Ultra-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study

An Overlap Between "Ultraprocessed" Foods and the Preexisting Nutrient Rich Foods Index?

The category of "ultra-processed" foods in the NOVA food classification scheme is ostensibly based on industrial processing. We compared NOVA category assignments with the pre-existing family of Nutrient Rich Food (NRF) indices, first developed in 2005. NRF n.3 indices are composed of two subscores; the positive NRn based on protein, fiber, and n vitamins and minerals, and the negative LIM subscore based on saturated fat, added sugar, and sodium. The 378 foods that were components of the widely used Fred Hutchinson Cancer Center food frequency questionnaire were assigned to NOVA categories and scored using multiple NRF indices. Contrary to published claims, NOVA was largely based on the foods' content of saturated fat, added sugars, and sodium. There were strong similarities between NOVA categories and NRF scores that were largely driven by the foods' content of fat, sugar, and salt. Nutrient density increased NRF scores but had less impact on NOVA categories. As a result, the NOVA scheme misclassified some nutrient-rich foods. Both NOVA categories and NRF9.3 scores were strongly affected by the amounts of saturated fat, added sugars, and sodium. Ultra-processed foods and culinary ingredients received lower NRFn.3 scores. We conclude that the arbitrary NOVA classification scheme adds little to the pre-existing nutrient profiling models. The purported links between NOVA categories and health outcomes could have been obtained using pre-existing NRFn.3 nutrient density metrics.

Bisphenol-A in the European Prospective Investigation into Cancer and Nutrition cohort in Spain: Levels at recruitment and associated dietary factors

Bisphenol A (BPA) is considered an endocrine disruptor and it is present in numerous products of daily use. The aim of this study was to analyze serum BPA concentrations in a subcohort of the Spanish European Prospective Investigation into Cancer and Nutrition (EPIC), as well as to identify potential predictors of the exposure. The population consisted on 3553 subjects from 4 EPIC-Spain centres and BPA levels were measured in serum samples by UHPLC-MS/MS. Almost 70% of the participants showed detectable BPA values (>0.2 ng/ml), with a geometric mean of 1.19 ng/ml (95% CI: 1.12-1.25). By sex, detectable percentages were similar (p = 0.56) but with higher serum levels in men (1.27 vs 1.11 ng/ml, p = 0.01). Based on the adjusted regression models, a 50 g/day increase in the consumption of added fats and oils were associated with 43% lower BPA serum levels, while sugar and confectionary was associated with 25% higher levels of serum BPA. We evidenced differential exposure levels by province, sex and age, but not by anthropometric or lifestyle characteristics. Further investigation is needed to understand the influence of diet in BPA exposure.

Urinary organophosphate ester concentrations in relation to ultra-processed food consumption in the general US population

BACKGROUND

Ultra-processed foods are highly processed foods which are manufactured with industrial substances to increase convenience and palatability. Some organophosphate esters (OPEs) are used as flame retardants and plasticizers and have been detected in food samples, particularly processed foods. However, little is known about dietary sources of OPEs or whether higher consumption of ultra-processed foods increases exposures.

OBJECTIVES

We evaluated whether higher consumption of ultra-processed food is associated with urinary OPE metabolite concentrations in a nationally representative sample of US children and adults.

METHODS

Among 2242 participants (≥6 years) in the National Health and Nutrition Examination Survey (NHANES) 2013-2014, we used the NOVA classification system to calculate percent of total energy from ultra-processed food using a 24 h dietary recall. Concentrations of 7 OPE metabolites, including diphenyl phosphate (DPHP), bis(1,3-dichloro-2-propyl) phosphate (BDCPP), bis(2-chloroethyl) phosphate (BCEP), dibutyl phosphate (DBUP), di-p-cresyl phosphate (DPCP), 2,3,4,5-tetrabromobenzoic acid (TBBA), and bis(1-chloro-2-propyl) phosphate (BCPP) were measured in urine. We used multivariable linear or logistic regressions to examine associations per 10% higher total energy from ultra-processed foods with percent changes or prevalence of detectable levels of creatinine-standardized OPEs.

RESULTS

In a model adjusting for only urinary creatinine, each 10% higher total energy from ultra-processed food was associated with 3.5% (95% CI: 0.7%, 6.3%) higher DPHP and 8.2% (95% CI: 4.6, 11.9%) higher BDCPP concentrations. However, none of the OPE metabolites was associated with ultra-processed food consumption in models adjusted for sociodemographic characteristics, health behaviors, and BMI (all p-values >0.05). Ultra-processed breads and tortillas; sauces, dressing, and gravies; and milk-based drinks were associated with higher concentrations of BDCPP while frozen and shelf-stable plate meals were associated with lower concentrations. Reconstituted meat or fish products and ultra-processed milk-based desserts were associated with greater odds of detectable levels of BCPP.

CONCLUSION

While some food groups were associated with urinary OPE metabolite concentrations, ultra-processed foods do not appear to be a major source of current OPE exposure in the US.

Chemicals, cans and factories: how grade school children think about processed foods

OBJECTIVE

To determine how children interpret terms related to food processing; whether their categorisation of foods according to processing level is consistent with those used in research; and whether they associate the degree of processing with healthfulness.

DESIGN

Qualitative data were collected from ten focus groups. Focus groups were audio-recorded, transcribed verbatim, and thematic analysis was conducted.

SETTING

Four elementary and afterschool programmes in a large, urban school district in the USA that served predominantly low-income, racial/ethnic minority students.

PARTICIPANTS

Children, 9-12 years old, in the fourth-sixth grades (n 53).

RESULTS

The sample was 40 % male, 47 % Hispanic with a mean age of 10·4 ± 1·1 years. Children's understanding of unprocessed foods was well aligned with research classifications, while concordance of highly processed foods with research categorisations varied. Five primary themes regarding the way children categorised foods according to their processing level emerged: type and amount of added ingredients; preparation method; packaging and storage; change in physical state or sensory experience; and growing method. Most children associated processing level with healthfulness, describing unprocessed foods as healthier. The most common reason provided for the unhealthfulness of processed foods was added ingredients, including 'chemicals' and 'sugar'.

CONCLUSIONS

The current study demonstrated that children have a working knowledge of processing that could be leveraged to encourage healthier eating patterns; however, their understanding is not always consistent with the classification systems used in research. The vocabulary used by researchers and consumers to talk about processing must be reconciled to translate findings into actionable messages.

Perceptions of Processed Foods Among Low-Income and Immigrant Parents

Background. Parent-aimed guidance on the topic of processed foods may help limit highly processed foods in children's diets, but little is known about parent understanding and perceptions of these products. Aims. To determine how parent perceptions of processing align with processing classification systems used in research, and to identify opportunities for future research in communicating information about processed foods. Method. Six focus groups with lower income, racial/ethnic minority and immigrant parents of fourth to sixth graders (n = 37) were conducted. Parents were asked to discuss their views on terminology related to food processing, classification of foods according to their processing level, the healthfulness of select foods, and criteria for choosing snacks for their children. Focus groups were guided by a thematic approach. NVivo 12 (QSR International) was used to facilitate analyses. Results. Thirty mothers and seven fathers participated. Two thirds (62%) were foreign-born; 38% identified as Hispanic. The term "processing" lacked consistent meaning among parents, with variation by immigrant status. Participants associated highly processed foods with convenience, packaging, and added ingredients; "less-processed" versions of foods (e.g., fresh; homemade) were perceived as healthier. Children's preferences were the main criteria for choosing snacks. Foreign-born parents were more likely to associate processed foods with positive characteristics (e.g., properly cooked). Conclusion. The concept of food processing is an area of misconception among parents, providing an opportunity for education that may be extended to larger audiences. A universally accepted definition of food classification by processing level is necessary to effectively communicate the link between processing and healthfulness.

