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Bestari FF, Andarwulan N, Palupi E. Synthesis of Effect Sizes on Dose Response from Ultra-Processed Food Consumption against Various Noncommunicable Diseases. Foods 2023; 12:4457. [PMID: 38137261 PMCID: PMC10742878 DOI: 10.3390/foods12244457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/29/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
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.
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Affiliation(s)
- Fairuz Firda Bestari
- Department of Food Science, Faculty of Agricultural Technology, IPB University, Bogor 16680, Indonesia
| | - Nuri Andarwulan
- Department of Food Science, Faculty of Agricultural Technology, IPB University, Bogor 16680, Indonesia
| | - Eny Palupi
- Department of Community Nutrition, Faculty of Human Ecology, IPB University, Bogor 16680, Indonesia
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Andrade GC, Mais LA, Ricardo CZ, Duran AC, Martins APB. Whole grain products in Brazil: the need for regulation to ensure nutritional benefits and prevent the misuse of marketing strategies. Rev Saude Publica 2023; 57:58. [PMID: 37878844 PMCID: PMC10519677 DOI: 10.11606/s1518-8787.2023057004790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 12/29/2022] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVE This study aims to evaluate the use of "whole grains" claims in food products marketed in Brazil and evaluate the nutrient profile of these products. METHODS Data from 775 grain-based packaged foods collected in Brazil from April to July 2017 were analyzed. Based on the INFORMAS protocol for food labeling, the prevalence of packaged foods with "whole grains" claims was estimated. Information on the list of ingredients was analyzed to evaluate the presence and amount of whole or refined grains in six food groups. The nutrient profiles of the products with and without "whole grains" claims were compared using the Pan American Health Organization (PAHO) nutrient profile model. RESULTS The packages of about 19% of the evaluated products showed "whole grains" claims in their front panel. Of these, 35% lacked any whole grains among their top three ingredients. Breakfast cereals, granola bars, bread, cakes and other bakery products, cookies, and pasta had higher amounts of refined flour than whole grain ingredients in their compositions.We found 66% of products with "whole grains" claims were high in nutrients of concern according to PAHO's criteria. CONCLUSION Our results showed that over a third of the products in Brazil with "whole grains" claims lacked whole grains as one of their main ingredients. Most had a high content of nutrients associated with noncommunicable chronic disease risk factors, indicating the overestimation of their health benefits.
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Affiliation(s)
- Giovanna Calixto Andrade
- Universidade de São PauloFaculdade de MedicinaDepartamento de Medicina PreventivaSão PauloSPBrasilUniversidade de São Paulo. Faculdade de Medicina. Departamento de Medicina Preventiva. São Paulo, SP, Brasil
- Universidade de São PauloNúcleo de Pesquisas Epidemiológicas em Nutrição e SaúdeSão PauloSPBrasil Universidade de São Paulo. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. São Paulo, SP. Brasil
| | - Laís Amaral Mais
- Instituto Brasileiro de Defesa do ConsumidorSão PauloSPBrasilInstituto Brasileiro de Defesa do Consumidor. São Paulo, SP, Brasil
| | - Camila Zancheta Ricardo
- Universidade de São PauloNúcleo de Pesquisas Epidemiológicas em Nutrição e SaúdeSão PauloSPBrasil Universidade de São Paulo. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. São Paulo, SP. Brasil
- Universidad de ChileEscuela de Salud PúblicaFacultad de MedicinaSantiagoChileUniversidad de Chile, Escuela de Salud Pública, Facultad de Medicina. Santiago, Chile
| | - Ana Clara Duran
- Universidade de São PauloNúcleo de Pesquisas Epidemiológicas em Nutrição e SaúdeSão PauloSPBrasil Universidade de São Paulo. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. São Paulo, SP. Brasil
- Universidade Estadual de CampinasNúcleo de Estudos e Pesquisas em AlimentaçãoCampinasSPBrasil Universidade Estadual de Campinas. Núcleo de Estudos e Pesquisas em Alimentação. Campinas, SP, Brasil
| | - Ana Paula Bortoletto Martins
- Universidade de São PauloNúcleo de Pesquisas Epidemiológicas em Nutrição e SaúdeSão PauloSPBrasil Universidade de São Paulo. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. São Paulo, SP. Brasil
- Instituto Brasileiro de Defesa do ConsumidorSão PauloSPBrasilInstituto Brasileiro de Defesa do Consumidor. São Paulo, SP, Brasil
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Krušič S, Hristov H, Hribar M, Lavriša Ž, Žmitek K, Pravst I. Changes in the Sodium Content in Branded Foods in the Slovenian Food Supply (2011-2020). Nutrients 2023; 15:4304. [PMID: 37836588 PMCID: PMC10574098 DOI: 10.3390/nu15194304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/27/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
High sodium intake is the leading diet-related risk factor for mortality globally. Many countries have introduced policies to support the reformulation of foods and to reduce sodium intake, mainly on a voluntary basis, but there are limited data available about the long-term efficiency of such measures. Slovenia implemented salt reduction policies for the period of 2010-2020; these policies also included the voluntary reformulation of foods with the lowering of sodium content. This study's aim was to explore the nationally representative branded food datasets collected in the years 2011, 2015, 2017, and 2020 to investigate the changes in the sodium content in prepacked branded foods. The study was conducted with datasets collected from food labels using standard food monitoring studies and included all the major retailers. Differences in market shares were adjusted by sales weighting, which was conducted using the yearly sales data provided by the major retailers. The food categories with a major contribution to the overall sales of sodium in prepacked branded foods were processed meat and derivatives (19.0%), canned vegetables (7.1%), water (6.7%), bread (7.2%), and cheese (6.3%). Considering the available food products, a notable decreasing sodium content trend was observed in biscuits, breakfast cereals, pizza, and spreads. Year-to-year differences were much less expressed after the correction for market share differences, and neutral trends were most frequently highlighted. This indicates that sodium was less frequently reduced in market-leading products. The study results revealed that very limited progress in sodium food reformulation was achieved in the 10-year period, indicating the need for more efficient policy approaches. The study demonstrated the importance of the systematic monitoring of the food supply for the evaluation of food policies.
