Ultra-Processing or Oral Processing? A Role for Energy Density and Eating Rate in Moderating Energy Intake from Processed Foods

Ultra-processed foods cause weight gain and increased energy intake associated with reduced chewing frequency: A randomized, open-label, crossover study

AIM

To elucidate the effects of ultra-processed foods (UPFs) on body weight and ad libitum energy intake compared with non-UPFs.

MATERIALS AND METHODS

In this randomized, open-label crossover study conducted at the University of Tokyo Hospital, overweight/obese Japanese male participants were randomly assigned (1:1) to start the study with consumption of either UPFs or non-UPFs for 1 week, followed by a 2-week washout period, before crossing over to the alternate food diet for 1 week. Individuals with diabetes, hypertension or any other medical conditions who visited a hospital regularly were excluded. The meals were designed to be matched for the total energy and macronutrient levels. The primary outcome was the difference in the body weight change between the UPF and non-UPF periods. The differences in the average daily energy intake and chewing frequency were assessed as one of the prespecified secondary outcomes.

RESULTS

Nine eligible participants were randomly assigned to start the study with either UPFs or non-UPFs. All participants completed the study. During the UPF period, participants gained 1.1 kg more weight (95% confidence interval 0.2 to 2.0; P = .021) and consumed 813.5 kcal more per day (342.4 to 1284.7; P = .0041) compared with during the non-UPF period. Regarding the chewing frequency, the number of chews per calorie was significantly lower during the UPF period (P = .016).

CONCLUSIONS

Consumption of UPFs causes significant weight gain. Medical nutritional therapy focused on reducing the consumption of UPFs could be an effective strategy for preventing obesity.

Food additives associated with gut dysbiosis in processed and ultra-processed products commercialized in the Uruguayan market

Recent empirical evidence suggests that gut dysbiosis is one of the negative health outcomes potentially associated with chronic consumption of some food additives. In this context, the present study aimed at analyzing the disclosure of food additives associated with gut dysbiosis in the labels of products commercialized in the Uruguayan market. A cross-sectional survey of packaged products commercialized in nine supermarkets was conducted between August and September 2021. All packaged processed and ultra-processed products available in each data collection site were surveyed using a cellphone app. The information available on the labels was manually extracted and the disclosure of food additives was analyzed using a computer assisted approach. Results showed that 38.1% of the products disclosed at least one food additive associated with gut dysbiosis. Disclosure was most frequent in ice-cream and popsicles, beverages, meat products and analogues, desserts, and fats, oils and fat and oil emulsions. Potassium sorbate was the individual additive associated with gut dysbiosis most frequently disclosed on the labels, followed by mono- and di-glycerides of fatty acid, sucralose, carboxymethylcellulose, acesulphame potassium, carrageenan, and sodium benzoate. These food additives frequently co-occurred and network analysis enabled the identification of patterns of co-occurrence. Taken together, results from the present work suggest the need to conduct additional research to assess the intake of food additives associated with gut dysbiosis at the population level, as well as to evaluate potential synergistic effects of food additives.

Ultraprocessed food consumption and risk of gallstone disease: analysis of 3 prospective cohorts

BACKGROUND

Majority of dietary intake in United States adults comes from ultraprocessed foods (UPFs), which have been linked to several adverse health outcomes. Gallstone disease is highly prevalent and constitutes a significant burden to the United States health system but remains understudied.

OBJECTIVES

This study aimed to investigate the association between UPF consumption and incident gallstone disease risk.

METHODS

In this analysis, 44,149 males in the Health Professionals' Follow-up Study (HPFS: 1986-2022), 71,145 females in the Nurses' Health Study (NHS: 1986-2021), and 90,932 females in the NHS II (1991-2021) were prospectively followed. Dietary intake was quadrennially assessed with semiquantitative food frequency questionnaires and used to identify UPFs. The primary outcome was defined as cholecystectomy. Cox proportional hazards model was used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

Baseline median age was 54 y in HPFS, 53 y in NHS, and 36 y in NHS II. We identified 32,374 incident gallstone disease cases over 5,077,059 person-years. Participants in the highest UPF quintile had a higher incidence of gallstone disease than those in the lowest quintile (aHR: 1.29; 95% CI: 1.24, 1.36; P < 0.001). Incremental risk of incident gallstone disease was 2.8% per daily serving (95% CI: 2.4%, 3.2%; P < 0.001). This risk was driven by sugar-sweetened beverages and artificially sweetened beverages on UPF subgroup analyses. The proportion of risk mediated by obesity was 12.8% (95% CI: 7.7%, 20.5%; P < 0.001) in HPFS, 14.3% (95% CI: 10.4%, 19.4%; P < 0.001) in NHS, and 39.4% (95% CI: 31.2%, 48.1%; P < 0.001) in NHS II. The partial population attributable risk was estimated at 15.9% (95% CI: 13.4%, 18.3%).

CONCLUSIONS

UPF consumption is associated with a higher risk of gallstone disease, particularly consumption of sugar-sweetened beverages and artificially sweetened beverages. A substantial proportion of this risk is potentially mediated by obesity in younger females.

The consumption of ultra-processed foods was associated with adiposity, but not with metabolic indicators in a prospective cohort study of Chilean preschool children

BACKGROUND

Increasing consumption of ultra-processed foods (UPF) has been identified as a risk factor for obesity and various diseases, primarily in adults. Nonetheless, research in children is limited, especially regarding longitudinal studies with metabolic outcomes. We aimed to evaluate the longitudinal association between consumption of UPF, adiposity, and metabolic indicators in Chilean preschool children.

METHODS

We conducted a prospective analysis of 962 children enrolled in the Food and Environment Chilean Cohort (FECHIC). Dietary data were collected in 2016 at age 4 years with 24-h recalls. All reported foods and beverages were classified according to the NOVA food classification, and the usual consumption of UPF in calories and grams was estimated using the Multiple Source Method. Adiposity (z-score of body mass index [BMI z-score], waist circumference [WC], and fat mass [in kg and percentage]) and metabolic indicators (fasting glucose, insulin, HOMA-IR, triglycerides, total cholesterol, and cholesterol fractions) were measured in 2018, at the age of 6 years. Linear regression models ((0) crude, (1) adjusted for covariables, and (2) adjusted for covariables plus total caloric intake) were used to evaluate the association between UPF and outcomes. All models included inverse probability weights to account for the loss to the follow-up.

RESULTS

At 4 years, usual consumption of UPF represented 48% of the total calories and 39% of the total food and beverages grams. In models adjusted for covariables plus caloric intake, we found a positive association between UPF and BMI z-score (for 100 kcal and 100 g, respectively: b = 0.24 [95%CI 0.16-0.33]; b = 0.21 [95%CI 0.10-0.31]), WC in cm (b = 0.89 [95%CI 0.41-1.37]; b = 0.86 [95%CI 0.32-1.40]), log-fat mass in kg b = 0.06 [95%CI 0.03-0.09]; b = 0.04 [95%CI 0.01-0.07]), and log-percentage fat mass (b = 0.03 [95%CI 0.01-0.04]; b = 0.02 [95%CI 0.003-0.04]), but no association with metabolic indicators.

CONCLUSIONS

In this sample of Chilean preschoolers, we observed that higher consumption of UPF was associated with adiposity indicators 2 years later, but not with metabolic outcomes. Longer follow-up might help clarify the natural history of UPF consumption and metabolic risks in children.

Toward a science-based classification of processed foods to support meaningful research and effective health policies

Processed foods have been part of the American diet for decades, with key roles in providing a safe, available, affordable, and nutritious food supply. The USDA Food Guides beginning in 1916 and the US Dietary Guidelines for Americans (DGA) since 1980 have included various types of commonly consumed processed foods (e.g., heated, fermented, dried) as part of their recommendations. However, there are multiple classification systems based on "level" of food processing, and additional evidence is needed to establish the specific properties of foods classified as "highly" or "ultra"-processed (HPF/UPFs). Importantly, many foods are captured under HPF/UPF definitions, ranging from ready-to-eat fortified whole grain breakfast cereals to sugar-sweetened beverages and baked goods. The consequences of implementing dietary guidance to limit all intake of foods currently classified as HPF/UPF may require additional scrutiny to evaluate the impact on consumers' ability to meet daily nutrient recommendations and to access affordable food, and ultimately, on health outcomes. Based on a meeting held by the Institute for the Advancement of Food and Nutrition Sciences in May 2023, this paper provides perspectives on the broad array of foods classified as HPF/UPFs based on processing and formulation, including contributions to nutrient intake and dietary patterns, food acceptability, and cost. Characteristics of foods classified as UPF/HPFs are considered, including the roles and safety approval of food additives and the effect of food processing on the food matrix. Finally, this paper identifies information gaps and research needs to better understand how the processing of food affects nutrition and health outcomes.

