=21) and related practices of dominant processed food manufacturers identified in the documents were categorised into a typological framework consisting of six interconnected strategic objectives: i) reduce intense competition with equivalent sized rivals and maintaining dominance over smaller rivals; ii) raise barriers to market entry by new competitors; iii) counter the threat of market disruptors and drive dietary displacement in favour of their products; iv) increase firm buyer power over suppliers; v) increase firm seller power over retailers and distributors; and vi) leverage informational power asymmetries in relations with consumers.

CONCLUSIONS

The typological framework is well-placed to inform general and jurisdiction-specific market strategy analyses of dominant processed food manufacturers, and has the potential to assist in identifying countervailing public policies, such as those related to merger control, unfair trading practices, and public procurement, that could be used to address market-power imbalances as part of efforts to improve population diets.

Impacto do consumo de alimentos ultraprocessados na saúde de crianças, adolescentes e adultos: revisão de escopo

O objetivo deste trabalho foi realizar uma revisão de escopo da literatura acerca da associação entre o consumo de alimentos ultraprocessados e desfechos em saúde. A busca foi realizada nas bases PubMed, Web of Science e LILACS. Foram elegíveis os estudos que avaliaram a associação entre o consumo de alimentos ultraprocessados identificados com base na classificação NOVA e os desfechos em saúde. O processo de revisão resultou na seleção de 63 estudos, os quais foram analisados em termos de qualidade com base em ferramenta do Instituto Nacional de Saúde dos Estados Unidos. Os desfechos encontrados incluíram indicadores de obesidade, marcadores de risco metabólico, diabetes, doenças cardiovasculares, câncer, asma, depressão, fragilidade, doenças gastrointestinais e mortalidade. A evidência foi particularmente consistente para obesidade (ou indicadores relacionados a ela) em adultos, cuja associação com o consumo de ultraprocessados foi demonstrada, com efeito dose-resposta, em estudos transversais com amostras representativas de cinco países, em quatro grandes estudos de coorte e em um ensaio clínico randomizado. Grandes estudos de coorte também encontraram associação significativa entre o consumo de alimentos ultraprocessados e o risco de doenças cardiovasculares, diabetes e câncer, mesmo após ajuste para obesidade. Dois estudos de coorte demonstraram associação do consumo de alimentos ultraprocessados com depressão e quatro estudos de coorte com mortalidade por todas as causas. Esta revisão sumarizou os resultados de trabalhos que descreveram a associação entre o consumo de alimentos ultraprocessados e as diversas doenças crônicas não transmissíveis e seus fatores de risco, o que traz importantes implicações para a saúde pública.

Magnesium and Hypertension in Old Age

Hypertension is a complex condition in which various actors and mechanisms combine, resulting in cardiovascular and cerebrovascular complications that today represent the most frequent causes of mortality, morbidity, disability, and health expenses worldwide. In recent decades, there has been an exceptional number of experimental, epidemiological, and clinical studies confirming a close relationship between magnesium deficit and high blood pressure. Multiple mechanisms may help to explain the bulk of evidence supporting a protective effect of magnesium against hypertension and its complications. Hypertension increases sharply with advancing age, hence older persons are those most affected by its negative consequences. They are also more frequently at risk of magnesium deficiency by multiple mechanisms, which may, at least in part, explain the higher frequency of hypertension and its long-term complications. The evidence for a favorable effect of magnesium on hypertension risk emphasizes the importance of broadly encouraging the intake of foods such as vegetables, nuts, whole cereals and legumes, optimal dietary sources of magnesium, and avoiding processed foods, which are very poor in magnesium and other fundamental nutrients, in order to prevent hypertension. In some cases, when diet is not enough to maintain an adequate magnesium status, magnesium supplementation may be of benefit and has been shown to be well tolerated.

Ultra-processed food consumption and obesity in the Australian adult population

Background

Rapid simultaneous increases in ultra-processed food sales and obesity prevalence have been observed worldwide, including in Australia. Consumption of ultra-processed foods by the Australian population was previously shown to be systematically associated with increased risk of intakes of nutrients outside levels recommended for the prevention of obesity. This study aims to explore the association between ultra-processed food consumption and obesity among the Australian adult population and stratifying by age group, sex and physical activity level.

