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

Ultraprocessed foods and cancer risk: the importance of distinguishing ultraprocessed food groups

Several case-control, cohort studies, and meta-analyses found a moderate association between ultraprocessed food consumption and the risk of colorectal and a few other cancers. The evidence is, however, not consistent. A reason for such inconsistence is that the NOVA classification of ultraprocessed foods may include unfavorable but also favorable dietary components, and it may vary across different populations.

Effects of Methylglyoxal on Intestine and Microbiome Composition in Aged Mice

BACKGROUND

Methylglyoxal (MGO), a highly reactive precursor of advanced glycation end products (AGEs), is endogenously produced and prevalent in various ultra-processed foods. MGO has emerged as a significant precursor implicated in the pathogenesis of type 2 diabetes and neurodegenerative diseases. To date, the effects of dietary MGO on the intestine have been limited explored. Thus, this study investigates the impact of prolonged oral administration of MGOs on gut health in aged mice.

METHODS

Aged mice received MGO chronically (100 mg/kg/day) for 4 weeks. Intestinal samples were analyzed using RT-PCR and immunohistochemistry for proinflammatory cytokines, permeability markers, and tight junction proteins. 16S rRNA gene-based microbiome analysis was also performed to characterize microbiome composition and its metabolic potential.

RESULTS

MGO treatment induced notable alterations at the intestinal level, characterized by an increased formation of MGO-glycated proteins with a concurrent induction of a pro-inflammatory status and reduced expression and delocalization of zonulin-1 and occludin, tight junction proteins. Changes in intestinal morphology were also observed, including hyperproliferation of Paneth cells and an augmented thickness of the intestinal mucus layer, as indicated by immunohistochemical data from MGO-treated mice. Investigation into the microbiota composition revealed that MGO is effective in selectively modifying its composition and metabolic pathways. A decreased abundance of bacterial genera associated with the production of acetic and butyric acids (i.e. Harryflintia, Intestinimonas and Ruminococcaceae genera) and a substantial increase in Lachnospiraceae and Akkermansia genera were found in MGO-treated mice.

CONCLUSION

These findings highlight how dietary MGO can affect intestinal balance, providing valuable insights into the potential links between glycotoxins, gut microbiota, and overall gut functionality.

Association between higher consumption of ultra-processed foods and risk of diabetes and its complications: A systematic review & updated meta-analysis

BACKGROUND & AIMS

Recent epidemiologic studies on the association between higher consumption of ultra-processed foods (UPFs) and risk of incident diabetes have reported conflicting results in populations worldwide. We conducted an updated systematic review and meta-analysis to quantify the magnitude of this association.

METHODS

PubMed and Embase databases were systematically searched (from 2009 to November 14, 2024) for prospective cohort studies reporting data on the association between UPF intake (defined by the NOVA classification) and the risk of incident diabetes or its complications in adults (>18 years). Meta-analysis was performed using random-effects modelling to obtain pooled hazard ratios (HRs) with 95 % confidence intervals (CIs), and the GRADE approach was applied to evaluate the certainty of evidence.

RESULTS

We included 14 prospective cohort studies with a total of 692,508 participants. The highest UPF consumption was significantly associated with an increased risk of diabetes (n = 9 studies; HR 1.24, 95 % CI 1.14 to 1.34, I2 = 69 %) compared with the lowest UPF intake (very low certainty of evidence). Subgroup analysis showed that studies published in 2024 had a smaller effect size compared with earlier studies. There were no significant differences between subgroups based on study location, duration of follow-up, method and frequency of dietary intake assessment, and risk of bias. Sensitivity analyses did not change these findings. Each 10 % increase in total UPF consumption was associated with a 13 % (n = 4 studies; HR 1.13, 95 % CI 1.08 to 1.18, I2 = 37 %) increased risk of diabetes. Preliminary data from 4 cohort studies also suggest that high UPF consumption may be associated with complications in diabetic patients, including microvascular/cardiovascular disease, chronic kidney disease, and mortality.

CONCLUSION

UPF consumption is associated with a higher risk of incident diabetes and may contribute to its complications. Urgent public health efforts should prioritize the reduction of UPF consumption.

Targeting ultra-processed foods for prevention of type 2 diabetes: state of the evidence and future directions

The incidence of type 2 diabetes has risen globally, in parallel with the obesity epidemic and environments promoting a sedentary lifestyle and low-quality diet. There has been scrutiny of ultra-processed foods (UPFs) as a driver of type 2 diabetes, underscored by their increasing availability and intake worldwide, across countries of all incomes. This narrative review addresses the accumulated evidence from investigations of the trends in UPF consumption and the relationship with type 2 diabetes incidence. Hypotheses for why UPFs may be causally implicated in the initiation and progression of weight gain and suboptimal blood glucose levels are varied. There is also uncertainty and debate about whether detrimental effects of UPFs could be owing to additives and other features of industrial processing, independent of established dietary risk factors, namely added sugar, sodium, saturated fat and low fibre content. However, these current research gaps are addressable with rigorous research and coordinated efforts across nutrition-science domains; for example, the strengths of longitudinal cohort studies can be leveraged to refine the characterisation of key UPF subcategories within the enormous and diverse category of UPFs and ultra-processed beverages, and to identify high-risk patterns of intake that are related to the development of chronic-disease outcomes. The notable advantages of dietary intervention studies are the critical gains in the reliability of dietary assessments, and isolating the effects of individual UPF additives and features through carefully formulated diets. Research improving our understanding of the modifiable food environment, the diet's causal drivers of weight gain and suboptimal cardiometabolic health, and the interactions among them, can be used to meaningfully shift the food supply for large-scale improvements in health. Thus, although the global market share of UPFs seems to outpace the research on its detrimental health effects, leaving the scientific community with the responsibility of generating proof, there may still be promising opportunities to reduce the burden of type 2 diabetes.