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Affiliation(s)
- Sanja Krušič
- Nutrition Institute, Koprska Ulica 98, SI-1000 Ljubljana, Slovenia; (S.K.); (H.H.); (M.H.); (Ž.L.); (K.Ž.)
| | - Hristo Hristov
- Nutrition Institute, Koprska Ulica 98, SI-1000 Ljubljana, Slovenia; (S.K.); (H.H.); (M.H.); (Ž.L.); (K.Ž.)
| | - Maša Hribar
- Nutrition Institute, Koprska Ulica 98, SI-1000 Ljubljana, Slovenia; (S.K.); (H.H.); (M.H.); (Ž.L.); (K.Ž.)
| | - Živa Lavriša
- Nutrition Institute, Koprska Ulica 98, SI-1000 Ljubljana, Slovenia; (S.K.); (H.H.); (M.H.); (Ž.L.); (K.Ž.)
| | - Katja Žmitek
- Nutrition Institute, Koprska Ulica 98, SI-1000 Ljubljana, Slovenia; (S.K.); (H.H.); (M.H.); (Ž.L.); (K.Ž.)
- VIST–Faculty of Applied Sciences, Gerbičeva Cesta 51A, SI-1000 Ljubljana, Slovenia
| | - Igor Pravst
- Nutrition Institute, Koprska Ulica 98, SI-1000 Ljubljana, Slovenia; (S.K.); (H.H.); (M.H.); (Ž.L.); (K.Ž.)
- VIST–Faculty of Applied Sciences, Gerbičeva Cesta 51A, SI-1000 Ljubljana, Slovenia
- Biotechnical Faculty, University of Ljubljana, Jamnikarjeva 101, SI-1000 Ljubljana, Slovenia
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Andrade GC, Mais LA, Ricardo CZ, Duran AC, Martins APB. Promotion of ultra-processed foods in Brazil: combined use of claims and promotional features on packaging. Rev Saude Publica 2023; 57:44. [PMID: 37556666 PMCID: PMC10355317 DOI: 10.11606/s1518-8787.2023057004410] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 07/17/2022] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVE To assess the availability of different promotional strategies applied for UPF sales in Brazilian food retailers. METHODS Information available on food packaging was gathered from all packaged products sold in the five largest food retail chains in Brazil in 2017. UPF were identified using the NOVA food classification system. From this sample, data related to promotional characteristics, nutrition claims and health claims were collected and coded using the INFORMAS methodology. Additional claims referring to the Brazilian Dietary Guidelines were also collected. RESULTS This study evaluated the packaging of 2,238 UPF, of which 59.8% presented at least one promotional strategy. Almost one third denoted a simultaneous use of different promotional strategies in the same packaging. Nutrition claims were the most commonly found promotional strategy, followed by health claims and the use of characters. The food subgroups comprising the highest prevalence of promotional strategies on their labels were: noncaloric sweeteners (100.0%), breakfast cereals and granola bars (96.2%), juices, nectars and fruit-flavoured drinks (92.9%), other unsweetened beverages (92.9%), and other sweetened beverages (92.6%). CONCLUSIONS Considering the poor nutritional quality of UPF, the widespread presence of promotional features on their packaging highlights the need for marketing restrictions on this kind of product.