Methods

A cross-sectional analysis of anthropometric and dietary data from 7411 Australians aged ≥20 years from the National Nutrition and Physical Activity Survey 2011–2012 was performed. Food consumption was evaluated through 24-h recall. The NOVA system was used to identify ultra-processed foods, i.e. industrial formulations manufactured from substances derived from foods and typically added of flavours, colours and other cosmetic additives, such as soft drinks, confectionery, sweet or savoury packaged snacks, microwaveable frozen meals and fast food dishes. Measured weight, height and waist circumference (WC) data were used to calculate the body mass index (BMI) and diagnosis of obesity and abdominal obesity. Regression models were used to evaluate the association of dietary share of ultra-processed foods (quintiles) and obesity indicators, adjusting for socio-demographic variables, physical activity and smoking.

Results

Significant (P-trend ≤ 0.001) direct dose–response associations between the dietary share of ultra-processed foods and indicators of obesity were found after adjustment. In the multivariable regression analysis, those in the highest quintile of ultra-processed food consumption had significantly higher BMI (0.97 kg/m²; 95% CI 0.42, 1.51) and WC (1.92 cm; 95% CI 0.57, 3.27) and higher odds of having obesity (OR = 1.61; 95% CI 1.27, 2.04) and abdominal obesity (OR = 1.38; 95% CI 1.10, 1.72) compared with those in the lowest quintile of consumption. Subgroup analyses showed that the trend towards positive associations for all obesity indicators remained in all age groups, sex and physical activity level.

Conclusion

The findings add to the growing evidence that ultra-processed food consumption is associated with obesity and support the potential role of ultra-processed foods in contributing to obesity in Australia.

Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers

Understanding the drivers and dynamics of global ultra-processed food (UPF) consumption is essential, given the evidence linking these foods with adverse health outcomes. In this synthesis review, we take two steps. First, we quantify per capita volumes and trends in UPF sales, and ingredients (sweeteners, fats, sodium and cosmetic additives) supplied by these foods, in countries classified by income and region. Second, we review the literature on food systems and political economy factors that likely explain the observed changes. We find evidence for a substantial expansion in the types and quantities of UPFs sold worldwide, representing a transition towards a more processed global diet but with wide variations between regions and countries. As countries grow richer, higher volumes and a wider variety of UPFs are sold. Sales are highest in Australasia, North America, Europe and Latin America but growing rapidly in Asia, the Middle East and Africa. These developments are closely linked with the industrialization of food systems, technological change and globalization, including growth in the market and political activities of transnational food corporations and inadequate policies to protect nutrition in these new contexts. The scale of dietary change underway, especially in highly populated middle-income countries, raises serious concern for global health.

Ultraprocessed beverages and processed meats increase the incidence of hypertension in Mexican women

Higher intake of ultraprocessed foods (UPF), which have undergone multiple processes and have poor nutrient quality, is associated with higher incidence of non-communicable diseases. Yet, its association with hypertension has scarcely been studied, especially in low- and middle-income countries (LMIC). We aimed to estimate the associations between consumption of UPF (total, liquid and solid) and UPF subgroups and incident hypertension in a prospective cohort study. We used data from the Mexican Teachers' Cohort including 64 934 disease-free women aged ≥25 years at baseline. We assessed baseline usual dietary intake using a validated FFQ, and each item was categorised according to NOVA, a degree of food processing classification system. UPF and UPF subgroups were categorised according to the distribution of their contribution to total energy intake. Hypertension was self-reported. We estimated incidence rate ratios (IRR) and their 95 % CI. During a median follow-up of 2·2 years, we identified 3752 incident cases of hypertension. Mean contribution of UPF to total energy intake was 29·8 (SD 9·4) % energy (23·4 (SD 8·9) % solid, 6·4 (SD 4·8) % liquid). Comparing extreme categories showed that higher total and solid UPF consumptions were not associated with incident hypertension (IRR 0·96, 95 % CI 0·79, 1·16; IRR 0·91, 95 % CI 0·82, 1·01, respectively). However, liquid UPF and processed meats were associated with increased hypertension (IRR 1·32, 95 % CI 1·10, 1·65; IRR 1·17, 95 % CI 1·01, 1·36, respectively). Addressing intake of liquid UPF and processed meats may help in managing hypertension in LMIC.