Ultraprocessed Food Intake and Risk of Systemic Lupus Erythematosus Among Women Observed in the Nurses' Health Study Cohorts

OBJECTIVE

We assessed ultraprocessed food (UPF) intake and systemic lupus erythematosus (SLE) incidence within the prospective Nurses' Health Study (NHS) cohorts.

METHODS

A total of 204,175 women were observed (NHS 1984-2016; NHSII 1991-2017). Semiquantitative food frequency questionnaires were completed every two to four years. UPF intake was determined as per the Nova classification. Nurses self-reported new doctor-diagnosed SLE, confirmed by medical records. Time-varying Cox regressions estimated hazard ratios (HRs; 95% confidence intervals [CIs]) for patients with incident SLE and SLE by anti-double-stranded DNA (dsDNA) antibody at diagnosis, according to cumulatively updated daily (a) UPF servings, (b) total intake (in grams and milliliters), and (c) percentage of total intake. Analyses adjusted for age, race, cohort, caloric and alcohol intakes, household income, smoking, body mass index (BMI), physical activity, menarchal age, and oral contraceptive use. We tested for interaction with BMI and examined UPF categories.

RESULTS

Mean baseline age was ~50 years (NHS) and ~36 years (NHSII); 93% self-reported White race. A total of 212 patients with incident SLE were identified. SLE risk was higher in the third versus first UPF tertile (servings per day pooled multivariable [MV] HR 1.56, 95% CI 1.04-2.32; P = 0.03). Results were stronger for dsDNA antibody in patients with SLE (servings per day pooled MV HR 2.05, 95% CI 1.15-3.65; P = 0.01) and for absolute (servings or total) than percentage of total intake. Sugar-sweetened/artificially sweetened beverages were associated with SLE risk (third vs first tertile MV HR 1.45, 95% CI 1.01-2.09). No BMI interactions were observed.

CONCLUSION

Higher cumulative average daily UPF intake was associated with >50% increased SLE risk and with doubled risk for anti-dsDNA antibody in patients with SLE. Many deleterious effects on systemic inflammation and immunity are postulated.

Trends in Adults' Intake of Un-processed/Minimally Processed, and Ultra-processed foods at Home and Away from Home in the United States from 2003-2018

BACKGROUND

Ultraprocessed foods (UPFs) comprise >50% of United States adults' energy intake, with the proportion of calories from UPFs increasing over time and the proportion of unprocessed/minimally processed foods (MPFs) decreasing over time. Whether UPFs are primarily consumed at home (AH) or away from home (AFH) is important to inform policies and messages to improve dietary quality.

OBJECTIVES

We examined trends in consumption of UPFs and MPFs AH and AFH in a nationally representative sample of United States adults and within sociodemographic subgroups.

METHODS

Data are from 34,628 adults (aged ≥20 y) with two 24-h dietary recalls from the 2003-2018 National Health and Nutrition Examination Survey. We examined trends over time in intake from MPFs and UPFs as a proportion of total energy intake and as a proportion of AH energy intake and AFH energy intake using generalized linear models adjusted for sex, age, race/ethnicity, education, and household income. We examined differences in trends by sociodemographic subgroups using interaction terms and stratified models.

RESULTS

Overall, and for most demographic subgroups, UPFs comprised >50% of AH energy intake and >50% of AFH energy intake, with UPFs increasing and MPFs decreasing over time as a proportion of energy intake AH and AFH. The proportion of total energy intake from UPFs increased for food consumed AH (33.6%-37.1%, P-trend < 0.001), but not for UPFs consumed AFH (19.5%-18.8%, P-trend = 0.88). From 2003-2004 to 2017-2018, the proportion of total energy intake from MPFs declined for foods consumed AH (23.6%-20.8%, P-trend <0.001) and AFH (9.7%-7.5%, P-trend <0.001). Interaction terms testing differences in trends of MPF and UPF intake AH and AFH by sociodemographic subgroups were mostly nonsignificant.

CONCLUSIONS

Findings highlight the ubiquity and increasing proportion of UPFs in United States adults' diets regardless of whether foods are consumed AH or AFH.

Association between gut microbiota and ultra-processed foods consumption among the patients with type 2 diabetes: a cross-sectional study

BACKGROUND

This study aimed to explore the relationship between ultra-processed foods (UPFs) consumption and gut microbiota in patients with type 2 diabetes (T2D).

METHODS

This cross-sectional study included 362 participants with T2D. UPFs consumption was assessed using a brief-type self-administered diet history questionnaire, quantified as the density of UPFs intake (g/1000 kcal). Gut microbial composition was evaluated via 16S rRNA gene sequencing. We investigated the association between gut microbiota, previously identified as relevant to T2D, and the density of UPFs intake using Spearman rank correlation coefficients. Multiple regression analysis, adjusting for age, sex, BMI, smoking status, exercise, and medication use, was conducted to further investigate these associations.

