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

Nutritional quality of new food products released into the Australian retail food market in 2015 - is the food industry part of the solution?

BACKGROUND

Food manufacturers have made public statements and voluntary commitments, such as the Healthier Australia Commitment (HAC), to improve the nutritional quality of foods. However, limited information about the nutritional quality or healthfulness of new products makes it difficult to determine if manufacturers are doing this. The purpose of this study was to assess the healthfulness of new food products released into the Australian retail market in 2015, and whether those companies who were HAC members released healthier food options compared to non-HAC members.

METHODS

This cross-sectional study assessed the healthfulness of all new retail food products launched in Australia in 2015 as indexed in Mintel's Global New Products Database. Healthfulness was assessed using three classification schemes: Healthy Choices Framework Victoria, Australian Dietary Guidelines and NOVA Food Classification System. Descriptive statistics and chi-squared tests described and compared the number and proportions of new foods falling within each of the food classification schemes' categories for companies that were and were not HAC members.

RESULTS

In 2015, 4143 new food products were launched into the Australian market. The majority of new products were classified in each schemes' least healthy category (i.e. red, discretionary and ultra-processed). Fruits and vegetables represented just 3% of new products. HAC members launched a significantly greater proportion of foods classified as red (59% vs 51% for members and non-members, respectively) discretionary (79% vs 61%), and ultra-processed (94% vs 81%), and significantly fewer were classified as green (8% vs 15%), core foods (18% vs 36%) and minimally processed (0% vs 6%) (all p < 0.001).

CONCLUSIONS

This study found that the majority of new products released into the Australian retail food market in 2015 were classified in each of three schemes' least healthy categories. A greater proportion of new products launched by companies that publicly committed to improve the nutritional quality of their products were unhealthy, and a lower proportion were healthy, compared with new products launched by companies that did not so commit. Greater monitoring of industry progress in improving the healthfulness of the food supply may be warranted, with public accountability if the necessary changes are not seen.

Seattle's minimum wage ordinance did not affect supermarket food prices by food processing category

OBJECTIVE

To examine the impacts of Seattle's minimum wage ordinance on food prices by food processing category.

DESIGN

Supermarket food prices were collected for 106 items using a University of Washington Center for Public Health Nutrition market basket at affected and unaffected supermarket chain stores at three times: March 2015 (1-month pre-policy enactment), May 2015 (1-month post-policy enactment) and May 2016 (1-year post-policy enactment). Food items were categorized into four food processing groups, from minimally to ultra-processed. Data were analysed across time using a multilevel, linear difference-in-differences model at the store and price level stratified by level of food processing.

SETTING

Six large supermarket chain stores located in Seattle ('intervention') affected by the policy and six same-chain but unaffected stores in King County ('control'), Washington, USA.

SUBJECTS

One hundred and six food and beverage items.

RESULTS

The largest change in average price by food item was +$US 0·53 for 'processed foods' in King County between 1-month post-policy and 1-year post-policy enactment (P < 0·01). The smallest change was $US 0·00 for 'unprocessed or minimally processed foods' in Seattle between 1-month post-policy and 1-year post-policy enactment (P = 0·94). No significant changes in averaged chain prices were observed across food processing level strata in Seattle v. King County stores at 1-month or 1-year post-policy enactment.

CONCLUSIONS

Supermarket food prices do not appear to be differentially impacted by Seattle's minimum wage ordinance by level of the food's processing. These results suggest that the early implementation of a city-level minimum wage policy does not alter supermarket food prices by level of food processing.

Collecting wrappers, labels, and packages to enhance accuracy of food records among children 2-8 years in the Pacific region: Children's Healthy Living Program (CHL)

The aim was to describe differences in dietary outcomes based on the provision of food wrappers, labels or packages (WLP) to complement data from dietary records (DR) among children from the US Affiliated Pacific. The WLP were intended to aid food coding. Since WLP can be associated with ultra-processed foods, one might expect differences in sodium, sugar, and other added ingredients to emerge. Dietary intakes of children (2-8 y) in Alaska, Hawai'i, Commonwealth of the Northern Mariana Islands, and Guam were collected using parent/caregiver completed 2-day DR. Parents were encouraged to collect WLP associated with the child's intake. Trained staff entered data from the DRs including the WLP when available using PacTrac3, a web application. Of the 1,868 DRs collected and entered at the time of this report, 498 (27%) included WLP. After adjusting for confounders (sex, age, location, education, food assistance), the DRs with WLP had significantly higher amounts of energy (kcal), total fat, saturated fat, added sugar, and sodium. These results suggest the inclusion of WLP enhanced the dietary intake data. The intake of energy, fat, added sugar and sodium derived from processed foods and foods consumed outside the home was better captured in children who had WLP.

Appetitive drives for ultra-processed food products and the ability of text warnings to counteract consumption predispositions

OBJECTIVE

The present study aimed to (i) assess the appetitive drives evoked by the visual cues of ultra-processed food and drink products and (ii) investigate whether text warnings reduce appetitive drives and consumers' reported intentions to eat or drink ultra-processed products.

DESIGN

In Study I, a well-established psychometric tool was applied to estimate the appetitive drives associated with ultra-processed products using sixty-four image representations. Sixteen product types with four exemplars of a given product were included. Pictures from the International Affective Picture System (IAPS) served as controls. The two exemplars of each product type rated as more appetitive were selected for investigation in the second study. Study II assessed the impact of textual warnings on the appetitive drive towards these thirty-two exemplars. Each participant was exposed to two picture exemplars of the same product type preceded by a text warning or a control text. After viewing each displayed picture, the participants reported their emotional reactions and their intention to consume the product.

SETTING

Controlled classroom experiments SUBJECTS: Undergraduate students (Study I: n 215, 135 women; Study II: n 98, 52 women).

RESULTS

In Study I, the pictures of ultra-processed products prompted an appetitive motivation associated with the products' nutritional content. In Study II, text warnings were effective in reducing the intention to consume and the appetitive drive evoked by ultra-processed products.

CONCLUSIONS

This research provides initial evidence favouring the use of text warnings as a public policy tool to curb the powerful influence of highly appetitive ultra-processed food cues.

Maintenance of Lost Weight and Long-Term Management of Obesity

Weight loss can be achieved through a variety of modalities, but long-term maintenance of lost weight is much more challenging. Obesity interventions typically result in early weight loss followed by a weight plateau and progressive regain. This review describes current understanding of the biological, behavioral, and environmental factors driving this near-ubiquitous body weight trajectory and the implications for long-term weight management. Treatment of obesity requires ongoing clinical attention and weight maintenance-specific counseling to support sustainable healthful behaviors and positive weight regulation.

Added sugars and ultra-processed foods in Spanish households (1990-2010)

BACKGROUND/OBJECTIVES

To study the association between ultra-processed foods acquisitions and added sugar content of total food purchases in Spanish households in 2010. Changes over time (1990-2000-2010) in ultra-processed food purchases and added sugars content of total food purchases are also compared.

SUBJECTS/METHODS

We used data from three nationally representative Household Budget Surveys (HBS) conducted in 1990, 2000 and 2010. Number of studied households was 21,012, 33,730 and 22,116, respectively. Purchased foods and drinks were classified according to NOVA food groups as ultra-processed foods, processed foods, unprocessed or minimally processed foods, or processed culinary ingredients. Linear and Poisson regressions were used to estimate the association between quintiles of energy contribution of ultra-processed foods and added sugars contents of total food purchases in 2010. Changes over time were assessed using tests of linear trend and Student's t test.

RESULTS

In 2010, ultra-processed foods represented 31.7% of daily energy acquisitions and 80.4% of all added sugars. Added sugars content of food purchases raised from 7.3% in the lowest to 18.2% in the highest quintiles of energy contribution of ultra-processed foods. The risk of exceeding 10% energy from added sugars quadrupled between the lowest and highest quintiles. The percentage of ultra-processed foods on all food purchases almost tripled between 1990 and 2010 (from 11.0 to 31.7%), paralleling the increase of added sugars content (from 8.4 to 13.0%).

CONCLUSIONS

Cutting down exceeding added sugars availability in Spain may require a reduction in ultra-processed food purchasing.

