Ultra-processed food consumption and type 2 diabetes incidence: A prospective cohort study

The effects of nudging and pricing strategies on the availability and purchases of ultra-processed foods: A secondary analysis of the Supreme Nudge trial

Regular consumption of ultra-processed foods (UPF) is a risk factor for morbidity and mortality. UPF are widely available in supermarkets. Nudging and pricing strategies are promising strategies to promote healthier supermarket purchases and may reduce UPF purchases. We investigated whether supermarket nudging and pricing strategies targeting healthy foods, but not specifically discouraging UPF, would change UPF availability, price, promotion and placement (UPF-APPP) in supermarkets and customer UPF purchases. We used data from the Supreme Nudge parallel cluster-randomized controlled trial, testing the effect of a combined nudging and pricing intervention promoting healthy products. The Dutch Consumer Food Environment Score (D-CFES) was used to audit 12 participating supermarkets in terms of UPF-APPP. We used customer loyalty card data of the first twelve intervention weeks from 321 participants to calculate the proportion of UPF purchases. Descriptive statistics were used to assess differences in D-CFES between supermarkets. Mixed model analyses were used to assess the association between the D-CFES and UPF purchases and the effect of the intervention on UPF purchases. No difference in the D-CFES between intervention and control supermarkets were found. No statistically significant association between the D-CFES and UPF purchases (β = -0.00, 95%CI: -0.02, 0.01) and no significant effect of the intervention on UPF purchases (β = 0.02, 95%CI: -0.07, 0.12) was observed. Given the significant proportion of unhealthy and UPF products in Dutch supermarkets, nudging and pricing strategies aimed at promoting healthy food purchases are not sufficient for reducing UPF-APPP nor purchases, and nationwide regulation may be needed.Trial registration number: Dutch Trial Register ID NL7064, May 30, 2018, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7302.

Mapping ultra-processed foods (UPFs) in India: a formative research study

BACKGROUND

Increased consumption of ultra-processed foods (UPFs) which have additives such as artificial colours, flavours and are usually high in salt, sugar, fats and specific preservatives, are associated with diet-related non-communicable diseases (NCDs). In India, there are no standard criteria for identifying UPFs using a classification system based on extent and purpose of industrial processing. Scientific literature on dietary intake of foods among Indian consumers classifies foods as unhealthy based on presence of excessive amounts of specific nutrients which makes it difficult to distinguish UPFs from other commercially available processed foods.

METHODS

A literature review followed by an online grocery retailer scan for food label reading was conducted to map the types of UPFs in Indian food market and scrutinize their ingredient list for the presence of ultra-processed ingredients. All UPFs identified were randomly listed and then grouped into categories, followed by saliency analysis to understand preferred UPFs by consumers. Indian UPF categories were then finalized to inform a UPF screener.

RESULTS

A lack of application of a uniform definition for UPFs in India was observed; hence descriptors such as junk-foods, fast-foods, ready-to-eat foods, instant-foods, processed-foods, packaged-foods, high-fat-sugar-and-salt foods were used for denoting UPFs. After initial scanning of such foods reported in literature based on standard definition of UPFs, an online grocery retailer scan of food labels for 375 brands (atleast 3 brands for each food item) confirmed 81 food items as UPFs. A range of packaged traditional recipes were also found to have UPF ingredients. Twenty three categories of UPFs were then developed and subjected to saliency analysis. Breads, chips and sugar-sweetened beverages (e.g. sodas and cold-drinks) were the most preferred UPFs while frozen ready-to-eat/cook foods (e.g. chicken nuggets and frozen kebabs) were least preferred.

CONCLUSION

India needs to systematically apply a food classification system and define Indian food categories based on the level of industrial processing. Mapping of UPFs is the first step towards development of a quick screener that would generate UPF consumption data to inform clear policy guidelines and regulations around UPFs and address their impact on NCDs.

Ultraprocessing and presence of additives in commercially produced complementary foods in seven Southeast Asian countries: a cross-sectional study

BACKGROUND

There has been a dramatic shift in food systems, and the consumption of commercially processed and packaged foods has grown globally, including among older infants and young children. Many of these products are ultraprocessed and contain additives, with concerning implications for the health and nutrition of children.

OBJECTIVES

The study objectives were as follows: 1) to assess the levels of processing among different commercially produced complementary food product (CPCF) categories marketed in the Southeast Asia region, 2) to compare the nutrient content of CPCF products across levels of processing, and 3) to assess the types of additives present in different CPCF categories.

METHODS

This cross-sectional study involved secondary analysis of a cross-sectional dataset of product label information from CPCF purchased in 2021 in Cambodia, Indonesia, Lao People's Democratic Republic, Malaysia, Philippines, Thailand, and Viet Nam. Ingredient lists were reviewed to determine the level of processing-based on the Nova classification-and the presence of additives. Nutrient declaration panels were reviewed to determine total sugar, sodium, and total fat.

RESULTS

Nearly half of all CPCF were ultraprocessed, with total sugar and sodium content significantly higher among ultraprocessed CPCF than unprocessed/minimally processed products. Almost half of CPCF contained additives, with a median of 6 per product. More than 30% of all CPCF made use of cosmetic additives to enhance the products' appearance, flavor, or texture, with emulsifiers, colors, and thickeners the most prevalent. Almost one-third of products contained additives not permitted in Codex Alimentarius standards and guidelines for CPCF.

CONCLUSIONS

Findings from this study should alert national governments to both adopt and ensure enforcement of Codex guidance on additives and regulations enacted to encourage lower levels of processing for CPCF.

Association of ultraprocessed food consumption with risk of microvascular complications among individuals with type 2 diabetes in the UK Biobank: a prospective cohort study

BACKGROUND

The poor nutritional characteristics and potentially harmful molecules in ultraprocessed foods (UPFs) are risk factors for diabetic microvascular complications. However, the evidence regarding UPFs and diabetic microvascular complications remains limited.

OBJECTIVES

We aimed to evaluate the associations between UPF consumption and risk of diabetic microvascular complications, to examine the underlying biological pathways (e.g., inflammation and lipid profile), and to identify whether the associations differ by type of UPF dietary patterns.

METHODS

We included a prospective cohort of UK Biobank participants with type 2 diabetes (T2D) having at least one 24-h dietary recall (N = 5685). UPFs were defined using the Nova classification. Principal component analysis was used to derive UPF consumption patterns. Associations of UPFs and their consumption patterns with microvascular complications were assessed using Cox proportional hazards regression models. Mediation analyses were used to estimate the mediating effects of 22 biomarkers.

RESULTS

During a median of 12.7 y of follow-up, 1243 composite microvascular complications events occurred (599 diabetic retinopathy, 237 diabetic neuropathy, and 662 diabetic kidney disease events). Five consumption patterns were identified (spread and bread, cereal prepared with liquids, dairy-based products, sugary beverage and snack, and mixed beverage and savory snack patterns). A 10% increment in the proportion of UPF was associated with higher hazards of the composite microvascular complications (hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 1.03, 1.13) and diabetic kidney disease (HR: 1.13; 95% CI: 1.06, 1.20). Triglycerides, C-reactive protein, and body mass index collectively explained 22.0% (9.6%-43.0%) of the association between UPF intake and composite microvascular complications. Pattern high in mixed beverage and savory snack was associated with a higher risk of composite microvascular complications.

CONCLUSIONS

Higher UPF consumption was associated with higher risks of diabetic microvascular complications, and the association was partly mediated through multiple potential ways.

Socioeconomic Inequalities in Intakes of Ultraprocessed and Minimally Processed Foods in Nationally Representative Samples of Adults in Canada: An Analysis of Trends between 2004 and 2015

BACKGROUND

Individuals with a lower socioeconomic position (SEP) often have higher intakes of ultraprocessed food (UPF) and lower intakes of minimally processed food (MPF); however, studies have not examined trends in absolute and relative gaps and gradients in UPF and MPF intake using multiple indicators of SEP.

OBJECTIVES

We examined within-year absolute and relative gaps and gradients in UPF and MPF intake and trends between 2004 and 2015 according to 6 indicators of SEP among nationally representative samples of adults in Canada.

METHODS

Adults (≥18 y) in the Canadian Community Health Survey-Nutrition 2004 (n = 20,880) or 2015 (n = 13,970) reported SEP (individual and household education, household income adequacy, household food insecurity, neighborhood material and social deprivation) and completed a 24-h dietary recall. Multivariable linear regression assessed within-year absolute and relative gaps and gradients in the proportion of energy from UPF and MPF and trends between 2004 and 2015.

RESULTS

The largest and most consistent within-year inequities in UPF and MPF intake were for individual and household educational attainment. Overall and among males, higher SEP groups had more favorable intakes over time based on trends in absolute and relative gaps and gradients in UPF and MPF intake by household food insecurity [for example, the absolute gap in UPF intake declined from -1.2% (95% confidence interval: -5.3%, 2.9%) to -7.9% of energy (95% confidence interval: -11.2%, -4.5%) in the overall population]. Overall and among males, lower SEP groups had more favorable intakes over time based on trends in absolute and relative gaps in UPF and MPF intake by neighborhood material deprivation.

CONCLUSIONS

Socioeconomic inequalities in UPF and MPF intake were most pronounced for individual and household education. Between 2004 and 2015, several inequalities in UPF and MPF intake emerged according to household food insecurity (favoring higher SEP groups) and neighborhood material deprivation (favoring lower SEP groups).

Ultra-processed food and drink consumption and lipoprotein subclass profiles: A cross-sectional study of a middle-to older-aged population

BACKGROUND AND AIMS

Studies have consistently demonstrated associations between ultra-processed food and drink (UPFD) consumption and non-communicable diseases. However, there is a lack of data investigating relationships between UPFD intake and intermediate cardiometabolic disease markers. In this study we explored UPFD associations with lipoprotein subclasses.

METHODS

This was a cross-sectional study of 1986 middle-to older-aged men and women randomly selected from a large primary care centre. The percentage contribution of UPFDs to total energy intake was calculated for each participant using the NOVA classification. Lipoprotein particle subclass concentrations and size were determined using nuclear magnetic resonance spectroscopy. Correlation and multivariate-adjusted linear regression analyses were performed to examine UPFD intake relationships with lipoprotein subclasses.

RESULTS

In fully adjusted regression models, higher UPFD consumption was associated with reduced high-density lipoprotein (HDL) cholesterol concentrations (β = -0.024, p = 0.001), large low-density lipoprotein (LDL) levels (β = -18.645, p = 0.002), total and medium HDL concentrations (β = -0.328, p = 0.012; β = -0.510, p < 0.001), smaller LDL and HDL size (β = -0.026, p = 0.023; β = -0.023, p = 0.024), and increased medium very low-density lipoprotein levels (β = 0.053, p = 0.022), small LDL and HDL concentrations (β = 20.358, p = 0.02; β = 0.336, p = 0.011), and higher lipoprotein insulin resistance scores (β = 0.048, p = 0.012), reflecting greater lipoprotein-related insulin resistance.