RESULTS

The mean age of participants was 68 (63-74) years. The density of UPFs intake showed significant associations with Bifidobacterium (r = 0.11, p = 0.031), Lactobacillus (r = 0.11, p = 0.046), Ruminococcus (r = -0.12, p = 0.019), Roseburia (r = 0.11, p = 0.045). After adjusting for covariates in multiple regression analysis, Ruminococcus and Roseburia showed modest negative (β = -0.11, p = 0.038) and positive (β = 0.12, p = 0.033) correlations, with the density of UPFs intake among participants with T2D, respectively.

CONCLUSIONS

The density of UPFs intake was modestly inversely associated with Ruminococcus among patients with T2D and modestly positively associated with Roseburia.

Foods, dietary patterns, and risk of vascular dementia: a systematic review

BACKGROUND

Vascular dementia (VaD) is the second most common cause of dementia globally and is associated with a significant economic and social burden. Diet could represent an important tractable risk factor for VaD. We synthesised current evidence on associations between consumption of specific foods or dietary patterns and VaD risk.

METHODS

Five databases were searched from inception to January 2024 for prospective cohort studies exploring associations between individual foods or dietary patterns and incident VaD.

RESULTS

Sixteen studies were included. Compared with low intake reference groups, higher fruit and vegetable intake, moderate alcoholic drink intake (1-3 drinks/day), higher tea and coffee intake, and following a plant-based dietary pattern were associated with lower VaD risk. Conversely, moderate fried fish intake (0.25-2 servings/week), higher ultra-processed food intake (especially intake of sweetened beverages) and higher processed meat intake (≥ 2 servings/week) were associated with increased VaD risk. Inconsistent findings were observed for other dietary exposures.

DISCUSSION

A healthy diet could lower VaD risk. However, evidence is characterised by a limited number of studies for specific dietary exposures. Further research is needed to inform personalised and population-based approaches to lower VaD risk.

Associations of Ultra-Processed Food Intake with the Incidence of Cardiometabolic and Mental Health Outcomes Go Beyond Specific Subgroups-The Brazilian Longitudinal Study of Adult Health

Background/Objectives: Avoidance of ultra-processed foods (UPFs) has been recommended to achieve a healthy diet, but whether it applies equally to all UPFs is uncertain. We evaluated individual UPF subgroups in the prediction of cardiometabolic and mental health outcomes. Methods: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is an occupational cohort study of 15,105 adults (35-74 years) recruited in 2008-2010. We followed participants up to 2018 to ascertain elevated weight and waist gains and the onset of metabolic syndrome, hypertension, metabolic dysfunction-associated steatotic liver disease, diabetes, common mental disorders, depressive episodes, and anxiety disorders. Results: In adjusted robust Poisson regression, greater overall UPF intake at the baseline predicted all studied outcomes. Various subgroups of UPF, most frequently processed meat and sweetened beverages, individually conferred a greater risk, and nearly all predicted at least one studied outcome. Considering all subgroups and outcomes, a broad pattern of overall risk was present. When subgroups not individually predictive of these outcomes were aggregated, increased risk (for a one-standard deviation change) was observed for elevated weight (RR = 1.05; 95% CI 1.01-1.11) and waist (RR = 1.05; 95% CI 1.00-1.10) gains, and for the incidence of common mental (RR = 1.06; 95% CI 1.01-1.12), and anxiety (RR = 1.09; 95% CI 1.02-1.16) disorders. Conclusions: UPFs overall and their subgroups predicted future cardiometabolic and mental health outcomes. The pattern of individual UPF subgroup associations varied across outcomes, and the aggregate of subgroups not individually predicting risk also predicted large gains in overall and central adiposity and the incidence of mental health disorders. While additional studies investigating other outcomes are needed, these findings justify avoidance of overall UPF intake in health promotion and disease prevention.

Trends in Plant-Based Diets among United States Adults, 1999-March 2020

BACKGROUND

Interest in plant-based eating has increased alongside increased variety and availability of highly processed plant-based meat and dairy alternatives. The impact of the shifting commercial landscape and public interest in plant-based eating on dietary intake is unknown.

OBJECTIVES

To examine trends in the consumption and composition of plant-based diets in the United States adults.

METHODS

Serial cross-sectional data from the National Health and Nutrition Examination Survey were used to assess trends in the proportion of United States adults aged ≥20 y consuming a plant-based diet (defined as ≥50% total protein from plants on a 24-h dietary recall) from 1999-2000 to 2017-March 2020 (n = 51,698). Trends in processing level (percentage energy intake from ultraprocessed foods) and diet quality [Healthy Eating Index (HEI)-2020 scores] were assessed in the subset of adults consuming plant-based diets (n = 8327).

RESULTS

The proportion of United States adults consuming plant-based diets increased from 14.4% (95% CI: 12.9%, 16.0%) to 17.2% (95% confidence interval [CI]: 15.5%, 19.1%; P = 0.005 for trend). In all survey cycles, ultraprocessed foods accounted for the majority of energy intake, and ultraprocessed food intake in plant-based diets did not significantly change over time [50.7% kcal (95% CI: 47.3%, 54.1%) in 1999-2000 compared with 52.7% kcal (95% CI: 49.7%, 55.6%) in 2017-March 2020; P for trend = 0.34]. The quality of plant-based diets, measured by HEI-2020 scores, improved from 52.1 (95% CI: 49.7, 54.6) to 55.8 (95% CI: 54.1, 57.5; P for trend <0.001).