Intake of dietary advanced glycation end products influences inflammatory markers, immune phenotypes, and antiradical capacity of healthy elderly in a little-studied population

Dietary advanced glycation end products (dAGE) have profound negative effects on overall health, and their intake must be assessed. In this cross-sectional study, we investigated dAGE intake of 337 adult participants (180/157:M/F; age range 50-73 years). Data were collected on anthropometrics, body composition, dietary intake, selected blood biochemistry, immunological parameters, and antiradical capacity (50% hemolysis time; HT50). From the dietary data, dAGEs and phytochemical index (PI) were calculated. Mean BMI, % body fat (%BF), and fasting plasma glucose were all within the accepted normal range. Subjects with high dAGE intake had higher %BF, higher energy intake, and lower PI. They tended to have lower CD4/CD8 ratios and higher proportions of B cells and NK cells, but had significantly higher hs-CRP levels and lower HT50 values. Results on HT50 suggested that being >60 years of age enhanced dAGE-associated impairment of defense capacity in both those with low and high HT50 compared with those <60 years of age. Thus, overall dAGE consumption was high, but elderly participants had lower dAGE intake than younger adults. Indicators of nutritional status and immunological parameters of the subjects were found to be associated with dAGE intake, suggesting a potential impact on health.

Ultraprocessed Food Consumption and Risk of Type 2 Diabetes Among Participants of the NutriNet-Santé Prospective Cohort

Importance

Ultraprocessed foods (UPF) are widespread in Western diets. Their consumption has been associated in recent prospective studies with increased risks of all-cause mortality and chronic diseases such as cancer, cardiovascular diseases, hypertension, and dyslipidemia; however, data regarding diabetes are lacking.

Objective

To assess the associations between consumption of UPF and risk of type 2 diabetes (T2D).

Design, Setting, and Participants

In this population-based prospective cohort study, 104 707 participants aged 18 years or older from the French NutriNet-Santé cohort (2009-2019) were included. Dietary intake data were collected using repeated 24-hour dietary records (5.7 per participant on average), designed to register participants' usual consumption for more than 3500 different food items. These were categorized according to their degree of processing by the NOVA classification system.

Main Outcomes and Measures

Associations between UPF consumption and risk of T2D were assessed using cause-specific multivariable Cox proportional hazard models adjusted for known risk factors (sociodemographic, anthropometric, lifestyle, medical history, and nutritional factors).

Results

A total of 104 707 participants (21 800 [20.8%] men and 82 907 [79.2%] women) were included. Mean (SD) baseline age of participants was 42.7 (14.5) years. Absolute T2D rates in the lowest and highest UPF consumers were 113 and 166 per 100 000 person-years, respectively. Consumption of UPF was associated with a higher risk of T2D (multi-adjusted hazard ratio [HR] for an absolute increment of 10 in the percentage of UPF in the diet, 1.15; 95% CI, 1.06-1.25; median follow-up, 6.0 years; 582 252 person-years; 821 incident cases). These results remained statistically significant after adjustment for several markers of the nutritional quality of the diet, for other metabolic comorbidities (HR, 1.13; 95% CI, 1.03-1.23), and for weight change (HR, 1.13; 95% CI, 1.01-1.27). The absolute amount of UPF consumption (grams per day) was consistently associated with T2D risk, even when adjusting for unprocessed or minimally processed food intake (HR for a 100 g/d increase, 1.05; 95% CI, 1.02-1.08).

Conclusions and Relevance

In this large observational prospective study, a higher proportion of UPF in the diet was associated with a higher risk of T2D. Even though these results need to be confirmed in other populations and settings, they provide evidence to support efforts by public health authorities to recommend limiting UPF consumption.

Trial Registration

ClinicalTrials.gov Identifier: NCT03335644.

Sources of dietary sodium and implications for a statewide salt reduction initiative in Victoria, Australia

In Victoria, Australia, a statewide salt reduction partnership was launched in 2015. The aim was to measure Na intake, food sources of Na (level of processing, purchase origin) and discretionary salt use in a cross-section of Victorian adults prior to a salt reduction initiative. In 2016/2017, participants completed a 24-h urine collection (n 338) and a subsample completed a 24-h dietary recall (n 142). Participants were aged 41·2 (sd 13·9) years, and 56 % were females. Mean 24-h urinary excretion was 138 (95 % CI 127, 149) mmol/d for Na. Salt equivalent was 8·1 (95 % CI 7·4, 8·7) g/d, equating to about 8·9 (95 % CI 8·1, 9·6) g/d after 10 % adjustment for non-urinary losses. Mean 24-h intake estimated by diet recall was 118 (95 % CI 103, 133) mmol/d for Na (salt 6·9 (95 % CI 6·0, 7·8 g/d)). Leading dietary sources of Na were cereal-based mixed dishes (12 %), English muffins, flat/savoury/sweet breads (9 %), regular breads/rolls (9 %), gravies and savoury sauces (7 %) and processed meats (7 %). Over one-third (38 %) of Na consumed was derived from discretionary foods. Half of all Na consumed came from ultra-processed foods. Dietary Na derived from foods was obtained from retail stores (51 %), restaurants and fast-food/takeaway outlets (28 %) and fresh food markets (9 %). One-third (32 %) of participants reported adding salt at the table and 61 % added salt whilst cooking. This study revealed that salt intake was above recommended levels with diverse sources of intake. Results from this study suggest a multi-faceted salt reduction strategy focusing on the retail sector, and food reformulation would most likely benefit Victorians and has been used to inform the ongoing statewide salt reduction initiative.

Perceptions of commercial snack food and beverages for infant and young child feeding: A mixed-methods study among caregivers in Kathmandu Valley, Nepal

Ensuring nutritious complementary feeding is vital for child nutrition. Prior research in Kathmandu Valley found high consumption rates of commercially produced snack foods among young children, which are often energy‐dense/nutrient poor. This mixed‐methods study was conducted to elicit Nepali caregivers' perceptions of commercial snack foods and beverages and factors influencing their use for young child feeding. Seven facilitated focus group discussions (FGD) were conducted with Kathmandu Valley caregivers of children 12–23 months, and a survey of 745 primary caregivers of children 12–23 months of age was then conducted. During the FGD, caregivers reported commonly providing commercial food and beverage products to their children as snacks, and 98.6% of caregivers participating in the survey reported feeding their child such a food in the previous week. Because of processing and packaging, snack foods were not trusted by many FGD participants and considered as “junk foods” and not healthy for children. However, commercial snack foods were consistently ranked highly on convenience, both because of minimal preparation and ease of feeding; 48.5% of all surveyed caregivers reported providing a snack food because of convenience. Other family members' diets or provision of snack foods as treats also influenced children's consumption of these snack foods and beverages. This study indicates that caregivers of young children prefer snack options that are nutrient rich; however, this may conflict with preferences for foods that require minimal preparation and are appealing to young children. Such findings carry programmatic implications for interventions aiming to address children's diet quality in urban Nepal.