Infants' Dietary Pattern Characterized by Ultraprocessed Foods Is Associated With Rapid Weight Gain and Overweight/Obesity Risk: National Health and Nutrition Examination Survey 2009-2018

BACKGROUND

Global trends toward childhood obesity have been associated with several factors, including suboptimal infant feeding practices, the increasing availability of ultraprocessed foods in the world's food supply, and the corresponding changes in children's dietary patterns.

OBJECTIVE

To describe infants' dietary patterns and assess their associations with weight status outcomes in a nationally representative sample of US infants.

DESIGN

Cross-sectional analyses were performed on data collected from infants participating in the 2009-2018 National Health and Nutrition Examination Survey.

PARTICIPANTS/SETTING

Participants included 744 infants aged 6 to 12 months who had data from at least 1 day of valid 24-hour dietary recall data.

MAIN OUTCOME MEASURES

Rapid weight gain and overweight/obesity risk.

STATISTICAL ANALYSES PERFORMED

Principal component analysis was used to identify dietary patterns considering the energy intake of 39 Nova food subgroups (expressed in calories per day), including breast milk. Associations were evaluated using logistic regression adjusted for potential confounders.

RESULTS

A total of 42% infants experienced rapid weight gain, and 33% were at risk of overweight/obesity. Most infants (65.5%) were started on solid foods early. Three main dietary patterns were derived. The first pattern, labeled Natural or Minimally Processed Foods, had positive loadings for a variety of natural or minimally processed foods, some processed culinary ingredients, and a few processed and ultraprocessed foods. The second pattern, labeled Infant Formula, had high negative loading for breast milk, and high positive loading for infant formula and breakfast cereal. The third pattern, labeled Ultraprocessed Foods, had negative loadings for natural or minimally processed foods and processed culinary ingredients, positive loadings for other processed foods and for a variety of ultraprocessed foods, and negative loading for infant formula. Infants who adhere to the Ultraprocessed Foods dietary pattern were more likely to present rapid weight gain (adjusted odds ratio 1.3, 95% CI 1.1 to 1.5) and overweight/obesity risk (adjusted odds ratio 1.2, 95% CI 1.0 to 1.4).

CONCLUSIONS

Higher adherence to a dietary pattern characterized by ultraprocessed foods was associated with a greater likelihood of both rapid weight gain and overweight/obesity risk early in life. Promoting breastfeeding and increasing consumption of unprocessed/minimally processed foods during early infancy while restricting ultraprocessed foods are key components to reducing the growing burden of childhood obesity.

Ultra-processing should be understood as a holistic issue, from food matrix, to dietary patterns, food scoring, and food systems

The ultra-processed food (UPF) concept first emerged 15 years ago, and is now studied worldwide in different contexts, for example, human health, food behavior, socio-economic, food consumption, food scoring, and food system sustainability. Briefly, UPFs are defined as containing at least one marker of ultra-processing (MUP). MUPs are (1) cosmetic additives, (2) aromas, (3) some highly processed carbohydrates, proteins, fats, and/or fiber, and (4) drastic processes directly applied to food such as extrusion cooking or puffing. The first three categories of MUPs are on the food packaging in the list of ingredients, and are extracted, then purified, from raw foods or coming from artificial syntheses, leading to a-matrix/a-cellular compounds. Therefore, the core paradigm to define MUP is extreme food matrix degradation, and for UPF, matrix artificialization. Besides, UPFs are more than just junk food, encompassing numerous industrialized foods, falsely presented as healthy, for example, animal-based food analogs, but also organic, vegan, gluten-free, micronutrient-enriched, and/or light foods. In this way, UPFs are "high-quality junk foods." Otherwise, UPF being a holistic and indivisible concept by essence, we propose in this review to analyze ultra-processing at four holistic levels corresponding to four important scientific issues: the food matrix, the dietary pattern, food system, and food scoring. We reached the main conclusion that UPFs should be first studied with a holistic and scientifically based approach, not a reductionist one. Otherwise, we take the risk of performing greenwashing and create still more new health threats at a global level.

Isocaloric replacement of ultraprocessed foods was associated with greater weight loss in the POUNDS Lost trial

OBJECTIVE

Higher intake of ultraprocessed foods (UPFs) is associated with obesity. We examined whether replacing UPFs (NOVA 4) with minimally processed foods and culinary ingredients (NOVA 1 + 2) was associated with differential weight change in this secondary prospective analysis of the Preventing Overweight Using Novel Dietary Strategies (POUNDS) Lost trial.

METHODS

We estimated percent energy intake (%kcal) from the four NOVA groups using 24-h dietary recalls in a subset of 356 participants. Multivariable-adjusted substitution models examined whether replacing %kcal from UPFs with NOVA 1 + 2 was associated with greater weight, body fat percentage, trunk fat, and waist circumference reduction at 6 months; changes in parameters were compared among NOVA 1 + 2 tertiles (T).

RESULTS

Participants were on average 52.3 years of age, 85% White, 55% female, and 58.2% nonsmoking, with a mean BMI of 32.7 kg/m2. Replacing 10%kcal of UPFs with NOVA 1 + 2 was associated with greater 6-month weight (ß = 0.51, 95% CI: -0.93 to -0.09, p = 0.02), body fat percentage (ß = 2.7, 95% CI: -5.10 to -0.43, p = 0.02), and trunk fat reduction (ß = 3.9, 95% CI: -7.01 to -0.70, p = 0.02), but not waist circumference reduction. Participants in T3 (-8.33 kg) versus T1 (-5.32 kg) of NOVA 1 + 2 had greater weight loss (p < 0.001).

CONCLUSIONS

Isocaloric substitution of UPFs with NOVA 1 + 2 was associated with marginally greater weight loss under energy restriction. These modest findings support more research exploring the mechanisms linking UPFs with body weight regulation beyond energy intake.

Associations of Ultra-Processed Food Intake with Body Fat and Skeletal Muscle Mass by Sociodemographic Factors

BACKGRUOUND

The effects of excessive ultra-processed food (UPF) consumption on body composition measures or sociodemographic disparities are understudied in Korea. We aimed to investigate the association of UPF intake with percent body fat (PBF) and percent appendicular skeletal muscle mass (PASM) by sociodemographic status in adults.

METHODS

This study used data from the Korea National Health and Nutrition Examination Survey 2008-2011 (n=11,123 aged ≥40 years). We used a NOVA system to classify all foods reported in a 24-hour dietary recall, and the percentage of energy intake (%kcal) from UPFs was estimated. PBF and PASM were measured by dual-energy X-ray absorptiometry. Tertile (T) 3 of PBF indicated adiposity and T1 of PASM indicated low skeletal muscle mass, respectively. Multinomial logistic regression models were used to estimate odds ratios (OR) with 95% confidence interval (CI) after adjusting covariates.

RESULTS

UPF intake was positively associated with PBF-defined adiposity (ORper 10% increase, 1.04; 95% CI, 1.002 to 1.08) and low PASM (ORper 10% increase, 1.05; 95% CI, 1.01 to 1.09). These associations were stronger in rural residents (PBF: ORper 10% increase, 1.14; 95% CI, 1.06 to 1.23; PASM: ORper 10% increase, 1.15; 95% CI, 1.07 to 1.23) and not college graduates (PBF: ORper 10% increase, 1.06; 95% CI, 1.02 to 1.11; PASM: ORper 10% increase, 1.07; 95% CI, 1.03 to 1.12) than their counterparts.

CONCLUSION

A higher UPF intake was associated with higher adiposity and lower skeletal muscle mass among Korean adults aged 40 years and older, particularly in those from rural areas and with lower education levels.

Type and timing of ultra-processed foods consumption and its association with dietary intake and physical activity in women with obesity living in poverty

BACKGROUND

The present study aimed to investigate the type and timing of ultra-processed foods (UPF) consumption and its association with dietary intake (DI) and physical activity (PA) in women with obesity living in poverty.