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Affiliation(s)
- Giovanna Calixto Andrade
- Universidade de São PauloFaculdade de MedicinaDepartamento de Medicina PreventivaSão PauloSPBrasilUniversidade de São Paulo. Faculdade de Medicina. Departamento de Medicina Preventiva. São Paulo, SP, Brasil
- Universidade de São PauloNúcleo de Pesquisas Epidemiológicas em Nutrição e SaúdeSão PauloSPBrasilUniversidade de São Paulo. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. São Paulo, SP, Brasil
| | - Laís Amaral Mais
- Instituto Brasileiro de Defesa do ConsumidorSão PauloSPBrasilInstituto Brasileiro de Defesa do Consumidor. São Paulo, SP, Brasil
| | - Camila Zancheta Ricardo
- Universidade de São PauloNúcleo de Pesquisas Epidemiológicas em Nutrição e SaúdeSão PauloSPBrasilUniversidade de São Paulo. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. São Paulo, SP, Brasil
- Universidad de Chile. Facultad de MecicinaEscola de Salud PúblicaSantiagoChileUniversidad de Chile. Facultad de Mecicina. Escola de Salud Pública. Santiago, Chile
| | - Ana Clara Duran
- Universidade de São PauloNúcleo de Pesquisas Epidemiológicas em Nutrição e SaúdeSão PauloSPBrasilUniversidade de São Paulo. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. São Paulo, SP, Brasil
- Universidade Estadual de CampinasNúcleo de Estudos e Pesquisas em AlimentaçãoCampinasSPBrasilUniversidade Estadual de Campinas. Núcleo de Estudos e Pesquisas em Alimentação. Campinas, SP, Brasil
| | - Ana Paula Bortoletto Martins
- Universidade de São PauloNúcleo de Pesquisas Epidemiológicas em Nutrição e SaúdeSão PauloSPBrasilUniversidade de São Paulo. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. São Paulo, SP, Brasil
- Instituto Brasileiro de Defesa do ConsumidorSão PauloSPBrasilInstituto Brasileiro de Defesa do Consumidor. São Paulo, SP, Brasil
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Sanuade OA, Alfa V, Yin X, Liu H, Ojo AE, Shedul GL, Ojji DB, Huffman MD, Orji IA, Okoli RCB, Akor B, Ripiye NR, Eze H, Okoro CE, Van Horn L, Tripathi P, Ojo TM, Trieu K, Neal B, Hirschhorn LR. Stakeholder perspectives on Nigeria's national sodium reduction program: Lessons for implementation and scale-up. PLoS One 2023; 18:e0280226. [PMID: 36638099 PMCID: PMC9838847 DOI: 10.1371/journal.pone.0280226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/26/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND To reduce excess dietary sodium consumption, Nigeria's 2019 National Multi-sectoral Action Plan (NMSAP) for the Prevention and Control of Non-communicable Diseases includes policies based on the World Health Organization SHAKE package. Priority actions and strategies include mandatory sodium limits in processed foods, advertising restrictions, mass-media campaigns, school-based interventions, and improved front-of-package labeling. We conducted a formative qualitative evaluation of stakeholders' knowledge, and potential barriers as well as effective strategies to implement these NMSAP priority actions. METHODS From January 2021 to February 2021, key informant interviews (n = 23) and focus group discussions (n = 5) were conducted with regulators, food producers, consumers, food retailers and restaurant managers, academia, and healthcare workers in Nigeria. Building on RE-AIM and the Consolidated Framework for Implementation Research, we conducted directed content qualitative analysis to identify anticipated implementation outcomes, barriers, and facilitators to implementation of the NMSAP sodium reduction priority actions. RESULTS Most stakeholders reported high appropriateness of the NMSAP because excess dietary sodium consumption is common in Nigeria and associated with high hypertension prevalence. Participants identified multiple barriers to adoption and acceptability of implementing the priority actions (e.g., poor population knowledge on the impact of excess salt intake on health, potential profit loss, resistance to change in taste) as well as facilitators to implementation (e.g., learning from favorable existing smoking reduction and advertising strategies). Key strategies to strengthen NMSAP implementation included consumer education, mandatory and improved front-of-package labeling, legislative initiatives to establish maximum sodium content limits in foods and ingredients, strengthening regulation and enforcement of food advertising restrictions, and integrating nutrition education into school curriculum. CONCLUSION We found that implementation and scale-up of the Nigeria NMSAP priority actions are feasible and will require several implementation strategies ranging from community-focused education to strengthening current and planned regulation and enforcement, and improvement of front-of-package labeling quality, consistency, and use.
