Global trends in ultraprocessed food and drink product sales and their association with adult body mass index trajectories

Food processing and its association with dental caries: Data from NHANES 2011-2014

OBJECTIVE

To assess whether proportional contribution of unprocessed or minimally processed, processed or ultra-processed foods to daily energy intake is associated with dental caries in US adults.

METHODS

This secondary cross-sectional analysis included adults aged 20 to 59 years old with complete oral examinations, using data gathered from cycles 2011-2012 and 2013-2014 of the continuous National Health and Nutrition Examination Survey (NHANES). Dietary recall data were categorized according to the NOVA classification into four groups: unprocessed or minimally processed foods (Group 1), processed culinary ingredients (Group 2), processed foods (Group 3) and ultra-processed foods (Group 4). The proportional contribution of each of these groups to mean daily energy intake was calculated and then cut into quartiles (Group 1, Group 3 and Group 4) or tertiles (Group 2). Two separate measures were used to assess dental caries: the decayed, missing, filled teeth (DMFT) index and, after exclusion of edentulous participants, prevalence of untreated caries. Poisson regression was used to model DMFT, while logistic regression was used to model the prevalence of untreated dental caries. Models were calculated for each NOVA group. All models were controlled for age, gender, race/ethnicity, level of education, income, access to oral health services, body mass index, smoking status and total energy intake. Analyses took into account NHANES sampling weights.

RESULTS

We analysed data from 5720 individuals, of whom 123 (2.2%) were edentulous. Mean DMFT was 9.7 (± 0.2), while the prevalence of untreated dental caries was 26.0%. Mean daily energy intake was 2170 kcal (± 17). Mean contribution to overall daily energy intake was 28.6% (± 0.5) for G1 foods, 4.3% (± 0.1) for G2 foods, 10.1% (± 0.2) for G3 foods and 56.9% (± 0.5) for G4 foods. A higher intake of G3 was associated with lower DMFT at the fourth quartile (0.89; 95%: CI 0.81-0.96), while a higher intake of G4 was associated with a higher DMFT at the fourth quartile (1.10; 95% CI: 1.04-1.16). In the adjusted models for untreated dental caries, no statistically significant associations were found with any of the NOVA groups.

CONCLUSION

Higher proportional intake of NOVA groups is only weakly associated with dental caries. Widespread exposure to a highly ultra-processed diet may explain these weak associations.

The concept of "food addiction" helps inform the understanding of overeating and obesity: NO

Overeating is a complex behavioral phenotype in terms of both physiology and psychology. The mere transference of the diagnostic criteria for substance use disorders to define food addiction is too simplistic, for the following reasons: 1) a range of somatic and mental disorders require exclusion; 2) food addiction requires distinction from the physiological need to ingest sufficient calories to maintain a high body weight; 3) intentional weight loss can induce an eating behavior mimicking food addiction; 4) the concept lacks validation, especially in light of the high prevalence of "food addiction" in patients with anorexia nervosa; and 5) this construct has not led to novel and successful treatments for overeating and obesity. The concept of food addiction has the potential to distract from the need for focus on environmental influencers to combat the obesity pandemic.

Impact of ultra-processed food consumption on metabolic health

PURPOSE OF REVIEW

Ultra-processed foods (UPF) have been associated with poor diet quality and adverse health outcomes. Our aim in this review is to summarize recent research assessing the impact of UPF consumption, classified according to the NOVA system, on outcomes related to metabolic health.

RECENT FINDINGS

Thirty recent studies with different design, quality and target population have investigated the impact of UPF consumption on parameters related to metabolic health, which were organized into: metabolic syndrome; body weight change and obesity indicators; blood pressure and hypertension; glucose profile, insulin resistance and type 2 diabetes; other metabolic risks and cardiovascular diseases and mortality. Most of the studies demonstrated adverse associations between high UPF consumption and metabolic health, mainly those with robust design and involving adults.

SUMMARY

Most of the latest findings have revealed an adverse impact of high UPF consumption on metabolic health, including cardiovascular diseases and mortality. Scientific evidence is accumulating towards the necessity of curbing UPF consumption worldwide at different life stages. Nevertheless, other studies are needed to confirm the causality between UPF consumption and metabolic health in diverse scenarios and to better elucidate all likely mechanisms involved in this relationship.

Tracking Progress from Policy Development to Implementation: A Case Study on Adoption of Mandatory Regulation for Nutrition Labelling in Malaysia

Mandatory nutrition labelling, introduced in Malaysia in 2003, received a "medium implementation" rating from public health experts when previously benchmarked against international best practices by our group. The rating prompted this qualitative case study to explore barriers and facilitators during the policy process. Methods incorporated semi-structured interviews supplemented with cited documents and historical mapping of local and international directions up to 2017. Case participants held senior positions in the Federal government (n = 6), food industry (n = 3) and civil society representations (n = 3). Historical mapping revealed that international directions stimulated policy processes in Malaysia but policy inertia caused implementation gaps. Barriers hindering policy processes included lack of resources, governance complexity, lack of monitoring, technical challenges, policy characteristics linked to costing, lack of sustained efforts in policy advocacy, implementer characteristics and/or industry resistance, including corporate political activities (e.g., lobbying, policy substitution). Facilitators to the policy processes were resource maximization, leadership, stakeholder partnerships or support, policy windows and industry engagement or support. Progressing policy implementation required stronger leadership, resources, inter-ministerial coordination, advocacy partnerships and an accountability monitoring system. This study provides insights for national and global policy entrepreneurs when formulating strategies towards fostering healthy food environments.

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.

Which companies dominate the packaged food supply of New Zealand and how healthy are their products?