METHODS

A cross-sectional study was employed. Obesity was defined by at least two criteria (body mass index, waist circumference or % fat mass). Poverty was defined as the three lowest classes of the Brazilian Economic Classification Criterion. PA was measured with triaxial accelerometers and DI was assessed with three 24-h dietary recalls. Foods were categorised according to the NOVA classification, with UPF classified into five subgroups, as well as the timing of consumption into six meals.

RESULTS

In total, 56 adult women were included. Overall energy intake was 1653.21 (503.22) kcal/day. UPF intake was 21.62% (11.94%) kcal/day, being higher at breakfast (4.91% kcal/day), afternoon snack (5.39% kcal/day) and dinner (5.01% kcal/day). Only UPF subgroup 4 (sandwich biscuits, sweets, or treats) showed a positive association with energy intake (β = 54.40 [27.6, 81.10] kcal/day) and a negative association with protein intake (β = -0.31% [-0.48%, -0.14%] kcal/day). UPF consumption in morning (β = -0.41% [-0.79%, -0.02%] kcal/day) and afternoon (β = -0.18% [-0.33%, -0.04%] kcal/day) snacks was associated with lower protein intake. Furthermore, lunchtime UPF consumption was positively associated with walking time (β = 0.16% [0.02%; 0.30%]) and steps/hour (β = 8.72 [1.50; 15.94] steps/h).

CONCLUSIONS

Women with obesity living in poverty consume more UPF during breakfast, afternoon snack and dinner. Physical activity is positively associated with UPF consumption at lunch. UPF, such as sandwich biscuits, sweets or treats, contribute to increasing energy intake and reducing protein intake.

Nutrients or processing? An analysis of food and drink items from the UK National Diet and Nutrition Survey based on nutrient content, the NOVA classification and front of package traffic light labelling

UK front of package labelling (FOPL) informs consumers on the nutrient content of food. However, FOPL does not consider food processing, and with the UK government being urged to act on ultra-processed food (UPF), whether UPF should be added to FOPL is unclear. This study compared food and drink in the UK National Diet and Nutrition Survey (NDNS) Intake24 database based on FOPL, nutrient content and NOVA classification, to understand whether UPF are covered by dietary recommendations for foods high in fat, salt and sugar. NDNS items were coded into minimally processed food (MPF), processed culinary ingredients, processed food and UPF according to the NOVA classification and FOPL traffic lights. UPF contained greater energy, fat, saturated fat (SF), total sugar (TS) and salt than MPF. UPF had a greater odds of containing red FOPL and an unhealthier overall FOPL score (OR:4·59 (95 % CI: 3·79, 5·57); OR:7·0 (95 % CI: 6·1, 8·2), respectively) and lower odds of containing green FOPL (OR:0·05 (95 % CI: 0·03, 0·10)), compared with MPFs. For items with no red FOPL, UPF still contained greater energy, fat, SF, TS and salt than MPF. However, several UPF have healthier FOPL scores. UPF had an unhealthier nutritional profile and FOPL score than MPF. For items with no red FOPL, UPF still had an unhealthier profile than MPF, with a higher energy density. Importantly, not all UPF were unhealthy according to FOPL. These results indicate partial overlap between FOPL, nutrient content and NOVA classification of UK food and drink products, with implications for UK food and drink labelling.

Ultra-processed Food and Obesity: What Is the Evidence?

PURPOSE OF REVIEW

Obesity is a growing global healthcare concern. A proposed driver is the recent increase in ultra-processed food (UPF) intake. However, disagreement surrounds the concept of UPF, the strength of evidence, and suggested mechanisms. Therefore, this review aimed to critically appraise the evidence on UPF and obesity.

RECENT FINDINGS

Observational studies demonstrate positive associations between UPF intake, weight gain, and overweight/obesity, more clearly in adults than children/adolescents. This is supported by high-quality clinical data. Several mechanisms are proposed, but current understanding is inconclusive. Greater UPF consumption has been a key driver of obesity. There is a need to change the obesogenic environment to support individuals to reduce their UPF intake. The UPF concept is a novel approach that is not explained with existing nutrient- and food-based frameworks. Critical analysis of methodologies provides confidence, but future observational and experimental research outputs with greater methodological rigor will strengthen findings, which are outlined.

The food and beverage cues in digital marketing model: special considerations of social media, gaming, and livestreaming environments for food marketing and eating behavior research

Digital marketing to children, teens, and adults contributes to substantial exposure to cues and persuasive messages that drive the overconsumption of energy dense foods and sugary beverages. Previous food marketing research has focused on traditional media, but less is known about how marketing techniques translate within digital platforms, such as social media, livestreaming, and gaming. Building upon previous theories and models, we propose a new model entitled food and beverage cues in digital marketing (FBCDM). The FBCDM model specifies key marking elements and marketing integration strategies that are common on digital platforms and are hypothesized to enhance the effects of advertising and incentive sensitization process. FBCDM also categorizes measurable outcomes into three domains that include brand, food, and social outcomes. Additionally, repeated marketing exposure and the resulting outcomes are hypothesized to have long term consequences related to consumer markets, consumption behavior, culture, and health. We include a discussion of what is currently known about digital marketing exposure within the outcome domains, and we highlight gaps in research including the long-term consequences of digital marketing exposure. The FBCDM model provides a conceptual framework to guide future research to examine the digital marketing of food and beverages to children and adolescents in order to inform government and industry policies that restrict the aggressive marketing of products associated with obesity and adverse diet related outcomes.

Examination of the interrelationships between nutrition, environmental sustainability and food-processing: A concept study using model diets

Recent work has focused on understanding the link between diet quality and environmental impact, however it is also important to consider the role food processing plays in this relationship. Using model meal plans, this paper examines the link between nutrient content, environmental impact, and processing. Four distinct meal plans were considered - 'Healthy', 'Unhealthy', 'Healthy (plant-based)', 'Healthy (plant-based, processed)'. For each a variety of environmental impact, processing and nutritional composition metrics were compared. Alternative healthy eating index (AHEI) score for the Unhealthy diet was significantly lower than the other three diets. The 'Healthy (plant-based)' diet had the highest AHEI score but was not significantly different to the 'Healthy (plant-based, processed)' and 'Healthy' diet scores. The greenhouse gas emissions for the two plant based diets were not significantly different to each other or to the 'Healthy' diet but were significantly lower than the 'Unhealthy' diet. The 'Healthy', 'Unhealthy', and 'Healthy (plant-based)' diets had similar processing specific energy consumption values however, the 'Healthy (plant-based, processed)' diets had significantly greater specific energy consumption. There was no clear link between diet quality and food processing when considered using processing specific energy value. When the number of processes in each diet was estimated, the unhealthier diet had considerably more processes associated with it. Examining the interaction of nutritional quality, environmental impact and processing of diets in this way highlights the complexity of the inter-relationships. Understanding these interactions is necessary to support the transition to healthy diets from sustainable sources.

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.

Ultraprocessed foods and chronic kidney disease-double trouble

High energy intake combined with low physical activity generates positive energy balance, which, when maintained, favours obesity, a highly prevalent morbidity linked to development of non-communicable chronic diseases, including chronic kidney disease (CKD). Among many factors contributing to disproportionately high energy intakes, and thereby to the obesity epidemic, the type and degree of food processing play an important role. Ultraprocessed foods (UPFs) are industrialized and quite often high-energy-dense products with added sugar, salt, unhealthy fats and food additives formulated to be palatable or hyperpalatable. UPFs can trigger an addictive eating behaviour and is typically characterized by an increase in energy intake. Furthermore, high consumption of UPFs, a hallmark of a Western diet, results in diets with poor quality. A high UPF intake is associated with higher risk for CKD. In addition, UPF consumption by patients with CKD is likely to predispose and/or to exacerbate uraemic metabolic derangements, such as insulin resistance, metabolic acidosis, hypertension, dysbiosis, hyperkalaemia and hyperphosphatemia. Global sales of UPFs per capita increased in all continents in recent decades. This is an important factor responsible for the nutrition transition, with home-made meals being replaced by ready-to-eat products. In this review we discuss the potential risk of UPFs in activating hedonic eating and their main implications for health, especially for kidney health and metabolic complications of CKD. We also present various aspects of consequences of UPFs on planetary health and discuss future directions for research to bring awareness of the harms of UPFs within the CKD scenario.