CONCLUSIONS

Between 1999 and March 2020, the proportion of United States adults consuming a plant-based diet increased. Among people consuming plant-based diets, ultraprocessed foods contributed most to energy intake and there was no sustained change in intake over time. The mean diet quality was low but improved modestly.

The Development of a Food Frequency Questionnaire for the Assessment of Ultra-Processed Food Consumption in the Italian Adult Population: Protocol for a Validity and Reproducibility Study

BACKGROUND

Over the last decade, while studies on the detrimental effects of ultra-processed food (UPF) consumption have increased, methodological limitations on the quality of available evidence have emerged. Starting from a critical reassessment of the NOVA classification, this project will aim to develop and validate a food frequency questionnaire (FFQ), which is based on the processing of consumed foods and specifically designed to estimate the UPF consumption and total dietary intake of macro- and micronutrients in the Italian adult population.

METHODS

This study will take place in selected workplaces and include healthy males and females aged ≥18 years, residing in Italy and with Italian citizenship. The FFQ will be online, voluntary, self-administered, semi-quantitative, and designed to assess food intake over the past year and distinguish between industrial, artisanal, and home-made products. This project will consist of two phases. First, a pilot study will be conducted to obtain the final version of the FFQ. The current food consumption of the target population will be investigated, through a 24 h dietary recall, and the face validity of the new tool will be tested. The second phase will involve at least 436 participants. To assess reproducibility, the FFQ will be administered twice (at an interval of 3-10 months), and the test-retest method will be used. A 7-day weighed dietary record (WDR) will also be completed after each FFQ administration. To evaluate criterion validity, data from the two WDRs will be compared against those from the first FFQ administration.

CONCLUSIONS

The results will provide a new valid tool focused on food processing, potentially useful for future studies.

One Month Whole Food Plant-Based Nutrition Educational Program Lowers LDL, A1C, and Decreases Inflammatory Markers

Lifestyle-related chronic disease increases in the United States have led to the need for innovative programs targeting dietary choices. Based on growing evidence supporting whole food plant-based (WFPB) nutrition to improve overall health, we devised a one-month WFPB intervention program, Jumpstart Your Health! (JYH), to introduce and encourage adoption of the WFPB dietary lifestyle. This paper investigates its effects on various health indicators associated with cardiovascular and metabolic diseases. Among the total of 150 participants, before and after physical measurements and blood chemistries demonstrate significant (p< 0.05) decreases in weight (-4.2 pounds), cholesterol (-25.3 mg/dl), LDL (-19.0 mg/dl), HDL (-5.6 mg/dl), hemoglobin A1c (-0.2%), and hsCRP (-1.9 mg/L). Among the high-risk participants, we found significant decreases in systolic blood pressure (-10 mmHg), diastolic blood pressure (-8.7 mmHg), weight (-4.3 pounds), cholesterol (-38.8 mg/dl), LDL (-22.7 mg/dl), HDL (-2.8 mg/dl), hemoglobin A1c (-0.2 %), and hsCRP (-2.3 mg/L). We demonstrate that a simple WFPB intervention implemented over one month resulted in significant reductions in physical measurements and blood chemistries that could translate to lowered risk or improvement for obesity, cardiovascular disease, and type-2 diabetes.

Food consumption by degree of food processing and risk of type 2 diabetes mellitus: a prospective cohort analysis of the European Prospective Investigation into Cancer and Nutrition (EPIC)

Background

It is unknown whether the association between ultra-processed food (UPF) intake and type 2 diabetes mellitus differs from other degrees of food processing. We examined the association between degree of food processing and incident type 2 diabetes mellitus.

Methods

This was a prospective cohort analysis of the European Prospective Investigation into Cancer and Nutrition (EPIC). Dietary intake was assessed at baseline using dietary questionnaires and classified according to the Nova classification into unprocessed/minimally processed food (MPF), processed culinary ingredients (PCI), processed food (PF) and UPF. Type 2 diabetes mellitus cases were verified through multiple methods. Cox regression and statistical substitution analysis was used to estimate associations between MPF + PCI, PF and UPF intake and incident type 2 diabetes mellitus. To investigate heterogeneity in the association between UPF and incident type 2 diabetes mellitus, UPF sub-group analysis was conducted. Different reference groups were used in each analysis.

Findings

Over an average 10.9 years follow-up of 311,892 individuals, 14,236 type 2 diabetes mellitus cases were identified. Each 10% increment of total daily food intake from UPF (%g/day) was associated with 17% (95% confidence interval (95%CI): 1.14-1.19) higher incident type 2 diabetes mellitus. Each 10% increment in MPF + PCI or PF intake was associated with lower incident type 2 diabetes mellitus (MPF + PCI hazard ratio: 0.94 (95%CI: 0.92-0.96); PF hazard ratio: 0.92 (95%CI: 0.89-0.95)). Replacing UPF with MPF + PCI or PF was associated with lower incident type 2 diabetes mellitus. However, heterogeneity was observed across UPF sub-groups, with breads, biscuits and breakfast cereals, sweets and desserts, and plant-based alternatives associated with lower incident type 2 diabetes mellitus.

Interpretation

These findings support recommendations to focus on reducing intake of specific UPF for lowering type 2 diabetes mellitus risk.

Funding

International Agency for Research on Cancer.