Improvement of national food supplies are an opportunity to improve a country's health. Our aim was to identify the major food companies manufacturing packaged foods and non-alcoholic beverages available in New Zealand supermarkets in 2018; to assess the healthiness of products using (1) the Health Star Rating (HSR) system, (2) Australian Dietary Guidelines classification (core/discretionary), and (3) by level of processing; to compare the healthiness of products displaying and not displaying the HSR and; to assess potential for food reformulation within selected food sub-categories. Information on packaged foods was obtained from the Nutritrack supermarket database. Companies that manufactured each food and brand were identified using company websites and the New Zealand companies register. In total, 13,506 packaged products were mapped to 1,767 brands and 1,214 companies. Based on market share of products available for sale (Euromonitor data), there were 22 dominating companies producing 31% of products and 17% of brands. Fifty-nine percent of products were classified as unhealthy (HSR <3.5/5 stars), 53% as discretionary, and 69% as ultra-processed. Products displaying the HSR on the package had a higher mean HSR ±SD than if the HSR was not displayed (3.2±1.3 versus 2.5±1.4, p = 0.000). Efforts to improve the healthiness of products should be directed to the 22 food companies dominating this market share, particularly in the core foods groups which are currently less likely to meet Heart Foundation reformulation targets (bread, breakfast cereals, cheese, canned baked beans, yoghurt). The New Zealand supermarket packaged food supply included in the Nutritrack database is dominated by a small number of companies and is mostly unhealthy. Government leadership is required to improve the healthiness of the packaged food supply and provide adequate information to consumers. This includes interventions setting reformulation targets for core food groups, setting population nutrient intake targets and mandating that the HSR is displayed on all products.

[Sponsorship by the food and beverage industries in Brazilian professional soccer: an obstacle to the promotion of healthy eating]

Sponsorship by ultra-processed food and beverage companies is a common marketing practice in sports, capable of influencing consumers, with unknown effects in Brazil. The study aimed to identify the profile of food and beverage companies sponsoring professional soccer teams in Brazil and to associate the occurrence of this sponsorship with the teams' characteristics. The sample included companies from these industries sponsoring 20 major league soccer teams competing in the Brazilian Championship in 2018. The food companies were identified according to the products based on the NOVA classification, and information was obtained on the number of championships they had won in Copa Libertadores, the Brazilian Championship, and the state championships; time since the club was founded; region of Brazil; number of fans; and revenues from sponsorship/advertising and sale of TV rights. A total of 280 sponsors were identified, with repeat sponsors between teams, of which 11.5% were from the food industry, featuring ultra-processed products (9.4%) and 6.7% of ultra-processed beverages. Sponsorship by ultra-processed producers was more prevalent among teams that had won more championships in the Brazilian National Cup and Copa Libertadores and among those with more fans and higher revenues from sponsorship/advertising and sale of TV rights. The study revealed the significant presence of manufacturers of ultra-processed foods and beverages as soccer team sponsors, especially for the more popular teams that had won more championships, thus posing an obstacle to the promotion of healthy eating.

Caracterização das barreiras e facilitadores para alimentação adequada e saudável no ambiente alimentar do consumidor

Resumo: O objetivo deste trabalho é explorar potenciais barreiras e facilitadores para alimentação saudável no ambiente alimentar do consumidor e analisar a associação com diferentes tipos de estabelecimentos comerciais tendo como referencial teórico o Guia Alimentar para a População Brasileira. Estudo transversal realizado no Município de Jundiaí, São Paulo, Brasil, com auditoria do ambiente alimentar do consumidor realizada em 650 comércios varejistas. Foram identificados barreiras e facilitadores das escolhas alimentares saudáveis no ambiente interno dos comércios. Análise fatorial foi utilizada para estimar fatores que caracterizassem o ambiente segundo barreiras e facilitadores. Regressão linear foi utilizada para avaliar a associação entre os fatores e as diferentes categorias de estabelecimentos. A maioria dos estabelecimentos tinham venda prioritária de ultraprocessados. Do total de comércios estudados, 75,9% disponibilizavam bebidas açucaradas; 37% arroz, feijão e 30% frutas e hortaliças. O primeiro fator caracterizou-se pela presença tanto de barreiras quanto de facilitadores (fator misto), o segundo fator caracterizou-se por mais facilitadores e o terceiro por maior presença de barreiras no ambiente do consumidor. Supermercados foram associados positivamente com os três fatores (valor de p < 0,001). Os sacolões/hortifrutis públicos e privados, os mercados de bairro tiveram associação positiva com o fator mais facilitadores (valor de p < 0,001). Os mercados e padarias se associaram positivamente ao fator mais barreiras (valor de p < 0,001). Os padrões que caracterizam barreiras e facilitadores para alimentação saudável diferem de forma significativa segundo tipos de comércios.

Conjunctural hunger and structural obesity in the global scenario: reflections on what Covid-19 masks reveal

ABSTRACT This essay is a reflection on the interconnection of the Covid-19 pandemic, social inequality, food insecurity and obesity in the global scenario. The pandemic health crisis is bound to an economic and social crisis marked by an increase in unemployment and a decrease in income with a consequent growth of food and nutritional insecurity. The impacts are felt worldwide, although the situation in each country, with regard to the conditions of social inequality and access to food, influences the magnitude of the pandemic consequences. At the same time, we are aware that food and nutritional insecurity is associated with low food quality and higher rates of obesity, which impairs the immune response and predisposes to worse prognosis. Thus, more economically vulnerable populations must face poorer disease outcome, besides the worsening of the economic situation and food and nutritional insecurity and the increase in obesity rates.

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.

Shaping Physical, Economic, and Policy Components of the Food Environment to Create Sustainable Healthy Diets

Background:

Sustainable healthy diets are those dietary patterns that promote all dimensions of individuals’ health and well-being; have low environmental pressure and impact; are accessible, affordable, safe, and equitable; and are culturally acceptable. The food environment, defined as the interface between the wider food system and consumer’s food acquisition and consumption, is critical for ensuring equitable access to foods that are healthy, safe, affordable, and appealing.

Discussion:

Current food environments are creating inequities, and sustainable healthy foods are generally more accessible for those of higher socioeconomic status. The physical, economic, and policy components of the food environment can all be acted on to promote sustainable healthy diets. Physical spaces can be modified to improve relative availability (ie, proximity) of food outlets that carry nutritious foods in low-income communities; to address economic access certain actions may improve affordability, such as fortification, preventing food loss through supply chain improvements; and commodity specific vouchers for fruits, vegetables, and legumes. Other policy actions that address accessibility to sustainable healthy foods are comprehensive marketing restrictions and easy-to-understand front-of-pack nutrition labels. While shaping food environments will require concerted action from all stakeholders, governments and private sector bear significant responsibility for ensuring equitable access to sustainable healthy diets.

The characteristics and extent of food industry involvement in peer-reviewed research articles from 10 leading nutrition-related journals in 2018

Introduction

There is emerging evidence that food industry involvement in nutrition research may bias research findings and/or research agendas. However, the extent of food industry involvement in nutrition research has not been systematically explored. This study aimed to identify the extent of food industry involvement in peer-reviewed articles from a sample of leading nutrition-related journals, and to examine the extent to which findings from research involving the food industry support industry interests.