The holistico-reductionist Siga classification according to the degree of food processing: an evaluation of ultra-processed foods in French supermarkets

The Siga classification of foods according to degree of processing showed that two-thirds of 24 932 packaged foods collected in French supermarkets are ultra-processed at various degrees.

Emotional disorder symptoms, anhedonia, and negative urgency as predictors of hedonic hunger in adolescents

Affect and reward are associated with unhealthy eating and weight; however, less research has examined affective predictors of hedonic hunger (i.e., extreme reward responsivity, pleasure toward, and drive for food), particularly among adolescents. Whether symptoms indicative of emotional disturbance increase risk of adverse reward-based eating-related symptoms such as hedonic hunger, is unknown. Such evidence could explain why emotional problems increase risk of eating and weight problems among adolescents, when eating-related health problems often originate. This report examined baseline emotional disorder symptoms, negative urgency (i.e., tendency to act impulsively in response to negative affect), and anhedonia (i.e., loss of interest in activities and decreased pleasure) as prospective predictors of increases in hedonic hunger in adolescents; associations between changes in emotional disturbance problems and hedonic hunger were also examined. Ninth-grade students (N = 2598) from high schools completed paper-and-pencil surveys at baseline and a 1-year follow-up. In a multivariable model controlling for the covariance of emotional problems, higher negative urgency, general anxiety, and obsessive-compulsive symptoms, and lower anhedonia at baseline independently predicted increases in hedonic hunger one year later. Also, increases in negative urgency, general anxiety, and obsessive-compulsive symptoms and decreases in anhedonia independently predicted increases in hedonic hunger. Affect- and reward-related variables may be important contributors to risk of hedonic hunger in adolescence.

A Nutrition Education Intervention Using NOVA Is More Effective Than MyPlate Alone: A Proof-of-Concept Randomized Controlled Trial

The ability to classify foods based on level of processing, not only conventional MyPlate food groups, might be a useful tool for consumers faced with a wide array of highly processed food products of varying nutritional value. The objective of this study was to assess the impact of a proof-of-concept nutrition education intervention on nutrition knowledge, assessed by correct classification of foods according to MyPlate food groups, MyPlate 'limit' status (for fat, sugar, sodium), and level of processing (NOVA categories). We utilized a randomized, controlled design to examine the impact of a MyPlate vs. combined MyPlate + NOVA intervention vs. control group. Intervention groups received educational flyers via email and participants were assessed using electronic baseline and follow-up surveys. The MyPlate + NOVA intervention group performed at least as well as the MyPlate group on classifying conventional food groups and 'limit' status. Moreover, the MyPlate + NOVA group far outperformed the other groups on classifying NOVA categories. Longer-term trials are needed, but our results suggest that NOVA principles may be more easily understood and applied than those of MyPlate. Education strategies focusing on level of food processing may be effective in the context of the modern food environment.

Chronic inflammation in the etiology of disease across the life span

Although intermittent increases in inflammation are critical for survival during physical injury and infection, recent research has revealed that certain social, environmental and lifestyle factors can promote systemic chronic inflammation (SCI) that can, in turn, lead to several diseases that collectively represent the leading causes of disability and mortality worldwide, such as cardiovascular disease, cancer, diabetes mellitus, chronic kidney disease, non-alcoholic fatty liver disease and autoimmune and neurodegenerative disorders. In the present Perspective we describe the multi-level mechanisms underlying SCI and several risk factors that promote this health-damaging phenotype, including infections, physical inactivity, poor diet, environmental and industrial toxicants and psychological stress. Furthermore, we suggest potential strategies for advancing the early diagnosis, prevention and treatment of SCI.

Processed and ultra-processed foods are associated with high prevalence of inadequate selenium intake and low prevalence of vitamin B1 and zinc inadequacy in adolescents from public schools in an urban area of northeastern Brazil

Changes in eating behavior of adolescents are associated with high consumption of processed and ultra-processed foods. This study evaluated the association between these foods and the prevalence of inadequate micronutrient intake in adolescents. A cross-sectional study was conducted with 444 adolescents from public schools in the city of Natal, northeastern Brazil. The adolescents' habitual food consumption was evaluated using two 24-hour dietary recalls. Foods were categorized according to the degree of processing (processed and ultra-processed) and distributed into energy quartiles, using the NOVA classification system. Inadequacies in micronutrient intake were assessed using the estimated average requirement (EAR) as the cutoff point. Multivariate logistic regression models were used to estimate the relationship between energy percentage from processed and ultra-processed foods and prevalence of inadequate micronutrient intake. The mean (Standard Deviation (SD)) consumption of total energy from processed foods ranged from 5.8% (1.7%) in Q1 to 20.6% (2.9%) in Q4, while the mean consumption of total energy from ultra-processed foods ranged from 21.4% (4.9%) in Q1 to 61.5% (11.7%) in Q4. The rates of inadequate intake of vitamin D, vitamin E, folate, calcium, and selenium were above 80% for both sexes across all age groups. Energy consumption from processed foods was associated with higher prevalence of inadequate selenium intake (p < 0.01) and lower prevalence of inadequate vitamin B1 intake (p = 0.04). Energy consumption from ultra-processed foods was associated with lower prevalence of inadequate zinc and vitamin B1 intake (p < 0.01 and p = 0.03, respectively). An increase in the proportion of energy obtained from processed and ultra-processed foods may reflect higher prevalence of inadequate selenium intake and lower prevalence of vitamin B1 and zinc inadequacy.

Food additives: Assessing the impact of exposure to permitted emulsifiers on bowel and metabolic health - introducing the FADiets study

Emulsifiers are common components of processed foods consumed as part of a Western diet. Emerging in vitro cell-line culture, mouse model and human intestinal tissue explant studies have all suggested that very low concentrations of the food emulsifier polysorbate 80 may cause bacterial translocation across the intestinal epithelium, intestinal inflammation and metabolic syndrome. This raises the possibility that dietary emulsifiers might be factors in conditions such as coronary artery disease, type 2 diabetes and Crohn's disease. The potential mechanism behind the observed effects of this emulsifier is uncertain but may be mediated via changes in the gut microbiota or by increased bacterial translocation, or both. It is also unknown whether these effects are generalisable across all emulsifiers and detergents, including perhaps the natural emulsifier lecithin or even conjugated bile acids, particularly if the latter escape reabsorption and pass through to the distal ileum or colon. A major objective of the Medical Research Council (MRC)-funded Mechanistic Nutrition in Health (MECNUT) Emulsifier project is therefore to investigate the underlying mechanisms and effects of a range of synthetic and natural emulsifiers and detergents in vitro and in vivo, and to determine the effects of a commonly consumed emulsifier (soya lecithin) on gut and metabolic health through a controlled dietary intervention study in healthy human volunteers - the FADiets study. This report provides an overview of the relevant literature, discussing the impact of emulsifiers and other additives on intestinal and metabolic health, and gives an overview of the studies being undertaken as part of the MECNUT Emulsifier project.

Consumption of ultra-processed foods and its association with added sugar content in the diets of US children, NHANES 2009-2014

BACKGROUND

There is cumulative recognition that increases in the dietary share of ultra-processed foods result in deterioration of the nutritional quality of the overall diet and adverse health outcomes.

OBJECTIVE

The purpose of this study was to assess the consumption of ultra-processed foods and to examine its association with added sugar content in the diet of US children aged 2 to 19 years.