Sociodemographic associations of the dietary proportion of ultra-processed foods in First Nations peoples in the Canadian provinces of British Columbia, Manitoba, Alberta and Ontario

We investigated the food types consumed by 3276 First Nations citizens from the First Nations Food Nutrition and Environment Study (FNFNES) living on-reserve in Canada. Data from 24-h dietary recalls were classified into NOVA categories: fresh or minimally processed foods (MPF), processed culinary ingredients, processed foods, and ultra-processed foods (UPF). Individuals were classified as traditional food (TF) eaters if they ate MPF of their First Nations culture. UPF accounted for 54.0% of energy intake; 23% of participants ate TF. Increasing age and household size, living in British Columbia and TF eating were associated with a lower intake of energy from UPF. Eating TF appeared to be protective against intake of UPF.

Relationships between consumption of ultra-processed foods, gestational weight gain and neonatal outcomes in a sample of US pregnant women

Background

An increasingly large share of diet comes from ultra-processed foods (UPFs), which are assemblages of food substances designed to create durable, convenient and palatable ready-to-eat products. There is increasing evidence that high UPF consumption is indicative of poor diet and is associated with obesity and metabolic disorders. This study sought to examine the relationship between percent of energy intake from ultra-processed foods (PEI-UPF) during pregnancy and maternal gestational weight gain, maternal lipids and glycemia, and neonatal body composition. We also compared the PEI-UPF indicator against the US government’s Healthy Eating Index-2010 (HEI-2010).

Methods

Data were used from a longitudinal study performed in 2013–2014 at the Women’s Health Center and Obstetrics & Gynecology Clinic in St. Louis, MO, USA. Subjects were pregnant women in the normal and obese weight ranges, as well as their newborns (n = 45). PEI-UPF and the Healthy Eating Index-2010 (HEI-2010) were calculated for each subject from a one-month food frequency questionnaire (FFQ). Multiple regression (ANCOVA-like) analysis was used to analyze the relationship between PEI-UPF or HEI-2010 and various clinical outcomes. The ability of these dietary indices to predict clinical outcomes was also compared with the predictive abilities of total energy intake and total fat intake.

Results

An average of 54.4 ± 13.2% of energy intake was derived from UPFs. A 1%-point increase in PEI-UPF was associated with a 1.33 kg increase in gestational weight gain (p = 0.016). Similarly, a 1%-point increase in PEI-UPF was associated with a 0.22 mm increase in thigh skinfold (p = 0.045), 0.14 mm in subscapular skinfold (p = 0.026), and 0.62 percentage points of total body adiposity (p = 0.037) in the neonate.

Discussion

PEI-UPF (percent of energy intake from ultra-processed foods) was associated with and may be a useful predictor of increased gestational weight gain and neonatal body fat. PEI-UPF was a better predictor of all tested outcomes than either total energy or fat intake, and a better predictor of the three infant body fat measures than HEI-2010. UPF consumption should be limited during pregnancy and diet quality should be maximized in order to improve maternal and neonatal health.

Ultra-processed Food Intake and Obesity: What Really Matters for Health-Processing or Nutrient Content?

PURPOSE OF REVIEW

The aim of this narrative review was to summarize and critique recent evidence evaluating the association between ultra-processed food intake and obesity.

RECENT FINDINGS

Four of five studies found that higher purchases or consumption of ultra-processed food was associated with overweight/obesity. Additional studies reported relationships between ultra-processed food intake and higher fasting glucose, metabolic syndrome, increases in total and LDL cholesterol, and risk of hypertension. It remains unclear whether associations can be attributed to processing itself or the nutrient content of ultra-processed foods. Only three of nine studies used a prospective design, and the potential for residual confounding was high. Recent research provides fairly consistent support for the association of ultra-processed food intake with obesity and related cardiometabolic outcomes. There is a clear need for further studies, particularly those using longitudinal designs and with sufficient control for confounding, to potentially confirm these findings in different populations and to determine whether ultra-processed food consumption is associated with obesity independent of nutrient content.

Old Fashioned vs. Ultra-Processed-Based Current Diets: Possible Implication in the Increased Susceptibility to Type 1 Diabetes and Celiac Disease in Childhood

Ultra-processed foods are ready-to-heat and ready-to-eat products created to replace traditional homemade meals and dishes due to convenience and accessibility. Because of their low-fiber and high-fat and sugar composition, these foodstuffs could induce a negative impact on health. They are partially responsible for obesity and chronic non-transmissible diseases; additionally, they could impact in the prevalence of autoimmune diseases such as type 1 diabetes and celiac disease. The rationale is that the nutritional composition of ultra-processed foodstuffs can induce gut dysbiosis, promoting a pro-inflammatory response and consequently, a “leaky gut”. These factors have been associated with increased risk of autoimmunity in genetically predisposed children. In addition, food emulsifiers, commonly used in ultra-processed products could modify the gut microbiota and intestinal permeability, which could increase the risk of autoimmunity. In contrast, unprocessed and minimally processed food-based diets have shown the capacity to promote gut microbiota eubiosis, anti-inflammatory response, and epithelial integrity, through bacterial butyrate production. Thus, to decrease the susceptibility to autoimmunity, genetically predisposed children should avoid ultra-processed food products and encourage the consumption of fresh and minimally processed foods.

Ultra-processing. An odd 'appraisal'

It is now generally agreed that the impact of the current nature, purpose and extent of food processing on human well-being, health and disease needs to be better understood and explained, in order to improve public health. The special issue of Public Health Nutrition devoted to the concept of ultra-processing of food, and the NOVA classification of which ultra-processed foods are one category, is a great step forward in this work. Coincidentally, a polemical 'critical appraisal' of ultra-processing was recently published in another journal. Debate and discussion are an essential part of the scientific endeavour. In this commentary, we correct inaccurate statements made about NOVA in the 'appraisal,' rebut points raised, and discuss the larger issue of scientific responsibility for publishing opposing views on controversial topics.

How poverty affects diet to shape the microbiota and chronic disease

Here, we discuss the link between nutrition, non-communicable chronic diseases and socio-economic standing, with a special focus on the microbiota. We provide a theoretical framework and several lines of evidence from both animal and human studies that support the idea that income inequality is an underlying factor for the maladaptive changes seen in the microbiota in certain populations. We propose that this contributes to the health disparities that are seen between lower-income and higher-income populations in high-income countries.

Each meal matters in the exposome: Biological and community considerations in fast-food-socioeconomic associations

Advances in omics and microbiome technology have transformed the ways in which the biological consequences of life in the 'ecological theatre' can be visualized. Exposome science examines the total accumulated environmental exposures (both detrimental and beneficial) as a means to understand the response of the 'total organism to the total environment' over time. The repetitive stimulation of compensatory physiological responses (immune, cardiovascular, neuroendocrine) in response to stress - including sources of stress highly relevant to socioeconomic disadvantage - may lead to metabolic dysregulation and cellular damage, ultimately influencing behavior and disease. The collective toll of physiological wear and tear, known as allostatic load, is not paid equally throughout developed societies. It is paid in excess by the disadvantaged. In the context of fast-food, human and experimental research demonstrates that the biological response to a single fast-food-style meal - especially as mediated by the microbiome- is a product of the person's total lived experience, including the ability to buffer the fast-food meal-induced promotion of inflammation and oxidative stress. Emerging research indicates that each meal and its nutritional context matters. As we discuss, equal weekly visits to major fast-food outlets by the affluent and deprived do not translate into biological equivalency. Hence, debate concerning reducing fast-food outlets through policy - especially in disadvantaged neighborhoods where they are prevalent - requires a biological context. The fast-food establishment and fast-food meal - as they represent matters of food justice and press upon non-communicable disease risk - are far more than physical structures and collections of carbohydrate, fat, sugar and sodium.

Nutrient density: addressing the challenge of obesity

Obesity rates are increasing worldwide. Potential reasons include excessive consumption of sugary beverages and energy-dense foods instead of more nutrient-rich options. On a per kJ basis, energy-dense grains, added sugars and fats cost less, whereas lean meats, seafood, leafy greens and whole fruit generally cost more. Given that consumer food choices are often driven by price, the observed social inequities in diet quality and health can be explained, in part, by nutrition economics. Achieving a nutrient-rich diet at an affordable cost has become progressively more difficult within the constraints of global food supply. However, given the necessary metrics and educational tools, it may be possible to eat better for less. New metrics of nutrient density help consumers identify foods, processed and unprocessed, that are nutrient-rich, affordable and appealing. Affordability metrics, created by adding food prices to food composition data, permit calculations of both kJ and nutrients per penny, allowing for new studies on the economic drivers of food choice. Merging dietary intake data with local or national food prices permits the estimation of individual-level diet costs. New metrics of nutrient balance can help identify those food patterns that provide optimal nutritional value. Behavioural factors, including cooking at home, have been associated with nutrition resilience, defined as healthier diets at lower cost. Studies of the energy and nutrient costs of the global food supply and diverse food patterns will permit a better understanding of the socioeconomic determinants of health. Dietary advice ought to be accompanied by economic feasibility studies.