Speed limits: the effects of industrial food processing and food texture on daily energy intake and eating behaviour in healthy adults

PURPOSE

Frequent consumption of industrially processed foods has been associated with obesity. However, it is unknown what drives this association. Food textures of industrially processed foods that stimulate energy overconsumption may be an important driver of this association. Therefore, this study aimed to determine the independent and combined effects of food texture and level of industrial food processing (based on the NOVA classification) on daily energy intake and eating behaviour.

METHODS

Eighteen healthy adults (F/M: 11/7, 23 ± 3 y, 22.1 ± 2.0 kg/m2) participated in a 2 × 2 randomized crossover dietary intervention with four conditions (total of 288 meals): hard unprocessed, hard (ultra-)processed, soft unprocessed and soft (ultra-)processed. Daily diets were offered ad libitum and were equal in energy density (1 kcal/g). Food Intake (g) was measured by pre- and post-consumption weighing of the plates. Eating behaviour parameters were derived from video annotations.

RESULTS

Daily energy intake and food intake were, respectively, 33% (571 ± 135 kcal) and 14% (247 ± 146 g) lower in the hard compared to the soft conditions (main texture p < 0.001). Energy intake was lower in both hard conditions compared to the (ultra)processed soft condition (Tukey p < 0.04). Eating rate (g/min) was on average 85% slower (P < 0.001) in the hard compared to the soft conditions (p < 0.001). Level of processing did not affect food intake.

CONCLUSION

Consumption of hard-textured foods reduces daily energy intake of (ultra-) processed foods. This preliminary investigation shows that there is great variability in food properties that affect energy and food intake beyond industrial food processing. However, findings should be interpreted with precaution considering the limited sample size of this trial. Future classification systems for public health messaging should include energy intake rate to help reduce overconsumption.

CLINICAL TRIAL REGISTRY

NCT04280146, https://www.

CLINICALTRIALS

gov , February 21st 2020.

Factors associated with eating rate: a systematic review and narrative synthesis informed by socio-ecological model

Accumulating evidence shows associations between rapid eating and overweight. Modifying eating rate might be a potential weight management strategy without imposing additional dietary restrictions. A comprehensive understanding of factors associated with eating speed will help with designing effective interventions. The aim of this review was to synthesise the current state of knowledge on the factors associated with eating rate. The socio-ecological model (SEM) was utilised to scaffold the identified factors. A comprehensive literature search of eleven databases was conducted to identify factors associated with eating rate. The 104 studies that met the inclusion criteria were heterogeneous in design and methods of eating rate measurement. We identified thirty-nine factors that were independently linked to eating speed and mapped them onto the individual, social and environmental levels of the SEM. The majority of the reported factors pertained to the individual characteristics (n = 20) including demographics, cognitive/psychological factors and habitual food oral processing behaviours. Social factors (n = 11) included eating companions, social and cultural norms, and family structure. Environmental factors (n = 8) included food texture and presentation, methods of consumption or background sounds. Measures of body weight, food form and characteristics, food oral processing behaviours and gender, age and ethnicity were the most researched and consistent factors associated with eating rate. A number of other novel and underresearched factors emerged, but these require replication and further research. We highlight directions for further research in this space and potential evidence-based candidates for interventions targeting eating rate.

Ultra-Processed Food Consumption and Risk of Overweight or Obesity in Chinese Adults: Chinese Food Consumption Survey 2017-2020

Overweight and obesity have increased rapidly in the past few decades in China, and less research has focused on the association between the consumption of ultra-processed foods (UPFs) and overweight or obesity in Chinese adults. The objective of this study was to determine the relationship of UPF consumption with the risk of overweight or obesity in Chinese adults. Residents aged 18 years and above who participated in the nationally representative survey Chinese Food Consumption Survey in 2017-2020 were included in this study. Dietary intake data were collected via non-consecutive three-day 24 h dietary recalls and weighing household foods and condiments. According to the NOVA food classification system, UPFs were classified depending on the purpose and extent of food processing. Multiple logistic regression and multivariate-adjusted restricted cubic spline (RCS) regressions were performed to estimate the association between UPF consumption (categorized into quartiles: quartile 1 (Q1), quartile 2 (Q2), quartile 3 (Q3), and quartile 4 (Q4)) and risk of overweight or obesity. A total of 38,658 adults aged 18 years and above participated in the present study. The prevalence of overweight and obesity in adults was 33.0% (95% CI: 32.91-33.10) and 9.6% (95% CI 9.55-9.67), respectively. After a multivariable adjustment, the risk of overweight or obesity was increased by 10% in Q3 (OR: 1.10, 95% CI: 1.04-1.17) compared to Q1 as a reference. Women (OR: 1.10, 95% CI: 1.01-1.20) and adults living in small and medium-sized cities (OR: 1.13, 95% CI: 1.01-1.26) with higher UPF consumption had higher odds of overweight or obesity. Nevertheless, the effect of higher UPF consumption on the risk of overweight or obesity was relatively weak for overall adults in China. The top three categories of subgroups consumption of UPFs were 1: sugar-sweetened beverages; 2: sauces, cheeses, spreads, and gravies; and 3: ultra-processed breads and breakfast cereals. These findings provide evidence that higher UPF consumption was positively associated with overweight or obesity, which was defined based on Chinese criteria among women and adults living in small and medium-sized cities in China. Further studies, such as intervention trials, are needed to identify the mechanism of correlation between the consumption of UPFs and health-related outcomes in Chinese adults. From a public health perspective, with the prevalence of overweight and obesity growing and the increase in UPF consumption in Chinese adults, it is necessary to promote healthy food intake and a balanced diet through active nutritional education actions for overweight and obesity prevention and control.

From dearth to excess: the rise of obesity in an ultra-processed food system

More people now have obesity than suffer from starvation thanks to our modern food system. Agriculture was transformed over the 20th century by a variety of technological advancements that relied heavily on fossil fuels. In the United States, government policies and economic incentives led to surplus production of cheap inputs to processed food industries that produced a wide variety of heavily marketed, convenient, rewarding, timesaving, and relatively inexpensive ultra-processed foods. The energy available in the food supply increased by much more than the population needs, albeit with large inequities in nutrition security. While most of the rise in per capita food availability during the late 20th and early 21st centuries in the United States resulted in increased food waste, a variety of mechanisms have been proposed by which changes in the increasingly ultra-processed food environment resulted in excess energy intake disproportionately in people genetically susceptible to obesity. As populations continue to grow, substantial investments in coordinated nutrition and agricultural research are needed to transform our current food system to one that relies less on fossil fuels, preserves biodiversity, ensures environmental health, and provides equitable access to affordable, safe and nutritious food that reduces the prevalence of chronic diet-related diseases like obesity. This article is part of a discussion meeting issue 'Causes of obesity: theories, conjectures and evidence (Part I)'.

Beyond ultra-processed: considering the future role of food processing in human health

Food-based dietary guidelines have been the basis of public health recommendations for over half a century, but more recently, there has been a trend to classify the health properties of food not by its nutrient composition, but by the degree to which it has been processed. This concept has been supported by many association studies, narrative reviews and the findings from one randomised controlled feeding trial, which demonstrated the sustained effect of ultra-processed diets on increasing both energy intake and body weight. This has led to widespread speculation as to specific features of ultra-processed foods that promote increased energy intakes. Rising interest in the ultra-processed topic has led to proposals to include guidance and restrictions on the consumption of processed foods in national dietary guidelines, with some countries encouraging consumers to avoid highly processed foods completely, and only choose minimally processed foods. However, there remains a lack of consensus on the role of processed foods in human health when faced with the challenges of securing the food supply for a growing global population, that is, healthy, affordable and sustainable. There has also been criticism of the subjective nature of definitions used to differentiate foods by their degree of processing, and there is currently a lack of empirical data to support a clear mechanism by which highly processed foods promote greater energy intakes. Recommendations to avoid all highly processed foods are potentially harmful if they remove affordable sources of nutrients and will be impractical for most when an estimated two-thirds of current energy purchased are from processed or ultra-processed foods. The current review highlights some considerations when interpreting the dietary association studies that link processed food intake to health and offers a critique on some of the mechanisms proposed to explain the link between ultra-processed food and poor health. Recent research suggests a combination of higher energy density and faster meal eating rates are likely to influence meal size and energy intakes from processed foods and offers new perspectives on how to manage this in the future. In going beyond the ultra-processed debate, the aim is to summarise some important considerations when interpreting existing data and identify the important gaps for future research on the role of processed food in health.