Food processing according to the NOVA classification is not associated with glycemic index and glycemic load: results from an analysis of 1995 food items

BACKGROUND

Ultraprocessed foods (UPFs) comprise most calories in the United States diet. Glycemic index (GI) and glycemic load (GL) are measures of the quality and quantity of carbohydrates in food based on their effect on postprandial blood glucose. Diets high in UPFs and GI/GL are associated with chronic metabolic diseases but the relationship between them is unclear.

OBJECTIVES

Our objective was to examine the GI and GL of foods assigned to NOVA food processing groups. We hypothesized that GI and GL would be lowest in minimally processed foods (MPFs) compared to processed food (PRF) and UPF (with no difference between PRF and UPF).

METHODS

GI and GL values produced by healthy individuals for 1995 food items were collated from published sources. Food items were manually coded by processing levels according to NOVA classification. In addition, as the effects of processing on glycemic potential may vary between types of foods, food items were coded into 8 groups (beans, nuts, and seeds; beverages; dairy; fats and sweets; fruit; grains; fish, meat, and poultry; and vegetables). Multilevel linear modeling was used to determine significance with an α value of 0.05.

RESULTS

The effect of food processing on GI and GL was contrary to our hypothesis as means did not differ significantly across processing levels: GI-MPF: 54.1 ± 19.5, PRF: 53.2 ± 18.9, UPF: 49.3 ± 18.1 (P = 0.712); GL-MPF: 17.1 ± 10.3, PRF: 15.8 ± 12.4, UPF; 11.5 ± 7.9 (P = 0.890). Within food groups, there was no significant association between processing level and GI (P = 0.184), but GL was inversely associated with grains and vegetables (P < 0.001).

CONCLUSIONS

Across analyzed foods, GI and GL do not differ between processing levels, whereas GL was lower in ultraprocessed grains and vegetables than MPF. Any potential adverse outcomes associated with UPF are unlikely to be related to effects on glycemia. This project was preregistered at the Open Science Framework (OSF) Registries through the Center for Open Science as 10.17605/OSF.IO/PJWG9.

Ultra-processed foods and the incidence of pre-diabetes and type 2 diabetes among Iranian adults: the Tehran lipid and glucose study

BACKGROUND

No study has investigated the association between ultra-processed food (UPF) and pre-diabetes development. Furthermore, prior investigations on the association between UPF and the risk of type 2 diabetes (T2D) were primarily conducted in Europe and America, and studies in other regions are lacking. We investigated the association between ultra-processed foods and the risk of pre-diabetes and T2D in a cohort of Iranians.

METHODS

This prospective study, with a sample size of 1954 for pre-diabetes and 2457 for T2D, was conducted among adults' participants (aged ≥ 18 years) from the Tehran Lipid and Glucose Study (TLGS). We defined UPF intake using NOVA calcification as a proportion of total energy, and calculated its average intake during the follow-ups. The hazard ratios (HR) and 95% confidence intervals (95% CI) for pre-diabetes/T2D across tertiles of total UPF and per 10% of its increment were examined using Cox proportional hazards models. We also investigated the possibility of non-linear association using a restricted cubic spline regression.

RESULTS

We identified 766 and 256 cases of pre-diabetes and T2D, respectively, during a median follow-up of 7 years for pre-diabetes and 8.6 years for T2D. In the multivariable adjusted model, a 10% increase in total UPF intake was associated with a 12% higher risk of pre-diabetes (HR = 1.12; 95% 1.02, 1.23). The incidence of pre-diabetes was also higher in those in tertile 3 than those in tertile 1 (HR = 1.28; 95% CI = 1.07, 1.52). Following additional adjustment for diet quality, the results remained unchanged. Spline regression demonstrated a J-shaped association between UPF and the risk of pre-diabetes; the risk of pre-diabetes did not increase until UPF consumption exceeded about 24% of total energy intake. Of the individual UPF, hydrogenated fat/mayonnaise/ margarine group was related to an increased risk of pre-diabetes. The total UPF and its individual items were not associated with T2D.

CONCLUSIONS

This study found a positive, non-linear relationship between total UPF and the risk of pre-diabetes in Iranian adults. Our data could not show any significant association between UPF and T2D risk.

Ultra-processed foods and type 2 diabetes mellitus incidence in RaNCD project: a prospective cohort study

BACKGROUND

Following rapid population growth and urbanization, global ultra-processed food consumption levels have increased. Additionally, type 2 diabetes mellitus, a non-communicable disease, is affecting one-tenth of the people worldwide. In this study, we aimed to investigate the association between ultra-processed food consumption and the risk of type 2 diabetes mellitus in different scenarios in a prospective cohort study in the western part of Iran.

METHODS

The RaNCD cohort includes 10,047 participants aged 35 to 65; we included participants susceptible to diabetes at enrolment with follow-up data. We used the widely accepted Nova classification to define ultra-processed foods. A multivariable Cox proportional hazards regression model was used as the main model; furthermore, the Cox model with different adjustments and the logistic regression model were used as sensitive analysis to evaluate the association between ultra-processed foods consumption and type 2 diabetes mellitus.