CONCLUSIONS

Findings from this research suggest that increased intake of UPFDs is associated with a more pro-atherogenic, insulin-resistant metabolic profile in middle-to older-aged adults which may be a potential mechanism underlying reported associations between UPFD consumption and chronic disease risk and mortality.

Ultra-processed food consumption and risk of diabetes: results from a population-based prospective cohort

AIMS/HYPOTHESIS

Understanding the impact of the overall construct of ultra-processed foods on diabetes risk can inform dietary approaches to diabetes prevention. In this study, we aimed to evaluate the association between ultra-processed food consumption and risk of diabetes in a community-based cohort of middle-aged adults in the USA. We hypothesised that a higher intake of ultra-processed foods is associated with a higher risk of incident diabetes.

METHODS

The study included 13,172 participants without diabetes at baseline (1987-1989) in the Atherosclerosis Risk in Communities (ARIC) study. Dietary intake was assessed with a 66-item semiquantitative food frequency questionnaire, and foods were categorised by processing level using the Nova classification system. Ultra-processed food was analysed categorically (quartiles of energy-adjusted intake) and continuously (per one additional serving/day). We used Cox regression to evaluate the association of ultra-processed food intake with risk of diabetes with adjustment for sociodemographic characteristics, total energy intake, health behaviours and clinical factors.

RESULTS

Over a median follow-up of 21 years, there were 4539 cases of incident diabetes. Participants in the highest quartile of ultra-processed food intake (8.4 servings/day on average) had a significantly higher risk of diabetes (HR 1.13; 95% CI 1.03, 1.23) compared with participants in the lowest quartile of intake after adjustment for sociodemographic, lifestyle and clinical factors. Each additional serving of ultra-processed food consumed daily was associated with a 2% higher risk of diabetes (HR 1.02; 95% CI 1.00, 1.04). Highest quartile consumption of certain ultra-processed food groups, including sugar- and artificially sweetened beverages, ultra-processed meats and sugary snacks, was associated with a 29%, 21% and 16% higher risk of diabetes, respectively, compared with the lowest quartile.

CONCLUSIONS/INTERPRETATION

We found that a higher intake of ultra-processed food was associated with higher risk of incident diabetes, particularly sugar- and artificially sweetened beverages, ultra-processed meats and sugary snacks. Our findings suggest interventions reducing ultra-processed food consumption and specific food groups may be an effective strategy for diabetes prevention.

The impact of ultra-processed foods on obesity and cardiometabolic comorbidities in children and adolescents: a systematic review

CONTEXT

Over the past few decades, traditional foods have been displaced by ultra-processed foods (UPFs), with the latter being associated with health problems.

OBJECTIVE

This scoping systematic review aimed to identify the relationship between UPF intake and overweight/obesity as well as other cardiometabolic risk factors during childhood and adolescence.

DATA SOURCES

The guidance for this protocol is the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P). A systematic search was undertaken on PubMed, Scopus, and Cochrane Library electronic databases based on prespecified inclusion and exclusion criteria up to 6 February 2022.

DATA EXTRACTION

A total of 17 observational studies-9 cross-sectional, 7 cohort-longitudinal, and 1 study reporting both cross-sectional and longitudinal outcomes-among children and adolescents aged ≤18 years were eligible for inclusion in this review. Fourteen studies evaluated the consumption of UPFs in association with overweight/obesity and 9 studies examined the association of UPF consumption and cardiometabolic-related risk factors.

DATA ANALYSIS

Most studies (14/17) showed that an increase in UPFs was associated with a higher prevalence of overweight/obesity and cardiometabolic comorbidities among children and adolescents, whereas 4 of 17 studies (3 cross-sectional and 1 cohort) found no association. Most cohort and cross-sectional studies showed good quality according to the National Institutes of Health and Newcastle-Ottawa quality assessment, respectively.

CONCLUSION

The positive association found between UPFs and overweight/obesity and cardiometabolic comorbidities among children and adolescents raises concerns for future health. Further investigation is recommended to explore the role of specific types of UPFs on cardiometabolic conditions and to identify the amount of daily intake that increase risk in order to shape appropriate public health policies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022316432.

Ultra-processed food consumption, genetic susceptibility, and the risk of hip/knee osteoarthritis

BACKGROUND

The associations between ultra-processed food (UPF) consumption, genetic susceptibility, and the risk of osteoarthritis (OA) remain unknown. This study was to examine the effect of UPF consumption, genetic susceptibility, and their interactions on hip/knee OA.

METHODS

Cohort analyses included 163,987 participants from the UK Biobank. Participants' UPF consumption was derived from their 24-h dietary recall using a questionnaire. Genetic risk scores (GRSs) of 70 and 83 single nucleotide polymorphisms (SNPs) for hip and knee OA were constructed.

FINDINGS

After 1,461,447 person-years of follow-up, 11,540 patients developed OA. After adjustments, compared to participants in the low quartile of UPF consumption, those in the high quartile had a 10 % (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03-1.18) increased risk of knee OA. No significant association was found between UPF consumption and hip OA. Replacing 20% of UPF diet weight with an equivalent proportion of unprocessed or minimally processed food caused a 6% (HR, 0.94; 95% CI, 0.89-0.98) decreased risk of knee OA, respectively. A significant interaction was found between UPF consumption, genetic predisposition, and the risk of knee OA (P = 0.01). Participants with lower OA-GRS scores experienced higher knee OA risks due to UPF consumption.

INTERPRETATION

UPF consumption was associated with a higher risk of knee OA but not hip OA, particularly in those with lower genetic susceptibility. These results highlight the importance of reducing UPF consumption to prevent knee OA.

Differential association of dietary scores with the risk of type 2 diabetes by metabotype

PURPOSE

We aimed to examine the association between dietary patterns and type 2 diabetes mellitus (T2DM) while considering the potential effect modification by metabolic phenotypes (metabotypes). Additionally, we aimed to explore the association between dietary scores and prediabetes.

METHODS

A total of 1460 participants (11.8% with T2DM) from the cross-sectional population-based KORA FF4 study were included. Participants, classified into three metabotype subgroups, had both their FSAm-NPS dietary index (underpinning the Nutri-Score) and ultra-processed foods (UPF) intake (using NOVA classification) calculated. Glucose tolerance status was assessed via oral glucose tolerance tests (OGTT) in non-diabetic participants and was classified according to the American Diabetes Association criteria. Logistic regression models were used for both the overall and metabotype-stratified analyses of dietary scores' association with T2DM, and multinomial probit models for their association with prediabetes.

RESULTS

Participants who had a diet with a higher FSAm-NPS dietary index (i.e., a lower diet quality) or a greater percentage of UPF consumption showed a positive association with T2DM. Stratified analyses demonstrated a strengthened association between UPF consumption and T2DM specifically in the metabolically most unfavorable metabotype (Odds Ratio, OR 1.92; 95% Confidence Interval, CI 1.35, 2.73). A diet with a higher FSAm-NPS dietary index was also positively associated with prediabetes (OR 1.19; 95% CI 1.04, 1.35).

CONCLUSION

Our study suggests different associations between poorer diet quality and T2DM across individuals exhibiting diverse metabotypes, pointing to the option for stratified dietary interventions in diabetes prevention.

Food additive emulsifiers and the risk of type 2 diabetes: analysis of data from the NutriNet-Santé prospective cohort study

BACKGROUND

Experimental studies have suggested potential detrimental effects of emulsifiers on gut microbiota, inflammation, and metabolic perturbations. We aimed to investigate the associations between exposures to food additive emulsifiers and the risk of type 2 diabetes in a large prospective cohort of French adults.

METHODS

We analysed data from 104 139 adults enrolled in the French NutriNet-Santé prospective cohort study from May 1, 2009, to April 26, 2023; 82 456 (79·2%) were female and the mean age was 42·7 years (SD 14·5). Dietary intakes were assessed with three 24 h dietary records collected over three non-consecutive days, every 6 months. Exposure to additive emulsifiers was evaluated through multiple food composition databases and ad-hoc laboratory assays. Associations between cumulative time-dependent exposures to food additive emulsifiers and the risk of type 2 diabetes were characterised with multivariable proportional hazards Cox models adjusted for known risk factors. The NutriNet-Santé study is registered at ClinicalTrials.gov (NCT03335644).

FINDINGS

Of 104 139 participants, 1056 were diagnosed with type 2 diabetes during follow-up (mean follow-up duration 6·8 years [SD 3·7]). Intakes of the following emulsifiers were associated with an increased risk of type 2 diabetes: total carrageenans (hazard ratio [HR] 1·03 [95% CI 1·01-1·05] per increment of 100 mg per day, p<0·0001), carrageenans gum (E407; HR 1·03 [1·01-1·05] per increment of 100 mg per day, p<0·0001), tripotassium phosphate (E340; HR 1·15 [1·02-1·31] per increment of 500 mg per day, p=0·023), acetyl tartaric acid esters of monoglycerides and diglycerides of fatty acids (E472e; HR 1·04 [1·00-1·08] per increment of 100 mg per day, p=0·042), sodium citrate (E331; HR 1·04 [1·01-1·07] per increment of 500 mg per day, p=0·0080), guar gum (E412; HR 1·11 [1·06-1·17] per increment of 500 mg per day, p<0·0001), gum arabic (E414; HR 1·03 [1·01-1·05] per increment of 1000 mg per day, p=0·013), and xanthan gum (E415, HR 1·08 [1·02-1·14] per increment of 500 mg per day, p=0·013).

INTERPRETATION

We found direct associations between the risk of type 2 diabetes and exposures to various food additive emulsifiers widely used in industrial foods, in a large prospective cohort of French adults. Further research is needed to prompt re-evaluation of regulations governing the use of additive emulsifiers in the food industry for better consumer protection.

FUNDING

European Research Council, French National Cancer Institute, French Ministry of Health, IdEx Université de Paris, and Bettencourt-Schueller Foundation.

Association of Ultraprocessed Food Consumption with Risk of Cardiovascular Disease Among Individuals with Type 2 Diabetes: Findings from the UK Biobank

SCOPE

Among patients with diabetes, who have modified nutritional behavior and a higher risk of cardiovascular disease (CVD), the influence of ultraprocessed foods (UPFs) on CVD remains unknown. The study aims to evaluate the association between UPF intake and the risk of CVD among individuals with type 2 diabetes (T2D) and further examine the potential biological pathways linking the association.