Ultra-processed food consumption and obesity indicators in individuals with and without type 1 diabetes mellitus: a longitudinal analysis of the prospective Coronary Artery Calcification in Type 1 Diabetes (CACTI) cohort study

OBJECTIVE

To evaluate the associations of ultra-processed food (UPF) consumption and obesity indicators among individuals with and without type 1 diabetes mellitus (T1DM) from the Coronary Artery Calcification in Type 1 Diabetes cohort study.

DESIGN

A secondary analysis. The consumption of UPF was assessed using the dietary data collected with the Harvard FFQ, and each food item was categorised according to the NOVA food processing classification. Height, weight and waist circumference were measured at baseline and after a mean of 14·6-year follow-up. Generalised estimating equations stratified by diabetes status were used to assess the associations between UPF intake and obesity indicators over 14 years of follow-up.

SETTING

USA.

PARTICIPANTS

A total of 600 adults (256 T1DM and 344 non-diabetic controls) aged 39 ± 9·1 years at baseline and followed up for over 14 years were included.

RESULTS

Participants with T1DM consumed significantly more UPF than non-diabetic controls at baseline: 7·6 ± 3·8 v. 6·6 ± 3·4 servings per day of UPF, respectively (P < 0·01). Participants with T1DM and with the highest UPF intake had the highest weight (βQ4 v. Q1 = 3·07) and BMI (βQ4 v. Q1 = 1·02, all P < 0·05) compared with those with the lowest UPF intake. Similar positive associations were observed in non-diabetic controls.

CONCLUSIONS

Individuals with T1DM may consume more UPF than non-diabetic controls. Positive associations between UPF consumption and obesity indicators suggest that limiting UPF can be recommended for obesity prevention and management. Further research is needed to confirm these findings.

Ultra-processed foods in public health nutrition: the unanswered questions

There is a growing interest in the study of the degree of food processing and both health and nutritional outcomes. To that end, several definitions of the degree of processing have been proposed. However, when each of these is used on a common database of nutritional, clinical and anthropometric variables, the observed effect of high intakes of highly processed food, varies considerably.. Moreover, assigning a given food by nutritional experts, to its appropriate level of processing, has been shown to be variable. Thus, the subjective definitions of the degree of food processing and the coding of foods according to these classifications is prone to error is prone to error. Another issue that need resolution is the relative importance of the degree of food processing and the formulation of a processed food. Although correlational studies linking processed food and obesity abound, there is a need for more investigative studies.

Effect of ultra-processed food intake on metabolic syndrome components and body fat in children and adolescents: A systematic review based on cohort studies

OBJECTIVES

The aim of this study was to thoroughly review the scientific literature related to cohort studies that evaluated the association between the intake of ultra-processed foods, according to the NOVA classification, and the increase in the components of metabolic syndrome and body fat in children and adolescents.

METHODS

We consulted the PubMed, Scielo, Lilacs, and ScienceDirect databases and selected cohort studies that met the main objective of this review and included the age group of interest. We used an adaptation of the Newcastle-Ottawa scale to evaluate cohort studies.

RESULTS

Of 383 articles identified, 367 were excluded after reading the title, abstract, and methodology. Only nine met the selection criteria defined for this review. Of the nine articles, two reported a positive association between high consumption of ultra-processed foods and total cholesterol levels; one reported a positive association with low-density lipoprotein cholesterol, one with triacylglycerols, one with diastolic blood pressure, three with body mass index, two with waist circumference, and two with body fat.

CONCLUSIONS

Seven of nine studies found at least one association with components of metabolic syndrome. This highlights the importance of early intervention to prevent non-communicable diseases in the future.

Highly Processed Food Consumption and Its Association with Anthropometric, Sociodemographic, and Behavioral Characteristics in a Nationwide Sample of 2742 Japanese Adults: An Analysis Based on 8-Day Weighed Dietary Records

This cross-sectional study assessed highly processed food (HPF) consumption and its association with individual characteristics in a nationwide sample of Japanese adults. Eight-day weighed dietary records were obtained from 2742 free-living adults aged 18-79 years across Japan. HPFs were identified based on a classification method developed by researchers at the University of North Carolina at Chapel Hill. The basic characteristics of the participants were assessed using a questionnaire. On average, HPF contributed to 27.9% of daily energy intake. The contribution of HPF to the daily intake of 31 nutrients ranged from 5.7% for vitamin C to 99.8% for alcohol (median, 19.9%). Cereals and starchy foods were the main food groups that contributed to the total energy intake of HPF. Multiple regression analysis showed that the older group (60-79 years) had a lower HPF energy contribution than the younger group (18-39 y) (regression coefficient (β) = -3.55, p < 0.0001). Compared to current smokers, past and never-smokers had lower HPF energy contributions (β = -1.41, p < 0.02; and -4.20, p < 0.0001, respectively). In conclusion, HPFs account for approximately one-third of energy intake in Japan. Younger age and current smoking status should be considered in future intervention strategies to reduce HPF consumption.

Associations Between Eating Speed, Diet Quality, Adiposity, and Cardiometabolic Risk Factors

OBJECTIVE

To assess the associations between eating speed, adiposity, cardiometabolic risk factors, and diet quality in a cohort of Spanish preschool-children.

STUDY DESIGN

A cross-sectional study in 1371 preschool age children (49% girls; mean age, 4.8 ± 1.0 years) from the Childhood Obesity Risk Assessment Longitudinal Study (CORALS) cohort was conducted. After exclusions, 956 participants were included in the analyses. The eating speed was estimated by summing the total minutes used in each of the 3 main meals and then categorized into slow, moderate, or fast. Multiple linear and logistic regression models were fitted to assess the β-coefficient, or OR and 95% CI, between eating speed and body mass index, waist circumference, fat mass index (FMI), blood pressure, fasting plasma glucose, and lipid profile.

RESULTS

Compared with participants in the slow-eating category, those in the fast-eating category had a higher prevalence risk of overweight/obesity (OR, 2.9; 95% CI, 1.8-4.4; P < .01); larger waist circumference (β, 2.6 cm; 95% CI, 1.5-3.8 cm); and greater FMI (β, 0.3 kg/m²; 95% CI, 0.1-0.5 kg/m²), systolic blood pressure (β, 2.8 mmHg; 95% CI, 0.6-4.9 mmHg), and fasting plasma glucose levels (β, 2.7 mg/dL, 95% CI, 1.2-4.2 mg/dL) but lower adherence to the Mediterranean diet (β, -0.5 points; 95% CI, -0.9 to -0.1 points).

CONCLUSIONS

Eating fast is associated with higher adiposity, certain cardiometabolic risk factors, and lower adherence to a Mediterranean diet. Further long-term and interventional studies are warranted to confirm these associations.

Does the concept of "ultra-processed foods" help inform dietary guidelines, beyond conventional classification systems? YES

The recommendation to prefer unprocessed/minimally processed foods and freshly made meals instead of ultra-processed foods (following the Nova food classification system) is being increasingly adopted in new official dietary guidelines issued by national governments and international health associations. This recommendation is supported by systematic reviews and meta-analyses of nationally representative dietary surveys and long-term cohort studies. These data show that increased intake of ultra-processed foods is associated with poor-quality diets and with increased morbidity and mortality from several chronic diseases. Various attributes of ultra-processed foods acting through known, plausible, or suggested physiologic and behavioral mechanisms relate them to ill health, and it is likely that different combinations of attributes and mechanisms affect different health outcomes. Although more research should be done to identify these mechanisms, existing evidence is sufficient to recommend the avoidance of ultra-processed foods to optimize health and policies to support and make feasible this recommendation.