RESULTS

A total of 8827 participants with a mean age of 46.92y, a mean follow-up time of 7.1y, and a mean daily ultra-processed food intake of 87.69 g were included. During the follow-up phases, we included 255 incidences of type 2 diabetes mellitus cases. After adjusting for confounders in the primary model, including age, gender, residence type, socioeconomic status, physical activity, body mass index, and familial history of diabetes despite the elevated hazard ratio of 1.08 (0.75, 1.55) in the fourth quartile compared to the first quartile, the P-value was insignificant (p-value = 0.665); p for trend in the UPF quartiles was also insignificant.

CONCLUSION

Our study has shed light on the association between ultra-processed food consumption and the risk of type 2 diabetes mellitus. However, further investigations are necessary to confirm or refute the UPFs/T2DM association.

Ultraprocessed food (UPF), health, and mechanistic uncertainty: What should we be advising the public to do about UPFs?

In this perspective, we discuss why current mechanistic uncertainty on ultraprocessed foods (UPFs) and health acts as a major challenge to providing informed dietary guidelines and public advice on UPFs. Based on the balance of current evidence, we do not believe it is appropriate to be advising consumers to avoid all UPFs and we await further evidence to inform consumer guidance on the need to limit consumption of specifics foods based on their degree or type of processing.

Association Between Ultra-Processed Food Consumption and Leucocyte Telomere Length: A cross-sectional study of UK Biobank

OBJECTIVE

This study aimed to investigate the association between consumption of ultra-processed foods (UPFs) and leucocyte telomere length (LTL).

METHODS

This cross-sectional study utilized data from the UK Biobank, including a total of 64,690 participants. LTL was measured using Q-PCR with natural logarithmic conversion and Z-score normalization. Dietary data were collected through a 24-hour recall questionnaire from 2009 to 2010. UPFs were identified using the Nova food classification and analyzed as either a continuous or categorical variable respectively. Multiple linear regression models were employed to analyze the association between UPF consumption and LTL.

RESULTS

The included participants had an average age of 56.26 years, of whom 55.2% were female. After adjusting for sociodemographic, lifestyle-related and anthropometric variables, LTL exhibited a decrease of 0.005 (95% CI: -0.007, -0.002) with one UPF serving/day increase. Compared to participants consuming ≤ 3.5 servings/day, those consuming 3.5 to < 6, 6 to ≤ 8 and > 8 servings/day showed a shortening of LTL by 0.025 (95% CI: -0.047, -0.004), 0.034 (95% CI: -0.055, -0.012) and 0.038 (95% CI: -0.062, -0.015), respectively (P for trend = 0.001). Subgroup analyses by UPF subclasses revealed that consumption of ready-to-eat/heated food (β = -0.008, 95% CI: -0.014, -0.002), beans and potatoes (β = -0.024, 95% CI: -0.039, -0.009), animal-based products (β = -0.011, 95% CI: -0.019, -0.004), artificial sugar (β = -0.014, 95% CI: -0.025, -0.004), and beverages (β = -0.005, 95% CI: -0.009, -0.001) showed negative associations with LTL. Conversely, breakfast cereals (β = 0.020, 95% CI: 0.004, 0.036) and vegetarian alternatives (β = 0.057, 95% CI: 0.027, 0.086) showed positive correlations with LTL.

CONCLUSIONS

Our study found that a higher consumption of total UPFs was associated with a shorter LTL. However, some subclass UPFs may be associated with longer LTL, depending on their nutritional composition.

Association of ultra-processed food consumption with muscle mass among young and middle-aged US adults

INTRODUCTION

Muscle mass is vital for physical activity and fundamental physiological processes supporting long-term health. While aging is inevitable, certain modifiable factors positively influence muscle preservation and overall well-being. However, the relationship between the consumption of ultra-processed foods (UPF) and muscle mass is not yet clear.

METHODS

This study included 7,173 men and nonpregnant women aged 20-59 years with valid 24-hour dietary recalls and accessible whole-body dual-energy x-ray absorptiometry (DXA) scans from NHANES 2011-2018. UPFs were identified through the NOVA classification system, and the percentage of energy derived from UPF consumption was evaluated in quintiles. Muscle mass measures were derived from DXA scans and quantified by the total and regional muscle mass index (MMI, kg/m²) and appendicular muscle mass index (AMMI, kg/m²). Multivariable-adjusted generalized linear regression models were applied to investigate the association between consumption of UPFs and muscle mass measures overall and by sociodemographic subgroups.

RESULTS

The multivariable-adjusted differences of total MMI from the lowest to highest quintile of UPF consumption were 0 (reference), -0.03 (95% CI, -0.13, 0.07), -0.13 (95%CI, -0.24, -0.04), -0.12 (95% CI, -0.23, -0.01), and - 0.17 (95% CI, -0.27, -0.08) (P for trend < 0.001). Subtotal MMI followed a similar magnitude of associational pattern as total MMI. For trunk MMI, corresponding values from the lowest to highest quintiles of UPF consumption were 0 (reference), -0.02 (95% CI, -0.07, 0.02), -0.05 (95%CI, -0.11, 0.00), -0.07 (95% CI, -0.13, -0.01), and - 0.07 (95% CI, -0.12, -0.01). For AMMI, corresponding values from the lowest to highest quintiles of UPF consumption were 0 (reference), -0.004 (95% CI, -0.07, 0.06), -0.08 (95%CI, -0.14, -0.02), -0.05 (95% CI, -0.11, 0.02), and - 0.10 (95% CI, -0.16, -0.04) (All P for trend < 0.001). While most subgroups maintained similar overall patterns, heterogeneous findings were also observed. For example, the multivariable-adjusted differences in total MMI between the lowest and highest quantile of UPF consumption were - 0.19 (95% CI, -0.32, -0.06) for non-Hispanic Whites, 0.18 (95% CI, 0.01, 0.36) for non-Hispanic Blacks, -0.25 (95%CI, -0.45, -0.04) for Hispanics, -0.25 (95% CI, -0.51, 0.05) for non-Hispanic Asians and - 0.32 (95% CI, -0.75, 0.12) for others (P for interaction < 0.001).