METHODS AND RESULTS

This study includes 5405 participants with T2D who provided at least one 24-h dietary recall from the UK Biobank study. In the fully adjusted models, a 10% increase in the proportion of UPFs is associated with higher hazards of overall CVD (hazard ratio [HR]: 1.10; 95% confidence interval [CI]: 1.04, 1.15), coronary heart disease (HR: 1.10; 95% CI: 1.04, 1.16), heart failure (HR: 1.14; 95% CI: 1.05, 1.25), but not stroke (HR: 1.01; 95% CI: 0.90, 1.12). Cystatin C, high-density lipoprotein cholesterol (HDL-C), apolipoprotein A, C-reactive protein, and body mass index collectively explain 26.9% (12.8%, 48.5%) of the association between UPF intake and the risk of overall CVD.

CONCLUSION

Higher UPF intakes are associated with increased hazards of CVD among individuals with T2D, and the association is partly mediated through worsening biomarkers of renal function, lipid metabolism, inflammation, and body weight.

Consumption of in natura and ultra-processed foods in adults: an analysis of social, metabolic, and lifestyle determinants

OBJECTIVE

To assess the social, metabolic, and lifestyle determinants of consumption of fruits, vegetables, and greens (FVG) and ultra-processed food (ULT) in adults from Pernambuco.

METHODS

Cross-sectional and analytical study, conducted in 2015/2016. In addition to sociodemographic variables, the determinants of lifestyle were level of physical activity, alcohol consumption, tobacco use, and metabolic variables were self-reported hypertension, blood glucose, and Body Mass Index (BMI). Consumption was measured by the Food Frequency Questionnaire, then created the Frequency of Consumption Index (SFI) of the mean intake of ULT and FVG foods. The indices of FVG and ULT consumption were transformed into quartiles and these variables were included in the multinomial logistic regression, considering their determinants when p<0.05.

RESULTS

The sample was representative of the state, with 1,067 people being interviewed, whose intake of ULT was higher than that of FVG in the lowest and highest quartile of the consumption index. Consumption of fruit and vegetables was higher in higher consumption of alcoholic beverages (p=0.031) and BMI>25 kg/m2 (p=0.047); and lower in the lowest income (p=0.001). ULT intake was higher in young adults (p=0.005), lower income (p=0.044), and controlled blood glucose (p=0.021). Rural areas were 52% less exposed to medium-high ULT consumption (p<0.006).

CONCLUSION

Higher rate of ULT consumption in relation to fresh foods, with income as a common determinant, inversely associated with ULT intake and directly related to FVG, which demands structuring policies.

Ultra-processed foods - a scoping review for Nordic Nutrition Recommendations 2023

Ultra-processed foods (UPFs) are increasingly consumed worldwide and have been linked to several chronic diseases. This paper aims to describe the totality of the available evidence regarding UPFs in relation to health-related outcomes as a basis for setting food-based dietary guidelines for the Nordic Nutrition Recommendations 2023. Systematic literature searches were conducted to identify systematic reviews, meta-analyses, randomized controlled trials (RCTs), and prospective cohort studies examining the association between UPF intake and non-communicable diseases or mortality. A total of 12 systematic reviews (including five meta-analyses) and 44 original research studies (43 prospective cohort studies and one RCT) were included. All original research studies were deemed to be of good methodological quality. The current evidence supports that greater consumption of UPFs is associated with weight gain and increased risk of obesity, cardiovascular disease, type 2 diabetes, and all-cause mortality. The available literature also supports an association between UPFs and hypertension, cancer, and depression; however, the limited number of studies and subjects investigated preclude strong conclusions. Due to the highly diverse nature of UPFs, additional studies are warranted, with special emphasis on disentangling mediating mechanisms, whether nutritional or non-nutrient based. Nevertheless, the available evidence regarding UPFs in relation to weight gain, CVD, type 2 diabetes, and all-cause mortality is considered strong enough to support dietary recommendations to limit their consumption.

Ultra-processed foods and incident cardiovascular disease and hypertension in middle-aged women

PURPOSE

Ultra-processed food (UPF) intake has increased in recent decades, yet limited knowledge of long-term effects on cardiovascular health persists and sex-specific data is scant. We determined the association of UPF intake with incident cardiovascular disease (CVD) and/or hypertension in a population-based cohort of women.

METHODS

In the Australian Longitudinal Study on Women's Health, women aged 50-55 years were prospectively followed (2001-2016). UPFs were identified using NOVA classification and contribution of these foods to total dietary intake by weight was estimated. Primary endpoint was incident CVD (self-reported heart disease/stroke). Secondary endpoints were self-reported hypertension, all-cause mortality, type 2 diabetes mellitus, and/or obesity. Logistic regression models assessed associations between UPF intake and incident CVD, adjusting for socio-demographic, medical comorbidities, and dietary variables.

RESULTS

We included 10,006 women (mean age 52.5 ± 1.5; mean UPF intake 26.6 ± 10.2% of total dietary intake), with 1038 (10.8%) incident CVD, 471 (4.7%) deaths, and 4204 (43.8%) hypertension cases over 15 years of follow-up. In multivariable-adjusted models, the highest [mean 42.0% total dietary intake] versus the lowest [mean 14.2% total dietary intake] quintile of UPF intake was associated with higher incident hypertension [odds ratio (OR) 1.39, 95% confidence interval (CI) 1.10-1.74; p = 0.005] with a linear trend (ptrend = 0.02), but not incident CVD [OR 1.22, 95% CI 0.92-1.61; p = 0.16] or all-cause mortality (OR 0.80, 95% CI 0.54-1.20; p = 0.28). Similar results were found after multiple imputations for missing values.

CONCLUSION

In women, higher UPF intake was associated with increased hypertension, but not incident CVD. These findings may support minimising UPFs within a healthy diet for women.

Increasing Health Behaviors and Psychological Measures with an Adapted Version of the ACCELERATION Program

BACKGROUND

Recent evidence highlights the importance of interventions tackling physical inactivity and unhealthy eating in lower-income countries. The purpose of this study was to examine the effectiveness of the Canadian ACCELERATION lifestyle program adapted to Brazilians. The main outcomes of the study were changes in the engagement in weekly moderate-to-vigorous physical activity (MVPA) and in the daily consumption of fruits/vegetables.

METHODS

The adapted intervention consisted of a 12-week quasi-randomized controlled trial delivered through email. The data from the original Canadian experimental group (CE, n = 194) and the two groups of Portuguese-speaking Brazilians living in Canada in the adapted program - Brazilian experimental (BE, n = 41) and Brazilian control (BC, n = 35) - were assessed at baseline and post-intervention. The data of the 270 participants were analyzed using two-way repeated measures factorial ANCOVA (group x time) for ratio variables and Chi-square and McNemar tests for the categorical variables.

RESULTS

The BE group had a significant increase in MVPA (mean difference, 95% CI: 86.3, 38.1-134.4 min/week) and fruits/vegetables intake (3.2, 1.4-5.1 servings/day) after the intervention (both p < 0.001). The proportion of participants engaging in ≥ 150 min of MVPA increased from 4.9% to 73.2%, while adoption of a healthy diet increased from 4.9% to 53.7% in the BE group (both p < 0.001). The CE group also improved on these variables (p < 0.05) with no difference vs the BE group (p > 0.05), whereas BC did not show changes (p > 0.05).

CONCLUSION

The Brazilian version of the ACCELERATION program effectively promoted positive health behavior changes in its participants and has the potential to contribute to the fight against risk factors for chronic diseases in Brazilians.

Ultra-processed food and non-communicable diseases in the United Kingdom: A narrative review and thematic synthesis of literature

The social and economic constructs of the United Kingdom (UK) provide a fertile food environment for the dramatic expansion in the ultra-processed food (UPF) market, driving increased UPF consumption. This has coincided with the significant increase in the incidence and prevalence of non-communicable diseases (NCDs) such as obesity, type 2 diabetes, cardiovascular disease, and cancer, with an inherent impact on morbidity and mortality. Our review aims to assess the current epidemiological and public health trends in the United Kingdom, specifically examining consumption of UPFs and subsequent development of NCDs, summarizing existing meta-analytical and experimental approaches. First, we address important socioeconomic and psychosocial domains that may contribute to increased availability and consumption of UPF. Additionally, we explore the putative mechanistic basis for the association between UPFs and NCDs: partly attributable to their energy density, the macro- and micronutrient composition (including high refined carbohydrate, saturated, and trans fats composition, in addition to low fiber and protein content), and artificially engineered additives and other compounds that adversely affect health in inadequately researched pathophysiological pathways. This review highlights the importance of promoting minimally processed diets to both clinical and political decision makers.

Enhancing the palatability of cultivated meat

Cultivated meat (CM) has transitioned from a futuristic concept to a present reality, with select products approved for consumption and sale in Singapore, Israel, and the USA. This evolution has emphasized scalable, cost-effective, and sustainable production, as well as navigation of regulatory pathways. As CM develops, a crucial challenge lies in delivering products that are highly appealing to consumers. Central to this will be refining CM palatability, a term encompassing food's taste, aroma, texture, tenderness, juiciness, and color. We explore the scientific and engineering approaches to producing palatable CM, including cell-line selection, cell differentiation, and post-processing techniques. This includes a discussion of the structural and compositional properties of meat that are intrinsically coupled to palatability.

Higher ultra-processed food intake is associated with an increased incidence risk of cardiovascular disease: the Tehran lipid and glucose study

BACKGROUND

Cardiovascular disease (CVD) is a major cause of death worldwide, although limited data are currently available regarding the impact of consuming ultra-processed food (UPF) on its incidence. Given the increased consumption of UPF in Iran, we aimed to investigate the association between UPF intake and CVD risk.

METHODS

Individuals without CVD (n = 2050) aged ≥ 30 years old were recruited from the Tehran Lipid and Glucose Study (TLGS). Dietary data were collected using a validated food frequency questionnaire (FFQ) and UPF intakes were assessed based on the Nova food classification. Multivariable Cox proportional hazard models adjusted for potential confounders were used to estimate the hazard ratio (HR) and 95% confidence intervals (95% CI) for the risk of CVD across tertiles of UPF intake.

RESULTS

A 10.1% incidence of CVD occurred over a median follow-up of 10.6 years, with a 22% increase in CVD risk per each 50 g/day UPF intake. Participants with the highest intake of UPF had a 68% greater incidence of CVD compared to those with the lowest intake (HR = 1.68, 95% CI=1.14-2.48) after controlling for potential confounders. Regarding sub-groups of UPF, participants in the 3rd tertile compared to the reference had a significantly increased risk of CVD (HR = 1.56, 95% CI=1.04-2.34). Nevertheless, intake of bread, fast food, sweetened beverages, sweets and desserts, high-fat dairy products, and other UPFs were not associated with greater CVD risk.