Does the concept of "ultra-processed foods" help inform dietary guidelines, beyond conventional classification systems? NO

The Nova classification of ultra-processed foods (UPFs) rests on poorly defined food processes and the presence of food additives from a chemically heterogeneous group, easily leading to misclassification. UPFs are claimed to promote overconsumption of energy and obesity due to high palatability, but little evidence supports effects beyond those that can be accounted for by nutrient composition, energy density, and food matrices. Observational studies link dietary intake of UPFs with obesity, but none have demonstrated independent associations after controlling for likely confounders. A highly cited randomized controlled feeding study that compared a UPF diet with an unprocessed diet showed a rapidly weaning effect on energy intake that can be entirely explained by more conventional and quantifiable dietary factors, including energy density, intrinsic fiber, glycemic load, and added sugar. Clearly, many aspects of food processing can affect health outcomes, but conflating them into the notion of ultra-processing is unnecessary, because the main determinants of chronic disease risk are already captured by existing nutrient profiling systems. In conclusion, the Nova classification adds little to existing nutrient profiling systems; characterizes several healthy, nutrient-dense foods as unhealthy; and is counterproductive to solve the major global food production challenges.

Ultra-processed foods in public health nutrition: the unanswered questions

There is a growing interest in the study of the degree of food processing and both health and nutritional outcomes. To that end, several definitions of the degree of processing have been proposed. However, when each of these is used on a common database of nutritional, clinical and anthropometric variables, the observed effect of high intakes of highly processed food, varies considerably.. Moreover, assigning a given food  by nutritional experts, to its appropriate level of processing, has been shown to be variable. Thus, the subjective definitions of the degree of food processing and the coding of foods according to these classifications is prone to error  is  prone to error. Another issue that need resolution is the relative importance of the degree of food processing and the formulation of a processed food. Although correlational studies linking processed food and obesity abound, there is a need for more investigative studies.

Ultra-processed foods and human health: from epidemiological evidence to mechanistic insights

Epidemiological studies have suggested a role for ultra-processed foods in numerous chronic inflammatory diseases such as inflammatory bowel diseases and metabolic syndrome. Preclinical and clinical studies are accumulating to better decipher the effects of various aspects of food processing and formulation on the aetiology of chronic, debilitating inflammatory diseases. In this Review, we provide an overview of the current data that highlight an association between ultra-processed food consumption and various chronic diseases, with a focus on epidemiological evidence and mechanistic insights involving the intestinal microbiota.

Consumption of ultra-processed foods and the eating location: can they be associated?

Studies indicate that eating locations can influence food choices. However, the relationship with ultra-processed foods has been little explored. The objective was to assess the association between eating locations and ultra-processed foods consumption in the UK in 2014-2016. Data from 2,449 individuals aged 4 years or older from the NDNS were analysed cross-sectionally. Food consumption information was collected through 4-day food diaries. Recorded foods were classified into NOVA system. The eating locations were grouped into nine categories (home, institutional places, sit-down restaurants, on the go, coffee shops, leisure and sports clubs, fast food, friends and relatives' house, and other places). Linear regression models were carried out. The coefficients represent the increment in the contribution of ultra-processed foods to total energy intake for each percentage point increase in the contribution of each eating location to total energy intake. Among children, consumption at home was inversely associated with ultra-processed foods consumption (β: -0.10; 95% CI -0.17, -0.03), while in leisure and sports places (0.47; 0.20, 0.73) directly associated. For adolescents, eating at home (-0.12; -0.19, -0.05) was inversely associated with the consumption of ultra-processed foods, as well as sit-down restaurants (-0.21; -0.38, -0.03). Fast food (0.29; 0.12, 0.47) were directly associated with the consumption of ultra-processed foods for adolescents. Finally, for adults, sit-down restaurants (-0.13; -0.22, -0.03) showed to be inversely associated with the consumption of ultra-processed foods while in fast food restaurants (0.77; 0.38, 1.17) it was directly associated. Our results showed that the eating locations have different impacts on diet quality.

The degree of food processing is associated with anthropometric measures of obesity in Canadian families with preschool-aged children

Adopting a healthy diet remains central for the prevention of obesity. In adults, higher intake of ultra-processed food is associated with a greater risk of overweight and obesity. However, little is known about the degree of food processing and its association with anthropometric measures in families with preschool-aged children, a critical period for the development of dietary patterns. This cross-sectional study included preschool-aged children (n = 267) between 1.5 and 5 years of age and their parents (n = 365) from 242 families enrolled in the Guelph Family Health Study. Dietary assessment was completed using ASA24-Canada-2016. Foods and beverages were classified based on their degree of food processing using the NOVA Classification (unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods). Associations between the energy contribution (% kcal) of each NOVA category and anthropometric measures were examined using linear regression models with generalized estimating equations, adjusted for sociodemographic variables. The energy contribution of ultra-processed foods was the highest relative to the other NOVA categories among parents (44.3%) and children (41.3%). The energy contribution of unprocessed or minimally processed foods was 29.1% for parents and 35.3% for children, processed foods was 24.0% for parents and 21.3% for children, and processed culinary ingredients was 2.6% for parents and 2.1% for children. Ultra-processed foods (% kcal) were positively associated with BMI (β = 0.04, 95% CI: 0.01–0.07, P = 0.02), waist circumference (β = 0.11, 95% CI: 0.03–0.18, P = 0.008) and body weight (β = 0.13, 95% CI: 0.03–0.22, P = 0.01) in parents, but not children. Unprocessed foods (% kcal) were negatively associated with waist circumference in parents (β = −0.09, 95% CI: 0.18–0.01, P = 0.03) and children (β = −0.03, 95% CI: 0.05–0.01, P = 0.01), as well as body weight (β = −0.12, 95% CI: 0.23–0.00, P = 0.04) in parents. The degree of food processing primarily influenced anthropometric outcomes in parents. Nevertheless, diets of children were similar, suggesting that such exposure in families may eventually lead to outcomes observed in parents.

Consumption of ultra-processed foods and growth outcomes in early childhood: 2015 Pelotas Birth Cohort

The current study aims to describe the consumption of ultra-processed foods, from 2 to 4 years old, and evaluate its association with growth outcomes during the same period. It is a prospective cohort study using data from the 2015 Pelotas-Brazil Birth Cohort. Outcomes assessed at the 2- and 4-year-old follow-ups were BMI-for-age Z-score and length/height-for-age Z-score. The exposure was a score of ultra-processed food consumption calculated at each follow-up by summing up the positive answers for the consumption of nine specific items/subgroups of ultra-processed foods: (i) instant noodles; (ii) soft drink; (iii) chocolate powder in milk; (iv) nuggets, hamburger or sausages; (v) packaged salty snacks; (vi) candies, lollipops, chewing gum, chocolate or jelly; (vii) sandwich cookie or sweet biscuit; (viii) juice in can or box or prepared from a powdered mix and (ix) yogurt. Crude and adjusted analyses between the score of ultra-processed foods and the outcomes were run using generalised estimating equations. Prevalence of consumption of ultra-processed foods increased from 2 to 4 years old, for all evaluated items/subgroups, except yogurt. In prospective analyses, higher scores of ultra-processed food consumption were associated with higher BMI-for-age Z-score and lower length/height-for-age Z-score, after adjustment for confounders. Ultra-processed food consumption, measured using a short questionnaire with low research burden, increased from 2 to 4 years old and was related to deleterious growth outcomes in early childhood. These results reinforce the importance of avoiding the consumption of these products in childhood to prevent the double burden of malnutrition and non-communicable chronic diseases throughout the life.

Ultra-processed foods: how functional is the NOVA system?

BACKGROUND

In the NOVA classification system, descriptive criteria are used to assign foods to one of four groups based on processing-related criteria. Although NOVA is widely used, its robustness and functionality remain largely unexplored. We determined whether this system leads to consistent food assignments by users.

METHODS

French food and nutrition specialists completed an online survey in which they assigned foods to NOVA groups. The survey comprised two lists: one with 120 marketed food products with ingredient information and one with 111 generic food items without ingredient information. We quantified assignment consistency among evaluators using Fleiss' κ (range: 0-1, where 1 = 100% agreement). Hierarchical clustering on principal components identified clusters of foods with similar distributions of NOVA assignments.

RESULTS

Fleiss' κ was 0.32 and 0.34 for the marketed foods (n = 159 evaluators) and generic foods (n = 177 evaluators), respectively. There were three clusters within the marketed foods: one contained 90 foods largely assigned to NOVA4 (91% of assignments), while the two others displayed greater assignment heterogeneity. There were four clusters within the generic foods: three clusters contained foods mostly assigned to a single NOVA group (69-79% of assignments), and the fourth cluster comprised 28 foods whose assignments were more evenly distributed across the four NOVA groups.