CONCLUSION

Higher consumption of UPFs was significantly associated with lower values of total and regional muscle mass. Specifically, comparing the highest quantile of UPF consumption to the lowest, total MMI decreased by 0.93%, trunk MMI decreased by 0.76%, and AMMI decreased by 1.25%. The differences in associational patterns between UPF consumption and muscle mass across sociodemographic subgroups require further investigation.

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

AIMS/HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS/INTERPRETATION

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

Ultra-processed foods and health: are we correctly interpreting the available evidence?

Several studies have linked adverse health effects to the consumption of ultra-processed foods (UPF) according to the NOVA classification. However, whether the consumption of UPF is the actual causal factor for such health outcomes is still unknown. Indeed, different groups of UPF examined in the same epidemiologic study often show markedly different associations with the occurrence of the health endpoints. In this Comment, we discuss some such studies and point out that the available evidence on how different UPFs have been associated with health, as well as the results of studies examining specific food additives, call into question the possibility that ultra-processing per se is the real culprit. It is possible that other unaccounted for confounding factors play an important role. Future, urgently needed studies will clarify this issue.

Ultra-processed foods and cardiovascular disease: analysis of three large US prospective cohorts and a systematic review and meta-analysis of prospective cohort studies

Background

Prospective associations between total and groups of ultra-processed foods (UPF) and cardiovascular disease (CVD) remained to be characterised. Our aim was to assess the association of total and group-specific UPF intakes with CVD, coronary heart disease (CHD), and stroke in three large prospective cohorts of US adults. Additionally, we conducted a systematic review and meta-analyses on the existing evidence on the associations of total UPF intake with these outcomes.

Methods

UPF intake was assessed through food frequency questionnaires in the Nurses' Health Study (NHS; n = 75,735), Nurses' Health Study II (NHSII; n = 90,813), and Health Professionals Follow-Up Study (HPFS; n = 40,409). Cox regression estimated cohort-specific associations of total and group-specific UPF intake with risk of CVD (cases = 16,800), CHD (cases = 10,401), and stroke (cases = 6758), subsequently pooled through fixed-effect models. Random-effects meta-analyses pooled existing prospective findings on the UPF-CVD association identified on Medline and Embase up to April 5, 2024, without language restrictions. Risk of bias was assessed with the Newcastle-Ottawa Scale, funnel plots, and Egger's tests, and meta-evidence was evaluated using NutriGrade.

Findings

The baseline mean (SD) age was 50.8 years (7.2) for the NHS, 36.7 years (4.6) for the NHSII, and 53.4 years (9.6) for the HPFS. The proportion of participants of White race was 97.7% in the NHS, 96.4% in the NHSII, and 94.9% in the HPFS. Among the three cohorts, multivariable-adjusted hazard ratios [HRs (95% CIs)] for CVD, CHD, and stroke for the highest (vs. lowest) total UPF intake quintile were 1.11 (1.06-1.16), 1.16 (1.09-1.24), and 1.04 (0.96-1.12), respectively. UPF groups demonstrated divergent associations. Sugar-/artificially-sweetened drinks and processed meats were associated with higher CVD risk, whereas inverse associations were observed for bread/cold cereals, yoghurt/dairy desserts, and savoury snacks. Meta-analysing 22 prospective studies showed that total UPF intake at the highest category (vs. lowest) was associated with 17% (11%-24%), 23% (12%-34%), and 9% (3%-15%) higher CVD, CHD, and stroke risk. Meta-evidence quality was high for CHD, moderate for CVD, and low for stroke.

Interpretation

Total UPF intake was adversely associated with CVD and CHD risk in US adults, corroborated by prospective studies from multiple countries, also suggesting a small excess stroke risk. Nutritional advice for cardiovascular health should consider differential consequences of group-specific UPF. Replication is needed in racially/ethnically-diverse populations.

Funding

National Institutes of Health (NIH) grants supported the NHS, NHSII, and HPFS.

Low-fat yogurt consumption maintains biomarkers of immune function relative to nondairy control food in women with elevated BMI: A randomized controlled crossover trial

Yogurt consumption may help reduce chronic inflammation associated with obesity. However, the underlying mechanism(s) by which yogurt consumption modulates the immune system have not been validated in human intervention studies. We hypothesized that 4-week yogurt consumption (12 oz/day) attenuates systemic inflammation by modulating the proportion of circulating T helper (Th) 17 and regulatory T (Treg) cells in adult women with elevated body mass index (BMI). To test the hypothesis, we conducted a randomized crossover dietary intervention study consisted of a 4-week dietary intervention in which participants consumed 12 oz of either low-fat dairy yogurt or a soy pudding control snack per day, with a 4-week washout between treatments. Thirty-nine healthy adult women with a BMI between 25 and 40 kg/m2 were enrolled and 20 completed the study. Changes in the biometrics, circulating T cells, and markers of systemic and colonic inflammation were assessed between the 2 treatment groups, as well as 24-hour diet recalls were conducted at baseline and following each treatment. The primary study outcome, the change in the proportion of circulating Th17 cells, was unaffected by the treatments. Secondary outcome measures, circulating Treg, Th17, and markers of chronic inflammation, were maintained by yogurt treatment, whereas circulating Treg was increased and interleukin-10 was reduced by control snack treatment. However, circulating Treg changes were not associated with changes to other biomarkers of inflammation, implying other immune cells and/or tissues may mediate circulating biomarkers of chronic inflammation. This study was approved by the University of Wisconsin-Madison institutional review board and registered at ClinicalTrials.gov NCT04149418.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevalence, Awareness, Treatment, and Control of Type 2 Diabetes in South Korea (1998 to 2022): Nationwide Cross-Sectional Study