CONCLUSION

Our findings support the hypothesis that the incidence of CVD is enhanced with the higher consumption of UPF in a representative sample of the Iranian population.

Food additive emulsifiers and cancer risk: Results from the French prospective NutriNet-Santé cohort

BACKGROUND

Emulsifiers are widely used food additives in industrially processed foods to improve texture and enhance shelf-life. Experimental research suggests deleterious effects of emulsifiers on the intestinal microbiota and the metabolome, leading to chronic inflammation and increasing susceptibility to carcinogenesis. However, human epidemiological evidence investigating their association with cancer is nonexistent. This study aimed to assess associations between food additive emulsifiers and cancer risk in a large population-based prospective cohort.

METHODS AND FINDINGS

This study included 92,000 adults of the French NutriNet-Santé cohort without prevalent cancer at enrolment (44.5 y [SD: 14.5], 78.8% female, 2009 to 2021). They were followed for an average of 6.7 years [SD: 2.2]. Food additive emulsifier intakes were estimated for participants who provided at least 3 repeated 24-h dietary records linked to comprehensive, brand-specific food composition databases on food additives. Multivariable Cox regressions were conducted to estimate associations between emulsifiers and cancer incidence. Overall, 2,604 incident cancer cases were diagnosed during follow-up (including 750 breast, 322 prostate, and 207 colorectal cancers). Higher intakes of mono- and diglycerides of fatty acids (FAs) (E471) were associated with higher risks of overall cancer (HR high vs. low category = 1.15; 95% CI [1.04, 1.27], p-trend = 0.01), breast cancer (HR = 1.24; 95% CI [1.03, 1.51], p-trend = 0.04), and prostate cancer (HR = 1.46; 95% CI [1.09, 1.97], p-trend = 0.02). In addition, associations with breast cancer risk were observed for higher intakes of total carrageenans (E407 and E407a) (HR = 1.32; 95% CI [1.09, 1.60], p-trend = 0.009) and carrageenan (E407) (HR = 1.28; 95% CI [1.06, 1.56], p-trend = 0.01). No association was detected between any of the emulsifiers and colorectal cancer risk. Several associations with other emulsifiers were observed but were not robust throughout sensitivity analyses. Main limitations include possible exposure measurement errors in emulsifiers intake and potential residual confounding linked to the observational design.

CONCLUSIONS

In this large prospective cohort, we observed associations between higher intakes of carrageenans and mono- and diglycerides of fatty acids with overall, breast and prostate cancer risk. These results need replication in other populations. They provide new epidemiological evidence on the role of emulsifiers in cancer risk.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03335644.

How and why ultra-processed foods harm human health

The analysis of food using a perspective centred on nutrients seems inadequate for understanding the dietary transition and its impact on the growth of obesity and chronic diseases. Industrial food processing is now proposed as the key to explain the relationship between food and health. The NOVA food classification considers the degree and the purpose of food processing, which includes physical, biological and chemical processes used after foods are separated from nature, and before being consumed or prepared as dishes and meals. NOVA has four food groups: (1) unprocessed and minimally processed foods; (2) processed culinary ingredients; (3) processed foods and (4) ultra-processed foods, which are formulations made mostly or entirely from substances derived from group 1 foods and additives, with little if any intact group 1 food. Many investigations linking high ultra-processed food consumption with deterioration of diets and adverse health outcomes are reinforced by prospective studies, systematic reviews and meta-analyses. There are various plausible explanations of why diets high in ultra-processed foods are harmful. Their production and consumption continue to rise worldwide. Efficient and effective public policies and actions that reduce production and consumption of ultra-processed products are needed, to protect human health now and in future.

Ultra-processed food consumption and metabolic disease risk: an umbrella review of systematic reviews with meta-analyses of observational studies

Background and aims

There is an ongoing debate on whether to advocate reducing ultra-processed food (UPF) in dietary guidelines to control metabolic disease (such as obesity and type 2 diabetes mellitus [T2DM]). We aimed to summarize the evidence from systematic reviews with meta-analyses between UPF consumption and metabolic diseases risk, assess the credibility, and verify the robustness of these associations.

Methods

We systematically searched PubMed, Web of Science, Embase, and Cochrane Library databases from their inception to July 15, 2023, to identify relevant systematic reviews with meta-analyses. We used the random-effects model to evaluate the summary effect size, along with 95% confidence interval and prediction interval. We also assessed heterogeneity, evidence of small-study effects and excess significance bias, and categorized the credibility of each association based on quantitative umbrella review criteria. Additionally, we conducted subgroup and sensitivity analyses to assess the robustness of associations based on continents, study design, dietary assessment methods, definition methods of UPF, population, and units of UPF consumption.

Results

Overall, 6 systematic reviews with 13 meta-analyses were included. Three (23.08%) meta-analyses were classified as highly suggestive evidence for meeting the criteria that associations were significant at p < 10-6, had more than 1,000 cases, and presented the largest study with significance at p < 0.05. Among them, the highest UPF consumption quantile was associated with an increased risk of obesity (OR = 1.55, 95% CI: 1.36-1.77) when compared with the lowest UPF consumption quantile. The highest UPF consumption quantile was associated with an increased risk of T2DM (RR = 1.40, 95% CI: 1.23-1.59) when compared with the lowest UPF consumption quantile, and a 10% increase in UPF consumption (% g/d) was associated with an increased risk of T2DM (RR = 1.12, 95% CI: 1.10-1.13). Meanwhile, the robustness of these associations was verified by a series of subgroup and sensitivity analyses.

Conclusion

UPF consumption may be a risk factor for several metabolic diseases. However, well-designed studies are still needed to verify our findings in the future.

Ultra-Processed Foods and Human Health: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

Evidence of associations between ultra-processed foods (UPF) and increased risk of cardiovascular disease is emerging, but it is unclear how much this is influenced by the methodology used to assess the UPF intake or by the level of consumption. We conducted a meta-analysis to evaluate 1) the association between UPF consumption and risk of diabetes, hypertension, dyslipidemia, and obesity, using prospective cohort studies; 2) the differential associations depending on the methodology used to assess UPF intake and the level of UPF consumption and 3) the quality of evidence using the NutriGrade scoring system. A systematic literature search was conducted in PubMed/MEDLINE, ISI Web of Science, and Scopus through 1 April, 2023, on studies conducted in humans providing data for the highest compared with the lowest UPF consumption categories. Summary relative ratios (RRs) and 95% confidence intervals (95% CI) were estimated using a random-effects model. Out of 4522 articles retrieved from the literature search, 25 reports met the criteria for inclusion in the meta-analysis, 7 for diabetes, 5 for hypertension, 3 for dyslipidemia, and 13 for obesity. A consistently positive association between high UPF intake and increased risk of developing diabetes (37%), hypertension (32%), hypertriglyceridemia (47%), low HDL cholesterol concentration (43%), and obesity (32%) was observed, even if the quality of evidence was not satisfying. However, these risks varied significantly depending on the methodology used to assess UPF consumption, with a difference of more than 50% between the methods. Based on the level of intake, we did not observe significant differences in the results. These findings show that UPF consumption is associated with higher risk of diabetes, hypertension, dyslipidemia, and obesity, but the level of risk consistently changes depending on the methodology used to assess UPF intake. Therefore, caution should be used when interpreting and extrapolating the results.

Ultra-processed food consumption and non-alcoholic fatty liver disease, metabolic syndrome and insulin resistance: A systematic review

Background

High ultra-processed food (UPF) consumption is associated with the development of various diet-related non-communicable diseases, especially obesity and type 2 diabetes. The present study aimed to systematically review the association between UPF consumption and non-alcoholic fatty liver disease (NAFLD) and its leading risk factors; metabolic syndrome (MetS) and insulin resistance (IR).

Methods

A comprehensive search was conducted in PubMed, Scopus, Embase, Web of Science, CINAHL, and Cochrane (March 2023), and references of the identified articles were checked. The search keywords were defined through an exploratory investigation in addition to MeSH and similarly controlled vocabulary thesauruses. Observational and interventional studies were included. Studies that focused only on specific groups of processed foods or overlapping dietary patterns were excluded. The quality assessment was conducted using the Joanna Briggs Institute's critical appraisal tools for observational studies and Cochrane's risk of bias 2 tool for randomized-control trials. A narrative synthesis was employed to report the results.

Results

Fifteen studies were included, with a total of 52,885 participants, one randomized-controlled trial, and fourteen observational studies (nine cross-sectional and five prospective). The review has shown a significant association between UPF consumption and NAFLD in three studies out of six, MetS in five out of eight, and IR in one out of three. All large-scale prospective cohorts that studied NAFLD or MetS outcomes demonstrated a positive association. In contrast, studies that did not demonstrate significant associations were mostly cross-sectional and small. The evidence for an association with IR was insufficient and conflicting.

Conclusion

The included studies are few, observational, and based upon self-reported dietary assessment tools. However, current evidence indicates that UPF is not only associated with obesity and type 2 diabetes but may also be a risk factor for NAFLD and MetS. UPF is a worldwide concern deserving further longitudinal research.

Impact and implications

Overconsumption of ultra-processed food (UPF) may lead to the development of obesity and type 2 diabetes, but the association with non-alcoholic fatty liver disease (NAFLD) is not well established. The present systematic review shows that UPF may be associated with NAFLD, although more large prospective studies are needed. These findings emphasize the importance of minimizing the consumption of UPF to prevent NAFLD and other metabolic diseases among the general adult population. This systematic review and further prospective studies, epidemiological or interventional, can help physicians provide patients with evidence-based nutritional recommendations and will support policymakers in restricting the marketing of UPF as well as promoting affordable, healthy, and minimally processed foods.

Higher ultra-processed food intake is associated with adverse liver outcomes: a prospective cohort study of UK Biobank participants

BACKGROUND

Ultra-processed food (UPF) intake has been positively associated with obesity and diabetes. The relationship between UPF intake and liver health has been scarcely studied.

OBJECTIVES

We aimed to evaluate the association of UPF intake with risk of adverse liver outcomes including nonalcoholic fatty liver disease (NAFLD), liver fibrosis/cirrhosis, liver cancer, severe liver disease, and serum biomarkers of liver health.

METHODS

A total of 173,889 participants aged 40 to 69 y from the UK Biobank were included. UPF intake was defined using 24-h dietary recalls and NOVA classification. Liver outcome data were obtained from cancer registry, in-hospital records, and death registries. Serum biomarkers were measured at baseline. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between UPF and adverse liver outcomes adjusting for demographics, lifestyle factors, body mass index, and diabetes. We used multinomial logistic regression to evaluate associations between UPF and liver function biomarkers.