METHODS

We classified all food items according to the NOVA food classification system and looked at the consumption of ultra-processed foods, measured as percentage of total energy intake. We assessed dietary added sugar content by estimating its contribution to total energy intake and the proportion of individuals with diets exceeding the recommended limit of 10% of total energy intake from added sugars. We also examined the proportion of those who surpassed twice that limit. Gaussian and Poisson regressions estimated the association between consumption of ultra-processed foods and estimates of added sugar content.

RESULTS

Ultra-processed foods contributed to 65% of total energy intake and to 92% of energy from added sugars in the diet of US children. The mean percent energy provided by added sugars in the observed period was 14.3%. Most individuals (70.9%) had diets exceeding the recommended limit of added sugar (<10% of total energy intake), and 18.4% of the population had diets surpassing twice the recommended level (20% of total energy intake). A 5.5% point increase in the dietary share of ultra-processed foods determined a 1 percentage point increase in the dietary content of added sugars, with stronger adjusted associations among younger children.

CONCLUSIONS

Public health efforts to reduce added sugars in the diet of US children must put greater emphasis on decreasing the consumption of ultra-processed foods.

Validation of a Newly Developed Food Frequency Questionnaire to Assess Dietary Intakes of Magnesium

Magnesium (Mg) intake is an important indication of an individual’s Mg status, but no validated food frequency questionnaire (FFQ) to assess intake currently exists. The purpose of this study was to develop and investigate the validity of a semi-quantitative Mg food frequency questionnaire (MgFFQ) against a 14-day food diary to assess average daily Mg intakes. In this cross-sectional study, 135 adults aged 18 to 75 completed the 33-item MgFFQ and a 14-day food diary to assess their Mg intakes. Coefficients of variance, Pearson’s correlation coefficients, and/or Spearman’s rank correlation coefficient tests were used to determine the relationship between the MgFFQ and the average Mg intake from the 14-day food diary among all participants, men, women, age groups, and body mass index (BMI) groups. The correlation between the MgFFQ and the 14-day food diary was significant (p < 0.05) for all participants (r = 0.798), men (r = 0.855), women (r = 0.759), normal weight (r = 0.762), overweight (r = 0.858), and obese (r = 0.675) weight statuses, and in all age groups. The calcium to magnesium intake (Ca:Mg) ratio in all participants was higher than optimal, 3.39 (2.11). Our results suggest that the MgFFQ is a valid method to capture Mg intake over an extended period of time, therefore acting as a valuable tool to quickly determine Mg intake.

Non-food rewards and highly processed food intake in everyday life

Reducing intake of highly processed, energy-dense food may prevent chronic disease. One proposed intervention strategy for reducing intake of these foods is to increase non-food reward experiences (e.g., music, socializing, art) in their place. However, research supporting this strategy has yet to establish temporal order between non-food reward experiences and highly processed food intake, and has yet to test mediators. The current study sought to build upon this literature with an ambulatory electronic diary study wherein the time-specific associations between non-food reward experiences and highly processed food intake were observed. A sample of 84 young adults reported on multiple types of non-food reward experiences and highly processed food intake hourly for two weekdays and two weekend days through an application on their personal electronic devices. Time-lagged analysis was employed to predict the odds of highly processed food intake in the following hour from non-food rewards experienced in the current hour. Secondary (e.g., receiving positive social feedback) and hedonic (e.g., viewing pleasant images) non-food reward experiences in the current hour predicted greater instead of lower odds of highly processed food intake in the following hour. These associations were mediated by increased subjective pleasure. Purely eudaimonic (e.g., affirming values), social (e.g., cooperating with others), and primary (e.g., having sex) reward experiences generally did not predict odds of highly processed food intake in the following hour. These results suggest that-at least for young adults-many non-food reward experiences may fail to reduce highly processed food intake, and some may even backfire. A different intervention strategy targeting reward processes implicated in highly processed food intake (e.g., interfering with conditioned learned associations) may prove a more promising avenue for improving physical health.

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

This study evaluated global trends in ultraprocessed food and drink (UPFD) volume sales/capita and associations with adult body mass index (BMI) trajectories. Total food/drink volume sales/capita from Euromonitor for 80 countries (2002-2016) were matched to mean adult BMI from the NCD Risk Factor Collaboration (2002-2014). Products were classified as UPFD/non-UPFD according to the NOVA classification system. Mixed models for repeated measures were used to analyse associations between UPFD volume sales/capita and adult BMI trajectories, controlling for confounding factors. The increase in UPF volume sales was highest for South and Southeast Asia (67.3%) and North Africa and the Middle East (57.6%), while for UPD, the increase was highest for South and Southeast Asia (120.0%) and Africa (70.7%). In 2016, baked goods were the biggest contributor to UPF volume sales (13.1%-44.5%), while carbonated drinks were the biggest contributor to UPD volume sales (40.2%-86.0%). For every standard deviation increase (51 kg/capita, 2002) in UPD volume sales, mean BMI increased by 0.195 kg/m² for men (P < .001) and 0.072 kg/m² for women (P = .003). For every standard deviation (40 kg/capita, 2002) increase in UPF volume sales, mean BMI increased by 0.316 kg/m² for men (P < .001), while the association was not significant for women. Increases in UPFD volume sales/capita were positively associated with population-level BMI trajectories.

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.

Advances in Nutrition Science and Integrative Physiology: Insights From Controlled Feeding Studies

Nutrition science is a highly impactful but contentious area of biomedical science. Establishing cause and effect relationships between the nutrients and/or diets we consume and the avoidance of or risk of disease is extremely challenging. As such, evidence-based nutrition is best served by considering the totality of evidence across multiple study types including nutritional epidemiological studies, randomized controlled trials of behavioral interventions, and controlled feeding studies. The purpose of the present review is to provide an overview for those conducting research outside of clinical nutrition on how controlled feeding studies can be used to gain insight into integrative physiology/metabolism as well as to inform dietary guidelines. We discuss the rationale, basic elements, and complexities of conducting controlled feeding studies and provide examples of contributions of controlled feeding studies to advances in nutrition science and integrative physiology. Our goal is to provide a resource for those wishing to leverage the experimental advantage provided by controlled feeding studies in their own research programs.

Ultra-processed foods and excessive free sugar intake in the UK: a nationally representative cross-sectional study

OBJECTIVES

To describe dietary sources of free sugars in different age groups of the UK population considering food groups classified according to the NOVA system and to estimate the proportion of excessive free sugars that could potentially be avoided by reducing consumption of their main sources.

DESIGN AND SETTING

Cross-sectional data from the UK National Diet and Nutrition Survey (2008-2014) were analysed. Food items collected using a 4-day food diary were classified according to the NOVA system.

PARTICIPANTS

9364 individuals aged 1.5 years and above.

MAIN OUTCOME MEASURES

Average dietary content of free sugars and proportion of individuals consuming more than 10% of total energy from free sugars.

DATA ANALYSIS

Poisson regression was used to estimate the associations between each of the NOVA food group and intake of free sugars. We estimated the per cent reduction in prevalence of excessive free sugar intake from eliminating ultra-processed foods and table sugar. Analyses were stratified by age group and adjusted for age, sex, ethnicity, survey year, region and equivalised household income (sterling pounds).

RESULTS

Ultra-processed foods account for 56.8% of total energy intake and 64.7% of total free sugars in the UK diet. Free sugars represent 12.4% of total energy intake, and 61.3% of the sample exceeded the recommended limit of 10% energy from free sugars. This percentage was higher among children (74.9%) and adolescents (82.9%). Prevalence of excessive free sugar intake increased linearly across quintiles of ultra-processed food consumption for all age groups, except among the elderly. Eliminating ultra-processed foods could potentially reduce the prevalence of excessive free sugar intake by 47%.