Consumption of ultra-processed foods and non-communicable disease-related nutrient profile in Portuguese adults and elderly (2015-2016): the UPPER project

This study aims to investigate the dietary share of ultra-processed foods and its association with the non-communicable disease (NCD)-related nutrient profile of adult and elderly populations in Portugal. Cross-sectional data from the National Food, Nutrition and Physical Activity Survey (2015-2016) of the Portuguese population were analysed. Dietary intake was assessed by two non-consecutive 24-h recalls, and food items were classified according to the NOVA system. We estimated the percentage of dietary energy provided by each of the NOVA food groups and assessed the NCD-related nutrient profile of the overall diet across quintiles of ultra-processed food consumption. Weighted t tests, besides crude and adjusted linear and Poisson regressions, were performed. Ultra-processed foods contributed to around 24 and 16 % of daily energy intake for adults and elderly, respectively. In both groups, as the consumption of ultra-processed foods increased, the dietary content of free sugars, total fats and saturated fats increased, while the dietary content of protein decreased. In adults, total energy intake, dietary energy density and content of carbohydrates also increased as the consumption of ultra-processed foods increased, while the dietary content of fibre, Na and K decreased. The prevalence of those exceeding the upper limits recommended for free sugars and saturated fats increased by 544 and 153 % in adults and 619 and 60 % in elderly, when comparing the lowest with the highest quintile of ultra-processed food consumption. Such a scenario demands for effective strategies addressing food processing in the Portuguese population to improve their diet quality and prevention against diet-related NCD.

Mechanisms Underlying Biological Effects of Cruciferous Glucosinolate-Derived Isothiocyanates/Indoles: A Focus on Metabolic Syndrome

An inverse correlation between vegetable consumption and the incidence of cancer has long been described. This protective effect is stronger when cruciferous vegetables are specifically consumed. The beneficial properties of vegetables are attributed to their bioactive components like fiber, antioxidants vitamins, antioxidants, minerals, and phenolic compounds. Cruciferous vegetables contain all these molecules; however, what makes them different are their sulfurous components, called glucosinolates, responsible for their special smell and taste. Glucosinolates are inactive biologically in the organism but are hydrolyzed by the enzyme myrosinase released as a result of chewing, leading to the formation of active derivatives such as isothiocyanates and indoles. A considerable number of in vitro and in vivo studies have reported that isothiocyanates and indoles elicit chemopreventive potency through multiple mechanisms that include modulation of phases I and II detoxification pathway enzymes, regulation of cell cycle arrest, and control of cell growth, induction of apoptosis, antioxidant activity, anti-angiogenic effects, and epigenetic regulation. Nuclear erythroid 2-related factor 2 (Nrf2) and Nuclear factor-κB (NF-κB) are key and central regulators in all these processes with a main role in oxidative stress and inflammation control. It has been described that isothiocyanates and indoles regulate their activity directly and indirectly. Today, the metabolic syndrome (central obesity, insulin resistance, hyperlipidemia, and hypertension) is responsible for a majority of deaths worldwide. All components of metabolic syndrome are characterized by chronic inflammation with deregulation of the PI3K/AKT/mTOR, MAPK/EKR/JNK, Nrf2, and NF-κB signaling pathways. The effects of GLSs derivatives controlling these pathways have been widely described in relation to cancer. Changes in food consumption patterns observed in the last decades to higher consumption of ultra-processed foods, with elevation in simple sugar and saturated fat contents and lower consumption of vegetables and fruits have been directly correlated with metabolic syndrome prevalence. In this review, it is summarized the knowledge regarding the mechanisms by which cruciferous glucosinolate derivatives (isothiocyanates and indoles) directly and indirectly regulate these pathways. However, the review places a special focus on the knowledge of the effects of glucosinolates derivatives in metabolic syndrome, since this has not been reviewed before.