RESULTS

After a median follow-up of 8.9 y, we documented 1108 NAFLD, 350 liver fibrosis/cirrhosis, 134 liver cancer, and 550 severe liver disease cases. Higher UPF intake was associated with increased risk of NAFLD (HRQuartile 4 vs. Quartile 1: 1.43; 95% CI: 1.21, 1.70; Ptrend < 0.001), liver fibrosis/cirrhosis (HR: 1.18; 95% CI: 0.87, 1.59; Ptrend = 0.009), and severe liver disease (HR: 1.50; 95% CI: 1.19, 1.90; Ptrend < 0.001) but not with liver cancer (HR: 1.00; 95% CI: 0.63, 1.58; Ptrend = 0.88). Higher UPF intake was associated with elevated levels of C-reactive protein, alkaline phosphatase, aspartate aminotransferase, γ-glutamyltransferase, and triglycerides and lower cholesterols (all Ptrend < 0.001).

CONCLUSIONS

Higher UPF intake is associated with an increased risk of NAFLD, liver fibrosis and cirrhosis, and severe liver disease and adverse levels of multiple clinical biomarkers, suggesting the potential importance of reducing UPF intake to improve liver health.

Ultra-processed Food Intake and Risk of Type 2 Diabetes in Korean Adults

BACKGROUND

Several studies from the United States and European countries reported a positive association between ultra-processed food intake and diabetes risk. However, little is known about the association in Asian populations. It is also unknown about the individual ultra-processed food items that are most unfavorably associated with diabetes risk.

OBJECTIVE

We examined the associations of ultra-processed food intake (combined, as well as individual ultra-processed food items) with the risk of type 2 diabetes.

METHODS

This prospective analysis included 7438 participants aged 40-69 y from the Korean Genome and Epidemiology Study Ansan-Ansung cohort. Dietary intake was assessed at baseline using a 103-item semiquantitative food-frequency questionnaire. Ultra-processed foods were classified using the Nova definition. Incident type 2 diabetes cases were identified via follow-up interviews and health examination. Multivariable Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for potential confounders.

RESULTS

During the follow-up (2001-2019; median: 15 y), a total of 1187 type 2 diabetes cases were identified. Compared with the lowest quartile of ultra-processed food intake, the highest quartile was positively associated with diabetes risk [HR (95% CI) = 1.34 (1.13, 1.59), P-trend = 0.002]. The association did not change after additional adjustment for diet quality or BMI. Among individual ultra-processed food items, a higher consumption of ham/sausage [per 1% increase in the weight ratio: HR (95% CI) = 1.40 (1.05, 1.86)], instant noodles [1.07 (1.02, 1.11)], ice cream [1.08 (1.03, 1.13)], and carbonated beverages [1.02 (1.00, 1.04)] were associated with an increased risk of type 2 diabetes, whereas a higher intake of candy/chocolate was associated with a decreased risk [0.78 (0.62, 0.99)].

CONCLUSIONS

Our data suggest that the high intake of ultra-processed foods, particularly ham/sausage, instant noodles, ice cream, and carbonated beverages, is associated with an increased risk of type 2 diabetes in Korean adults.

Association between ultra-processed foods and recurrence of depressive symptoms: the Whitehall II cohort study

OBJECTIVES

To examine the association between high intakes of ultra-processed foods (UPF) and recurrence of depressive symptoms (DepS) in a Western non-Mediterranean country and its contribution to the overall diet-depression relationship.

METHODS

Analyses were carried out on British participants from the Whitehall II cohort. Present analyses were restricted to white participants N = 4554 (74% men, mean age = 61; SD = 5.9). UPF consumption was estimated from a 127-item food frequency questionnaire using the NOVA classification, and cumulative average of UPF intakes (g/day) over 11 years of exposure (1991/1994-2002/2004) was computed. Recurrent DepS after measurement of UPF was defined as having two or more episodes of DepS (the Center for Epidemiologic Studies Depression Scale (CES-D) score ≥ 16 or antidepressants use) during four phases of follow-up (2002/2004-2015/2016).

RESULTS

Over the follow-up, 588 (12.9%) cases of recurrent DepS were observed. After adjusting for socio-demographic factors, health behaviours and health status, participants in top quintile of UPF intakes [mean 33% of total daily intakes in grams] had 31% higher odds of recurrent DepS (odds ratio 1.31; 95% CI 1.04-1.64) compared to participants in the four lowest quintiles of UPF [mean 18.1% of total daily intakes in grams]. Additional analyses showed that associations between adherence to several diet quality measures and recurrent DepS were partially attenuated (17-27%) by UPF intakes.

CONCLUSION

In this British population, high intakes of ultra-processed foods were associated with increased odds of recurrent depressive symptoms and contributed to the overall diet quality-depressive symptoms association.

Synthesis of Effect Sizes on Dose Response from Ultra-Processed Food Consumption against Various Noncommunicable Diseases

Ultra-processed foods (UPFs), according to the NOVA classification food system, are food products that are processed using advanced processing technology, which improves palatability and sensory quality. However, UPFs increase the daily intake of energy, sodium, sugar, and total fat (including saturated fat), and decrease the intake of fiber. This might trigger overweight and obesity, the initial stages of noncommunicable diseases (NCDs). However, the effect of UPF consumption on NCDs remains under debate. This study aimed to synthesize the effect size of UPF dose response on various NCDs by using a meta-analysis method. The main output was a hazard ratio (HR) and a 95% confidence interval (CI). Using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) selection guidelines, 18 research articles were chosen for further effect size synthesis. The results showed that UPF consumption significantly increased the daily intake of carbohydrates, added sugar, saturated fat, sodium, energy, cholesterol, and total fat; increases of 49.64, 40.78, 30.00, 27.76, 26.67, 25.69, and 15.77%, respectively, were observed. Moreover, with UPF consumption, the fiber intake was way below the daily dietary recommendation (DR), at -38.55%. Further, a 10% increment in UPF consumption significantly affects diabetes, cardiovascular diseases, obesity, and cancer (HR ± 95% CI: 1.115 ± 0.044, 1.096 ± 0.053, 1.068 ± 0.050, and 1.020 ± 0.020, respectively). Thus, limiting daily UPF consumption could help prevent obesity and various NCDs.

Association between ultra-processed food consumption and the incidence of type 2 diabetes: the ELSA-Brasil cohort

BACKGROUND

Ultra-processed food (UPF) consumption increases the risk of type 2 diabetes in various high-income countries, with some variation in the magnitude across studies. Our objective was to investigate the association of UPF consumption and specific subgroups with incident type 2 diabetes in Brazilian adults.

METHODS

The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a multicenter cohort study of 15,105 adults (35-74 years) enrolled in public institutions in Brazil (2008-2010). We followed participants with two clinic visits (2012-2014; 2017-2019) and annual telephone surveillance. After excluding those with diabetes at baseline, who died or were lost in the follow-up, with missing data, with implausible energy food intake, or reporting bariatric surgery, there were 10,202 participants. We used the NOVA classification to assess UPF consumption based on a food frequency questionnaire. We defined type 2 diabetes by self-report, medication use, or comprehensive laboratory tests. We estimated relative risks (RR) and 95% confidence intervals (95% CI) using robust Poisson regression.

RESULTS

Median UPF consumption was 372 g/day. Over 8.2 (0.7) years of follow-up, we detected 1799 (17.6%) incident cases. After adjustment for socio-demographics, family history of diabetes, and behavioral risk factors, comparing the fourth (≥ 566 g/day) with the first (< 236 g/day) quartile of UPF distribution, RR was 1.24 (1.10-1.39); every 150 g/day increments in UPF consumption resulted in a RR of 1.05 (1.03-1.07). Reclassifying natural beverages with added sweeteners as UPF increased risk (RR 1.40; 1.25-1.58). Among UPF subgroupings, consumption of processed meats and sweetened beverages increased diabetes risk, while yogurt and dairy sweets decreased the risk (p < 0.05).

CONCLUSIONS

UPF consumption increased the incidence of type 2 diabetes in Brazilian adults, with heterogeneity across specific food items. These findings add to previous evidence for the role of UPFs in the development of diabetes and other chronic diseases, supporting recommendations to avoid their intake in diabetes prevention and management.

Perspective: A Research Roadmap about Ultra-Processed Foods and Human Health for the United States Food System: Proceedings from an Interdisciplinary, Multi-Stakeholder Workshop

Our objective was to convene interdisciplinary experts from government, academia, and industry to develop a Research Roadmap to identify research priorities about processed food intake and risk for obesity and cardiometabolic diseases (CMD) among United States populations. We convened attendees at various career stages with diverse viewpoints in the field. We held a "Food Processing Primer" to build foundational knowledge of how and why foods are processed, followed by presentations about how processed foods may affect energy intake, obesity, and CMD risk. Breakout groups discussed potential mechanistic and confounding explanations for associations between processed foods and obesity and CMD risk. Facilitators created research questions (RQs) based on key themes from discussions. Different breakout groups convened to discuss what is known and unknown for each RQ and to develop sub-RQs to address gaps. Workshop attendees focused on ultra-processed foods (UPFs; Nova Group 4) because the preponderance of evidence is based on this classification system. Yet, heterogeneity and subjectivity in UPF classification was a challenge for RQ development. The 6 RQs were: 1) What objective methods or measures could further categorize UPFs, considering food processing, formulation, and the interaction of the two? 2) How can exposure assessment of UPF intake be improved? 3) Does UPF intake influence risk for obesity or CMDs, independent of diet quality? 4) What, if any, attributes of UPFs influence ingestive behavior and contribute to excess energy intake? 5) What, if any, attributes of UPFs contribute to clinically meaningful metabolic responses? 6) What, if any, external environmental factors lead people to consume high amounts of UPFs? Uncertainty and complexity around UPF intake warrant further complementary and interdisciplinary causal, mechanistic, and methodological research related to obesity and CMD risk to understand the utility of applying classification by degree of processing to foods in the United States.

Association between a mediterranean lifestyle and Type 2 diabetes incidence: a prospective UK biobank study

BACKGROUND

There is mounting evidence that the Mediterranean diet prevents type 2 diabetes, but little is known about the role of Mediterranean lifestyles other than diet and among non-Mediterranean populations. This work aimed to examine the association between a comprehensive Mediterranean-type lifestyle and type 2 diabetes incidence in a British adult population.

METHODS

We used data from 112,493 individuals free of cardiovascular disease and type 2 diabetes mellitus, aged 40-69 years, from the UK Biobank cohort, who were followed from 2009 to 2010 to 2021. The Mediterranean lifestyle was assessed through the 25-item MEDLIFE index, which comprises three blocks: (a) "Mediterranean food consumption", (b) "Mediterranean dietary habits", (c) "Physical activity, rest, social habits, and conviviality". Diabetes incidence was obtained from clinical records. Cox proportional-hazards regression models were used to analyze associations and adjusted for the main potential confounders.