CONCLUSION

Our findings suggest that actions to reduce the ultra-processed food consumption generally rich in free sugars could lead to substantial public health benefits.

Free Sugar Content in Pre-Packaged Products: Does Voluntary Product Reformulation Work in Practice?

Ultra-processed, pre-packaged foods are becoming a growing part of our diet, while displacing whole and minimally processed foods. This results in an increased intake of free sugar, salt, and saturated fats, that have a profoundly negative effect on health. We aimed to assess the trend in free sugar content in pre-packaged foods in Slovenia and evaluate the efficacy of industry self-regulations designed to combat the excess consumption of free sugar. A nation-wide data collection of the Slovenian food supply was performed in 2015 and repeated in 2017. In 2017, 54.5% of all products (n = 21,115) contained free sugars (median: 0.26 g free sugar/100 g). Soft drinks became the main free sugar source among pre-packaged goods (28% of all free sugar sold on the market) in place of chocolates and sweets, of which relative share decreased by 4.4%. In the categories with the highest free sugar share, market-leading brands were often sweeter than the average free sugar value of the category. This indicates that changes in on-shelf availability towards a greater number of healthier, less sweet products are not necessarily reflected in healthier consumers’ choices. Relying solely on voluntary industrial commitments to reduce free sugar consumption will likely not be sufficient to considerably improve public health. While some further improvements might be expected over the longer term, voluntarily commitments are more successful in increasing the availability of healthier alternatives, rather than improving the nutritional composition of the market-leading products. Additional activities are, therefore, needed to stimulate reformulation of the existing market-leading foods and drinks, and to stimulate the consumption of healthier alternatives.

From the Table to the Tumor: The Role of Mediterranean and Western Dietary Patterns in Shifting Microbial-Mediated Signaling to Impact Breast Cancer Risk

Diet is a modifiable component of lifestyle that could influence breast cancer development. The Mediterranean dietary pattern is considered one of the healthiest of all dietary patterns. Adherence to the Mediterranean diet protects against diabetes, cardiovascular disease, and cancer. Reported consumption of a Mediterranean diet pattern was associated with lower breast cancer risk for women with all subtypes of breast cancer, and a Western diet pattern was associated with greater risk. In this review, we contrast the available epidemiological breast cancer data, comparing the impact of consuming a Mediterranean diet to the Western diet. Furthermore, we will review the preclinical data highlighting the anticancer molecular mechanism of Mediterranean diet consumption in both cancer prevention and therapeutic outcomes. Diet composition is a major constituent shaping the gut microbiome. Distinct patterns of gut microbiota composition are associated with the habitual consumption of animal fats, high-fiber diets, and vegetable-based diets. We will review the impact of Mediterranean diet on the gut microbiome and inflammation. Outside of the gut, we recently demonstrated that Mediterranean diet consumption led to distinct microbiota shifts in the mammary gland tissue, suggesting possible anticancer effects by diet on breast-specific microbiome. Taken together, these data support the anti-breast-cancer impact of Mediterranean diet consumption.

Nutrition Label Use Is Related to Chronic Conditions among Mexicans: Data from the Mexican National Health and Nutrition Survey 2016

BACKGROUND

Non-communicable diseases, such as obesity, diabetes, and hypertension, can be prevented and treated through a balanced nutrient-rich diet. Nutrition labels have been recognized as crucial to preventing obesity and non-communicable diseases through a healthier diet.

OBJECTIVE

Our aim was to examine the association between nutrition label use and chronic conditions (overweight, obesity, previously diagnosed diabetes, and hypertension) among an adult Mexican population.

DESIGN

This was a cross-sectional study that used data from the Mexican National Health and Nutrition Survey of 2016 (ENSANUT MC 2016).

PARTICIPANTS/SETTING

The participants were 5,013 adults aged 20 to 70 years old. Older adults (>70 years), illiterate participants, pregnant women, and participants with implausible blood pressure data were excluded from the sample. The survey was conducted from May to August 2016 in the participants' households.

MAIN OUTCOME MEASURES

We measured chronic conditions (overweight, obesity, previously diagnosed diabetes, and hypertension).

STATISTICAL ANALYSES PERFORMED

Pearson χ² test was used to examine the associations among the use of nutrition labels and sociodemographic characteristics and chronic conditions. Multiple logistic regression was used to determine the association between nutrition label use and chronic conditions adjusting for the effect of confounding variables like sex, age, body mass index, education level, marital status, ethnicity, residence area, region, and socioeconomic status.

RESULTS

From the total sample, 40.9% (95% CI 38.4% to 43.8%) reported using nutrition labeling. Respondents with overweight or obesity were less likely to use nutrition labels (odds ratio 0.74; P<0.05). Participants who self-reported diabetes had significantly lower odds of nutrition label use than participants who did not report to have diabetes (odds ratio 0.66; P<0.05). Participants having 3 chronic conditions had lower odds of nutrition label use (odds ratio 0.34; P<0.01) relative to having zero chronic conditions.

CONCLUSIONS

This study suggests an association between nutrition label use and chronic conditions (obesity and diabetes). These findings demonstrate that people with obesity, diabetes, and a combination of chronic conditions were less likely to use nutrition labels than people without these conditions.

Ultra-processed food consumption and exposure to phthalates and bisphenols in the US National Health and Nutrition Examination Survey, 2013-2014

BACKGROUND

Ultra-processed food has low nutritional quality, is associated with development of chronic diseases, and may increase exposure to chemicals used in food packaging and production.

OBJECTIVES

To assess associations of ultra-processed food consumption with exposure to phthalates and bisphenols, including newer replacements, in the general U.S.

METHODS

Among 2212 National Health and Nutrition Examination Survey (NHANES) 2013-2014 participants (≥6 years), we classified items reported in a 24-h dietary recall according to the NOVA food processing classification system and calculated energy intake from ultra-processed food. Urinary concentrations of mono-benzyl (MBzP), mono-(3-carboxypropyl) (MCPP), mono-(carboxyisononyl) (MCNP), mono-(carboxyisoctyl) (MCOP), and four metabolites of di(2-ethylhexyl) (∑DEHP) phthalates and bisphenols A, F, and S were measured in spot urine samples. We estimated percent changes in natural log creatinine-standardized concentrations per 10% higher energy from ultra-processed food in covariate-adjusted multivariable linear regression models. We examined effect measure modification by age group, race/ethnicity, and poverty:income ratio and assessed associations with minimally processed food intake.

RESULTS

In adjusted models, higher energy from ultra-processed food was associated with higher urinary concentrations of MCPP, MCNP, and MCOP but not MBzP, ∑DEHP, or bisphenols. Each 10% higher energy from ultra-processed food was associated with 8.0% (95% CI: 5.6%, 10.3%) higher urinary MCOP concentrations, with a stronger association among children than adolescents or adults. Ultra-processed sandwiches/hamburgers, French fries/other potato products, and ice cream/pops were associated with higher concentrations of multiple chemicals. Higher energy from minimally processed food was associated with lower concentrations of MCPP, MCNP, MCOP, and bisphenols A and F.