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Affiliation(s)
- Olutobi A. Sanuade
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah, United States of America
| | - Vanessa Alfa
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Xuejun Yin
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hueiming Liu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Adedayo E. Ojo
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Gabriel L. Shedul
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Dike B. Ojji
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Mark D. Huffman
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Cardiovascular Division and Global Health Center, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Ikechukwu A. Orji
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | | | - Blessing Akor
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Nanna R. Ripiye
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Helen Eze
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Clementina Ebere Okoro
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Linda Van Horn
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Priya Tripathi
- Stanley Manne Children’s Research Institute, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, United States of America
| | - Tunde M. Ojo
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lisa R. Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Robert J Havey Institute for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
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Nichols S, Dalrymple N, Prout P, Ramcharitar-Bourne A. Dietary intake patterns, nutrient adequacy and associated factors in a multi-ethnic Caribbean population. Nutr Health 2022; 29:297-307. [PMID: 35014896 DOI: 10.1177/02601060211070907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Diet is a significant contributor to health and wellbeing of individuals. Aim: In this study we investigated patterns of dietary intakes, levels of nutrient inadequacies and associated sociodemographic, anthropometric and lifestyle factors among adults in Trinidad and Tobago. Method: The study was cross-sectional in nature. A convenience sample of 11783 persons from districts throughout Trinidad and Tobago completed a self-administered questionnaire comprising socio-demographic and lifestyle items. Anthropometry was self-reported with 15% of participants having measurements done according to recommended procedures. Dietary patterns were determined by principal component analysis (PCA) while nutrient intakes and adequacy were assessed using the NutriGenie 7.0 software and nutrient adequacy ratio (MAR) respectively. Foods were categorised as unprocessed/minimally processed and processed/ultra-processed. The University of The West Indies Ethics Committee approved the study. Results: Approximately 72.5% of participants met the Goldberg criteria for plausible reporting. The three predominant dietary patterns 'Typical', 'Fruits and Vegetables', and 'High Fat' explained 45% of the total variance in foods consumed. Processed/ultra-processed foods accounted for most of the energy (80%) and nutrients consumed. Nutrient inadequacies were observed for potassium, vitamins B12, D, E, K, fibre, magnesium; and iron among females. The mean adequacy ratio (MAR) for participants was 67%. MAR was positively associated with predominant dietary patterns independent of socioe demographic and lifestyle factors (p < 0.001). Conclusion: Irrespective of their nature, the predominant dietary pattern was associated with nutrient adequacy among participants. Reducing the risk of inadequate nutrient intakes may be addressed by increasing availability, access and consumption of appropriate sources of these micronutrients.
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Affiliation(s)
- Selby Nichols
- Department of Agricultural Economics and Extension (DAEE), 37612The University of The West Indies, St. Augustine, Trinidad and Tobago
| | - Nequesha Dalrymple
- Department of Agricultural Economics and Extension (DAEE), 37612The University of The West Indies, St. Augustine, Trinidad and Tobago.,Department of Curriculum and Instruction, Faculty of Education and Humanities, University of Guyana
| | - Patrice Prout
- Department of Agricultural Economics and Extension (DAEE), 37612The University of The West Indies, St. Augustine, Trinidad and Tobago
| | - Anisa Ramcharitar-Bourne
- Department of Agricultural Economics and Extension (DAEE), 37612The University of The West Indies, St. Augustine, Trinidad and Tobago
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Beltrá M, Borrás F, Ropero AB. Sodium Content of Foods Sold in the Spanish Market. Results from the BADALI Project. Nutrients 2021; 13:3410. [PMID: 34684411 PMCID: PMC8539754 DOI: 10.3390/nu13103410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 12/27/2022] Open
Abstract
High sodium/salt intake is a risk factor for Non-Communicable Diseases (NCDs). Excess sodium intake has been associated with high coronary heart disease, stroke and high blood pressure. The sodium daily intake is above the recommendations in the world as well as in Spain. Reducing salt content in processed foods and ready meals is one of the main strategies for reducing sodium intake. The aim of the present work is to characterise the presence of sodium in foods sold in the Spanish market. We also study a possible shift in sodium content in products over the last few years. For this purpose, 3897 products included in the BADALI food database were analysed, classified into 16 groups (G). We found that 93.3% of all foods displayed the sodium/salt content in the nutrition declaration. Meat-processed and derivatives (G8) had the highest mean and median values for sodium content, followed by snacks (G15) and sauces (G14). Only 12.7% of foods were sodium-free (≤5 mg/100 g or 100 mL), 32.4% had very low sodium (≤40 mg/100 g or 100 mL) and 48.2% were low in sodium (≤120 mg/100 g or 100 mL). On the contrary, 47.2% were high in sodium according to the Pan American Health Organisation Nutrient Profile Model (PAHO-NPM), while there were 31.9% according to the Chile-NPM. The agreement between the two NPMs was considered 'substantial' (κ = 0.67). When sodium content was compared over the years, no decrease was observed. This analysis was performed in the entire food population, by food group and in matched products. Therefore, more effort should be made by all parties involved in order to decrease the sodium/salt intake in the population.