RESULTS

After a median follow-up of 9.4 years, 2,724 cases of type 2 diabetes were ascertained. Compared to the first quartile of MEDLIFE adherence, the hazard ratios (95% confidence interval) for increasing quartiles of adherence were 0.90 (0.82-0.99), 0.80 (0.72-0.89) and 0.70 (0.62-0.79) (p-trend < 0.001). All three blocks of MEDLIFE were independently associated with lower risk of diabetes.

CONCLUSIONS

Higher adherence to the MEDLIFE index was associated with lower risk of type 2 diabetes in the UK Biobank. A Mediterranean-type lifestyle, culturally adapted to non-Mediterranean populations, could help prevent diabetes.

The association between ultra-processed foods and conventional markers of cardiovascular risk in an adult Iranian population

BACKGROUND AND AIMS

According to the NOVA classification system, ultra-processed foods result from extensive industrial processing and use ingredients derived from food and non-food products, which can negatively impact on cardiovascular disease risk factors. Despite this, few studies have investigated UPFs in Middle Eastern populations regardless of high consumption in this region.

METHODS AND RESULTS

This cross-sectional study was conducted on data from the Prospective Epidemiological Research Studies in Iran Kharemeh cohort (n = 6611). Food frequency questionnaires were assessed and the ratio of total UPFs energy/total energy intake was calculated. Data was categorized into tertiles of UPF consumption using the NOVA classification system. Kruskal-Wallis tests were used to assess differences in nutrient and food intakes between tertiles and logistic regression analysis was applied to assess the associations between UPFs and CVD risk factors. After adjustment for potential confounders the logistic regression analysis revealed significant positive relationships between intakes of UPFs and waist circumference (WC) (T2: OR; 1.34, 95% CI; 1.13-1.60 - T3: OR; 1.41, 95% CI; 1.18-1.69, P ˂0.001), low-density lipoprotein cholesterol (LDL-C) (T2: OR; 1.20, 95% CI; 1.05-1.37 - T3: OR; 1.27, 95% CI; 1.11-1.45, P ˂0.001), non-high-density lipoprotein cholesterol (non-HDL) (T2: OR; 1.21, 95% CI; 1.07-1.37 - T3: OR; 1.24, 95% CI; 1.10-1.41, P ˂0.001) and LDL-C to HDL-C ratio (T2: OR; 1.15, 95% CI; 1.02-1.31 - T3: OR; 1.21, 95% CI; 1.07-1.38, P = 0.002).

CONCLUSION

The consumption of UPFs was positively associated with WC and atherogenic blood lipids. However, increased intakes of fiber and unsaturated fats were also found in those consuming more UPFs, which was not expected. These findings offer insights into an understudied population and warrant further research.

Consumption of ultra-processed foods and all-cause and cause-specific mortality in the Southern Community Cohort Study

BACKGROUND & AIMS

Higher intake of ultra-processed foods (UPF) has been linked with higher risks of cancer, cardiovascular disease, and diabetes, as well as all-cause mortality. However, studies on UPF and cause-specific mortality remain limited, especially among disadvantaged populations. We aimed to examine associations of UPF intake with all-cause and cause-specific mortality among low-income Americans.

METHODS

In the Southern Community Cohort Study (SCCS), a prospective cohort of mostly low-income Black and White Americans, we included 77,060 participants who completed a food frequency questionnaire (FFQ) at baseline (2002-2009) and had at least 1 year follow-up. All 89 items in the FFQ were categorized using the Nova classification. UPF intake was calculated as % of daily foods intake by weight (grams). Cox regression was used to estimate HR (95% CI) for the association of UPF intake (quartile or per 10% increase) with total and cause-specific mortality (cancer, coronary heart disease [CHD], stroke, and diabetes) after adjusting for sociodemographics, lifestyles, and disease history.

RESULTS

Of 77,060 participants, 46,175 (59.9%) were women, 49,857 were Black (64.7%), and mean age was 52.4 (SD: 8.8) years at baseline. The mean intake of UPF was 41.0% (SD: 15.7%). UPF intake was inversely associated with Healthy Eating Index and intakes of fiber, minerals, and vitamins but positively associated with intakes of sugars and fats (all PFDR<0.0001). During an average follow-up of 12.2 years, we documented 17,895 total deaths, including 4267 from cancer, 2208 from CHD, 867 from stroke, and 997 from diabetes. In the fully adjusted model, higher UPF intake was not associated with all-cause, cancer, CHD, or stroke mortality but showed a significant association with increased diabetes mortality (HR [95% CI] = 1.32 [1.07, 1.62] for the highest versus lowest quartiles [>51.1% vs. <29.3%] and 1.09 [1.04, 1.15] per 10% increase). The adverse UPF-diabetes mortality association was noted regardless of sex, race, income, neighborhood deprivation, lifestyles, and cardiometabolic disease history, while particularly evident in participants with no more than high school education or a history of hypercholesterolemia (HR [95% CI] per 10% increase = 1.12 [1.05, 1.18] and 1.14 [1.07, 1.22], respectively; both Pinteraction<0.05).

CONCLUSIONS

Among predominantly low-income Black and White American adults, UPF intake was associated with increased diabetes mortality, especially for individuals with limited education or hypercholesterolemia. Our findings suggest the potential impact of increasing access and intake of un/minimally processed food to replace UPF on reducing diabetes-related mortality among populations facing socioeconomic and health disparities.

Ultraprocessed food consumption is associated with all-cause and cardiovascular mortality in participants with type 2 diabetes independent of diet quality: a prospective observational cohort study

BACKGROUND

Nutritional strategies for prevention and management of type 2 diabetes traditionally emphasize dietary patterns reflecting nutrient goals, but the health implications of ultraprocessed food (UPF) for patients with type 2 diabetes remain unknown.

OBJECTIVES

This study aimed to evaluate the association of UPF intake with all-cause and cardiovascular disease (CVD) mortality among participants with type 2 diabetes from the Moli-sani Study in Italy (enrollment 2005-2010).

METHODS

This was a prospective observational cohort study on 1065 individuals with type 2 diabetes at baseline, followed up for 11.6 y (median). Food intake was assessed by a 188-item food-frequency questionnaire. UPF was defined following the Nova classification and calculated as the ratio (weight ratio; %) between UPF (g/d) and total food eaten (g/d). Overall diet quality was assessed through the Mediterranean Diet Score (MDS). Multivariable-adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality.

RESULTS

The average UPF consumption was 7.4% (±5.0%). In multivariable-adjusted Cox analyses, greater UPF intake (Q4, ≥10.5% and ≥9% of total food eaten for females and males, respectively), as opposed to the lowest (Q1, UPF <4.7% and <3.7% for females and males, respectively), was associated with higher hazards of both all-cause (HR: 1.70; 95% CI: 1.25, 2.33) and CVD mortality (HR: 2.64; 95% CI: 1.59, 4.40); inclusion of the MDS into the model did not substantially alter the magnitude of these associations (HR: 1.64; 95% CI: 1.19, 2.25 and HR: 2.55; 95% CI: 1.53, 4.24 for all-cause and CVD mortality, respectively). A linear dose-response relationship of UPF intake with both all-cause and CVD mortality was also observed.

CONCLUSIONS

In participants with type 2 diabetes at study entry, higher UPF consumption was associated with reduced survival and higher CVD mortality rate, independent of diet quality. Besides prioritizing the adoption of a diet based on nutritional requirements, dietary guidelines for the management of type 2 diabetes should also recommend limiting UPF.

Food Processing and Risk of Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Several studies have been published on the association between food processing and risks of Crohn's disease (CD) and ulcerative colitis (UC), with some variability in results. We performed a systematic literature review and meta-analysis to study this association.

METHODS

From PubMed, Medline, and Embase until October 2022, we identified cohort studies that studied the association between food processing and the risk of CD or UC. Risk of bias of the included studies was assessed by the Newcastle-Ottawa scale. We computed pooled hazard ratios (HRs) and 95% confidence intervals (CIs) using random-effects meta-analysis based on estimates and standard errors.

RESULTS

A total of 1,068,425 participants were included (13,594,422 person-years) among 5 cohort studies published between 2020 and 2022. Four of the 5 included studies were scored as high quality. The average age of participants ranged from 43 to 56 years; 55%-83% were female. During follow-up, 916 participants developed CD, and 1934 developed UC. There was an increased risk for development of CD for participants with higher consumption of ultra-processed foods compared with those with lower consumption (HR, 1.71; 95% CI, 1.37-2.14; I2 = 0%) and a lower risk of CD for participants with higher consumption of unprocessed/minimally processed foods compared with those with lower consumption (HR, 0.71; 95% CI, 0.53-0.94; I2 = 11%). There was no association between risk of UC and ultra-processed foods (HR, 1.17; 95% CI, 0.86-1.61; I2 = 74%) or unprocessed/minimally processed foods (HR, 0.84; 95% CI, 0.68-1.02; I2 = 0%).

CONCLUSIONS

Higher ultra-processed food and lower unprocessed/minimally processed food intakes are associated with higher risk of CD but not UC.

Oxidative Stress and Inflammatory Biomarkers Are Related to High Intake of Ultra-Processed Food in Old Adults with Metabolic Syndrome

In the last few decades the consumption of ultra-processed foods (UPFs) worldwide has substantially augmented. Increasing evidence suggests that high UPF consumption is associated with an increase in non-communicable diseases, being overweight, and obesity. The aim of this study was to assess how UPF consumption affects oxidative and inflammatory status in the plasma, neutrophils, and urine of old adults with metabolic syndrome. Participants (n = 92) were classified into two groups according to UPF consumption. Dietary intakes were measured by a validated semi-quantitative 143-item food frequency questionnaire and UPF consumption was determined according to the NOVA classification system. Low UPF consumers showed higher adherence to the Mediterranean diet than high UPF consumers. A high intake of fiber and a high concentration of polyphenols in urine were also observed in subjects with low UPF consumption. Despite the absence of differences in biochemical profile, oxidative and inflammatory biomarkers showed some significant changes. Catalase and superoxide dismutase activities were lower in high UPF consumers, whereas myeloperoxidase activity was higher. ROS production in neutrophils stimulated with zymosan was higher in high UPF consumers than in low UPF consumers. Biomarkers such as xanthine oxidase, tumor necrosis factor α (TNFα), interleukin (IL)-6, IL-15, and leptin levels were higher in participants with high intake of UPF. No differences were found in malondialdehyde and other inflammatory cytokines. The current study evidenced that MetS participants with high UPF consumption have a more pro-oxidant and inflammatory profile than those with low UPF consumption, despite showing similar blood biochemical profiles.