Ultra-processed foods, protein leverage and energy intake in the USA

OBJECTIVE

Experimental studies have shown that human macronutrient regulation minimizes variation in absolute protein intake and consequently energy intake varies passively with dietary protein density ('protein leverage'). According to the 'protein leverage hypothesis' (PLH), protein leverage interacts with a reduction in dietary protein density to drive energy overconsumption and obesity. Worldwide increase in consumption of ultra-processed foods (UPF) has been hypothesized to be an important determinant of dietary protein dilution, and consequently an ecological driving force of energy overconsumption and the obesity pandemic. The present study examined the relationships between dietary contribution of UPF, dietary proportional protein content and the absolute intakes of protein and energy.

DESIGN

National representative cross-sectional study.

SETTING

National Health and Nutrition Examination Survey 2009-2010.

SUBJECTS

Participants (n 9042) aged ≥2 years with at least one day of 24 h dietary recall data.

RESULTS

We found a strong inverse relationship between consumption of UPF and dietary protein density, with mean protein content dropping from 18·2 to 13·3 % between the lowest and highest quintiles of dietary contribution of UPF. Consistent with the PLH, increase in the dietary contribution of UPF (previously shown to be inversely associated with protein density) was also associated with a rise in total energy intake, while absolute protein intake remained relatively constant.

CONCLUSIONS

The protein-diluting effect of UPF might be one mechanism accounting for their association with excess energy intake. Reducing UPF contribution in the US diet may be an effective way to increase its dietary protein concentration and prevent excessive energy intake.

A minimally processed dietary pattern is associated with lower odds of metabolic syndrome among Lebanese adults

OBJECTIVE

To (i) estimate the consumption of minimally processed, processed and ultra-processed foods in a sample of Lebanese adults; (ii) explore patterns of intakes of these food groups; and (iii) investigate the association of the derived patterns with cardiometabolic risk.

DESIGN

Cross-sectional survey. Data collection included dietary assessment using an FFQ and biochemical, anthropometric and blood pressure measurements. Food items were categorized into twenty-five groups based on the NOVA food classification. The contribution of each food group to total energy intake (TEI) was estimated. Patterns of intakes of these food groups were examined using exploratory factor analysis. Multivariate logistic regression analysis was used to evaluate the associations of derived patterns with cardiometabolic risk factors.

SETTING

Greater Beirut area, Lebanon.

SUBJECTS

Adults ≥18 years (n 302) with no prior history of chronic diseases.

RESULTS

Of TEI, 36·53 and 27·10 % were contributed by ultra-processed and minimally processed foods, respectively. Two dietary patterns were identified: the 'ultra-processed' and the 'minimally processed/processed'. The 'ultra-processed' consisted mainly of fast foods, snacks, meat, nuts, sweets and liquor, while the 'minimally processed/processed' consisted mostly of fruits, vegetables, legumes, breads, cheeses, sugar and fats. Participants in the highest quartile of the 'minimally processed/processed' pattern had significantly lower odds for metabolic syndrome (OR=0·18, 95 % CI 0·04, 0·77), hyperglycaemia (OR=0·25, 95 % CI 0·07, 0·98) and low HDL cholesterol (OR=0·17, 95 % CI 0·05, 0·60).

CONCLUSIONS

The study findings may be used for the development of evidence-based interventions aimed at encouraging the consumption of minimally processed foods.

Phytosterol-enriched milk lowers LDL-cholesterol levels in Brazilian children and adolescents: Double-blind, cross-over trial

BACKGROUND AND AIMS

Despite evidence of the lipid-lowering effect of plant sterols among adults with hypercholesterolemia, data regarding phytosterol use in children are limited. In this paper, we examined the effects of daily consumption of a phytosterol-enriched milk compound on the lipid profiles of Brazilian children and adolescents with dyslipidemia.

METHODS AND RESULTS

This was a randomized, double blind, crossover clinical trial. Twenty eight dyslipidemics outpatients (aged 6-9 years) from an University Hospital were randomly allocated to control or intervention group. The intervention group received milk enriched with 1.2 g/day of plant sterol and the control group received the equivalent amount of skim milk during the period of 8 weeks. Changes from baseline in the mean lipid profile, including total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), and triglyceride (TG) concentrations. Serum lipid profiles, glucose levels, dietary and anthropometric data were determined at weeks 0, 4, 8, 16, and 20. Details regarding the safety and tolerance of phytosterol were obtained, using an open-ended questionnaire. Intention-to-treat analysis were performed, using the proc mixed procedure in SAS. After 8 weeks, the mean concentrations of TC and LDL-C were significantly reduced in the intervention group as compared to the control group with reductions of 5.9% (p = 0.09) and 10.2% (p = 0.002), respectively. In addition, TG concentrations were reduced by 19.7% (p = 0.09). No serious side effects were reported during the study.

CONCLUSION

Our results confirm that plant sterols are an effective and safe treatment of infantile dyslipidemia.

TRIAL REGISTRATION

RBR-3h7f9k.

Energy contribution of NOVA food groups and sociodemographic determinants of ultra-processed food consumption in the Mexican population

OBJECTIVE

To identify the energy contributions of NOVA food groups in the Mexican diet and the associations between individual sociodemographic characteristics and the energy contribution of ultra-processed foods (UPF).

DESIGN

We classified foods and beverages reported in a 24 h recall according to the NOVA food framework into: (i) unprocessed or minimally processed foods; (ii) processed culinary ingredients; (iii) processed foods; and (iv) UPF. We estimated the energy contribution of each food group and ran a multiple linear regression to identify the associations between sociodemographic characteristics and UPF energy contribution.

SETTING

Mexican National Health and Nutrition Survey 2012.

SUBJECTS

Individuals ≥1 years old (n 10 087).

RESULTS

Unprocessed or minimally processed foods had the highest dietary energy contribution (54·0 % of energy), followed by UPF (29·8 %), processed culinary ingredients (10·2 %) and processed foods (6·0 %). The energy contribution of UPF was higher in: pre-school-aged children v. other age groups (3·8 to 12·5 percentage points difference (pp)); urban areas v. rural (5·6 pp); the Central and North regions v. the South (2·7 and 8·4 pp, respectively); medium and high socio-economic status v. low (4·5 pp, in both); and with higher head of household educational level v. without education (3·4 to 7·8 pp).

CONCLUSIONS

In 2012, about 30 % of energy in the Mexican diet came from UPF. Our results showed that younger ages, urbanization, living in the North region, high socio-economic status and high head of household educational level are sociodemographic factors related to higher consumption of UPF in Mexico.

Food pyramid intake and nutrient profiles of Brazilian girls

Purpose

This paper aims to evaluate the impact of the groups from the Brazilian Food Pyramid on macro and micronutrient content of food consumed by adolescent girls from a school-based study.

Design/methodology/approach

Baseline data from “Healthy Habits, Healthy Girls” school-based randomized control trial was used for this study. A sample of the girls aged 14 to 18 years old (n = 253) from ten schools in Brazil was evaluated. Participants completed validated food frequency questionnaire, from which, the total kilocalories and/or grams from each food groups were calculated. Descriptive statistics, t-student test and linear regression were used for the analysis with a significant level of p < 0.05.

Findings

Mean daily intake of the girls was 2,887.09 (standard error 91.50) kcal/day. There was a positive significant association between relative intake of the “Oil and Fats” group and protein (ranged from 24.95 to 96.12 kcal/d), fats (48.36 to 192.62 kcal/d), iron (56.93 to 162.85 kcal/d) and sodium (208.08 to 699.69 kcal/d) contents. In regards to the intake of “Sugars and Sweets” group, there was a positive significant association for carbohydrates (97.53 to 491.70 kcal/day), total fiber (0.56 to 2.64 kcal/d), iron (0.85 to 4.40 kcal/d) and sodium (175.59 to 838.48 kcal/d) content.