CONCLUSIONS

Although assignments were more consistent for some foods than others, overall consistency among evaluators was low, even when ingredient information was available. These results suggest current NOVA criteria do not allow for robust and functional food assignments.

Toward Systems Models for Obesity Prevention: A Big Role for Big Data

The relation among the various causal factors of obesity is not well understood, and there remains a lack of viable data to advance integrated, systems models of its etiology. The collection of big data has begun to allow the exploration of causal associations between behavior, built environment, and obesity-relevant health outcomes. Here, the traditional epidemiologic and emerging big data approaches used in obesity research are compared, describing the research questions, needs, and outcomes of 3 broad research domains: eating behavior, social food environments, and the built environment. Taking tangible steps at the intersection of these domains, the recent European Union project "BigO: Big data against childhood obesity" used a mobile health tool to link objective measurements of health, physical activity, and the built environment. BigO provided learning on the limitations of big data, such as privacy concerns, study sampling, and the balancing of epidemiologic domain expertise with the required technical expertise. Adopting big data approaches will facilitate the exploitation of data concerning obesity-relevant behaviors of a greater variety, which are also processed at speed, facilitated by mobile-based data collection and monitoring systems, citizen science, and artificial intelligence. These approaches will allow the field to expand from causal inference to more complex, systems-level predictive models, stimulating ambitious and effective policy interventions.

Ultra-Processed Food Consumption and Mental Health: A Systematic Review and Meta-Analysis of Observational Studies

Since previous meta-analyses, which were limited only to depression and by a small number of studies available for inclusion at the time of publication, several additional studies have been published assessing the link between ultra-processed food consumption and depression as well as other mental disorders. We aimed to build on previously conducted reviews to synthesise and meta-analyse the contemporary evidence base and clarify the associations between the consumption of ultra-processed food and mental disorders. A total of 17 observational studies were included (n = 385,541); 15 cross-sectional and 2 prospective. Greater ultra-processed food consumption was cross-sectionally associated with increased odds of depressive and anxiety symptoms, both when these outcomes were assessed together (common mental disorder symptoms odds ratio: 1.53, 95%CI 1.43 to 1.63) as well as separately (depressive symptoms odds ratio: 1.44, 95%CI 1.14 to 1.82; and, anxiety symptoms odds ratio: 1.48, 95%CI 1.37 to 1.59). Furthermore, a meta-analysis of prospective studies demonstrated that greater ultra-processed food intake was associated with increased risk of subsequent depression (hazard ratio: 1.22, 95%CI 1.16 to 1.28). While we found evidence for associations between ultra-processed food consumption and adverse mental health, further rigorously designed prospective and experimental studies are needed to better understand causal pathways.

Changes in Obesity Prevalence Attributable to Ultra-Processed Food Consumption in Brazil Between 2002 and 2009

Objectives: To quantify the impact of temporal changes in the consumption of ultra-processed foods on obesity trends in Brazil between 2002 and 2009. Methods: We analyzed data from two Household Budget Surveys carried out in 2002/2003 (n = 182,333) and 2008/2009 (n = 190,159), which provided information on household food acquisition and individuals' weight and height. We examined the association between ultra-processed foods consumption and obesity and quantified the fraction of increase in obesity prevalence attributable to the rise in the consumption of ultra-processed foods. Results: From 2002 to 2009, there was an increase in the obesity prevalence from 9.9% (95% CI 9.3; 10.4) to 13.2% (12.8; 13.7) while the contribution of ultra-processed foods to total energy consumption raised from 14.3% (13.4; 15.1) to 17.3% (16.5; 18.1). Ultra-processed foods consumption was positively associated with obesity prevalence. More than one quarter (28.6%) of the increase in obesity prevalence was attributable to the rise in the consumption of ultra-processed foods in the period. Conclusion: We found that the rise in the consumption of ultra-processed foods played a major role on the increase of obesity epidemic in Brazil.

The Importance of Food Processing and Eating Behavior in Promoting Healthy and Sustainable Diets

Numerous association studies and findings from a controlled feeding trial have led to the suggestion that "processed" foods are bad for health. Processing technologies and food formulation are essential for food preservation and provide access to safe, nutritious, affordable, appealing and sustainable foods for millions globally. However, food processing at any level can also cause negative health consequences that result from thermal destruction of vitamins; formation of toxins such as acrylamide; or excessive intakes of salt, sugar, and fat. Research on ultraprocessed foods centers on food composition and formulation. In addition, many modern food formulations can have poor nutritional quality and higher energy density. We outline the role of processing in the provision of a safe and secure food supply and explore the characteristics of processed foods that promote greater energy intake. Despite the potential for negative health effects, food processing and formulation represent an opportunity to apply the latest developments in technology and ingredient innovation to improve the food supply by creating foods that decrease the risk of overeating. Expected final online publication date for the Annual Review of Nutrition, Volume 42 is August 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Ultra-processed foods and health: a comprehensive review

Dramatically increasing trends in consumption of ultra-processed foods have been reported across the globe. Public concern about the health consequences of ultra-processed foods is high. This manuscript provides a comprehensive review of trends in global consumption of ultra-processed foods, dietary nutrient profile of ultra-processed foods, demographic, socioeconomic, psychological, and behavioral characteristics of ultra-processed food consumers, current evidence from longitudinal studies at the population level on the association between ultra-processed foods consumption and major health outcomes (including all-cause and cause-specific mortality, cardiovascular disease, overweight and obesity, body composition and fat deposition, diabetes, cancer, and gastrointestinal and other diseases), potential mechanisms linking ultra-processed foods with these outcomes (nutrient displacement, factors that influence adiposity, and processing), and challenges and future research directions. The global trends in consumption of ultra-processed foods, the generally unfavorable nutrient profile of ultra-processed foods, the characteristics of ultra-processed food consumers, the accumulating longitudinal studies associating ultra-processed foods with major health outcomes, and the uncertainties and complexities in putative mechanisms all highlight the need for future high-quality epidemiologic and mechanistic investigations on this topic. It is critical to interpret findings in the light of the totality of evidence.

Perspective: Soy-based Meat and Dairy Alternatives, Despite Classification as Ultra-processed Foods, Deliver High-quality Nutrition on Par with Unprocessed or Minimally Processed Animal-based Counterparts

In many non-Asian countries, soy is consumed via soy-based meat and dairy alternatives, in addition to the traditional Asian soyfoods, such as tofu and miso. Meat alternatives are typically made using concentrated sources of soy protein, such as soy protein isolate (SPI) and soy protein concentrate (SPC). Therefore, these products are classified as ultra-processed foods (UPFs; group 4) according to NOVA, an increasingly widely used food-classification system that classifies all foods into 1 of 4 groups according to the processing they undergo. Furthermore, most soymilks, even those made from whole soybeans, are also classified as UPFs because of the addition of sugars and emulsifiers. Increasingly, recommendations are being made to restrict the consumption of UPFs because their intake is associated with a variety of adverse health outcomes. Critics of UPFs argue these foods are unhealthful for a wide assortment of reasons. Explanations for the proposed adverse effects of UPFs include their high energy density, high glycemic index (GI), hyper-palatability, and low satiety potential. Claims have also been made that UPFs are not sustainably produced. However, this perspective argues that none of the criticisms of UPFs apply to soy-based meat and dairy alternatives when compared with their animal-based counterparts, beef and cow milk, which are classified as unprocessed or minimally processed foods (group 1). Classifying soy-based meat and dairy alternatives as UPFs may hinder their public acceptance, which could detrimentally affect personal and planetary health. In conclusion, the NOVA classification system is simplistic and does not adequately evaluate the nutritional attributes of meat and dairy alternatives based on soy.

Interrelations Between Food Form, Texture, and Matrix Influence Energy Intake and Metabolic Responses

PURPOSE OF REVIEW

Nutrition often focuses on food composition, yet differences in food form, texture, and matrix influence energy intake and metabolism. This review outlines how these attributes of food impact oral processing, energy intake, and metabolism.