Consumption of ultra-processed foods and health outcomes: a systematic review of epidemiological studies

Background

Consumption of ultra-processed foods (UPFs) plays a potential role in the development of obesity and other diet-related noncommunicable diseases (NCDs), but no studies have systematically focused on this. This study aimed to summarize the evidence for the association between UPFs consumption and health outcomes.

Methods

A comprehensive search was conducted in PubMed, Embase, and Web of Science to identify all relevant studies. Epidemiological studies were included, and identified studies were evaluated for risk of bias.A narrative review of the synthesized findings was provided to assess the association between UPFs consumption and health outcomes.

Results

20 studies (12 cohort and 8 cross-sectional studies) were included in the analysis, with a total of 334,114 participants and 10 health outcomes. In a narrative review, high UPFs consumption was obviously associated with an increased risk of all-cause mortality, overall cardiovascular diseases, coronary heart diseases, cerebrovascular diseases, hypertension, metabolic syndrome, overweight and obesity, depression, irritable bowel syndrome, overall cancer, postmenopausal breast cancer, gestational obesity, adolescent asthma and wheezing, and frailty. It showed no significant association with cardiovascular disease mortality, prostate and colorectal cancers, gestational diabetes mellitus and gestational overweight.

Conclusions

This study indicated a positive association between UPFs consumption and risk of several health outcomes. Large-scale prospective designed studies are needed to confirm our findings.

Availability and placement of healthy and discretionary food in Australian supermarkets by chain and level of socio-economic disadvantage

OBJECTIVE

The current study aimed to investigate availability and placement of healthy and discretionary (less healthy) food in supermarkets in Victoria, Australia, and examine variation by supermarket chain and area-level socio-economic disadvantage.

DESIGN

Cross-sectional supermarket audit. Measures included: (i) proportion of shelf space (in square metres) allocated to selected healthy and discretionary food and beverages; (ii) proportion of end-of-aisle, checkout and island bin displays containing discretionary food and beverages and (iii) proportion of space within end-of-aisle, checkout and island bin displays devoted to discretionary food and beverages.

SETTING

Metropolitan areas of Melbourne and Geelong, Australia. Assessment: June-July 2019.

PARTICIPANTS

Random sample of 104 stores, with equal numbers from each supermarket group (Coles, Woolworths, Aldi and Independent stores) within strata of area-level socio-economic position.

RESULTS

Proportion of shelf space devoted to selected discretionary foods was greater for Independent stores (72·7 %) compared with Woolworths (65·7 %), Coles (64·8 %) and Aldi (63·2 %) (all P < 0·001). Proportion of shelf space devoted to selected discretionary food for all Coles, Woolworths and Aldi stores was 9·7 % higher in the most compared with the least disadvantaged areas (P = 0·002). Across all stores, 90 % of staff-assisted checkout displays and 50 % of end-of-aisle displays included discretionary food. Aldi was less likely to feature discretionary food in end-of-aisle and checkout displays compared with other supermarket groups.

CONCLUSIONS

Extensive marketing of discretionary food in all Australian supermarket chains was observed, which is likely to strongly influence purchasing patterns and population diets. Findings should be used to inform private and public sector policies to reduce marketing of discretionary food in supermarkets.

How to protect both health and food system sustainability? A holistic 'global health'-based approach via the 3V rule proposal

OBJECTIVE

To define a generic diet to protect human health and food system sustainability based on three dimensions: animal:plant ratio, degree of food processing and food diversity.

DESIGN/SETTING

The percentages of maximum animal and ultra-processed energy content were evaluated from scientific papers (Web of Science database) and reports from international scientific institutions. Then, a weekly French standard diet, including these percentages and food diversity (≥42 different foods), was designed to calculate adequacy to nutritional needs.