Originality/value

Findings demonstrate that girls over consumed the “Oils and Fats” and “Sugars and Sweets” groups reflecting on increased of important macro and micronutrients of their diet. Therefore, consuming up to 1 serving size of these groups is a good way to promote healthy eating among this population.

Effects of reducing processed culinary ingredients and ultra-processed foods in the Brazilian diet: a cardiovascular modelling study

OBJECTIVE

To estimate the impact of reducing saturated fat, trans-fat, salt and added sugar from processed culinary ingredients and ultra-processed foods in the Brazilian diet on preventing cardiovascular deaths by 2030.

DESIGN

A modelling study.

SETTING

Data were obtained from the Brazilian Household Budget Survey 2008/2009. All food items purchased were categorized into food groups according to the NOVA classification. We estimated the energy and nutrient profile of foods then used the IMPACT Food Policy model to estimate the reduction in deaths from CVD up to 2030 in three scenarios. In Scenario A, we assumed that the intakes of saturated fat, trans-fat, salt and added sugar from ultra-processed foods and processed culinary ingredients were reduced by a quarter. In Scenario B, we assumed a reduction of 50 % of the same nutrients in ultra-processed foods and processed culinary ingredients. In Scenario C, we reduced the same nutrients in ultra-processed foods by 75 % and in processed culinary ingredients by 50 %.

RESULTS

Approximately 390 400 CVD deaths might be expected in 2030 if current mortality patterns persist. Under Scenarios A, B and C, CVD mortality can be reduced by 5·5, 11·0 and 29·0 %, respectively. The main impact is on stroke with a reduction of approximately 6·0, 12·6 and 32·0 %, respectively.

CONCLUSIONS

Substantial potential exists for reducing the CVD burden through overall improvements of the Brazilian diet. This might require reducing the penetration of ultra-processed foods by means of regulatory policies, as well as improving the access to and promotion of fresh and minimally processed foods.

Ultra-processed foods in human health: a critical appraisal

The NOVA classification of foods proposes 4 categories: unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods and drinks (UPFDs). It is argued that the latter relies heavily on modifications to foods, resulting in enhanced amounts of salt, added sugar, and fat as well as the use of additives in an attempt to make this food category highly palatable. It further argues that controlling food processing, rather than examining nutrients, should be foremost in shaping nutrition policy. This commentary challenges many of the basic arguments of using the NOVA food classification system to examine the link between food and health. We believe that there is no evidence to uphold the view that UPFDs give rise to hyperpalatable foods associated with a quasi-addictive effect and that the prevailing European Union and US data fail to uphold the assertion that UPFDs, which dominate energy intake, give rise to dietary patterns that are low in micronutrients. With regard to the use of the NOVA food classification in the development of food-based dietary guidelines, we show that the very broad definition of UPFDs makes this impossible. Finally, the available evidence does not support the view that the globalization of food is the driver of increased intakes of UPFDs in low- to middle-income countries but rather that this is driven by small indigenous companies. On balance, therefore, there seems to be little advantage from the use of the NOVA classification compared with the current epidemiologic approach, which relies on the linkage of nutrient intakes to chronic disease with subsequent identification of foods that merit consideration in public health nutrition strategies.

Participation in a farmers' market fruit and vegetable prescription program at a federally qualified health center improves hemoglobin A1C in low income uncontrolled diabetics

Fruit and vegetable prescription programs have been shown to increase consumption of fresh produce, but whether they have an impact on medical outcomes is unknown. The purpose of this study was to examine the role of participation in a farmers' market and fruit and vegetable prescription program on changes in hemoglobin A1C (HbA1C), blood pressure (BP) and weight in patients with uncontrolled type 2 diabetes at a federally qualified health center (FQHC) in Detroit, MI. The 13-week Fresh Prescription program (June 2015-October 2015) was designed to improve access and consumption of produce among low-income patients with uncontrolled type 2 diabetes. The program allotted up to $40 ($10 per week for up to four weeks) for purchase of produce from a FQHC located farmers' market. Adult, non-pregnant patients with a history of type 2 diabetes that had an elevated HbA1C > 6.5 within three months before Fresh Prescription program were eligible to participate. HgA1c, BP and weight were collected within three months of program start and within three months of completion. There were 65 eligible participants with complete biometric data. A statistically significant (p = 0.001) decrease in HbA1C was found (9.54% to 8.83%). However, weight (208.3 lbs. to 209.0 lbs.) and BP (135.1/79.3 mm Hg to 135.8/77.6 mm Hg) did not change from pre- to post-study (p > 0.05). Access to a fruit and vegetable prescription program over a 13-week period led to decreased HbA1C concentrations in uncontrolled type 2 diabetic patients living in an urban area of predominately-lower socioeconomic status.

Characterization of Breakfast Cereals Available in the Mexican Market: Sodium and Sugar Content

Preschool Mexican children consume 7% of their total energy intake from processed breakfast cereals. This study characterized the nutritional quality and labelling (claims and Guideline Daily Amount (GDA)) of the packaged breakfast cereals available in the Mexican market. Photographs of all breakfast cereals available in the 9 main food retail chains in the country were taken. The nutrition quality of cereals was assessed using the United Kingdom Nutrient Profiling Model (UKNPM). Claims were classified using the International Network for Food and Obesity/non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) taxonomy and the GDA was defined according to the Mexican regulation, NOM-051. Overall, a total of 371 different breakfast cereals were analysed. The nutritional profile showed that 68.7% were classified as “less healthy”. GDAs and claims were displayed more frequently on the “less healthy” cereals. Breakfast cereals within the “less healthy” category had significantly higher content of energy, sugar and sodium (p < 0.001). Most of the claims were displayed in the “less healthy” cereals (n = 313). This study has shown that there is a lack of consistency between the labelling on the front of the pack and the nutritional quality of breakfast cereals.

Barriers to and facilitators of ultra-processed food consumption: perceptions of Brazilian adults

OBJECTIVE

To explore how individuals perceive the availability of ultra-processed foods in their neighbourhoods and the barriers to and facilitators of consumption of such foods.

DESIGN

A qualitative design was chosen. In-depth, face-to-face semi-structured interviews were conducted and a content analysis was performed.

SETTING

São Paulo, Brazil.

SUBJECTS

A purposeful sample of adults (n 48), stratified by sex and age group (20-39 years and 40-59 years).

RESULTS

All participants perceived their neighbourhoods as favourable regarding the availability of ultra-processed foods. Three barriers were identified: health concerns, not appreciating the taste of these foods and not being used to eating them. Five facilitators, however, were identified: appreciating the taste of these foods, their children's preference, convenience, addiction and cost.

CONCLUSIONS

Participants perceived their neighbourhoods as favourable to the consumption of ultra-processed foods and reported more facilitators than barriers to their consumption. Reported barriers point to the need to include measures promoting a healthy food system and traditional eating practices. The facilitators reinforce the idea that these foods are habit-forming and that regulatory measures to offset the exposure to ultra-processed foods are necessary.

Quantifying associations of the dietary share of ultra-processed foods with overall diet quality in First Nations peoples in the Canadian provinces of British Columbia, Alberta, Manitoba and Ontario

OBJECTIVE

To quantify associations of the dietary share of ultra-processed foods (UPF) with the overall diet quality of First Nations peoples.

DESIGN

A cross-sectional analysis of data from the First Nations Food, Nutrition and Environment Study, designed to contribute to knowledge gaps regarding the diet of First Nations peoples living on-reserve, south of the 60th parallel. A multistage sampling of communities was conducted. All foods from 24 h dietary recalls were categorized into NOVA categories and analyses were performed to evaluate the impact of UPF on diet quality.

SETTING

Western and Central Canada.

SUBJECTS

First Nations participants aged 19 years or older.

RESULTS

The sample consisted of 3700 participants. UPF contributed 53·9 % of energy. Compared with the non-UPF fraction of the diet, the UPF fraction had 3·5 times less vitamin A, 2·4 times less K, 2·2 times less protein, 2·3 times more free sugars and 1·8 times more Na. As the contribution of UPF to energy increased so did the overall intakes of energy, carbohydrate, free sugar, saturated fat, Na, Ca and vitamin C, and Na:K; while protein, fibre, K, Fe and vitamin A decreased. Diets of individuals who ate traditional First Nations food (e.g. wild plants and game animals) on the day of the recall were lower in UPF.