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Affiliation(s)
- Marta Beltrá
- Institute of Bioengineering, Miguel Hernández University, 03202 Elche, Spain;
| | - Fernando Borrás
- Department of Statistics, Mathematics and Informatics, Miguel Hernández University, 03202 Elche, Spain;
| | - Ana B. Ropero
- Institute of Bioengineering, Miguel Hernández University, 03202 Elche, Spain;
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Bayram HM, Ozturkcan A. The presence of sodium content and sodium-containing food additives in packaged foods and beverages sold in Turkey. J Food Compost Anal 2021. [DOI: 10.1016/j.jfca.2021.104078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Sodium and salt content of Portuguese rolls produced in a city of southern Brazil: a comparison of laboratory analysis, food labelling and nutrition standards. Public Health Nutr 2020; 24:2337-2344. [PMID: 32618554 DOI: 10.1017/s1368980020000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To analyse the Na content of bread by comparing the amount of salt and Na among the label, laboratory analysis and international guidelines. DESIGN Ten selected bakeries provided 3239 randomly selected samples of bread, which were weighed on-site. Triplicate samples were retrieved from each bakery (thirty samples) for analysis. Bread production was observed, and ingredient labels were queried to determine salt weights, which were used for comparison with the laboratory analysis. Flame photometry and the method for chlorides were utilised for analysing Na. Laboratory findings were compared to nine different international nutritional guidelines for Na consumption. SETTING Florianopolis, south of Brazil. PARTICIPANTS Ninety independent bakeries locally producing Portuguese rolls were queried; rolls from ten conveniently selected bakeries were retrieved for further analysis. RESULTS The average weight of the rolls was 50·2 ± 5·3 g. The average amount of salt (g) per roll, by laboratory and label analyses, was 0·69 ± 0·0 and 0·62 ± 0·1 g, respectively. The mean level of Na (mg) reported on nutrient labels (478·2 ± 93·4/100 g) was significantly lower than by laboratory analysis (618·2 ± 73·8/100 g), P < 0·001. There was a difference for Na in rolls produced in the bakeries considering the unit weight of rolls (P ≤ 0·001) per 100 g (P = 0·026) and the mode of production. The consumption of two averaged units of rolls was equivalent to 51·7 % of the Brazilian guideline daily amount for Na for children and 31 % for adults. CONCLUSIONS The nutrient labels underreported Na values. This study strengthens the importance of monitoring Na of breads in Brazil.
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The food environment in Latin America: a systematic review with a focus on environments relevant to obesity and related chronic diseases. Public Health Nutr 2019; 22:3447-3464. [PMID: 31666140 DOI: 10.1017/s1368980019002891] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Food environments may be contributing to the rapid increase in obesity occurring in most Latin American (LA) countries. The present study reviews literature from LA that (i) describes the food environment and policies targeting the food environment (FEP); and (ii) analytic studies that investigate associations between the FEP and dietary behaviours, overweight/obesity and obesity related chronic diseases. We focus on six dimensions of the FEP: food retail, provision, labelling, marketing, price and composition. DESIGN Systematic literature review. Three databases (Web of Science, SciELO, LILACS) were searched, from 1 January 1999 up to July 2017. Two authors independently selected the studies. A narrative synthesis was used to summarize, integrate and interpret findings. SETTING Studies conducted in LA countries. PARTICIPANTS The search yielded 2695 articles of which eighty-four met inclusion criteria. RESULTS Most studies were descriptive and came from Brazil (61 %), followed by Mexico (18 %) and Guatemala (6 %). Studies were focused primarily on retail/provision (n 27), marketing (n 16) and labelling (n 15). Consistent associations between availability of fruit and vegetable markets and higher consumption of fruits and vegetables were found in cross-sectional studies. Health claims in food packaging were prevalent and mostly misleading. There was widespread use of marketing strategies for unhealthy foods aimed at children. Food prices were lower for processed relative to fresh foods. Some studies documented high sodium in industrially processed foods. CONCLUSIONS Gaps in knowledge remain regarding policy evaluations, longitudinal food retail studies, impacts of food price on diet and effects of digital marketing on diet/health.
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Lima LR, Nascimento LM, Gomes KRO, Martins MDCDCE, Rodrigues MTP, Frota KDMG. [Association between ultra-processed food consumption and lipid parameters among adolescents]. CIENCIA & SAUDE COLETIVA 2019; 25:4055-4064. [PMID: 33027399 DOI: 10.1590/1413-812320202510.24822018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 02/11/2019] [Indexed: 02/11/2023] Open
Abstract
The scope of this study was to analyze the association between ultra-processed food (UPF) consumption and lipid parameters. It was a cross-sectional study performed with high school adolescents. Food consumption was analyzed by means of a 24-hour food recall form, where UPF were identified in line with the NOVA system of food classification. The total cholesterol levels, HDL-c and triglycerides were determined by enzymatic colorimetry and the LDL-c fraction estimated by formula. The Student's t-test or Mann-Whitney was used to compare averages, and linear regression to make associations among the variables. The results show that UPF consumption was more frequent in female adolescents between 17 and 19 years of age, with a family income above two minimum wages and from private schools. It was observed that individuals in the upper third of UPF consumption had a higher energetic, carbohydrate and sodium intake, with a lower intake of proteins and fibers. Moreover, it was found that a higher UPF intake was negatively associated with HDL-c levels and positively associated with triglyceride levels and dyslipidemia. Therefore, UPF is associated with a worsening of the nutritional profile of the diet and contributes to negative changes in the lipid parameters of young individuals.
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Affiliation(s)
- Laurineide Rocha Lima
- Centro de Ciências da Saúde, Universidade Federal do Piauí (UFPI). Campus Universitário Ministro Petrônio Portela, Planalto Ininga. 64049-550 Teresina PI Brasil.
| | - Larisse Monteles Nascimento
- Centro de Ciências da Saúde, Universidade Federal do Piauí (UFPI). Campus Universitário Ministro Petrônio Portela, Planalto Ininga. 64049-550 Teresina PI Brasil.