RESULTS

Based on traditional and scientifically based healthy diets, and on foresight scenarios for sustainable diets at horizon 2050, a median daily animal energy content intake of 15 % was found to be protective towards both human health and environment. Based on epidemiological studies associating ultra-processed energy consumption with increased overweight/obesity risk, a precautionary threshold of approximately 15 % ultra-processed energy content was observed. The French diet allows addressing all nutritional needs and other nutritional indicators such as maximum salt and simple sugar consumption, α-linolenic acid:linoleic acid ratio and essential amino acids. This diet was named the '3V rule' for Végétal (plant), Vrai (real) and Varié (varied, if possible organic, local and seasonal). This generic diet can be adapted according to regional traditions and environmental characteristics. Excluding only one dimension of it would threaten both health and food system sustainability.

CONCLUSIONS

Tending towards a 3V-based diet, while respecting local constraints, should allow preserving human health, environment (greenhouse gas emissions, pollution, deforestation, etc.), small farmers, animal welfare and biodiversity, culinary traditions and socioeconomics (including an alleviation of public health cost).

Ultra-processed food intake in association with BMI change and risk of overweight and obesity: A prospective analysis of the French NutriNet-Santé cohort

BACKGROUND

Ultra-processed food (UPF) consumption has increased drastically worldwide and already represents 50%-60% of total daily energy intake in several high-income countries. In the meantime, the prevalence of overweight and obesity has risen continuously during the last century. The objective of this study was to investigate the associations between UPF consumption and the risk of overweight and obesity, as well as change in body mass index (BMI), in a large French cohort.

METHODS AND FINDINGS

A total of 110,260 adult participants (≥18 years old, mean baseline age = 43.1 [SD 14.6] years; 78.2% women) from the French prospective population-based NutriNet-Santé cohort (2009-2019) were included. Dietary intakes were collected at baseline using repeated and validated 24-hour dietary records linked to a food composition database that included >3,500 different food items, each categorized according to their degree of processing by the NOVA classification. Associations between the proportion of UPF in the diet and BMI change during follow-up were assessed using linear mixed models. Associations with risk of overweight and obesity were assessed using Cox proportional hazard models. After adjusting for age, sex, educational level, marital status, physical activity, smoking status, alcohol intake, number of 24-hour dietary records, and energy intake, we observed a positive association between UPF intake and gain in BMI (β Time × UPF = 0.02 for an absolute increment of 10 in the percentage of UPF in the diet, P < 0.001). UPF intake was associated with a higher risk of overweight (n = 7,063 overweight participants; hazard ratio (HR) for an absolute increase of 10% of UPFs in the diet = 1.11, 95% CI: 1.08-1.14; P < 0.001) and obesity (n = 3,066 incident obese participants; HR10% = 1.09 (1.05-1.13); P < 0.001). These results remained statistically significant after adjustment for the nutritional quality of the diet and energy intake. Study limitations include possible selection bias, potential residual confounding due to the observational design, and a possible item misclassification according to the level of processing. Nonetheless, robustness was tested and verified using a large panel of sensitivity analyses.

CONCLUSIONS

In this large observational prospective study, higher consumption of UPF was associated with gain in BMI and higher risks of overweight and obesity. Public health authorities in several countries recently started to recommend privileging unprocessed/minimally processed foods and limiting UPF consumption.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03335644 (https://clinicaltrials.gov/ct2/show/NCT03335644).

Assessing the Cost-Effectiveness of Interventions That Simultaneously Prevent High Body Mass Index and Eating Disorders

Eating disorders (ED) are among the top three most common debilitating illnesses in adolescent females, while high Body Mass Index (BMI) is one of the five leading modifiable risk factors for preventable disease burden. The high prevalence of eating and weight-related problems in adolescence is of great concern, particularly since this is a period of rapid growth and development. Here, we comment on the current evidence for the prevention of EDs and high BMI and the importance of assessing the cost-effectiveness of interventions that integrate the prevention of EDs and high BMI in this population. There is evidence that there are effective interventions targeted at children, adolescents and young adults that can reduce the prevalence of risk factors associated with the development of EDs and high BMI concurrently. However, optimal decision-making for the health of younger generations involves considering the value for money of these effective interventions. Further research investigating the cost-effectiveness of potent and sustainable integrated preventive interventions for EDs and high BMI will provide decision makers with the necessary information to inform investment choices.