CONCLUSIONS

UPF were prevalent in First Nations diets. Efforts to curb UPF consumption and increase intake of traditional First Nations foods and other fresh or minimally processed foods would improve diet quality and health in First Nations peoples.

Can nutritional information modify purchase of ultra-processed products? Results from a simulated online shopping experiment

OBJECTIVE

The aim of the present work was to evaluate the influence of two front-of-pack nutrition information schemes (traffic-light system and Chilean warning system) on consumer purchase of ultra-processed foods in a simulated online grocery store.

DESIGN

Following a between-subjects design, participants completed a simulated weekly food purchase in an online grocery store under one of three experimental conditions: (i) a control condition with no nutrition information, (ii) a traffic-light system and (iii) the Chilean warning system. Information about energy (calories), sugar, saturated fats and salt content was included in the nutrition information schemes.

SETTING

Participants were recruited from a consumer database and a Facebook advertisement.

SUBJECTS

People from Montevideo (Uruguay), aged 18-77 years (n 437; 75 % female), participated in the study. All participants were in charge of food purchase in the household, at least occasionally.

RESULTS

No significant differences between experimental conditions were found in the mean share of ultra-processed foods purchased by participants, both in terms of number of products and expenditure, or in the mean energy, sugar, saturated fat and salt content of the purchased items. However, the Chilean warning system decreased intended purchase of sweets and desserts.

CONCLUSIONS

Results from this online simulation provided little evidence to suggest that the traffic-light system or the Chilean warning system in isolation could be effective in reducing purchase of ultra-processed foods or improving the nutritional composition of the purchased products.

Household availability of ultra-processed foods and obesity in nineteen European countries

OBJECTIVE

To assess household availability of NOVA food groups in nineteen European countries and to analyse the association between availability of ultra-processed foods and prevalence of obesity.

DESIGN

Ecological, cross-sectional study.

SETTING

Europe.

SUBJECTS

Estimates of ultra-processed foods calculated from national household budget surveys conducted between 1991 and 2008. Estimates of obesity prevalence obtained from national surveys undertaken near the budget survey time.

RESULTS

Across the nineteen countries, median average household availability amounted to 33·9 % of total purchased dietary energy for unprocessed or minimally processed foods, 20·3 % for processed culinary ingredients, 19·6 % for processed foods and 26·4 % for ultra-processed foods. The average household availability of ultra-processed foods ranged from 10·2 % in Portugal and 13·4 % in Italy to 46·2 % in Germany and 50·4 % in the UK. A significant positive association was found between national household availability of ultra-processed foods and national prevalence of obesity among adults. After adjustment for national income, prevalence of physical inactivity, prevalence of smoking, measured or self-reported prevalence of obesity, and time lag between estimates on household food availability and obesity, each percentage point increase in the household availability of ultra-processed foods resulted in an increase of 0·25 percentage points in obesity prevalence.

CONCLUSIONS

The study contributes to a growing literature showing that the consumption of ultra-processed foods is associated with an increased risk of diet-related non-communicable diseases. Its findings reinforce the need for public policies and actions that promote consumption of unprocessed or minimally processed foods and make ultra-processed foods less available and affordable.

Ultra-processed family foods in Australia: nutrition claims, health claims and marketing techniques

Objective

To objectively evaluate voluntary nutrition and health claims and marketing techniques present on packaging of high-market-share ultra-processed foods (UPF) in Australia for their potential impact on public health.

Design

Cross-sectional.

Setting

Packaging information from five high-market-share food manufacturers and one retailer were obtained from supermarket and manufacturers’ websites.

Subjects

Ingredients lists for 215 UPF were examined for presence of added sugar. Packaging information was categorised using a taxonomy of nutrition and health information which included nutrition and health claims and five common food marketing techniques. Compliance of statements and claims with the Australia New Zealand Food Standards Code and with Health Star Ratings (HSR) were assessed for all products.

Results

Almost all UPF (95 %) contained added sugars described in thirty-four different ways; 55 % of UPF displayed a HSR; 56 % had nutrition claims (18 % were compliant with regulations); 25 % had health claims (79 % were compliant); and 97 % employed common food marketing techniques. Packaging of 47 % of UPF was designed to appeal to children. UPF carried a mean of 1·5 health and nutrition claims (range 0–10) and 2·6 marketing techniques (range 0–5), and 45 % had HSR≤3·0/5·0.

Conclusions

Most UPF packaging featured nutrition and health statements or claims despite the high prevalence of added sugars and moderate HSR. The degree of inappropriate or inaccurate statements and claims present is concerning, particularly on packaging designed to appeal to children. Public policies to assist parents to select healthy family foods should address the quality and accuracy of information provided on UPF packaging.

Contribution of ultra-processed foods in the diet of adults from the French NutriNet-Santé study

Objective

Concerns have been raised about the potential health impact of ultra-processed foods (UPF) in the diet. Our objective was to investigate the contribution of UPF in the diet in a large French population and its association with sociodemographic factors and dietary patterns.

Design

Cross-sectional analysis of dietary data from 74 470 participants in the web-based NutriNet-Santé cohort. UPF were identified in repeated 24 h records and the proportion (in weight) of UPF in the total diet (UPFp) was computed for each participant. Associations of sociodemographic characteristics and UPFp in quartiles were assessed using multivariate multinomial logistic regression. Food group consumption and nutrient intakes across quartiles of UPFp were estimated using linear regression adjusted for sociodemographic factors and energy intake.

Setting

France.

Results

UPF contributed 18·4 % of the foods consumed in weight and 35·9 % of total energy intake. Higher UPFp consumption was independently associated with male gender, younger age, lower education, smoking, and overweight and obesity (all P<0·0001). Participants in the highest UPFp quartile consumed lower amounts of fruit and vegetables (difference between quartile 4 and quartile 1 of UPFp, Δ=−180·3 g/d) and higher amounts of sweet products (Δ=68·5 g/d) and soft drinks (Δ=98·6 g/d; all P<0·0001). They had higher intakes of energy (Δ=610 kJ/d (145·7 kcal/d)) and added sugar (Δ=17·1 g/d), and lower intakes of fibre (Δ=−4·04 g/d), β-carotene (Δ=−1019·6 μg/d) and Ca (Δ=−87·8 mg/d; all P<0·0001).

Conclusions

UPF represent an important part of the diet in adults from the French general population and are associated with unbalanced nutritional intakes.

Diet quality indices in relation to metabolic syndrome in an Indigenous Cree (Eeyouch) population in northern Québec, Canada

Objective

To assess associations between three diet quality indices and metabolic syndrome (MetS) in the Cree (Eeyouch) of northern Québec, Canada, as well as to evaluate their pertinence in this Indigenous context.

Design

The alternative-Healthy Eating Index 2010 (aHEI-2010), the Food Quality Score (FQS) and the contribution of ultra-processed products (UPP) to total daily dietary energy intake using the NOVA classification were calculated from 24 h food recalls. MetS was determined with the latest harmonized definition. Logistic regressions assessed the relationship between quintiles of dietary quality scores with MetS and its components.

Setting

Study sample from the 2005–2009 cross-sectional Nituuchischaayihititaau Aschii Environment-and-Health Study.

Subjects

Eeyouch (n 811) from seven James Bay communities (≥18 years old).

Results

MetS prevalence was 56·6 % with 95·4 % abdominal adiposity, 50·1 % elevated fasting plasma glucose, 43·4 % hypertension, 38·6 % elevated TAG and 44·5 % reduced HDL cholesterol. Comparing highest and lowest quintiles of scores, adjusted OR (95 % CI) of MetS was 0·70 (0·39, 1·08; P-trend=0·05) for aHEI-2010, 1·06 (0·63, 1·76; P-trend=0·87) for FQS and 1·90 (1·14, 3·17; P-trend=0·04) for the contribution of UPP to total daily dietary energy intake.

Conclusions

Although diet quality indices have been associated with cardiometabolic risk, only the dietary intake of UPP was significantly associated with MetS in the Eeyouch. Indices tailored to the food environment of northern communities are essential to further understand the impact of diet quality in this context.