Association between ultra-processed food intake and risk of colorectal cancer: a systematic review and meta-analysis

Background

Although some epidemiological studies have shown a positive relationship between high intake of ultra-processed food (UPF) and risk of colorectal cancer (CRC), the results remain inconsistent. Therefore, we conducted this systematic review and meta-analysis to clarify the association between UPF intake and CRC risk.

Methods

PubMed/MEDLINE, Web of Science, EMBASE, China National Knowledge Infrastructure (CNKI) and Wan fang databases were used to search the relevant studies published up to February 2023. The summary relative risks (RRs) with the corresponding 95% confidence intervals (CIs) were estimated by comparing the highest category vs. the lowest category of UPF intake, using the random-effects models (DerSimonian-Laird method). Heterogeneity between studies was explored using the Cochran's Q test and I-square (I²). Publication bias was assessed by examining the funnel plots, and quantified by Begg's or Egger's tests.

Results

A total of seven articles (three cohort and four case-control studies), involving 18,673 CRC cases and 462,292 participants, were included in our study. Combining nine effect sizes from seven articles, an increased risk of CRC was shown in the highest compared with the lowest category of UPF intake (RR = 1.26; 95%CI:1.14-1.38, p < 0.0001). Subgroup analyses showed a positive association between UPF intake and CRC risk in case-control studies (RR = 1.41; 95%CI: 1.22-1.63, p < 0.0001). When we conducted analyses separately by study area, there was a significant association between UPF intake and CRC risk in developed countries (RR = 1.20; 95%CI: 1.11-1.30, p < 0.0001).

Conclusion

Our results show that high UPF intake is significantly associated with a higher risk of CRC, in the absence, however, of a dose-response association. Further studies in particular of large prospective cohort studies are necessary to confirm these results.

Ultra-Processed Food Consumption and Risk of Type 2 Diabetes: Three Large Prospective U.S. Cohort Studies

OBJECTIVE

We examined the relationship between ultra-processed food (UPF) intake and type 2 diabetes (T2D) risk among 3 large U.S. cohorts, conducted a meta-analysis of prospective cohort studies, and assessed meta-evidence quality.

RESEARCH DESIGN AND METHODS

We included 71,871 women from the Nurses' Health Study, 87,918 women from the Nurses' Health Study II, and 38,847 men from the Health Professional Follow-Up Study. Diet was assessed using food frequency questionnaires and UPF was categorized per the NOVA classification. Associations of total and subgroups of UPF with T2D were assessed using Cox proportional hazards models. We subsequently conducted a meta-analysis of prospective cohort studies on total UPF and T2D risk, and assessed meta-evidence quality using the NutriGrade scoring system.

RESULTS

Among the U.S. cohorts (5,187,678 person-years; n = 19,503 T2D cases), the hazard ratio for T2D comparing extreme quintiles of total UPF intake (percentage of grams per day) was 1.46 (95% CI 1.39-1.54). Among subgroups, refined breads; sauces, spreads, and condiments; artificially and sugar-sweetened beverages; animal-based products; and ready-to-eat mixed dishes were associated with higher T2D risk. Cereals; dark and whole-grain breads; packaged sweet and savory snacks; fruit-based products; and yogurt and dairy-based desserts were associated with lower T2D risk. In the meta-analysis (n = 415,554 participants; n = 21,932 T2D cases), each 10% increment in total UPF was associated with a 12% (95% CI 10%-13%) higher risk. Per NutriGrade, high-quality evidence supports this relationship.

CONCLUSIONS

High-quality meta-evidence shows that total UPF consumption is associated with higher T2D risk. However, some UPF subgroups were associated with lower risk in the U.S. cohorts.

Food contaminants and potential risk of diabetes development: A narrative review

The number of people diagnosed with diabetes continues to increase, especially among younger populations. Apart from genetic predisposition and lifestyle, there is increasing scientific and public concern that environmental agents may also contribute to diabetes. Food contamination by chemical substances that originate from packaging materials, or are the result of chemical reactions during food processing, is generally recognized as a worldwide problem with potential health hazards. Phthalates, bisphenol A (BPA) and acrylamide (AA) have been the focus of attention in recent years, due to the numerous adverse health effects associated with their exposure. This paper summarizes the available data about the association between phthalates, BPA and AA exposure and diabetes. Although their mechanism of action has not been fully clarified, in vitro, in vivo and epidemiological studies have made significant progress toward identifying the potential roles of phthalates, BPA and AA in diabetes development and progression. These chemicals interfere with multiple signaling pathways involved in glucose and lipid homeostasis and can aggravate the symptoms of diabetes. Especially concerning are the effects of exposure during early stages and the gestational period. Well-designed prospective studies are needed in order to better establish prevention strategies against the harmful effects of these food contaminants.

Ultra-processed food consumption and increased risk of metabolic syndrome: a systematic review and meta-analysis of observational studies

Background

Although higher consumption of ultra-processed food (UPF) has been linked to a higher risk of metabolic syndrome (MetS), the results remain controversial. Herein, we performed a systematic review and meta-analysis of observational studies to clarify the relationship between UPF consumption defined by the NOVA framework and risk of MetS.

Methods

An extensive literature search on PubMed, ISI Web of Science, EBSCO and China National Knowledge Infrastructure (CNKI) databases was conducted to search for the relevant articles published priori to January 2023, and newly published articles between January 2023 and March 2023 were re-searched. Random-effects or fixed-effects models were adopted to calculate the pooled relative risks (RRs) and 95% confidence intervals (CIs). The between-study heterogeneity was explored using the Cochran's Q test and I-square (I²). Publication bias was investigated using the visual inspection of asymmetry in funnel plots and Begg's and Egger's tests.

Results

Nine studies (six cross-sectional and three prospective cohort studies) totaling 23,500 participants with 6,192 MetS cases were included in the final analysis. The pooled effect size for the highest vs. lowest categories of UPF consumption indicated a positive association with the risk of MetS (RR: 1.25, 95%CI: 1.09-1.42, P < 0.0001). Subgroup analyses revealed a positive association between consumption of UPF and MetS risk in cross-sectional studies (RR: 1.47, 95%CI: 1.16-1.87, P = 0.002), and no significant association in cohort studies (RR: 1.10, 95%CI: 0.96-1.27, P = 0.104), respectively. In addition, a more significant association between UPF consumption and increased risk of MetS was found in the subgroups of study quality <7 (RR: 2.22; 95%CI: 1.28-3.84, P = 0.004) than study quality ≥7 (RR: 1.20; 95%CI: 1.06-1.36, P = 0.005). Similarly, when we performed analyses separately by sample size, there was a significant association between UPF consumption and MetS risk in sample size ≥5,000 (RR: 1.19; 95%CI: 1.11-1.27, P < 0.0001), and in sample size <5,000 (RR: 1.43; 95%CI: 1.08-1.90, P = 0.013), respectively.

Conclusions

Our findings suggest that higher consumption of UPF is significantly associated with an increased risk of MetS. Further longitudinal studies are needed to confirm the effect of UPF consumption on MetS.

Increased ultra-processed food consumption is associated with worsening of cardiometabolic risk factors in adults with metabolic syndrome: Longitudinal analysis from a randomized trial

BACKGROUND AND AIMS

The association between changes in ultra-processed food (UPF) consumption and cardiometabolic risk (CMR) factors remains understudied. We evaluated the association between changes in UPF consumption over 12 months of follow-up and changes in CMR factors in adults diagnosed with metabolic syndrome.

METHODS

We analysed data from 5373 adults (aged 55-75 years) participating in the PREDIMED-Plus trial. Diet was evaluated at baseline, 6- and 12-month visits using a validated food frequency questionnaire, and UPF consumption (in grams/day and percentage of total daily dietary intake in grams) was categorized based on NOVA classification. We used mixed-effects linear models with repeated measurements at baseline, 6 and 12 months of follow-up to assess the associations between changes in UPF consumption and changes in CMR factors adjusting for sociodemographic and lifestyles variables.

RESULTS

In multivariable-adjusted models, when comparing the highest versus the lowest quartile of UPF consumption, positive associations were found for several CMR factors: weight (kg, β = 1.09; 95% confidence interval 0.91 to 1.26); BMI (kg/m², β = 0.39; 0.33 to 0.46); waist circumference (cm, β = 1.03; 0.81 to 1.26); diastolic blood pressure (mm Hg, β = 0.67; 0.29 to 1.06); fasting blood glucose (mg/dl, β = 1.66; 0.61 to 2.70); HbA1c (%, β = 0.04; 0.01 to 0.07); triglycerides (mg/dl, β = 6.79; 3.66 to 9.91) and triglycerides and glucose index (β = 0.06; 0.04 to 0.08).

CONCLUSIONS

Higher UPF consumption was associated with adverse evolution in objectively measured CMR factors after 12 months of follow-up in adults with metabolic syndrome. Further research is needed to explore whether these changes persist for longer periods.

Food Processing and Risk of Crohn's Disease and Ulcerative Colitis: A European Prospective Cohort Study

BACKGROUND & AIMS

Industrial foods have been associated with increased risks of several chronic conditions. We investigated the relationship between the degree of food processing and risks of Crohn's disease (CD) and ulcerative colitis (UC) in the European Prospective Investigation into Cancer and Nutrition cohort.

METHODS

Analyses included 413,590 participants (68.6% women; mean baseline age, 51.7 y) from 8 European countries. Dietary data were collected at baseline from validated country-specific dietary questionnaires. Associations between proportions of unprocessed/minimally processed and ultraprocessed food intake and CD and UC risks were estimated using Cox models to obtain hazard ratios (HRs) and 95% CIs. Models were stratified by center, age, and sex, and adjusted for smoking status, body mass index, physical activity, energy intake, educational level, and alcohol consumption.

RESULTS

During a mean follow-up period of 13.2 years, 179 incident cases of CD and 431 incident cases of UC were identified. The risk of CD was lower in people consuming high proportions of unprocessed/minimally processed foods (adjusted HR for the highest vs lowest quartile: 0.57; 95% CI, 0.35-0.93; P trend < .01), particularly fruits and vegetables (adjusted HRs, 0.54; 95% CI, 0.34-0.87 and 0.55; 95% CI, 0.34-0.91, respectively). There was no association between unprocessed/minimally processed food intake and the risk of UC. No association was detected between ultraprocessed food consumption and CD or UC risks.

CONCLUSIONS

In the European Prospective Investigation into Cancer and Nutrition cohort, consumption of unprocessed/minimally processed foods was associated with a lower risk of CD. No association between UC risk and food processing was found.