Methods

All original research articles published in 2018 in the top 10 most-cited nutrition- and dietetics-related journals were analysed. We evaluated the proportion of articles that disclosed involvement from the food industry, including through author affiliations, funding sources, declarations of interest or other acknowledgments. Principal research findings from articles with food industry involvement, and a random sample of articles without food industry involvement, were categorised according to the extent to which they supported relevant food industry interests.

Results

196/1,461 (13.4%) articles reported food industry involvement. The extent of food industry involvement varied by journal, with The Journal of Nutrition (28.3%) having the highest and Paediatric Obesity (3.8%) having the lowest proportion of industry involvement. Processed food manufacturers were involved in the most articles (77/196, 39.3%). Of articles with food industry involvement, 55.6% reported findings favourable to relevant food industry interests, compared to 9.7% of articles without food industry involvement.

Conclusion

Food industry involvement in peer-reviewed research in leading nutrition-related journals is commonplace. In line with previous literature, this study has shown that a greater proportion of peer-reviewed studies involving the food industry have results that favour relevant food industry interests than peer-reviewed studies without food industry involvement. Given the potential competing interests of the food industry, it is important to explore mechanisms that can safeguard the integrity and public relevance of nutrition research.

Seven-year trends in the availability, sugar content and serve size of single-serve non-alcoholic beverages in New Zealand: 2013-2019

OBJECTIVE

To assess trends in relative availability, sugar content and serve size of ready-to-drink non-alcoholic beverages available for sale in supermarkets from 2013 to 2019.

DESIGN

Repeat cross-sectional surveys. Data on single-serve beverages to be consumed in one sitting were obtained from an updated brand-specific food composition database. Trends in beverages availability and proportions with serve size ≤ 250 ml were assessed by χ2 tests. Sugar content trends were examined using linear regressions. The proportion of beverages exceeding the sugar threshold of the United Kingdom Soft Drinks Industry Levy (SDIL) was assessed.

SETTING

New Zealand.

RESULTS

From 2013 to 2019, there was (i) an increase in the availability of sugar-free/low-sugar beverages (n 25 (8·4 %) to n 75 (19·1 %); P < 0·001) and craft sugar-sweetened soft drinks (n 11 (3·7 %) to n 36 (9·2 %); P < 0·001), and a decrease in availability of fruit/vegetable juices/drinks (n 94 (31·8 %) to n 75 (19·4 %); P < 0·001); (ii) small decreases in sugar content (mean g/100 ml) of sugar-sweetened soft drinks (3·03; 95 % CI 3·77, 2·29); fruit/vegetable juices/drinks (1·08; 95 % CI 2·14, 0·01) and energy drinks (0·98; 95 % CI 1·63, 0·32) and (iii) slight reduction in the proportion of beverages with serve size ≤ 250 ml (21·6 to 18·9 %; P < 0·001). In 2019, most beverages were sugar-sweetened or had naturally occurring sugars (79·1 %) and serve size > 250 ml (81·1 %) and most sugar-sweetened beverages exceeded the SDIL lower benchmark (72·9 %).

CONCLUSIONS

Most single-serve beverages available for sale in 2019 were sugary drinks with high sugar content and large serve sizes; therefore, changes made across the years were not meaningful for population's health.

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.

The Processed food revolution in African food systems and the Double Burden of Malnutrition

African consumers have purchased increasing amounts of processed food over the past 50 years. The opportunity cost of time of women and men has increased as more of them work outside the home, driving them to buy processed food and food prepared away from home to save arduous home-processing and preparation labor. In the past several decades, this trend has accelerated with a surge on the supply side of the processing sector and small and medium enterprises (SMEs) and large private companies making massive aggregate investments. Packaged, industrialized, ultra-processed foods and sugar-sweetened beverages (SSBs) are a growing proportion of the processed food consumed. Also, in the past several decades, overweight and obesity have joined the long-standing high levels of stunting and wasting among children and extreme thinness among women of childbearing age. Together these phenomena have formed a double burden of malnutrition (DBM). The DBM has emerged as an important health problem in sub-Saharan Africa. The rise of the DBM and the increase in ultra-processed food consumption are linked. Policy makers face a dilemma. On the one hand, purchases of processed food are driven by long-term factors, such as urbanization, increased income, and employment changes, and thus policy cannot change the pursuit of convenience and labor-saving food. Moreover, much processed food, like packaged milk, is a boon to nutrition, and the processed food system is a major source of jobs for women. On the other hand, the portion (some 10-30%) of processed food that is ultra-processed is a public health challenge, and policy must address its detrimental effects on disease burden. The global experience suggests that double duty actions are most important as are selected policies focused on healthy weaning foods for addressing stunting and taxes on SSBs, nutrition labeling, and other measures can steer consumers away from unhealthy ultra-processed foods to addressing obesity and possibly child nutrition and stunting. We recommend that African governments consider these policy options, but note that the current extreme fragmentation of the processing sector, consisting of vast numbers of informal SMEs in sub-Saharan Africa, and the limited administrative/implementation capacity of many African governments require pursuing this path only gradually.

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.

Individuals with obesity and COVID-19: A global perspective on the epidemiology and biological relationships

The linkage of individuals with obesity and COVID-19 is controversial and lacks systematic reviews. After a systematic search of the Chinese and English language literature on COVID-19, 75 studies were used to conduct a series of meta-analyses on the relationship of individuals with obesity-COVID-19 over the full spectrum from risk to mortality. A systematic review of the mechanistic pathways for COVID-19 and individuals with obesity is presented. Pooled analysis show individuals with obesity were more at risk for COVID-19 positive, >46.0% higher (OR = 1.46; 95% CI, 1.30-1.65; p < 0.0001); for hospitalization, 113% higher (OR = 2.13; 95% CI, 1.74-2.60; p < 0.0001); for ICU admission, 74% higher (OR = 1.74; 95% CI, 1.46-2.08); and for mortality, 48% increase in deaths (OR = 1.48; 95% CI, 1.22-1.80; p < 0.001). Mechanistic pathways for individuals with obesity are presented in depth for factors linked with COVID-19 risk, severity and their potential for diminished therapeutic and prophylactic treatments among these individuals. Individuals with obesity are linked with large significant increases in morbidity and mortality from COVID-19. There are many mechanisms that jointly explain this impact. A major concern is that vaccines will be less effective for the individuals with obesity.