Modeled dietary impact of industry-wide food and beverage reformulations in the United States and France

Background: Food reformulation has been identified as a strategy to improve nutritional intakes; however, little is known about the potential impact of industry-wide reformulations.Objective: The aim of the study was to model the dietary impact of food and beverage reformulation following the Nestlé Nutritional Profiling System (NNPS) standards for children, adolescents, and adults in the United States and France.Design: Dietary intakes of individuals aged ≥4 y were retrieved from nationally representative surveys: the US NHANES 2011-2012 (n = 7456) and the French Individual and National Survey on Food Consumption (n = 3330). The composition of all foods and beverages consumed were compared with the NNPS standards for energy, total and saturated fats, sodium, added sugars, protein, fiber, and calcium. Two scenarios were modeled. In the first, the nutrient content of foods and beverages was adjusted to the NNPS standards if they were not met. In the second, products not meeting the standards were replaced by the most nutritionally similar alternative meeting the standards from the same category. Dietary intakes were assessed against local nutrient recommendations, and analyses were stratified by body mass index and socioeconomic status.Results: Scenarios 1 and 2 showed reductions in US adults' mean daily energy (-88 and -225 kcal, respectively), saturated fats (-4.2, -6.9 g), sodium (-406, -324 mg), and added sugars (-29.4, -35.8 g). Similar trends were observed for US youth and in France. The effects on fiber and calcium were limited. In the United States, the social gradient of added sugars intake was attenuated in both scenarios compared with the baseline values.Conclusions: Potential industry-wide reformulation of the food supply could lead to higher compliance with recommendations in both the United States and France, and across all socioeconomic groups. NNPS standards seemed to be especially effective for nutrients consumed in excess.

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

OBJECTIVE

To assess the consumption of ultra-processed foods and analyse its association with the content of added sugars in the Chilean diet.

DESIGN

Cross-sectional study of national dietary data obtained through 24 h recalls and classified into food groups according to the extent and purpose of food processing (NOVA classification).

SETTING

Chile.

SUBJECTS

A probabilistic sample of 4920 individuals (aged 2 years or above) studied in 2010 by a national dietary survey (Encuesta Nacional de Consumo Alimentario).

RESULTS

Ultra-processed foods represented 28·6 (se 0·5) % of total energy intake and 58·6 (se 0·9) % of added sugars intake. The mean percentage of energy from added sugars increased from 7·7 (se 0·3) to 19·7 (se 0·5) % across quintiles of the dietary share of ultra-processed foods. After adjusting for several potential sociodemographic confounders, a 5 percentage point increase in the dietary share of ultra-processed foods determined a 1 percentage point increase in the dietary content of added sugars. Individuals in the highest quintile were three times more likely (OR=2·9; 95 % CI 2·4, 3·4) to exceed the 10 % upper limit for added sugars recommended by the WHO compared with those in the lowest quintile, after adjusting for sociodemographic variables. This association was strongest among individuals aged 2-19 years (OR=3·9; 95 % CI 2·7, 5·9).

CONCLUSIONS

In Chile, ultra-processed foods are important contributors to total energy intake and to the consumption of added sugars. Actions aimed at limiting consumption of ultra-processed foods are being implemented as effective ways to achieve WHO dietary recommendations to limit added sugars and processed foods, especially for children and adolescents.

Front-of-package nutrition references are positively associated with food processing

Objective

Foods characterized by a high degree of processing are pervasive in the global food supply and concerns have been raised about their contribution to the escalating burden of diet-related disease. It has been suggested that the dominance of these products relates in part to their aggressive on-package marketing. The purpose of the present study was to assess the relationship between the extent and nature of front-of-package (FOP) nutrition references on products sold in Canadian supermarkets and the level of food processing.

Design

FOP references were recorded from all packaged foods. Nutrition references were classified as ‘negative’ and ‘positive’ and further differentiated in terms of the use of regulated and unregulated text. Foods were coded for level of processing, using three different classification systems. Logistic and negative binomial regression analyses were conducted to assess associations.

Setting

Three large Toronto supermarkets, from the top Canadian food retailers.

Subjects

Packaged foods (n 20 520).

Results

Forty-one per cent of products had FOP nutrition references. Irrespective of the classification system considered, the most processed category comprised the greatest proportion of products and nearly half of these bore FOP references. Foods deemed most processed were more likely than less processed products to bear FOP references and regulated and unregulated references to negative ingredients, but they were equally or less likely to bear positive nutrition references, depending on the classification system.

Conclusions

The greater frequency of FOP nutrition references on heavily processed foods raises questions about the extent to which discretionary FOP labelling supports public health efforts to promote healthy eating.

Targeting Overconsumption of Sugar-Sweetened Beverages vs. Overall Poor Diet Quality for Cardiometabolic Diseases Risk Prevention: Place Your Bets!

Chronic overconsumption of sugar-sweetened beverages (SSBs) is amongst the dietary factors most consistently found to be associated with obesity, type 2 diabetes (T2D) and cardiovascular disease (CVD) risk in large epidemiological studies. Intervention studies have shown that SSB overconsumption increases intra-abdominal obesity and ectopic lipid deposition in the liver, and also exacerbates cardiometabolic risk. Similar to the prevalence of obesity and T2D, national surveys of food consumption have shown that chronic overconsumption of SSBs is skyrocketing in many parts of the world, yet with marked heterogeneity across countries. SSB overconsumption is also particularly worrisome among children and adolescents. Although the relationships between SSB overconsumption and obesity, T2D, and CVD are rather consistent in epidemiological studies, it has also been shown that SSB overconsumption is part of an overall poor dietary pattern and is particularly prevalent among subgroups of the population with low socioeconomic status, thereby questioning the major focus on SSBs to target/prevent cardiometabolic diseases. Public health initiatives aimed specifically at decreasing SSB overconsumption will most likely be successful in influencing SSB consumption per se. However, comprehensive strategies targeting poor dietary patterns and aiming at improving global dietary quality are likely to have much more impact in addressing the unprecedented public health challenges that we are currently facing.

Association between home food preparation skills and behaviour, and consumption of ultra-processed foods: Cross-sectional analysis of the UK National Diet and nutrition survey (2008-2009)

BACKGROUND

'Ultra-processed foods' (UPF) have been industrially processed and tend to be higher in saturated fat, sodium and sugar than other foods. There is some evidence that consumption of UPF is associated with overweight, obesity and related diseases. In developed countries more than half of dietary energy is attributed to UPF. One reason for reliance on UPF may be poor home food preparation skills or infrequent use of these. This relationship has been previously proposed but not tested. We examined the relationship between home food preparation skills and behaviour and consumption of UPF.

METHODS

We used data from adults in the UK National Diet & Nutrition Survey 2008-09. Home food preparation skills and behaviours of adults (n = 509) were assessed using questions on confidence using eight cooking techniques, confidence cooking 10 foods, ability to prepare a cake or biscuits without help, and whether or not participants prepared a main meal five or more days per week. Individuals' UPF consumption was determined from four-day estimated diet diaries. Associations were adjusted for age, gender, occupational social class and household composition.

RESULTS

In fully adjusted models, individuals who were confident with all 10 foods (adjusted beta (95% CI) = -3.76 (-6.02 to -1.50)), able to bake cakes or biscuits without help (-3.87 (-6.62 to -1.12)), and cooked a main meal at least five days a week (-2.84 (-5.43 to -0.24)) consumed a lower percentage of dietary energy from UPF.

CONCLUSIONS

In UK adults better home food preparation skills and more frequent use of these skills tended to be cross-sectionally associated with lower UPF consumption. Greater encouragement of these skills may help reduce reliance on UPF.

The association between time scarcity, sociodemographic correlates and consumption of ultra-processed foods among parents in Norway: a cross-sectional study

Background

Use of ultra-processed foods has expanded rapidly over the last decades and high consumption has been positively associated with risk of e.g. overweight, obesity and type 2 diabetes. Ultra-processed foods offer convenience as they require minimal time for preparation. It is therefore reasonable to assume that such foods are consumed more often among people who experience time scarcity. The main aim of this study was to investigate the association between time scarcity and consumption of ultra-processed foods among parents of 2-year olds in Norway. A secondary aim was to investigate the association between sociodemographic correlates, weight status and consumption of ultra-processed foods.

Methods

This cross-sectional study included 497 participants. Chi-square and cross tabulations were used to calculate proportions of high vs. low consumption of ultra-processed foods in relation to time scarcity, sociodemographic correlates and weight status. Binary logistic regression analyses were performed to test the relationship between independent variables and consumption of ultra-processed foods.