DISCUSSION

Ultra-processed food consumption may increase exposure to currently used phthalates. Additional research is needed to determine whether minimally processed food diets or changes in food production practices can reduce phthalate and bisphenol exposures and related health effects, particularly among children who are more vulnerable to toxicants and tend to consume more ultra-processed food than adults.

Recent surge of ready meals in South Korea: can they be healthy alternatives?

OBJECTIVE

The present study analysed and compared the nutritional qualities of private brand (PB) and national brand (NB) ready meal (RM) products in South Korea.

DESIGN

Data on RM products were collected via a food information database (EatSight) between February and May of 2017. A total of ninety-one PB products from a leading discount store chain in South Korea and 415 NB products were selected and divided into four main categories of 'refrigerated soups/stews', 'refrigerated noodles', 'frozen rice/noodles' and 'frozen dumplings'. Nutritional information was extracted for each product and analyses were performed to compare nutritional differences.

SETTING

South Korea.

PARTICIPANTS

A total of 506 RM products.

RESULTS

PB products explained the highest percentage of refrigerated RM products while NB products occupied the highest percentage of frozen ones. Notably, main PB and NB products showed evident nutritional problems. Among PB products, refrigerated soups/stews were significantly higher in energy, fat, Na, saturated fat and trans-fat. Likewise, in the case of NB products, frozen rice/noodles were significantly higher in Na and saturated fat. Particularly, overall Na contents were high. When the Korean guidance on traffic-light labelling was applied, a mere 0·2 and 5·9 % of total RM products showed all four and three green lights, respectively. Meanwhile, those with no green lights accounted for 42·3 %.

CONCLUSIONS

Although it is difficult to draw a definitive conclusion on the comparative nutritional qualities due to the lack of consistency in the results, the study suggests that there is room to improve the nutritional qualities of overall RM products.

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

OBJECTIVE

This study aimed to describe the consumption of ultra-processed foods in Australia and its association with the intake of nutrients linked to non-communicable diseases (NCDs).

DESIGN

Cross-sectional study.

SETTING

National Nutrition and Physical Activity Survey (2011-2012).

PARTICIPANTS

12,153 participants aged 2+ years.

MAIN OUTCOME MEASURES

Average dietary content of nutrients linked to NCDs and the prevalence of intake outside levels recommended for the prevention of NCDs.

DATA ANALYSIS

Food items were classified according to the NOVA system, a classification based on the nature, extent and purpose of industrial food processing. The contribution of each NOVA food group and their subgroups to total energy intake was calculated. Mean nutrient content of ultra-processed food and non-ultra-processed food fractions of the diet were compared. Across quintiles of the energy contribution of ultra-processed foods, differences in the intake of nutrients linked to NCDs as well as in the prevalence of intakes outside levels recommended for the prevention of NCDs were examined.

RESULTS

Ultra-processed foods had the highest dietary contribution (42.0% of energy intake), followed by unprocessed or minimally processed foods (35.4%), processed foods (15.8%) and processed culinary ingredients (6.8%). A positive and statistically significant linear trend was found between quintiles of ultra-processed food consumption and intake levels of free sugars (standardised β 0.43, p<0.001); total (β 0.08, p<0.001), saturated (β 0.18, p<0.001) and trans fats (β 0.10, p<0.001); sodium (β 0.21, p<0.001) and diet energy density (β 0.41, p<0.001), while an inverse relationship was observed for dietary fibre (β -0.21, p<0.001) and potassium (β -0.27, p<0.001). The prevalence of non-recommended intake levels of all studied nutrients increased linearly across quintiles of ultra-processed food intake, notably from 22% to 82% for free sugars, from 6% to 11% for trans fat and from 2% to 25% for dietary energy density, from the lowest to the highest ultra-processed food quintile.

CONCLUSION

The high energy contribution of ultra-processed foods impacted negatively on the intake of non-ultra-processed foods and on all nutrients linked to NCDs in Australia. Decreasing the dietary share of ultra-processed foods would substantially improve the diet quality in the country and help the population achieve recommendations on critical nutrients linked to NCDs.

Presence and consumption of sugars and low and no-calorie sweeteners in the Spanish diet: an updated overview

INTRODUCTION

Introduction: the term "sugars" describes a specific group of carbohydrates and one of the most controversial components of our diet, as public health authorities worldwide acknowledge that there is an excessive intake. Reformulation practices with low and no-calorie sweeteners (LNCS) are being carried out worldwide. However, a lack of information about the present market status and evolution is highly recognized. Materials and methods: review of the most recent studies. Results: there is a lack of comprehensive Food Composition Tables (FCT) and Databases (DB) including sugar contents and many countries have developed their own for the estimation of sugar intakes or with the aim of monitoring changes in processed food composition. Moreover, surveys assessing carbohydrate and sugar consumption and their dietary sources are scarce and sometimes not comparable due to the different methodologies, FCT and DB used, and non-harmonised use of terms and nomenclature, especially for the estimation of added sugars. Results from studies show that total and added sugar intakes around the world are quite comparable in terms of percentage of total energy from diet and major dietary sources. WHO's recommendations are being exceeded, especially amongst the younger population groups. Conclusions: future research on sweeteners, both caloric and low or non-caloric, should comprise the development of comprehensible, harmonized and updated databases of added sugar and LNCS, the evaluation of the frequent consumption of LNCS from foods and beverages and its potential association with an improved food model/pattern and lifestyles. Finally, intervention studies with LNCS are urgently needed.

A Diet High in Processed Foods, Total Carbohydrates and Added Sugars, and Low in Vegetables and Protein Is Characteristic of Youth with Avoidant/Restrictive Food Intake Disorder

Avoidant/restrictive food intake disorder (ARFID) is characterized in part by limited dietary variety, but dietary characteristics of this disorder have not yet been systematically studied. Our objective was to examine dietary intake defined by diet variety, macronutrient intake, and micronutrient intake in children and adolescents with full or subthreshold ARFID in comparison to healthy controls. We collected and analyzed four-day food record data for 52 participants with full or subthreshold ARFID, and 52 healthy controls, aged 9-22 years. We examined frequency of commonly reported foods by logistic regression and intake by food groups, macronutrients, and micronutrients between groups with repeated-measures ANOVA. Participants with full or subthreshold ARFID did not report any fruit or vegetable category in their top five most commonly reported food categories, whereas these food groups occupied three of the top five groups for healthy controls. Vegetable and protein intake were significantly lower in full or subthreshold ARFID compared to healthy controls. Intakes of added sugars and total carbohydrates were significantly higher in full or subthreshold ARFID compared to healthy controls. Individuals with full or subthreshold ARFID had lower intake of vitamins K and B12, consistent with limited vegetable and protein intake compared to healthy controls. Our results support the need for diet diversification as part of therapeutic interventions for ARFID to reduce risk for nutrient insufficiencies and related complications.