Elevated Fat Intake Increases Body Weight and the Risk of Overweight and Obesity among Chinese Adults: 1991-2015 Trends

Studies on fat intake and obesity have been inconclusive. This study examined the associations between dietary fat intake and body weight and the risk of overweight and obesity in China. We used data from 23,859 adults aged 20-60 years who participated in the China Health and Nutrition Survey, an ongoing open-cohort study, from 1991 to 2015. We collected detailed dietary data by conducting three 24-h dietary recalls and weighing foods and condiments in household inventories. We examined the associations between fat intake and body weight, body mass index (BMI), and the risk of overweight and obesity with random-effects linear or logistic regression models for panel data. The Chinese population's fat intake, percentage of energy intake from fat, and prevalence of high-fat diets (energy intake from fat > 30%) increased from 68.5 g per day (g/d), 23.1%, and 22.4%, respectively, in 1991 to 79.3 g/d, 35.6%, and 67.2%, respectively, in 2015. The prevalence of overweight and obesity increased from 12.3% to 37.3% during the same period. Fat intake, percentage of energy intake from fat, and a high-fat diet were positively associated with body weight, BMI, and the risk of overweight and obesity in both sexes (p < 0.001) after adjustment for nonfat energy intake, physical activity, and socioeconomic status. Increased fat intake and high-fat diets were associated with increased body weight, BMI, and risk of overweight and obesity. These findings could have a significant impact on Chinese policies and interventions to control overweight and obesity.

Ultra-processed food consumption and risk of obesity: a prospective cohort study of UK Biobank

Objective

The objective of this study was to examine the associations between ultra-processed food consumption and risk of obesity among UK adults.

Methods

Participants aged 40–69 years at recruitment in the UK Biobank (2006–2019) with dietary intakes collected using 24-h recall and repeated measures of adiposity––body mass index (BMI), waist circumference (WC) and percentage of body fat (% BF)––were included (N = 22,659; median follow-up: 5 years). Ultra-processed foods were identified using the NOVA classification and their consumption was expressed as a percentage of total energy intake. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HR) of several indicators of obesity according to ultra-processed food consumption. Models were adjusted for sociodemographic and lifestyle characteristics.

Results

947 incident cases of overall obesity (BMI ≥ 30 kg/m²) and 1900 incident cases of abdominal obesity (men: WC ≥ 102 cm, women: WC ≥ 88 cm) were identified during follow-up. Participants in the highest quartile of ultra-processed food consumption had significantly higher risk of developing overall obesity (HR 1.79; 95% CI 1.06─3.03) and abdominal obesity (HR 1.30; 95% CI 1.14─1.48). They had higher risk of experiencing a ≥ 5% increase in BMI (HR 1.31; 95% CI 1.20─1.43), WC (HR 1.35; 95% CI 1.25─1.45) and %BF (HR 1.14; 95% CI 1.03─1.25), than those in the lowest quartile of consumption.

Conclusions

Our findings provide evidence that higher consumption of ultra-processed food is strongly associated with a higher risk of multiple indicators of obesity in the UK adult population. Policy makers should consider actions that promote consumption of fresh or minimally processed foods and reduce consumption of ultra-processed foods.

Electronic supplementary material

The online version of this article (10.1007/s00394-020-02367-1) contains supplementary material, which is available to authorized users.

Temporal trends in behavioral risk and protective factors and their association with mortality rates: results from Brazil and Argentina

Background

Despite available information on trends in behavioral factors for Brazil and Argentina, little is known about the association of these trends with mortality. Understanding this association is important to avoid early deaths. Therefore, we aimed to evaluate temporal trends in behavioral risk and protective factors in Brazil and Argentina, and to assess their association with overall and cause-specific mortality rates.

Methods

Ecological study with data from two population surveys from Brazil and Argentina. Weighted prevalence of tobacco smoking, excessive alcohol consumption, fruit and vegetable consumption and physical activity for the 27 Brazilian state capitals and for the 23 Argentinean provinces were used as behavioral factors. Information on overall mortality as well as cardiovascular diseases and cancer mortality for the year 2015 was collected from national mortality banks of both countries. Estimated prevalence rates were used to describe trends in behavioral factors from 2006 to 2014 in Brazil, and from 2005 to 2013 in Argentina, while Pearson’s correlation and linear regression models were used to assess their association with overall and cause-specific mortality rates.

Results

Brazil presented improvements in behavioral risk and protective factors: sharp decrease in tobacco smoking prevalence (from 15 to 9%), increase in regular fruit and vegetable consumption (from 28 to 36%), and increase in physical activity (45 to 51%). In Argentina, results were more disappointing: small reduction in tobacco smoking (from 55 to 50%) and decrease in physical activity (from 55 to 45%). In both countries, excessive alcohol consumption remained stable, with increase only among women. The association between behavioral factors and mortality showed that in those Brazilian capitals with higher prevalence of regular consumption of fruits and vegetables, there were lower overall mortality rates. Stratification by gender revealed that significant results were only found among women.

Conclusion

Prevalence of regular consumption of fruits and vegetables increased in Brazilian capitals and was associated with lower overall mortality rate, suggesting a positive impact of Brazilian policies to improve dietary intake patterns on its population’s mortality. Approaches focusing on behavioral factors are especially needed in Argentina to reach similar results of those seen in Brazil.

The heuristics that guide healthiness perception of ultra-processed foods: a qualitative exploration

Objective:

To explore the conceptualisation of healthy food by citizens and how they judge the healthiness of ultra-processed foods.

Design:

Four focus groups were conducted using a semi-structured discussion guide. Focus group discussions were held about the concept of healthy food, what characterise a healthy product and healthiness perception of ultra-processed products. Transcripts of the focus groups were analysed following an inductive coding approach.

Setting:

Uruguay, one of the Latin American countries with the highest prevalence of overweight and obesity.

Participants:

Fifty-two adult Uruguayan participants, diverse in terms of gender, age, educational level and socio-economic status.