Food Additives in Ultra-Processed Packaged Foods: An Examination of US Household Grocery Store Purchases

BACKGROUND

Food additives have been used mainly in the past century to perform specific functions in foods. Some types of food additives have been linked to adverse health outcomes, yet there is little research examining food additives in the US food supply.

OBJECTIVE

To examine the proportion of products purchased by US households containing four common technical food additives using time-specific food composition data and examine whether purchases have changed over time.

PARTICIPANTS/SETTING

Nielsen Homescan Consumer Panels, 2001 and 2019.

MAIN OUTCOME MEASURES

The proportion of packaged food products containing common types of food additives purchased by US households was determined overall and by food category.

STATISTICAL ANALYSIS PERFORMED

Differences were examined using Student t test; P value < 0.001 was considered significant.

RESULTS

Between 2001 and 2019, the proportion of food products purchased by US households that contained additives increased from 49.6% to 59.5% (P < 0.001). The proportion of carbonated soft drinks purchased containing flavors decreased, with a subsequent increase in purchases containing nonnutritive sweeteners. Baby foods showed a 20% increase in the proportion of purchases containing additives and >15% increase in the proportion of purchases containing three or more additives.

CONCLUSIONS

There is convincing evidence that US household purchases of common types of technical food additives are increasing. Despite some positive changes such as a decrease in the use of added flavors in carbonated soft drinks, across most food categories an increase in purchases of all types of products containing additives was observed. In particular the finding that purchases of baby food products containing additives have increased substantially is crucial in informing future research in this area and warrants further investigation.

Ultra-Processed Food Consumption and Incidence of Obesity and Cardiometabolic Risk Factors in Adults: A Systematic Review of Prospective Studies

Ultra-processed foods (UPF) are energy-dense, nutritionally unbalanced products, low in fiber but high in saturated fat, salt, and sugar. Recently, UPF consumption has increased likewise the incidence of obesity and cardiometabolic diseases. To highlight a possible relationship, we conducted a systematic review of prospective studies from PubMed and Web of Science investigating the association between UPF consumption and the incidence of obesity and cardiometabolic risk factors. Seventeen studies were selected. Eight evaluated the incidence of general and abdominal obesity, one the incidence of impaired fasting blood glucose, four the incidence of diabetes, two the incidence of dyslipidemia, and only one the incidence of metabolic syndrome. Studies' quality was assessed according to the Critical Appraisal Checklist for cohort studies proposed by the Joanna Briggs Institute. Substantial agreement emerged among the studies in defining UPF consumption as being associated with the incident risk of general and abdominal obesity. More limited was the evidence on cardiometabolic risk. Nevertheless, most studies reported that UPF consumption as being associated with an increased risk of hypertension, diabetes, and dyslipidemia. In conclusion, evidence supports the existence of a relationship between UPF consumption and the incidence of obesity and cardiometabolic risk. However, further longitudinal studies considering diet quality and changes over time are needed.

Assessing the per Capita Food Supply Trends of 38 OECD Countries between 2000 and 2019-A Joinpoint Regression Analysis

Food supply has an impact on the prevalence of diet-related non-communicable diseases. We aimed to analyze the protein, fat (g/capita/day) and calorie (kcal/capita/day) supply from 2000 to 2019 as derived from the OECD Health Statistics database. A joinpoint regression was used to examine the number and location of breakpoints in the time series. The annual percent change (APC) was calculated using Joinpoint 4.9.0.0. The per capita daily kcal per nutrient was calculated for each country and the resulting percentage distributions were compared to the acceptable macronutrient distribution ranges. Protein, fat and calorie supplies have increased significantly between 2000 and 2019. Each started to show a much steeper, positive change between 2012 and 2014 (APC_fat: 1.0; 95%CI: 0.8-1.1; APC_protein: 0.5; 95%CI: 0.3-0.6; APC_kcal: 0.4; 95%CI: 0.3-0.5). In terms of the composition of the daily calorie intake per capita, the overall share of fat (+4.9%) and protein (+1.0%) increased between 2000 and 2019. We found significant differences among countries and also an increasing and optimal proportion of consumed protein per total calorie in all countries over the last two decades. We concluded that several countries have access to fat availability above the optimal level, which deserves particular attention from health policy makers in the fight against obesity and diet-related diseases.

Machine learning prediction of the degree of food processing

Despite the accumulating evidence that increased consumption of ultra-processed food has adverse health implications, it remains difficult to decide what constitutes processed food. Indeed, the current processing-based classification of food has limited coverage and does not differentiate between degrees of processing, hindering consumer choices and slowing research on the health implications of processed food. Here we introduce a machine learning algorithm that accurately predicts the degree of processing for any food, indicating that over 73% of the US food supply is ultra-processed. We show that the increased reliance of an individual's diet on ultra-processed food correlates with higher risk of metabolic syndrome, diabetes, angina, elevated blood pressure and biological age, and reduces the bio-availability of vitamins. Finally, we find that replacing foods with less processed alternatives can significantly reduce the health implications of ultra-processed food, suggesting that access to information on the degree of processing, currently unavailable to consumers, could improve population health.

Clusters of lifestyle behaviors associated with atherosclerosis risk factors in children and adolescents with congenital heart disease: Floripa CHild Study

Secondary cardiovascular disease is the main cause of mortality in congenital heart disease (CHD) patients. The cardiovascular risk could be widely prevented with adherence to a healthy lifestyle; however, clusters of lifestyle behaviors related to atherosclerosis risk factors in children and adolescents with CHD remain unclear. We aimed to describe the clusters of lifestyle behaviors of children and adolescents with CHD and to evaluate their association with atherosclerosis risk factors. We conducted a cross-sectional study on 227 children and adolescents with CHD (median age:10.02 [IQR:7.08-13.02] years). Dietary intake, physical activity (PA), and sedentary behavior (SB) were evaluated. Clusters of lifestyle behaviors were determined using a two-step cluster analysis. Atherosclerosis risk factors evaluated include body fat mass, central obesity, blood pressure, lipid parameters, glucose, C-reactive protein, and carotid intima-media thickness (cIMT). Multiple logistic regressions were used. The "unhealthy: high SB + low PA" cluster was associated with elevated body fat mass, central obesity, and elevated cIMT. Furthermore, the "unhealthy: low PA + unhealthy eating habits" cluster was associated with elevated body fat mass, central obesity, and elevated glucose. The unhealthier lifestyle behavior clusters were associated with atherosclerosis risk factors in children and adolescents with CHD. Multidisciplinary strategies to promote healthy behaviors are needed to prevent cardiovascular disease in later life.

Association between Ultra-Processed Food Consumption and Metabolic Syndrome among Adults in China-Results from the China Health and Nutrition Survey

The prevalence of metabolic syndrome (MetS) is increasing and the relationship between ultra-processed food (UPF) consumption and MetS remains uncertain in Chinese adults. This study aimed to examine the longitudinal association of UPF consumption with the risk of MetS and its components in Chinese adults. Adults aged 18 years and above who participated in at least two waves of the China Health and Nutrition Survey (CHNS) in 2009, 2015, and 2018 were included in this analysis. Dietary intake data were collected by three consecutive 24 h dietary recalls and weighing household foods and condiments. Depending on the purpose and extent of food processing, UPFs were classified using the NOVA food classification system. A multivariate Cox proportional risk model was used to explore the association between UPF consumption (grouped by quartile: quartile 1 (Q1), quartile 2 (Q2), quartile 3 (Q3), and quartile 4 (Q4)) and risk of MetS and its components. A total of 5147 adults were included. During a median (IQR) 6.0 (3.0, 9.0) year follow-up with 31,878 person-years, 1712 MetS cases were identified, with an incidence of 33.26%. After multivariable adjustment, the risk of MetS was increased by 17% in the highest quartile with UPF consumption (HR: 1.17, 95% CI: 1.01-1.35, p trend: 0.047), with the lowest quartile as a reference. For the components of MetS, the risk of central obesity, raised triglycerides (TG), reduced high-density lipoprotein cholesterol (HDL-C), and raised blood pressure (BP) was increased by 33% (HR: 1.33, 95% CI: 1.18-1.51, p trend: <0.001), 26% (HR: 1.26, 95% CI: 1.08-1.48, p trend: 0.003), 25% (HR: 1.25, 95% CI: 1.07-1.46, p trend: 0.007), and 16% (HR: 1.16, 95% CI: 1.03-1.32, p trend: 0.018) in the highest quartile with UPF consumption, respectively. Adults aged 45-59 years and living in urban areas with higher UPF consumption had higher odds of MetS. These results indicate that higher long-term UPF consumption was associated with an increased risk of MetS in Chinese adults. Further studies such as intervention trials are needed to confirm the mechanism of correlation between UPF consumption and health-related outcomes. Nutritional education actions are warranted to promote a balanced diet and improve the overall dietary quality of residents to reduce the risk of MetS effectively.

Ultra-Processed Food Consumption and Increased Risk of Metabolic Syndrome in Adults: The ELSA-Brasil

OBJECTIVE

To investigate the association between ultra-processed food (UPF) consumption and the incidence of metabolic syndrome (MetS).

RESEARCH DESIGN AND METHODS

From 2008 to 2010, we enrolled 15,105 adults, aged 35-74 years, who were employees from six public education and research institutions to assemble the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). We used a food frequency questionnaire to assess UPF consumption (measured in grams per day) at baseline. We then assessed the outcomes of those returning to visits between 2012 and 2014 and between 2017 and 2019. We defined incident MetS by the presence of at least three of the following five abnormalities: high fasting glucose level, high triglyceride level, low HDL cholesterol level, high blood pressure, and abdominal obesity, after excluding those meeting such criteria at baseline. We also excluded those who had missing data or an implausible energy intake, leaving 8,065 participants in the study.

RESULTS

The median age was 49 years, 59% of participants were women, and the median consumption of UPFs was 366 g/day. After 8 years, there were 2,508 new cases of MetS. In robust Poisson regression, adjusting for sociodemographics, behavioral factors, and energy intake, we found a 7% (relative risk [RR] 1.07; 95% CI 1.05-1.08) higher risk of incident MetS for an increase of 150 g/day in UPF consumption. Similarly, those in the fourth quartile (compared with the first quartile) had a 33% increased risk (RR 1.33; 95% CI 1.20-1.47). Further adjustment for BMI attenuated these associations (for 150 g/day increases in UPF consumption and for the fourth quartile compared to the first one, respectively, RR = 1.04, 95% CI 1.02-1.06; RR = 1.19, 95% CI 1.07-1.32).

CONCLUSIONS

Greater consumption of UPFs is associated with an increased risk of MetS. These findings have important implications for diabetes and cardiovascular disease prevention and management.