Results

Participants reporting medium and high time scarcity were more likely to have a high consumption of ultra-processed dinner products (OR = 3. 68, 95% CI = 2. 32–5.84 and OR = 3.10, 1.80–5.35, respectively) and fast foods (OR = 2.60, 1.62–4.18 and OR = 1.90, 1.08–3.32, respectively) compared to those with low time scarcity. Further, participants with medium time scarcity were more likely to have a high consumption of snacks and soft drinks compared to participants with low time scarcity (OR = 1.63, 1.06–2.49). Finally, gender, ethnicity, educational level, number of children in the household and weight status were identified as important factors associated with the consumption of certain types of ultra-processed foods.

Conclusions

Results from the present study showed that time scarcity, various sociodemographic factors and weight status was associated with consumption of processed foods. Future studies with a longitudinal design are needed to further explore these patterns over a longer period of time.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4408-3) contains supplementary material, which is available to authorized users.

Nutrient profiling for product reformulation: public health impact and benefits for the consumer

The food industry holds great potential for driving consumers to adopt healthy food choices as (re)formulation of foods can improve the nutritional quality of these foods. Reformulation has been identified as a cost-effective intervention in addressing non-communicable diseases as it does not require significant alterations of consumer behaviour and dietary habits. Nutrient profiling (NP), the science of categorizing foods based on their nutrient composition, has emerged as an essential tool and is implemented through many different profiling systems to guide reformulation and other nutrition policies. NP systems should be adapted to their specific purposes as it is not possible to design one system that can equally address all policies and purposes, e.g. reformulation and labelling. The present paper discusses some of the key principles and specificities that underlie a NP system designed for reformulation with the example of the Nestlé nutritional profiling system. Furthermore, the impact of reformulation at the level of the food product, dietary intakes and public health are reviewed. Several studies showed that food and beverage reformulation, guided by a NP system, may be effective in improving population nutritional intakes and thereby its health status. In order to achieve its maximum potential and modify the food environment in a beneficial manner, reformulation should be implemented by the entire food sector. Multi-stakeholder partnerships including governments, food industry, retailers and consumer associations that will state concrete time-bound objectives accompanied by an independent monitoring system are the potential solution.

Consumer Perception of the Healthfulness of Ultra-processed Products Featuring Different Front-of-Pack Nutrition Labeling Schemes

OBJECTIVE

To examine the influence of front-of-pack nutrition information on the perception of healthfulness of ultra-processed products across 2 income levels.

DESIGN

A between-participants design was used to compare healthfulness perception of ultra-processed products featuring different front-of-pack nutrition information schemes (guideline daily amount system, traffic light system, and monochromatic traffic light system).

PARTICIPANTS

A total of 300 people (aged 18-70 years, 75% female) from Montevideo, Uruguay, participated in the study; half were middle- or high-income people and the other half were low-income people.

MAIN OUTCOME MEASURES

Participants were shown the labels of each product and asked to rate their perceived healthfulness and the frequency with which each product should be consumed.

ANALYSIS

Results were analyzed using analysis of variance for statistical significance (P < .05).

RESULTS

Low-income participants perceived ultra-processed products to be significantly (P < .05) more healthful than did middle- and high-income participants. The lowest perceived healthfulness scores for low-income participants were obtained for products featuring the colored and monochromatic traffic light system whereas no significant differences (P > .05) among schemes were found for middle- and high-income participants.

CONCLUSIONS AND IMPLICATIONS

Nutrition education programs aimed at increasing low-income people's knowledge of the nutritional composition of these products and their potential negative effects on health seem to be necessary. Although the inclusion of semidirective front-of-pack nutrition information decreased the perceived healthfulness of low-income people, it seemed unlikely to influence how they perceive these products.

Assessment of the construct validity of the Australian Health Star Rating: a nutrient profiling diagnostic accuracy study

BACKGROUND/OBJECTIVES

Nutrient profiling models classify the healthiness of foods based on their nutritional composition and provide the science that underlies nutrition signposting schemes. The two objectives were to examine the construct validity of the Health Star Rating (HSR) system by determining its diagnostic accuracy and to detect the optimal HSR cutoff points to define healthiness in packaged dairy foods. We hypothesised that ultra-processed dairy, defined by NOVA, would have less stars (less healthy) and non-ultra-processed dairy would have more stars (more healthy).

SUBJECTS/METHODS

The diagnostic accuracy of the HSR system used for 621 dairy foods for sale in an Australian regional supermarket was investigated. The healthiness of packaged dairy was measured using the NOVA food classification system.

RESULTS

The dairy beverages model was found to discriminate between healthy and less healthy dairy beverages as classified by NOVA (AUC: 0.653; 95% CI: 0.556-0.750; P=0.005). A receiver operating characteristic curve analysis for dairy beverages demonstrated that the optimal cutoff point corresponded to a rating of four stars. There was no discrimination power when using the HSR for predicting the health value of yoghurt and other dairy, or cheeses.

CONCLUSIONS

At the optimal cutoff point of four stars the HSR has a high sensitivity but a low specificity to correctly classify healthy packaged dairy beverages, as defined by NOVA. We provide evidence to support the construct validity of the HSR model for dairy beverages, but not for the models used for yoghurts and other dairy products, or cheeses.

Association between Dietary Share of Ultra-Processed Foods and Urinary Concentrations of Phytoestrogens in the US

The aim of this study was to examine the relationship between dietary contribution of ultra-processed foods and urinary phytoestrogen concentrations in the US. Participants from cross-sectional 2009-2010 National Health and Nutrition Examination Survey aged 6+ years, selected to measure urinary phytoestrogens and with one 24-h dietary recall were evaluated (2692 participants). Food items were classified according to NOVA (a name, not an acronym), a four-group food classification based on the extent and purpose of industrial food processing. Ultra-processed foods are formulations manufactured using several ingredients and a series of processes (hence "ultra-processed"). Most of their ingredients are lower-cost industrial sources of dietary energy and nutrients, with additives used for the purpose of imitating sensorial qualities of minimally processed foods or of culinary preparations of these foods. Studied phytoestrogens included lignans (enterolactone and enterodiol) and isoflavones (genistein, daidzein, O-desmethylangolensin and equol). Gaussian regression was used to compare average urinary phytoestrogen concentrations (normalized by creatinine) across quintiles of energy share of ultra-processed foods. Models incorporated survey sample weights and were adjusted for age, sex, race/ethnicity, family income, and education, among other factors. Adjusted enterodiol geometric means decreased monotonically from 60.6 in the lowest quintile to 35.1 µg/g creatinine in the highest, while adjusted enterolactone geometric means dropped from 281.1 to 200.1 across the same quintiles, respectively. No significant linear trend was observed in the association between these quintiles and isoflavone concentrations. This finding reinforces the existing evidence regarding the negative impact of ultra-processed food consumption on the overall quality of the diet and expands it to include non-nutrients such as lignans.

The share of ultra-processed foods and the overall nutritional quality of diets in the US: evidence from a nationally representative cross-sectional study

Background

Recent population dietary studies indicate that diets rich in ultra-processed foods, increasingly frequent worldwide, are grossly nutritionally unbalanced, suggesting that the dietary contribution of these foods largely determines the overall nutritional quality of contemporaneous diets. Yet, these studies have focused on individual nutrients (one at a time) rather than the overall nutritional quality of the diets. Here we investigate the relationship between the energy contribution of ultra-processed foods in the US diet and its content of critical nutrients, individually and overall.

Methods

We evaluated dietary intakes of 9,317 participants from 2009 to 2010 NHANES aged 1+ years. Food items were classified into unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods. First, we examined the average dietary content of macronutrients, micronutrients, and fiber across quintiles of the energy contribution of ultra-processed foods. Then, we used Principal Component Analysis (PCA) to identify a nutrient-balanced dietary pattern to enable the assessment of the overall nutritional quality of the diet. Linear regression was used to explore the association between the dietary share of ultra-processed foods and the balanced-pattern PCA factor score. The scores were thereafter categorized into tertiles, and their distribution was examined across ultra-processed food quintiles. All models incorporated survey sample weights and were adjusted for age, sex, race/ethnicity, family income, and educational attainment.