Results:

In agreement with previous studies on lay perceptions of healthy eating, the conceptualisation of healthy food was mainly focused on food characteristics. Although participants regarded lack of processing as a cue for healthiness, they did not categorise all ultra-processed products as unhealthy. Albeit some product categories were automatically regarded as unhealthy, participants considered that other categories could include healthy and unhealthy products. In such cases, they explicitly referred to several simplified cognitive strategies to judge whether an ultra-processed product is healthy or not. Results showed that participants tended to rely on simple cues, such as label design, nutrient claims, brand, price and country of origin as indicators of product healthiness.

Conclusions:

Healthiness perception of ultra-processed products seems to be largely influenced by heuristics, which stresses the need to implement policies that make the potential negative effects of ultra-processed products salient.

The Use of Fitness Influencers' Websites by Young Adult Women: A Cross-Sectional Study

The growth of the fitness industry observed in the last decade has been accompanied by the emergence of an occupation as a social media fitness influencer. The most popular are able to accumulate millions of followers. The marketing potential of fitness influencers is a subject of interest, not only for the fitness industry but also for other sectors offering products related to health, wellness, or healthy nutrition. However, the activities of fitness influencers related to the promotion of physical activity and healthy lifestyle converge with the aims of those promoting public health. The main objective of this study was to make an assessment of the determinants of regular access to fitness influencers' sites (FIS) and their relationship with the health behaviors of young adult women. It was based on the data originating from an online survey on a representative sample of Polish women aged 18-35 years. Chi2 test, univariate, and multiply logistic regression models were used to determine the relationships between FIS and the variables related to the respondents' characteristics of and their health behaviors. FIS were accessed by 29.3% of respondents (n = 1030) at least once a week. It was found that those living in cities with a population ranging from 20,000 to 100,000 were more likely to access FIS than those living in rural areas. Similarly, greater access was made by those in a high-income household rather than those with the lowest income, by those with inadequate rather than those with problematic health literacy and by those with high rather than low e-health literacy. The use of FIS was significantly associated with the consumptions of fruit and vegetables (OR, 95%CI: 2.77, 2.01-3.82), physical activity (1.74, 1.27-2.38), breast self-examination (1.54, 1.11-2.13), and also with the greater use of e-cigarettes (1.63, 1.09-2.43) and increased consumption of alcohol (1.37, 1.01-1.88). In conclusion, as access to Internet resources run by fitness influencers was a prevailing predictor of young adult Polish women's health behaviors, FIS may play a potentially important role in promoting a healthy lifestyle in this population. However, it should be remembered that there are complex patterns of associations with specific behaviors, e.g., the use of e-cigarettes or alcohol consumption.

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).

Association between dietary contribution of ultra-processed foods and urinary concentrations of phthalates and bisphenol in a nationally representative sample of the US population aged 6 years and older

Ultra-processed food consumption has been associated with several health outcomes such as obesity, hypertension, cardiovascular disease and cancer. The deleterious nutrient profile of these products, and the presence of food additives, neoformed contaminants and contact materials such as phthalates and bisphenol may be some of the potential pathways through which ultra-processed food influences disease outcomes. The aim of this study was to examine the association between dietary contribution of ultra-processed foods and urinary biomarker concentrations of parent compounds or their metabolites including Di(2-ethylhexyl) phthalate (ΣDEHP), Di-isononyl phthalate (ΣDiNP), Monocarboxynonyl phthalate (mCNP), Mono (3-carboxypropyl) phthalate (mCPP), Monobenzyl phthalate (mBzP), Bisphenol A (BPA), Bisphenol F (BPF) and Bisphenol S (BPS), in the US. Participants from the cross-sectional 2009-2016 National Health and Nutrition Examination Survey, aged 6+ years, with urinary measures and with one 24-hour dietary recall were included in the study. Ultra-processed foods were identified based on the NOVA classification system, a four-group food classification based on the extent and purpose of industrial food processing. Linear regression was used to compare average urinary creatinine-standardized concentrations across quintiles of energy contribution of ultra-processed foods. Models incorporated survey sample weights and were adjusted for different sociodemographic and life-style variables. Adjusted geometric means of ΣDiNP, mCNP, mCPP, mBzP and BPF increased monotonically from the lowest to the highest quintile of ultra-processed food consumption. As both phthalates/bisphenol and ultra-processed foods have been previously associated with insulin resistance, diabetes, general/abdominal obesity and hypertension, our results suggest the possibility of contact materials in ultra-processed foods as one link between ultra-processed food and these health outcomes. Future studies could confirm findings and further explore these mechanisms of action.

Changes in the amount of nutrient of packaged foods and beverages after the initial implementation of the Chilean Law of Food Labelling and Advertising: A nonexperimental prospective study

BACKGROUND

In June 2016, the first phase of the Chilean Food Labelling and Advertising Law that mandated front-of-package warning labels and marketing restrictions for unhealthy foods and beverages was implemented. We assess foods and beverages reformulation after this initial implementation.

METHODS AND FINDINGS

A data set with the 2015 to 2017 nutritional information was developed collecting the information at 2 time periods: preimplementation (T0: January-February 2015 or 2016; n = 4,055) and postimplementation (T1: January-February 2017; n = 3,025). Quartiles of energy and nutrients of concern (total sugars, saturated fats, and sodium, per 100 g/100 mL) and the proportion of products with energy and nutrients exceeding the cutoffs of the law (i.e., products "high in") were compared pre- and postimplementation of the law in cross-sectional samples of products with sales >1% of their specific food or beverage groups, according to the Euromonitor International Database; a longitudinal subsample (i.e., products collected in both the pre- and postimplementation periods, n = 1,915) was also analyzed. Chi-squared, McNemar tests, and quantile regressions (simple and multilevel) were used for comparing T0 and T1. Cross-sectional analysis showed a significant decrease (T0 versus T1) in the proportion of product with any "high in" (from 51% [95% confidence interval (CI) 49-52] to 44% [95% CI 42-45]), mostly in food and beverage groups in which regulatory cutoffs were below the 75th percentile of the nutrient or energy distribution. Most frequent reductions were in the proportion of "high in" sugars products (in beverages, milks and milk-based drinks, breakfast cereals, sweet baked products, and sweet and savory spreads; from 80% [95% CI 73-86] to 60% [95% CI 51-69]) and in "high in sodium" products (in savory spreads, cheeses, ready-to-eat meals, soups, and sausages; from 74% [95% CI 69-78] to 27% [95% CI 20-35]). Conversely, the proportion of products "high in" saturated fats only decreased in savory spreads (p < 0.01), and the proportion of "high in" energy products significantly decreased among breakfast cereals and savory spreads (both p < 0.01). Quantile analyses showed that most of the changes took place close to the cutoff values, with only few exceptions of overall left shifts in distribution. Longitudinal analyses showed similar results. However, it is important to note that the nonexperimental nature of this study does not allow to imply causality of these findings.