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Sodium Content of Processed Foods Available in the Mexican Market. Nutrients 2018; 10:nu10122008. [PMID: 30572568 PMCID: PMC6316842 DOI: 10.3390/nu10122008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/10/2018] [Accepted: 12/17/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Sodium intake is related to several adverse health outcomes, such as hypertension and cardiovascular diseases. Processed foods are major contributors to the population's sodium intake. The aim of the present study was to determine sodium levels in Mexican packaged foods, as well as to evaluate the proportion of foods that comply with sodium benchmark targets set by the United Kingdom Food Standards Agency (UK FSA) and those set by the Mexican Commission for the Protection of Health Risks (COFEPRIS). We also evaluated the proportion of foods that exceeded the Pan American Health Organization (PAHO) targets. METHODS This was a cross-sectional study that comprised data collected from the package of 2248 processed foods from selected supermarkets in Mexico. RESULTS Many processed food categories contained an excessive amount of sodium. Processed meats, ham, bacon and sausages, had the highest concentrations. The proportion of foods classified as compliant in our sample was lower for international targets (FSA UK and PAHO) compared to the Mexican COFEPRIS criteria. CONCLUSIONS These data provided a critical baseline assessment for monitoring sodium levels in Mexican processed foods.
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Scapin T, Fernandes AC, dos Anjos A, Proença RPDC. Use of added sugars in packaged foods sold in Brazil. Public Health Nutr 2018; 21:3328-3334. [PMID: 30157986 PMCID: PMC10261071 DOI: 10.1017/s1368980018002148] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 06/27/2018] [Accepted: 07/31/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Studies have shown that the consumption of added sugars may be associated with harmful health effects. The present study investigated the presence and types of added sugars in packaged foods. DESIGN Cross-sectional analysis of the presence and types of added sugars in the ingredients lists of packaged foods sold in a major Brazilian supermarket. The nomenclature of ingredients classified as added sugars and their frequency were identified. Data were organised and analysed through descriptive statistics: absolute and relative frequencies of the presence of added sugars categorised by food groups were calculated, and ingredients were analysed by text mining using R statistical environment. SETTING A supermarket in Florianópolis, a metropolis in southern Brazil. SUBJECTS Packaged food products (n 4539) classified into eight groups. RESULTS Of the 4539 products, 71 % had some type of added sugar. The group with the highest frequency of added sugars was 'products in which carbohydrates and fats are the main energy source' (93 %). Food groups containing predominantly salty foods had a high frequency of added sugars, such as 'meats and eggs' (61 %). In total, 179 different terms for added sugars were identified, of which sugar, maltodextrin and glucose syrup were the most frequent. CONCLUSIONS Most of the packaged foods sold in Brazil contain added sugars, which may hamper adherence to the recommendation of limiting added sugars intake. The data may be useful for monitoring tendencies in the use of added sugars in packaged foods and as supplementary information to support the improvement of food label regulations.
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Affiliation(s)
- Tailane Scapin
- Nutrition Postgraduate Program (Programa de Pós-graduação em Nutrição – PPGN) and Nutrition in Foodservice Research Centre (Núcleo de Pesquisa de Nutrição em Produção de Refeições – NUPPRE), Federal University of Santa Catarina (Universidade Federal de Santa Catarina – UFSC), Health Sciences Centre, Reitor João David Ferreira Lima Campus, Florianópolis– SC, 88040-900, Brazil
| | - Ana Carolina Fernandes
- Nutrition Postgraduate Program (Programa de Pós-graduação em Nutrição – PPGN) and Nutrition in Foodservice Research Centre (Núcleo de Pesquisa de Nutrição em Produção de Refeições – NUPPRE), Federal University of Santa Catarina (Universidade Federal de Santa Catarina – UFSC), Health Sciences Centre, Reitor João David Ferreira Lima Campus, Florianópolis– SC, 88040-900, Brazil
- Department of Nutrition (Departamento de Nutrição), Federal University of Santa Catarina (Universidade Federal de Santa Catarina – UFSC), Health Sciences Centre, Florianópolis, SC, Brazil
| | - Adilson dos Anjos
- Department of Statistics (Departamento de Estatística), Federal University of Paraná (Universidade Federal do Paraná – UFPR), Curitiba, PR, Brazil
| | - Rossana Pacheco da Costa Proença
- Nutrition Postgraduate Program (Programa de Pós-graduação em Nutrição – PPGN) and Nutrition in Foodservice Research Centre (Núcleo de Pesquisa de Nutrição em Produção de Refeições – NUPPRE), Federal University of Santa Catarina (Universidade Federal de Santa Catarina – UFSC), Health Sciences Centre, Reitor João David Ferreira Lima Campus, Florianópolis– SC, 88040-900, Brazil
- Department of Nutrition (Departamento de Nutrição), Federal University of Santa Catarina (Universidade Federal de Santa Catarina – UFSC), Health Sciences Centre, Florianópolis, SC, Brazil
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Serving Size and Nutrition Labelling: Implications for Nutrition Information and Nutrition Claims on Packaged Foods. Nutrients 2018; 10:nu10070891. [PMID: 30002339 PMCID: PMC6073381 DOI: 10.3390/nu10070891] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/08/2018] [Accepted: 06/23/2018] [Indexed: 12/13/2022] Open
Abstract
The presentation of nutrition information on a serving size basis is a strategy that has been adopted by several countries to promote healthy eating. Variation in serving size, however, can alter the nutritional values reported on food labels and compromise the food choices made by the population. This narrative review aimed to discuss (1) current nutrition labelling legislation regarding serving size and (2) the implications of declared serving size for nutrition information available on packaged foods. Most countries with mandatory food labelling require that serving size be presented on food labels, but variation in this information is generally allowed. Studies have reported a lack of standardisation among serving sizes of similar products which may compromise the usability of nutrition information. Moreover, studies indicate that food companies may be varying serving sizes as a marketing strategy to stimulate sales by reporting lower values of certain nutrients or lower energy values on nutrition information labels. There is a need to define the best format for presenting serving size on food labels in order to provide clear and easily comprehensible nutrition information to the consumer.