Low dietary magnesium intake alters vitamin D-parathyroid hormone relationship in adults who are overweight or obese

Vitamin D metabolism is dependent on magnesium (Mg) as a cofactor; therefore, poor Mg status may alter the relationship between vitamin D metabolite serum 25-hydroxyvitamin D (s25OHD) and serum parathyroid hormone (sPTH). We hypothesized that low dietary Mg intake may alter sPTH response to s25OHD in a population with excess body weight, thereby leading to a worsening of cardiometabolic health. To explore this hypothesis, we conducted a cross-sectional study on adults who were either overweight or obese (owt/ob). Dietary Mg intake was measured using a Mg food frequency questionnaire (MgFFQ). Body composition information was measured using Dual Energy X-ray Absorptiometry (DXA). Blood samples were obtained for all biochemical analyses. A total of 57 participants, 22 to 65 years of age, with a body mass index between 25 to 45 kg/m² were divided into 3 groups, according to dietary Mg intake percentiles (Low Mg Group = <33 percentile, Medium Mg Group = 33 to 66 percentile, High Mg Group = >66 percentile). Higher s25OHD was negatively associated with lower sPTH in the High Mg Intake group (r = -0.472, P = .041), but not in other groups. A positive relationship between s25OHD and serum high-molecular weight adiponectin concentrations was observed in the High Mg Group (r = 0.532, r = 0.022), but not in other groups. Serum Interleukin-6 concentrations were negatively associated with s25OHD (r = -0.316, P = .017) for the entire study group. Based on these results, our study demonstrated that a low dietary Mg intake may alter PTH response to 25OHD.

The price of ultra-processed foods and beverages and adult body weight: Evidence from U.S. veterans

The consumption of ultra-processed foods in the U.S. and globally has increased and is associated with lower diet quality, higher energy intake, higher body weight, and poorer health outcomes. This study drew on individual-level data on measured height and weight from U.S. Department of Veterans Affairs medical records for adults aged 20 to 64 from 2009 through 2014 linked to food and beverage price data from the Council for Community and Economic Research to examine the association between the price of ultra-processed foods and beverages and adult body mass index (BMI). We estimated geographic fixed effects models to control for unobserved heterogeneity of prices. We estimated separate models for men and women and we assessed differences in price sensitivity across subpopulations by socioeconomic status (SES). The results showed that a one-dollar increase in the price of ultra-processed foods and beverages was associated with 0.08 lower BMI units for men (p ≤ 0.05) (price elasticity of BMI of -0.01) and 0.14 lower BMI units for women (p ≤ 0.10) (price elasticity of BMI of -0.02). Higher prices of ultra-processed foods and beverages were associated with lower BMI among low-SES men (price elasticity of BMI of -0.02) and low-SES women (price elasticity of BMI of -0.07) but no statistically significant associations were found for middle- or high-SES men or women. Robustness checks based on the estimation of an individual-level fixed effects model found a consistent but smaller association between the price of ultra-processed foods and beverages and BMI among women (price elasticity of BMI of -0.01) with a relatively larger association for low-SES women (price elasticity of BMI of -0.04) but revealed no association for men highlighting the importance of accounting for individual-level unobserved heterogeneity.

Dietary share of ultra-processed foods and metabolic syndrome in the US adult population

This study sought to examine the relationship between dietary share of ultra-processed foods and metabolic syndrome among US adults. We studied 6, 385 participants from the cross-sectional National Health and Nutrition Examination Survey 2009-2014, aged 20+ years, with blood tests under fasting conditions and at least one 24-hour dietary recall. Food items were classified according to the extent and purpose of industrial food processing. Ultra-processed foods (UPF) are formulations of many ingredients, mostly of exclusive industrial use, that result from a sequence of industrial processes (hence ultra-processed). Metabolic Syndrome (MetS) was defined according to the 2009 Joint Scientific Statement as meeting three or more of the following criteria: (1) elevated waist circumference (2) elevated fasting plasma glucose (3) elevated blood pressure (4) elevated triglycerides (5) reduced high-density lipoprotein (HDL-C). Poisson regression models with robust variance adjusted for age, sex, race/ethnicity, family income, education, physical activity and smoking showed significant linear association between the dietary contribution of UPF and the prevalence of MetS (a 10% increase in contribution was associated with a 4% prevalence increase) (prevalence ratio -PR- = 1.04; 95% CI 1.02, 1.07). A dietary UPF contribution of >71% (5th population quintile) was associated with 28% higher prevalence of MetS compared to a contribution below 40% (1st population quintile) (PR = 1.28; 95% CI 1.09, 1.50). The association was stronger in young adults (PR between upper and lower quintiles = 1.94; 95% CI 1.39, 2.72) and decreased with age. These findings add to the growing evidence that UPF consumption is associated with diet-related non-communicable diseases.

Cancer Prevention with Nutrition and Lifestyle

Background

Although the crucial role of nutrition on wellbeing was known several hundreds of years ago in ancient healing methods such as traditional Chinese medicine, it often plays a minor role in modern society. However, 30-50% of all cancer cases are preventable by following a healthy diet and lifestyle, in accordance with the World Cancer Research Fund (WCRF) cancer prevention recommendations.

Summary

In addition to maintaining a healthy weight and being physically active, a balanced plant-based diet with limited amounts of fast foods, sugar-sweetened drinks, red meat, and alcohol is recommended for enhancing health. Such a way of life helps to prevent both cancer and other noncommunicable diseases (NCDs) because of the common risk factors. Although these facts are widely known, the figures are still alarming. Only a fraction of the population follows the WCRF recommendations.

Key Message

Urgent policy action is needed to promote healthy ways of living and to create health-enhancing environments to effectively reduce the risk of cancer and NCDs.

Association between consumption of ultra-processed foods and serum C-reactive protein levels: cross-sectional results from the ELSA-Brasil study

BACKGROUND

There may be a direct association between consumption of ultra-processed foods and C-reactive protein (CRP) levels, under the assumption that the high glycemic index of these food products could stimulate the entire chronic inflammation cascade, along with an indirect association mediated by obesity. The types of food consumed, including ultra-processed products, strongly influence obesity, and are also associated with higher serum CRP levels.

OBJECTIVE

Our aim was to investigate whether the caloric contribution of ultra-processed foods to diet is associated with CRP levels, independent of body mass index (BMI).

DESIGN AND SETTING

Cross-sectional analysis on the Longitudinal Study of Adult Health (ELSA-Brasil) baseline cohort (2008-2010).

METHODS

Dietary information, obtained through a food frequency questionnaire, was used to estimate the percentage of energy contribution from ultra-processed food to individuals' total caloric intake. CRP levels were the response variable. Sex-specific associations were estimated using generalized linear models with gamma distribution and log-link function.

RESULTS

Ultra-processed food accounted for 20% of total energy intake. Among men, after adjustments for sociodemographic characteristics, there was no association between ultra-processed food intake and CRP levels. Among women, after adjustment for sociodemographic characteristics, smoking and physical activity, the highest tercile of ultra-processed food intake was associated with mean CRP levels that were 14% higher (95% confidence interval: 1.04-1.24) than those of the lowest tercile. However, after considering BMI, this association lost statistical significance.

CONCLUSION

Our findings suggest that the positive association of ultra-processed food consumption with CRP levels among women seems to be mediated by the presence of adiposity.

Operationalizing the 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Cancer Prevention Recommendations: A Standardized Scoring System

Background: Following the publication of the 2018 World Cancer Research Fund (WCRF) and American Institute for Cancer Research (AICR) Third Expert Report, a collaborative group was formed to develop a standardized scoring system and provide guidance for research applications. Methods: The 2018 WCRF/AICR Cancer Prevention Recommendations, goals, and statements of advice were examined to define components of the new Score. Cut-points for scoring were based on quantitative guidance in the 2018 Recommendations and other guidelines, past research that operationalized 2007 WCRF/AICR Recommendations, and advice from the Continuous Update Project Expert Panel. Results: Eight of the ten 2018 WCRF/AICR Recommendations concerning weight, physical activity, diet, and breastfeeding (optional), were selected for inclusion. Each component is worth one point: 1, 0.5, and 0 points for fully, partially, and not meeting each recommendation, respectively (Score: 0 to 7–8 points). Two recommendations on dietary supplement use and for cancer survivors are not included due to operational redundancy. Additional guidance stresses the importance of accounting for other risk factors (e.g., smoking) in relevant models. Conclusions: The proposed 2018 WCRF/AICR Score is a practical tool for researchers to examine how adherence to the 2018 WCRF/AICR Recommendations relates to cancer risk and mortality in various adult populations.

Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake

We investigated whether ultra-processed foods affect energy intake in 20 weight-stable adults, aged (mean ± SE) 31.2 ± 1.6 years and BMI = 27 ± 1.5 kg/m². Subjects were admitted to the NIH Clinical Center and randomized to receive either ultra-processed or unprocessed diets for 2 weeks immediately followed by the alternate diet for 2 weeks. Meals were designed to be matched for presented calories, energy density, macronutrients, sugar, sodium, and fiber. Subjects were instructed to consume as much or as little as desired. Energy intake was greater during the ultra-processed diet (508 ± 106 kcal/day; p = 0.0001), with increased consumption of carbohydrate (280 ± 54 kcal/day; p < 0.0001) and fat (230 ± 53 kcal/day; p = 0.0004), but not protein (-2 ± 12 kcal/day; p = 0.85). Weight changes were highly correlated with energy intake (r = 0.8, p < 0.0001), with participants gaining 0.9 ± 0.3 kg (p = 0.009) during the ultra-processed diet and losing 0.9 ± 0.3 kg (p = 0.007) during the unprocessed diet. Limiting consumption of ultra-processed foods may be an effective strategy for obesity prevention and treatment.

Food Processing at a Crossroad

Recently, processed foods received negative images among consumers and experts regarding food-health imbalance. This stresses the importance of the food processing-nutrition interface and its relevance within the diet-health debates. In this review, we approach the related questions in a 3-fold way. Pointing out the distinguished role food processing has played in the development of the human condition and during its 1.7 million year old history, we show the function of food processing for the general design principles of food products. Secondly, a detailed analysis of consumer related design principles and processing reveals questions remaining from the historical transformation from basic cooking into advanced food technology. As a consequence, we analyze new and emerging technologies in relation to their contributions to food-health impacts. During the last 35 years, new and emerging food technologies have initiated a paradigm shift away from conventional process methodologies to gentler, non-thermal processing. Reducing the existing uncertainties in the assessment of impact of technology like "minimal processing," we propose the use of the newly established ISO standard for natural food ingredients as a "reference point." Finally, we assess the usefulness of recently proposed classification systems, e.g., NOVA classification, based on comprehensive insights of recently published nutritional analysis of those classifications. This paper calls for a radical change and worldwide adaptation of the key research and developmental areas tackling the grand challenges in our food systems.

Consumption of ultra-processed foods decreases the quality of the overall diet of middle-aged Japanese adults

Objective:

To estimate the consumption of ultra-processed foods and determine its association with dietary quality among middle-aged Japanese adults.

Design:

Cross-sectional study using data from the Saitama Prefecture Health and Nutrition Survey 2011. Dietary intake was assessed using one- or two-day dietary records. Sociodemographic and lifestyle factors were obtained via self-administered questionnaire. Food items were classified according to the NOVA system into four groups: unprocessed or minimally processed foods; processed culinary ingredients; processed foods; and ultra-processed foods. The dietary share of each NOVA food group and their subgroups was calculated in relation to total energy intake, and the average dietary content of key nutrients was determined across tertiles of the dietary energy share of ultra-processed foods (low, middle and high intake).

Setting:

Saitama Prefecture in Japan.

Participants:

Community-dwelling adults aged 30–59 years (256 men, 361 women).

Results:

Consumption of unprocessed or minimally processed foods, processed culinary ingredients, processed foods and ultra-processed foods contributed 44·9 (se 0·8) %, 5·5 (se 0·2) %, 11·3 (se 0·4) % and 38·2 (se 0·9) % of total daily energy intake, respectively. A positive and statistically significant linear trend was found between the dietary share of ultra-processed foods (tertiles) and the dietary content of total and saturated fat, while an inverse relationship was observed for protein, vitamin K, vitamin B6, dietary fibre, magnesium, phosphorus and iron.

Conclusions:

Our findings show that higher consumption of ultra-processed foods was associated with decreased dietary quality among Japanese adults.

Robustness of Food Processing Classification Systems

Discrepancies exist among food processing classification systems and in the relationship between processed food intake and dietary quality of children. This study compared inter-rater reliability, food processing category, and the relationship between processing category and nutrient concentration among three systems (Nova, International Food Information Council (IFIC), and University of North Carolina at Chapel Hill (UNC)). Processing categories for the top 100 most commonly consumed foods children consume (NHANES 2013-2014) were independently coded and compared using Spearman's rank correlation coefficient. Relative ability of nutrient concentration to predict processing category was investigated using linear discriminant analysis and multinomial logistic regression and compared between systems using Cohen's kappa coefficient. UNC had the highest inter-rater reliability (ρ = 0.97), followed by IFIC (ρ = 0.78) and Nova (ρ = 0.76). UNC and Nova had the highest agreement (80%). Lower potassium was predictive of IFIC's classification of foods as moderately compared to minimally processed (p = 0.01); lower vitamin D was predictive of UNC's classification of foods as highly compared to minimally processed (p = 0.04). Sodium and added sugars were predictive of all systems' classification of highly compared to minimally processed foods (p < 0.05). Current classification systems may not sufficiently identify foods with high nutrient quality commonly consumed by children in the U.S.

Relative Validity and Reproducibility of a Food Frequency Questionnaire to Assess Energy Intake from Minimally Processed and Ultra-Processed Foods in Young Children

NOVA is a food classification system that categorises food items into one of four categories according to the extent and purpose of their processing: minimally processed food (MPF), processed culinary ingredient (PCI), processed food (PF), or ultra-processed food (UPF). The aim of this study was to determine the relative validity and reproducibility of a food frequency questionnaire (EAT5 FFQ) for measuring daily energy intake (EI kJ) and percentage of daily energy intake (EI%) from each NOVA group in New Zealand children. One hundred parents of five year old children completed the 123 item EAT5 FFQ on two occasions four weeks apart. A 3 day weighed diet record (WDR) was completed on non-consecutive randomly assigned days between FFQ appointments. The FFQ overestimated EI (both as kJ and %) from MPF and UPF, and underestimated intakes from PCI and PF, compared with the WDR. Bland–Altman plots indicated reasonably consistent agreement between FFQ and WDR for MPF and UPF but not PCI or PF. Correlation coefficients between the FFQ and WDR were acceptable for EI (%) for MPF (r = 0.31) and UPF (r = 0.30). The FFQ differentiated between the highest and lowest quartiles for EI (%) from MPF and UPF foods (p-values for the trends were 0.006 and 0.009 respectively), and for EI (kJ) from UPF foods (p-value for trend 0.003). Bland–Altman plots indicated consistent agreement between repeat administrations of FFQ for MPF and UPF only, while intra-class correlations suggested good reproducibility for EI (kJ and %) for all four NOVA categories (range 0.51–0.76). The EAT5 FFQ has acceptable relative validity for ranking EI (%) from MPF and UPF. It has good reproducibility for measuring EI from all four NOVA categories, in young children.