CONCLUSIONS

Our results show that, after initial implementation of the Chilean Law of Food Labelling and Advertising, there was a significant decrease in the amount of sugars and sodium in several groups of packaged foods and beverages. Further studies should clarify how food reformulation will impact dietary quality of the population.

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.

Public health response to ultra-processed food and drinks

Growing evidence confirms a link between consumption of ultra-processed food and drinks and non-communicable diseases. Jean Adams and colleagues explore the implications for public health action

Effects of Menu Labeling Policies on Transnational Restaurant Chains to Promote a Healthy Diet: A Scoping Review to Inform Policy and Research

There is insufficient evidence that restaurant menu labeling policies are cost-effective strategies to reduce obesity and diet-related non-communicable diseases (NCDs). Evidence suggests that menu labeling has a modest effect on calories purchased and consumed. No review has been published on the effect of menu labeling policies on transnational restaurant chains globally. This study conducted a two-step scoping review to map and describe the effect of restaurant menu labeling policies on menu reformulation. First, we identified national, state, and municipal menu labeling policies in countries from global databases. Second, we searched four databases (i.e., PubMed, CINHAL/EBSCO, Web of Science, and Google Scholar) for peer-reviewed studies and gray-literature sources in English and Spanish (2000-2020). Step 1 identified three voluntary and eight mandatory menu labeling policies primarily for energy disclosures for 11 upper-middle and high-income countries, but none for low- or middle-income countries. Step 2 identified 15 of 577 studies that met the inclusion criteria. The analysis showed reductions in energy for newly introduced menu items only in the United States. We suggesr actions for governments, civil society organizations, and the restaurant businesses to develop, implement, and evaluate comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.

Ultra-processed food consumption and indicators of obesity in the United Kingdom population (2008-2016)

We examined the association between the consumption of ultra-processed foods and adiposity in a nationally representative sample of the UK adult population. We studied 6,143 participants (19 to 96 years, 51.6% female) sampled by the UK National Diet and Nutrition Survey (2008-16). Food items reported in four-day food diary were classified according to the NOVA system. Multiple linear and logistic regressions were used to evaluate associations between the dietary contribution of ultra-processed foods (sex-specific quartile and continuous) and Body Mass Index (BMI), Waist Circumference (WC) and obesity (BMI>30kg/m2) and abdominal obesity (men: WC≥102cm, women: WC≥88cm) status. Models were adjusted for sociodemographic and lifestyle characteristics. In multivariable analyses, the highest consumption of ultra-processed food was associated with 1.66 kg/m2 higher BMI (95%CI 0.96-2.36), 3.56 cm greater WC (95%CI 1.79-5.33) and 90% higher odds for being obese (OR = 1.90, 95%CI 1.39-2.61), compared with the lowest consumption. A 10% increase in the consumption of ultra-processed foods was associated with an increase of 0.38 kg/m2 in BMI (95%CI 0.20-0.55), 0.87 cm in WC (95%CI 0.40-1.33) and 18% higher odds of being obese (OR = 1.18, 95%CI 1.08-1.28). The consumption of ultra-processed food was associated with an increase in BMI, WC and prevalence of obesity in both sexes. A dose response relationship was observed in both sexes, with a 10% increase in the consumption of ultra-processed foods being associated with a 18% increase in the prevalence of obesity in men and a 17% increase in women. Higher consumption of ultra-processed food is associated with greater adiposity in the UK adult population. Policy makers should consider actions that promote consumption of unprocessed or minimally processed foods and reduce consumption of ultra-processed foods.

Benchmarking the transparency, comprehensiveness and specificity of population nutrition commitments of major food companies in Malaysia

Background

The aim of this study was to assess the commitments of food companies in Malaysia to improving population nutrition using the Business Impact Assessment on population nutrition and obesity (BIA-Obesity) tool and process, and proposing recommendations for industry action in line with government priorities and international norms.

Methods

BIA-Obesity good practice indicators for food industry commitments across a range of domains (n = 6) were adapted to the Malaysian context. Euromonitor market share data was used to identify major food and non-alcoholic beverage manufacturers (n = 22), quick service restaurants (5), and retailers (6) for inclusion in the assessment. Evidence of commitments, including from national and international entities, were compiled from publicly available information for each company published between 2014 and 2017. Companies were invited to review their gathered evidence and provide further information wherever available. A qualified Expert Panel (≥5 members for each domain) assessed commitments and disclosures collected against the BIA-Obesity scoring criteria. Weighted scores across domains were added and the derived percentage was used to rank companies. A Review Panel, comprising of the Expert Panel and additional government officials (n = 13), then formulated recommendations.

Results

Of the 33 selected companies, 6 participating companies agreed to provide more information. The median overall BIA-Obesity score was 11% across food industry sectors with only 8/33 companies achieving a score of > 25%. Participating (p < 0.001) and global (p = 0.036) companies achieved significantly higher scores than non-participating, and national or regional companies, respectively. Corporate strategy related to population nutrition (median score of 28%) was the highest scoring domain, while product formulation, accessibility, and promotion domains scored the lowest (median scores < 10%). Recommendations included the establishment of clear targets for product formulation, and strong commitments to reduce the exposure of children to promotion of unhealthy foods.

Conclusions

This is the first BIA-Obesity study to benchmark the population nutrition commitments of major food companies in Asia. Commitments of companies were generally vague and non-specific. In the absence of strong government regulation, an accountability framework, such as provided by the BIA-Obesity, is essential to monitor and benchmark company action to improve population nutrition.