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Where are the low-calorie sweeteners? An analysis of the presence and types of low-calorie sweeteners in packaged foods sold in Brazil from food labelling. Public Health Nutr 2017; 21:447-453. [PMID: 29072154 DOI: 10.1017/s136898001700283x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Studies have shown that consumption of low-calorie sweeteners (LCS) may be associated with harmful health effects. The current study investigated the presence and types of LCS added to packaged foods. DESIGN Cross-sectional study analysing the presence and types of LCS in the ingredients lists of packaged foods sold at a major Brazilian supermarket. To identify types of LCS allowed for use in foods in Brazil, current legislation was consulted. Data were organised and analysed through descriptive statistics, presenting simple and relative frequencies of LCS presence categorised by food group. SETTING Supermarket in Florianópolis, southern Brazil. SUBJECTS Packaged food products (n 4539) from eight food groups. RESULTS One or more LCS were found in 602 (13·3 %) of the packaged foods analysed. There were 1329 citations of LCS among these foods, with a mean of 2·2 sweeteners per food. Groups with the highest frequency of foods containing LCS were: products with energy derived from carbohydrates and fats (25·0 %); milk and dairy products (11·7 %); bakery products, cereals, legumes, roots and tubers (11·2 %); and fruits, juices, nectars and fruit drinks (8·3 %). CONCLUSIONS There was high prevalence of packaged foods with LCS, especially in food groups that form the basis of the Brazilian diet. The study was the first to extensively analyse the presence and types of LCS in packaged foods available for sale in a Brazilian supermarket and can be useful to monitor the use of LCS in these foods, as well as to support future changes in legislation to label sugars.
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Nieto C, Rincon-Gallardo Patiño S, Tolentino-Mayo L, Carriedo A, Barquera S. Characterization of Breakfast Cereals Available in the Mexican Market: Sodium and Sugar Content. Nutrients 2017; 9:nu9080884. [PMID: 28813010 PMCID: PMC5579677 DOI: 10.3390/nu9080884] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/27/2017] [Accepted: 08/03/2017] [Indexed: 12/31/2022] Open
Abstract
Preschool Mexican children consume 7% of their total energy intake from processed breakfast cereals. This study characterized the nutritional quality and labelling (claims and Guideline Daily Amount (GDA)) of the packaged breakfast cereals available in the Mexican market. Photographs of all breakfast cereals available in the 9 main food retail chains in the country were taken. The nutrition quality of cereals was assessed using the United Kingdom Nutrient Profiling Model (UKNPM). Claims were classified using the International Network for Food and Obesity/non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) taxonomy and the GDA was defined according to the Mexican regulation, NOM-051. Overall, a total of 371 different breakfast cereals were analysed. The nutritional profile showed that 68.7% were classified as “less healthy”. GDAs and claims were displayed more frequently on the “less healthy” cereals. Breakfast cereals within the “less healthy” category had significantly higher content of energy, sugar and sodium (p < 0.001). Most of the claims were displayed in the “less healthy” cereals (n = 313). This study has shown that there is a lack of consistency between the labelling on the front of the pack and the nutritional quality of breakfast cereals.
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Affiliation(s)
- Claudia Nieto
- Instituto Nacional de Salud Pública, Av. Universidad 655, Col. Santa María Ahuacatitlán, Cuernavaca C.P 62100, Morelos, Mexico.
| | | | - Lizbeth Tolentino-Mayo
- Instituto Nacional de Salud Pública, Av. Universidad 655, Col. Santa María Ahuacatitlán, Cuernavaca C.P 62100, Morelos, Mexico.
| | - Angela Carriedo
- London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK.
| | - Simón Barquera
- Instituto Nacional de Salud Pública, Av. Universidad 655, Col. Santa María Ahuacatitlán, Cuernavaca C.P 62100, Morelos, Mexico.