Results

The average content of protein, fiber, vitamins A, C, D, and E, zinc, potassium, phosphorus, magnesium, and calcium in the US diet decreased significantly across quintiles of the energy contribution of ultra-processed foods, while carbohydrate, added sugar, and saturated fat contents increased. An inverse dose–response association was found between ultra-processed food quintiles and overall dietary quality measured through a nutrient-balanced-pattern PCA-derived factor score characterized by being richer in fiber, potassium, magnesium and vitamin C, and having less saturated fat and added sugars.

Conclusions

This study suggests that decreasing the dietary share of ultra-processed foods is a rational and effective way to improve the nutritional quality of US diets.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-017-0119-3) contains supplementary material, which is available to authorized users.

A novel processed food classification system applied to Australian food composition databases

BACKGROUND

The extent of food processing can affect the nutritional quality of foodstuffs. Categorising foods by the level of processing emphasises the differences in nutritional quality between foods within the same food group and is likely useful for determining dietary processed food consumption. The present study aimed to categorise foods within Australian food composition databases according to the level of food processing using a processed food classification system, as well as assess the variation in the levels of processing within food groups.

METHODS

A processed foods classification system was applied to food and beverage items contained within Australian Food and Nutrient (AUSNUT) 2007 (n = 3874) and AUSNUT 2011-13 (n = 5740). The proportion of Minimally Processed (MP), Processed Culinary Ingredients (PCI) Processed (P) and Ultra Processed (ULP) by AUSNUT food group and the overall proportion of the four processed food categories across AUSNUT 2007 and AUSNUT 2011-13 were calculated.

RESULTS

Across the food composition databases, the overall proportions of foods classified as MP, PCI, P and ULP were 27%, 3%, 26% and 44% for AUSNUT 2007 and 38%, 2%, 24% and 36% for AUSNUT 2011-13. Although there was wide variation in the classifications of food processing within the food groups, approximately one-third of foodstuffs were classified as ULP food items across both the 2007 and 2011-13 AUSNUT databases.

CONCLUSIONS

This Australian processed food classification system will allow researchers to easily quantify the contribution of processed foods within the Australian food supply to assist in assessing the nutritional quality of the dietary intake of population groups.

Nutrition facts panel use is associated with higher diet quality and lower glycated hemoglobin concentrations in US adults with undiagnosed prediabetes

BACKGROUND

The majority of US consumers use the nutrition facts panel (NFP) or health claims for food selections. Although previous studies have consistently reported positive impacts of NFP use on dietary intake, evidence regarding the effect of the use of health claims, either alone or in combination with the NFP, on diet quality and health outcomes is scarce.

OBJECTIVES

Our primary objective was to test for associations of the use of food labels (the NFP or health claims) with overall diet quality in individuals with prediabetes. In addition, we examined the association between food label use and glycated hemoglobin (HbA1c) concentrations.

DESIGN

We conducted a weighted linear regression, which was appropriate for a complex sampling survey, with the use of cross-sectional data from 2654 US adults with undiagnosed prediabetes who participated in the 2005-2010 NHANES cycles. The following 4 categories of food label (NFP or health claims) use were identified: 1) both labels, 2) health claims only, 3) neither label, and 4) the NFP only. Healthy Eating Index-2010 score, which we used to assess diet quality, was calculated from two 24-h recalls. Blood samples for analyzing HbA1c concentrations (glycemic control) were collected in the mobile examination center.

RESULTS

The overall diet quality scores for the use of both labels [b: -2.76 (95% CI: -5.04, -0.48); P = 0.019], of health claims only [b: -3.46 (-6.64, -0.28); P = 0.033], and of neither label [b: -4.01 (-5.75, -2.28); P < 0.001] were lower than those of NFP-only users. Moreover, HbA1c concentrations of users of both labels [b: 0.09% (95% CI: 0.03%, 0.16%); P = 0.008] and health claims only [b: 0.13% (95% CI: 0.02%, 0.25%); P = 0.021] were higher than those of NFP-only users.

CONCLUSIONS

In participants with undiagnosed prediabetes, the use of health claims alone, of both labels, or of neither label (compared with the use of the NFP only) was associated with poorer diet quality. In addition, users of neither label and users of both labels had poorer glycemic control. Further studies are needed to understand why the use of health claims may not be health promoting in this high-risk population.

Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra Follow-Up (SUN) cohort study

BACKGROUND

Ultraprocessed food consumption has increased in the past decade. Evidence suggests a positive association between ultraprocessed food consumption and the incidence of overweight and obesity. However, few prospective studies to our knowledge have investigated this potential relation in adults.

OBJECTIVE

We evaluated the association between ultraprocessed food consumption and the risk of overweight and obesity in a prospective Spanish cohort, the SUN (University of Navarra Follow-Up) study.

DESIGN

We included 8451 middle-aged Spanish university graduates who were initially not overweight or obese and followed up for a median of 8.9 y. The consumption of ultraprocessed foods (defined as food and drink products ready to eat, drink, or heat and made predominantly or entirely from processed items extracted or refined from whole foods or synthesized in the laboratory) was assessed with the use of a validated semiquantitative 136-item food-frequency questionnaire. Cox proportional hazards models were used to estimate adjusted HRs and 95% CIs for incident overweight and obesity.

RESULTS

A total of 1939 incident cases of overweight and obesity were identified during follow-up. After adjustment for potential confounders, participants in the highest quartile of ultraprocessed food consumption were at a higher risk of developing overweight or obesity (adjusted HR: 1.26; 95% CI: 1.10, 1.45; P-trend = 0.001) than those in the lowest quartile of consumption.

CONCLUSIONS

Ultraprocessed food consumption was associated with a higher risk of overweight and obesity in a prospective cohort of Spanish middle-aged adult university graduates. Further longitudinal studies are needed to confirm our results. This trial was registered at clinicaltrials.gov as NCT02669602.

Consumers' conceptualization of ultra-processed foods

Consumption of ultra-processed foods has been associated with low diet quality, obesity and other non-communicable diseases. This situation makes it necessary to develop educational campaigns to discourage consumers from substituting meals based on unprocessed or minimally processed foods by ultra-processed foods. In this context, the aim of the present work was to investigate how consumers conceptualize the term ultra-processed foods and to evaluate if the foods they perceive as ultra-processed are in concordance with the products included in the NOVA classification system. An online study was carried out with 2381 participants. They were asked to explain what they understood by ultra-processed foods and to list foods that can be considered ultra-processed. Responses were analysed using inductive coding. The great majority of the participants was able to provide an explanation of what ultra-processed foods are, which was similar to the definition described in the literature. Most of the participants described ultra-processed foods as highly processed products that usually contain additives and other artificial ingredients, stressing that they have low nutritional quality and are unhealthful. The most relevant products for consumers' conceptualization of the term were in agreement with the NOVA classification system and included processed meats, soft drinks, snacks, burgers, powdered and packaged soups and noodles. However, some of the participants perceived processed foods, culinary ingredients and even some minimally processed foods as ultra-processed. This suggests that in order to accurately convey their message, educational campaigns aimed at discouraging consumers from consuming ultra-processed foods should include a clear definition of the term and describe some of their specific characteristics, such as the type of ingredients included in their formulation and their nutritional composition.

Artificial sweeteners and metabolic dysregulation: Lessons learned from agriculture and the laboratory

Escalating rates of obesity and public health messages to reduce excessive sugar intake have fuelled the consumption of artificial sweeteners in a wide range of products from breakfast cereals to snack foods and beverages. Artificial sweeteners impart a sweet taste without the associated energy and have been widely recommended by medical professionals since they are considered safe. However, associations observed in long-term prospective studies raise the concern that regular consumption of artificial sweeteners might actually contribute to development of metabolic derangements that lead to obesity, type 2 diabetes and cardiovascular disease. Obtaining mechanistic data on artificial sweetener use in humans in relation to metabolic dysfunction is difficult due to the long time frames over which dietary factors might exert their effects on health and the large number of confounding variables that need to be considered. Thus, mechanistic data from animal models can be highly useful because they permit greater experimental control. Results from animal studies in both the agricultural sector and the laboratory indicate that artificial sweeteners may not only promote food intake and weight gain but can also induce metabolic alterations in a wide range of animal species. As a result, simple substitution of artificial sweeteners for sugars in humans may not produce the intended consequences. Instead consumption of artificial sweeteners might contribute to increases in risks for obesity or its attendant negative health outcomes. As a result, it is critical that the impacts of artificial sweeteners on health and disease continue to be more thoroughly evaluated in humans.