Longitudinal associations between ultra-processed foods and blood lipids in childhood

Emerging evidence suggests that the consumption of ultra-processed foods (UPF) plays a role in the development of chronic diseases, but evidence of their influence in children is limited. Our objective was to study longitudinal trends of UPF intake and determine their impact on blood lipids in young children. The present study was a follow-up of a randomised field trial of children (n 308) from Porto Alegre, Brazil. Dietary intake was collected using two 24-h recalls at 3 and 6 years of age, and consumption of UPF was classified according to the NOVA system, a food classification based on the extent and purpose of industrial food processing. At age 6 years, blood tests were performed to measure lipid profile. Contribution of UPF to total energy intake increased by 10 % during the follow-up period, from 43·4 % at 3 years to 47·7 % at 6 years of age. Linear regression models showed that children in the highest tertile of UPF consumption at age 3 years had higher levels of total cholesterol (TC; β 0·22 mmol/l; 95 % CI 0·04, 0·39) and TAG at age 6 years (β 0·11 mmol/l, 95 % CI 0·01, 0·20) compared with those in the lowest tertile. A positive dose-response was observed for an absolute increment of 10 % of UPF on TC (β 0·07 mmol/l, 95 % CI 0·00, 0·14) and TAG (β 0·04 mmol/l, 95 % CI 0·01, 0·07). Based on our data, consumption of UPF increased significantly over time and was associated with higher blood lipid levels in children from a low-income community. Our findings highlight the need for effective strategies to minimise the consumption of UPF in early life.

Traditional Food, Health, and Diet Quality in Syilx Okanagan Adults in British Columbia, Canada

In Canada, store-bought food constitutes the majority of First Nations (FN) people’s diets; however, their traditional foods (TF; wild fish, game, fowl, and plants) remains vital for their health. This study compares health indicators and diet quality among 265 Syilx Okanagan adults according to whether or not they reported eating TF during a 24-h dietary recall. Three methods assessed diet quality: nutrient intakes and adequacy, Healthy Eating Index (HEI-C), and contributions of ultra-processed products (UPP) to %energy using the NOVA classification. Fifty-nine participants (22%) reported eating TF during the dietary recall; TF contributed to 13% of their energy intake. There were no significant differences in weight status or prevalence of chronic disease between TF eaters and non-eaters. TF eaters had significantly higher intakes of protein; omega-3 fatty acids; dietary fibre; copper; magnesium; manganese; phosphorus; potassium; zinc; niacin; riboflavin; and vitamins B6, B12, D, and E than non-eaters. TF eaters also had significantly better diet quality based on the HEI-C and the %energy from UPP. Findings support that TF are critical contributors to the diet quality of FN individuals. Strength-based FN-led interventions, such as Indigenous food sovereignty initiatives, should be promoted to improve access to TF and to foster TF consumption.

What role should the commercial food system play in promoting health through better diet?

Martin White and coauthors consider that the commercial food system has the potential to show leadership and support for dietary public health, but systemic change is needed first and this is likely to require governmental action

Experimental Studies of Front-of-Package Nutrient Warning Labels on Sugar-Sweetened Beverages and Ultra-Processed Foods: A Scoping Review

Policies that require front-of-package (FoP) nutrient warnings are becoming increasingly common across the globe as a strategy to discourage excess consumption of sugary drinks and ultra-processed food. However, a better understanding of the pathway through which FoP nutrient warnings work, as well as a review of how outcomes being measured in recent studies map onto this pathway, are needed in order to inform policy on the most effective FoP label design for reducing purchases of ultra-processed foods. This scoping review describes a conceptual model for how FoP nutrient warnings affect consumer behavior, examines which of these outcomes are currently being measured, and summarizes evidence from randomized controlled experiments. Twenty-two studies which experimentally tested nutrient warnings against a control label or other labeling systems were included for full-text review. Our conceptual model includes attention; comprehension, cognitive elaboration, and message acceptance; negative affect and risk perception; behavioral intentions, and behavioral response, along with other elements such as external factors and interpersonal communications. We found that many studies focused on outcomes such as attention, comprehension, and behavioral intentions, but considerable gaps in the evidence remain, particularly for intermediary steps on the pathway to behavioral change, such as negative affect and social interactions. FoP nutrient warnings were visually attended to by consumers, easy to understand, helped consumers identify products high in nutrients of concern, and discouraged them from purchasing these products, although other labeling systems were perceived as containing more information and performed better at helping consumers rank the healthfulness of products. More research is needed to understand whether and how nutrient warnings work in the real world to discourage consumer purchases of sugary drinks and ultra-processed food.

The Andean Latin-American burden of diabetes attributable to high body mass index: A comparative risk assessment

BACKGROUND

Body mass index (BMI) has increased in Latin-America, but the implications for the diabetes burden have not been quantified. We estimated the proportion and absolute number of diabetes cases attributable to high BMI in Bolivia, Ecuador and Peru (Andean Latin-America), with estimation of region-level indicators in Peru.

METHODS

We estimated the population attributable fraction (PAF) of BMI on diabetes (regardless of type 1 or 2) from 1980 to 2014, including the number of cases attributable to overweight (BMI 25-<30), class I (30-<35), class II (BMI 35-<40) and class III (BMI ≥ 40) obesity. We used age- and sex-specific prevalence estimates of diabetes and BMI categories (NCD-RisC and Peru's DHS survey) combined with relative risks from population-based cohorts in Peru.

FINDINGS

Across Andean Latin-America in 2014, there were 1,258,313 diabetes cases attributable to high BMI: 209,855 in Bolivia, 367,440 in Ecuador and 681,018 in Peru. Between 1980 and 2010, the absolute proportion of diabetes cases attributable to class I obesity increased the most (from 12.9% to 27.2%) across the region. The second greatest increase was for class II obesity (from 3.6% to 16.5%). There was heterogeneity in the fraction of diabetes cases attributable to high BMI by region in Peru, as coastal regions had the largest fractions, and so did high-income regions.

INTERPRETATION

Over one million diabetes cases are attributable to high BMI in Andean Latin-America. Public health efforts should focus on implementing population-based interventions to reduce high BMI and to develop focused interventions targeted at those at highest risk of diabetes.

Evaluation of sex differences in dietary behaviours and their relationship with cardiovascular risk factors: a cross-sectional study of nationally representative surveys in seven low- and middle-income countries

BACKGROUND

Cardiovascular diseases (CVD) are the leading causes of death for men and women in low-and-middle income countries (LMIC). The nutrition transition to diets high in salt, fat and sugar and low in fruit and vegetables, in parallel with increasing prevalence of diet-related CVD risk factors in LMICs, identifies the need for urgent action to reverse this trend. To aid identification of the most effective interventions it is crucial to understand whether there are sex differences in dietary behaviours related to CVD risk.