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Nilson EAF, Spaniol AM, Gonçalves VSS, Moura I, Silva SA, L'Abbé M, Jaime PC. Sodium Reduction in Processed Foods in Brazil: Analysis of Food Categories and Voluntary Targets from 2011 to 2017. Nutrients 2017; 9:nu9070742. [PMID: 28704932 PMCID: PMC5537856 DOI: 10.3390/nu9070742] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/07/2017] [Accepted: 07/10/2017] [Indexed: 01/10/2023] Open
Abstract
Non-communicable diseases, including cardiovascular diseases, are responsible for over 70% of deaths in Brazil. Currently, over 25% of Brazilian adults are diagnosed as hypertensive; overall, current dietary sodium intake in Brazil (4700 mg/person) is over twice the international recommendations, and 70-90% of adolescents and adults consume excessive sodium. National sodium reduction strategies consider the main dietary sources of sodium to be added salt to foods, foods consumed outside of the household, and sodium in processed foods. The national voluntary strategy for sodium reduction in priority food categories has been continuously monitored over a 6-year period (2011-2017) and there was a significant 8-34% reduction in the average sodium content of over half food categories. Different food categories have undergone differing reductions in sodium over time, aiding gradual biannual targets to allow industries to develop new technologies and consumers to adapt to foods with less salt. By 2017, most products of all food categories had met the regional targets proposed by the Pan American Health Organization, showing that voluntary sodium reduction strategies can potentially contribute to food reformulation. Nevertheless, regulatory approaches may still be necessary in the future in order to reach all food producers and to allow stronger enforcement to meet more stringent regional targets.
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Affiliation(s)
- Eduardo A F Nilson
- Ministry of Health of Brazil, Brasilia 70058-900, Brazil.
- Global Health and Sustainability Program, University of Sao Paulo, Sao Paulo 01255-001, Brazil.
| | - Ana M Spaniol
- Ministry of Health of Brazil, Brasilia 70058-900, Brazil.
| | | | - Iracema Moura
- Ministry of Health of Brazil, Brasilia 70058-900, Brazil.
| | - Sara A Silva
- Ministry of Health of Brazil, Brasilia 70058-900, Brazil.
| | - Mary L'Abbé
- University of Toronto, Toronto, ON M5S 2E8, Canada.
| | - Patricia C Jaime
- Department of Nutrition, University of Sao Paulo, Sao Paulo 01255-001, Brazil.
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Mendonça RDD, Lopes ACS, Pimenta AM, Gea A, Martinez-Gonzalez MA, Bes-Rastrollo M. Ultra-Processed Food Consumption and the Incidence of Hypertension in a Mediterranean Cohort: The Seguimiento Universidad de Navarra Project. Am J Hypertens 2017; 30:358-366. [PMID: 27927627 DOI: 10.1093/ajh/hpw137] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/14/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Some available evidence suggests that high consumption of ultra-processed foods (UPFs) is associated with a higher risk of obesity. Collectively, this association and the nutritional characteristics of UPFs suggest that UPFs might also be associated with hypertension. METHODS We prospectively evaluated the relationship between UPF consumption and the risk of hypertension in a prospective Spanish cohort, the Seguimiento Universidad de Navarra project. We included 14,790 Spanish adult university graduates who were initially free of hypertension at baseline who were followed for a mean of 9.1 years (SD, 3.9 years; total person-years: 134,784). UPF (industrial formulations of chemical compounds which, beyond substances of common culinary use such as salt, sugar, oils, and fats, include substances also derived from foods but not used in culinary preparations) consumption was assessed using a validated semi-quantitative 136-item food-frequency questionnaire. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for hypertension incidence. RESULTS During follow-up, 1,702 incident cases of hypertension were identified. Participants in the highest tertile of UPF consumption had a higher risk of developing hypertension (adjusted HR, 1.21; 95% CI, 1.06, 1.37; P for trend = 0.004) than those in the lowest tertile after adjusting for potential confounders. CONCLUSIONS In this large prospective cohort of Spanish middle-aged adult university graduates, a positive association between UPF consumption and hypertension risk was observed. Additional longitudinal studies are needed to confirm our results.
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Affiliation(s)
- Raquel de Deus Mendonça
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Departament of Nutrition, School of Nursing, Federal University of Minas Gerais, Belo Horizonte, Brazil
- CAPES Foundation, Ministry of Education of Brazil, Brasília, Brazil
| | | | - Adriano Marçal Pimenta
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Department of Maternal-Child Nursing and Public Health, School of Nursing, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Alfredo Gea
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Navarra's Health Research Institute (IDISNA), Pamplona, Spain
- Biomedical Research Center Network on Physiopathology of Obesity and Nutrition (CIBERobn), Institute of Health Carlos III, Madrid, Spain
| | - Miguel Angel Martinez-Gonzalez
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Navarra's Health Research Institute (IDISNA), Pamplona, Spain
- Biomedical Research Center Network on Physiopathology of Obesity and Nutrition (CIBERobn), Institute of Health Carlos III, Madrid, Spain
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, USA
| | - Maira Bes-Rastrollo
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- Navarra's Health Research Institute (IDISNA), Pamplona, Spain
- Biomedical Research Center Network on Physiopathology of Obesity and Nutrition (CIBERobn), Institute of Health Carlos III, Madrid, Spain
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