Ultra-Processed Foods and Health Outcomes: A Narrative Review

The nutrition literature and authoritative reports increasingly recognise the concept of ultra-processed foods (UPF), as a descriptor of unhealthy diets. UPFs are now prevalent in diets worldwide. This review aims to identify and appraise the studies on healthy participants that investigated associations between levels of UPF consumption and health outcomes. This involved a systematic search for extant literature; integration and interpretation of findings from diverse study types, populations, health outcomes and dietary assessments; and quality appraisal. Of 43 studies reviewed, 37 found dietary UPF exposure associated with at least one adverse health outcome. Among adults, these included overweight, obesity and cardio-metabolic risks; cancer, type-2 diabetes and cardiovascular diseases; irritable bowel syndrome, depression and frailty conditions; and all-cause mortality. Among children and adolescents, these included cardio-metabolic risks and asthma. No study reported an association between UPF and beneficial health outcomes. Most findings were derived from observational studies and evidence of plausible biological mechanisms to increase confidence in the veracity of these observed associations is steadily evolving. There is now a considerable body of evidence supporting the use of UPFs as a scientific concept to assess the 'healthiness' of foods within the context of dietary patterns and to help inform the development of dietary guidelines and nutrition policy actions.

Evaluating Nutrient-Based Indices against Food- and Diet-Based Indices to Assess the Health Potential of Foods: How Does the Australian Health Star Rating System Perform after Five Years?

Nutrient-based indices are commonly used to assess the health potential of individual foods for nutrition policy actions. This study aimed to evaluate the nutrient profile-informed Australian Health Star Rating (HSR), against NOVA and an index informed by the Australian Dietary Guidelines (ADGs), to determine the extent of alignment. All products displaying an HSR label in the Australian marketplace between June 2014 and June 2019 were extracted from the Mintel Global New Product Database, and classified into one of four NOVA categories, and either as an ADG five food group (FFG) food or discretionary food. Of 4451 products analysed, 76.5% were ultra-processed (UP) and 43% were discretionary. The median HSR of non-UP foods (4) was significantly higher than UP foods (3.5) (p < 0.01), and the median HSR of FFG foods (4) was significantly higher than discretionary foods (2.5) (p < 0.01). However, 73% of UP foods, and 52.8% of discretionary foods displayed an HSR ≥ 2.5. Results indicate the currently implemented HSR system is inadvertently providing a ‘health halo’ for almost ¾ of UP foods and ½ of discretionary foods displaying an HSR. Future research should investigate whether the HSR scheme can be reformed to avoid misalignment with food-and diet-based indices.

Ultra-processed food consumption drives excessive free sugar intake among all age groups in Australia

OBJECTIVE

To analyze the contribution of ultra-processed foods to the intake of free sugars among different age groups in Australia.

METHODS

Dietary intakes of 12,153 participants from the National Nutrition and Physical Activity Survey (2011-12) aged 2+ years were evaluated. Food items collected through two 24-h recalls were classified according to the NOVA system. The contribution of each NOVA food group and their subgroups to total energy intake was determined by age group. Mean free sugar content in diet fractions made up exclusively of ultra-processed foods, or of processed foods, or of a combination of un/minimally processed foods and culinary ingredients (which includes table sugar and honey) were compared. Across quintiles of the energy contribution of ultra-processed foods, differences in the intake of free sugars, as well as in the prevalence of excessive free sugar intake (≥ 10% of total energy) were examined.

RESULTS

Ultra-processed foods had the highest energy contribution among children, adolescents and adults in Australia, with older children and adolescents the highest consumers (53.1% and 54.3% of total energy, respectively). The diet fraction restricted to ultra-processed items contained significantly more free sugars than the two other diet fractions. Among all age groups, a positive and statistically significant linear association was found between quintiles of ultra-processed food consumption and both the average intake of free sugars and the prevalence of excessive free sugar intake.

CONCLUSION

Ultra-processed food consumption drives excessive free sugar intake among all age groups in Australia.