RECENT FINDINGS

Food form has a well-established impact on intake, where liquids are consumed more than solids and semi-solids. For solids, texture properties like thickness, hardness, and lubrication, and geometrical properties like size and shape influence oral processing, eating rate, and intake. Food matrix integrity can influence nutrient and energy absorption and is strongly influenced by food processing. Food texture and matrix play important roles in modulating energy intake and absorption. Future research needs to consider the often overlooked role of texture and matrix effects on energy and metabolic responses to composite foods and meals. Research is needed to understand how processing impacts macro- and micro-structure of food and its long-term impact on energy balance and health.

Texture-based differences in eating rate influence energy intake for minimally processed and ultra-processed meals

BACKGROUND

Consumption of ultra-processed foods has been linked with higher energy intakes. Food texture is known to influence eating rate (ER) and energy intake to satiation, yet it remains unclear whether food texture influences energy intakes from minimally processed and ultra-processed meals.

OBJECTIVES

We examined the independent and combined effects of food texture and degree of processing on ad libitum food intake. We also investigated whether differences in energy intake during lunch influenced postmeal feelings of satiety and later food intake.

METHODS

In this crossover study, 50 healthy-weight participants [n = 50 (24 men); mean ± SD age: 24.4 ± 3.1 y; BMI: 21.3 ± 1.9 kg/m2] consumed 4 ad libitum lunch meals consisting of "soft minimally processed," "hard minimally processed," "soft ultra-processed," and "hard ultra-processed" components. Meals were matched for total energy served, with some variation in meal energy density (±0.20 kcal/g). Ad libitum food intake (kcal and g) was measured and ER derived using behavioral coding of videos. Subsequent food intake was self-reported by food diary.

RESULTS

There was a main effect of food texture on intake, whereby "hard minimally processed" and "hard ultra-processed" meals were consumed slower overall, produced a 21% and 26% reduction in food weight (g) and energy (kcal) consumed, respectively. Intakes were higher for "soft ultra-processed" and "soft minimally processed" meals (P < 0.001), after correcting for meal pleasantness. The effect of texture on food weight consumed was not influenced by processing levels (weight of food: texture*processing-effect, P = 0.376), but the effect of food texture on energy intake was (energy consumed: texture*processing-effect, P = 0.015). The least energy was consumed from the "hard minimally processed" meal (482.9 kcal; 95% CI: 431.9, 531.0 kcal) and the most from the "soft ultra-processed" meal (789.4 kcal; 95% CI: 725.9, 852.8 kcal; Δ=↓∼300 kcal). Energy intake was lowest when harder texture was combined with the "minimally processed" meals. Total energy intake across the day varied directly with energy intakes of the test meals (Δ15%, P < 0.001).

CONCLUSIONS

Findings suggest that food texture-based differences in ER and meal energy density contribute to observed differences in energy intake between minimally processed and ultra-processed meals.This trial was registered at clinicaltrials.gov as NCT04589221.

"Even We Are Confused": A Thematic Analysis of Professionals' Perceptions of Processed Foods and Challenges for Communication

Processed foods are increasingly under the spotlight since the development of classification systems based on proxies for food processing. Published critical reviews and commentaries suggest different views among professional disciplines about the definition and classification of processed food. There is a need to further understand perspectives of professionals on the conceptualisation of processed food and the agreements and disagreements among experts, to encourage interdisciplinary dialogue and aid communication to the public. The aim of this research was to elicit views and understandings of professionals on processed food, their perceptions of lay people's perceptions of the same, and their perspectives on the challenges of communicating about processed foods to the public. The online discussion groups brought together a range of professionals (n = 27), covering the fields of nutrition, food technology, policy making, industry, and civil society, mixed in 5 heterogenous groups. Through thematic analysis the following themes relating to the conceptualisation of processed food and challenges for communication were identified: (1) Broad concepts that need differentiation; (2) Disagreements on scope and degree of processing; (3) The role of food processing within the food system: the challenges in framing risks and benefits; and (4) The challenge of different perspectives and interests for risk communication. Throughout the discussions blurred lines in the characterisation of processing, processed foods, and unhealthy foods were observed. Participants agreed that consensus is important, but difficult. Participants identified a need for further interdisciplinary dialogue, including public engagement, to break down the observed issues, and work towards a mutual understanding and develop clear communication messages.

Influence of Sensory Properties in Moderating Eating Behaviors and Food Intake

Sensory properties inform likes and dislikes, but also play an important functional role in guiding food choice and intake behavior. Odors direct food choice and stimulate sensory-specific appetites and taste helps to anticipate calorie and nutrient content of food. Food textures moderate eating rate and the energy consumed to satiation and post-ingestive metabolism. We summarize how sensory cues moderate intake, and highlight opportunities to apply sensory approaches to improve dietary behavior. Salt, sweet and savory taste influence liking, but also influence energy intake to fullness, with higher taste intensity and duration linked to lower intake. Psycho-physical studies show it is relatively easy to rank taste intensities at different concentrations but more challenging to discriminate fat contents, and fat discrimination declines further when combined with high-taste intensity. Fat has low impact on sensory intensity, but makes significant contributions to energy content. Combinations of high taste and fat-content can promote passive energy over-consumption, and adding fat also increases energy intake rate (kcals/min), reducing opportunities to orally meter consumption. Consumers adapt their oral processing behaviors to a foods texture, which can influence the rate and extent of energy intake. Understanding how texture influences eating behaviors and bolus formation, affords new opportunities to impact eating rate, energy intake and metabolic response to food. Food formulation has traditionally focused on composition and sensory appeal. Future research needs to consider the role of sensory properties in moderating consumer interaction with their food environment, and how they influence calorie selection, and shape our eating behaviors and intake.

Nutrition research challenges for processed food and health

Existing highly processed food (HPF) classification systems show large differences in the impact of these foods on biochemical risk factors for disease. If public health nutrition is to consider the degree of food processing as an important element of the link between food and health, certain gaps in research must be acknowledged. Quantifying the food additive exposure derived from HPFs is a task made challenging by the lack of data available on the occurrence and concentration of additives in food and the degree to which the natural occurrence of additives in unprocessed foods confounds exposure estimates. The proposed role of HPFs in health outcomes could also be associated with altered nutrient profiles. Differences exist within and between HPF classification systems in this regard and there are conflicting data on the impact of controlling for nutrient intake. Furthermore, research is needed on how the sensory aspects of HPFs contribute to energy intake. Current data suggest that high energy intake rate may be the mechanism linking HPFs and increased energy intake. A high priority now is to clarify the basis of definitions used to categorize foods as highly processed and, in a constructive sense, to distinguish between the contributions of nutrients, additives and sensory properties to health.

“How to Select a Representative Product Set From Market Inventory?” A Multicriteria Approach as a Base for Future Reformulation of Cookies

Consuming too much fat, sugar, and salt is associated with adverse health outcomes. Food reformulation is one possible strategy to enhance the food environment by improving the nutritional quality of commercial products. However, food reformulation faces many hindrances. One way to alleviate some of these hindrances is to embrace a multicriteria approach that is based on a market inventory. In this objective, additional sensory screening and water content analyses allow going beyond nutrition and composition information on the packaging. However, due to feasibility reasons for later in-depth analyses, it is necessary to work with several reduced and manageable products. To the best of the authors' knowledge, in the literature, there is no sample selection approach taking into account multiple criteria as a base for future food reformulation. The overall aim of this paper is to propose a method to select the best representative products from the market base, for future reformulation by going beyond nutrition and composition information on the packaging. This approach considered therefore nutrition, composition, economic, water content, and sensory information with the example of the cookies market. The first step is the creation of an extensive cookie database including sensory and water content information. In total 178 cookies among the French market were identified, then focus was placed on 62 chocolate chip cookies only. Sensory screening and water content analyses of all 62 products were conducted. The second step is to make an informed subset selection, thanks to a cluster analysis based on 11 nutrition, composition, and water content variables. A representative subset of 18 cookies could be derived from the obtained clusters. The representativity was evaluated with statistical uni- and multivariate analyses. Results showed a broad variety of chocolate chips cookies with a large nutritional, compositional, water content, and sensory differences. These results highlighted the first paths for future reformulation in this product category and showed the importance to include physical product information beyond the information on the packaging. This complete database on the selected cookies constituted a solid base for identifying future reformulation levers, in order to improve the nutritional quality and health.