METHODS

From a dataset of 46 nationally representative surveys, we included data from seven countries that had recorded the same dietary behaviour measurements in adults; Bhutan, Eswatini, Georgia, Guyana, Kenya, Nepal and St Vincent and the Grenadines (2013-2017). Three dietary behaviours were investigated: positive salt use behaviour (SUB), meeting fruit and vegetable (F&V) recommendations and use of vegetable oil rather than animal fats in cooking. Generalized linear models were used to investigate the association between dietary behaviours and waist circumference (WC) and undiagnosed and diagnosed hypertension and diabetes. Interaction terms between sex and dietary behaviour were added to test for sex differences.

RESULTS

Twenty-four thousand three hundred thirty-two participants were included. More females than males reported positive SUB (31.3 vs. 27.2% p-value < 0.001), yet less met F&V recommendations (13.2 vs. 14.8%, p-value< 0.05). The prevalence of reporting all three dietary behaviours in a positive manner was 2.7%, varying by country, but not sex. Poor SUB was associated with a higher prevalence of undiagnosed hypertension for females (13.1% vs. 9.9%, p-value = 0.04), and a higher prevalence of undiagnosed diabetes for males (2.4% vs. 1.5%, p-value = 0.02). Meeting F&V recommendations was associated with a higher prevalence of high WC (24.4% vs 22.6%, p-value = 0.01), but was not associated with undiagnosed or diagnosed hypertension or diabetes.

CONCLUSION

Interventions to increase F&V intake and positive SUBs in the included countries are urgently needed. Dietary behaviours were not notably different between sexes. However, our findings were limited by the small proportion of the population reporting positive dietary behaviours, and further research is required to understand whether associations with CVD risk factors and interactions by sex would change as the prevalence of positive behaviours increases.

Association between Adherence to the Mediterranean Diet and Physical Fitness with Body Composition Parameters in 1717 European Adolescents: The AdolesHealth Study

Obesity, low levels of physical fitness, and unhealthy eating patterns are responsible for part of the health problems of adolescents today. The current study aimed at examining the association between the adherence to the Mediterranean diet (MD), through each answer to the items of the Adherence to the MD Questionnaire (KIDMED), and physical fitness with body composition parameters (body mass index (BMI), percentage of body fat, and waist circumference) in 1717 European adolescents (N = 900 boys, N = 817 girls). Data of body composition, physical fitness results, and the answers to KIDMED were analyzed by the Student’s t-test. Additionally, the effect size (ES) was calculated and a Chi-square test analyzed the proportion of participants with and without over waist circumference, overfat, and overweight in each KIDMED question. The relative risk of suffering over waist circumference, overfat and overweight in relation to the responses was calculated by Odd-Ratio. Adherence to the MD did not influence the condition of over waist circumference, overfat and overweight, although certain dietary habits were identified as risk factors for their development. Over waist circumference, overfat, and overweight boys and girls presented higher levels of body mass, waist circumference, body fat percentage, and BMI (p < 0.001; ES = 1.73–3.38), as well as lower levels of all the parameters of the physical fitness analyzed (p < 0.001; ES = 0.45–1.08), except the handgrip test. A direct relationship between fitness and over waist circumference, overfat, and overweight was found.

Understanding the rise of cardiometabolic diseases in low- and middle-income countries

Increases in the prevalence of noncommunicable diseases (NCDs), particularly cardiometabolic diseases such as cardiovascular disease, stroke and diabetes, and their major risk factors have not been uniform across settings: for example, cardiovascular disease mortality has declined over recent decades in high-income countries but increased in low- and middle-income countries (LMICs). The factors contributing to this rise are varied and are influenced by environmental, social, political and commercial determinants of health, among other factors. This Review focuses on understanding the rise of cardiometabolic diseases in LMICs, with particular emphasis on obesity and its drivers, together with broader environmental and macro determinants of health, as well as LMIC-based responses to counteract cardiometabolic diseases.

Progress Evaluation for Transnational Restaurant Chains to Reformulate Products and Standardize Portions to Meet Healthy Dietary Guidelines and Reduce Obesity and Non-Communicable Disease Risks, 2000-2018: A Scoping and Systematic Review to Inform Policy

Transnational restaurant chains sell food and beverage products in 75 to 139 countries worldwide linked to obesity and non-communicable diseases (NCDs). This study examined whether transnational restaurant chains reformulated products and standardized portions aligned with healthy dietary guidelines and criteria. Firstly, we describe the transnational restaurant industry structure and eating trends. Secondly, we summarize results from a scoping review of healthy dietary guidelines for restaurants. Thirdly, we describe a systematic review of five electronic databases (2000-2018) to identify studies on nutrient profile and portion size changes made by transnational restaurants over 18 years. We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, identified 179 records, and included 50 studies conducted in 30 countries across six regions. The scoping review found a few expert-recommended targets for restaurants to improve offerings, but no internationally accepted standard for portions or serving sizes. The systematic review results showed no standardized assessment methods or metrics to evaluate transnational chain restaurants' practices to improve menu offerings. There was wide variation within and across countries, regions, firms, and chains to reduce energy, saturated and trans fats, sodium, and standardized portions. These results may inform future research and encourage transnational chain restaurants to offer healthy product profiles and standardized portions to reduce obesity and NCD risks worldwide.

Vegetable Consumption and Factors Associated with Increased Intake among College Students: A Scoping Review of the Last 10 Years

Vegetable consumption is a predictor for improved health outcomes, such as reduced obesity and likelihood of food-related noncommunicable diseases. Young adults are a key population, being in a transitional stage-of-life: Habits gained here are taken through the lifespan. This review establishes insight into the consumption of vegetables among young adults during their college/university years, and factors associated with increased consumption. Seventy-one papers were extracted, published between January 2009 and October 2018. Search terms related to consumption; vegetables; and college/university setting and sample. A diverse range of definitions, guidelines, and study approaches were observed. Findings identify that the majority of students do not consume World Health Organization recommendations. Being female was the most frequent predictor of higher intake of vegetables, and no consumption patterns were identified by countries. Living at family home; body mass index; happiness and stress level; perceived importance of healthy eating; socioeconomic level; breakfast consumption; stage of study; openness to new experiences; sleep pattern; nutrition knowledge; activity level; alcohol usage; and energy intake were identified as influential factors. Public policies and new strategies to encourage vegetable consumption among college students are indispensable, especially targeting subgroups with even lower intakes, such as males and those living outside family home.