BACKGROUND

Type 2 diabetes poses an increasing disease burden in South Korea. The development and management of type 2 diabetes are closely related to lifestyle and socioeconomic factors, which have undergone substantial changes over the past few decades, including during the COVID-19 pandemic.

OBJECTIVE

This study aimed to investigate long-term trends in type 2 diabetes prevalence, awareness, treatment, and control. It also aimed to determine whether there were substantial alterations in the trends during the pandemic and whether these changes were more pronounced within specific demographic groups.

METHODS

This study examined the prevalence, awareness, treatment, and control of type 2 diabetes in a representative sample of 139,786 South Koreans aged >30 years, using data from the National Health and Nutrition Examination Survey and covering the period from 1998 to 2022. Weighted linear regression and binary logistic regression were performed to calculate weighted β coefficients or odds ratios. Stratified analyses were performed based on sex, age, region of residence, obesity status, educational background, household income, and smoking status. β (difference) was calculated to analyze the trend difference between the prepandemic period and the COVID-19 pandemic. To identify groups more susceptible to type 2 diabetes, we estimated interaction terms for each factor and calculated weighted odds ratios.

RESULTS

From 1998 to 2022, a consistent increase in the prevalence of type 2 diabetes was observed among South Koreans, with a notable rise to 15.61% (95% CI 14.83-16.38) during the pandemic. Awareness followed a U-shaped curve, bottoming out at 64.37% (95% CI 61.79-66.96) from 2013 to 2015 before increasing to 72.56% (95% CI 70.39-74.72) during the pandemic. Treatment also increased over time, peaking at 68.33% (95% CI 65.95-70.71) during the pandemic. Control among participants with diabetes showed no substantial change, maintaining a rate of 29.14% (95% CI 26.82-31.47) from 2020 to 2022, while control among treated participants improved to 30.68% (95% CI 27.88-33.48). During the pandemic, there was a steepening of the curves for awareness and treatment. However, while the slope of control among participants being treated increased, the slope of control among participants with diabetes showed no substantial change during the pandemic. Older populations and individuals with lower educational level exhibited less improvement in awareness and control trends than younger populations and more educated individuals. People with lower income experienced a deceleration in prevalence during the pandemic.

CONCLUSIONS

Over the recent decade, there has been an increase in type 2 diabetes prevalence, awareness, treatment, and control. During the pandemic, a steeper increase in awareness, treatment, and control among participants being treated was observed. However, there were heterogeneous changes across different population groups, underscoring the need for targeted interventions to address disparities and improve diabetes management for susceptible populations.

A diet-wide Mendelian randomization analysis: causal effects of dietary habits on type 2 diabetes

Background

Traditional clinical studies have indicated a link between certain food intakes and type 2 diabetes (T2D), but the causal relationships between different dietary habits and T2D remain unknown. Using Mendelian randomization (MR) approaches, we investigated the potential causal association between dietary habits and T2D risk.

Methods

We collected publicly available genome-wide association studies' summary statistics for 18 dietary habits from the UK Biobank and T2D data from the DIAbetes Genetics Replication And Meta-analysis (DIAGRAM) consortium. We applied the inverse variance weighted (IVW) method, supplemented with the MR-Egger method, weighted median method (WMM), simple method, weighted mode, MR-Egger regression, and the MR pleiotropy residual sum and outlier test to determine whether a particular diet was causal for T2D.

Results

Reliable and robust MR estimates demonstrated that poultry intake has a causal effect on a higher risk of T2D (IVW: OR 6.30, 95% CI 3.573-11.11, p = 2.02e - 10; WMM: OR 5.479, 95% CI 0.2758-10.88, p = 1.19e - 06). Conversely, dried fruit intake (IVW: OR 0.380, 95% CI 0.237-0.608, p = 5.57e - 05; WMM: OR 0.450, 95% CI 0.321-0.630, p = 3.33e - 06) and cereal intake (IVW: OR 0.455, 95% CI 0.317-0.653, p = 1.924e - 05; WMM: OR 0.513, 95% CI 0.379-0.694, p = 1.514e - 05) were causally associated with T2D as protective factors. Sensitivity analyses confirmed the reliability and robustness of these findings.

Discussion

Our study established the causal effects of poultry intake, dried fruit intake, and cereal intake on T2D, identifying poultry intake as a risk factor and the other two as protective factors. Further research into potential mechanisms is required to validate these novel findings.

Modifying the Health Star Rating nutrient profiling algorithm to account for ultra-processing

AIM

To modify the Australian and New Zealand Health Star Rating to account for ultra-processing and compare the alignment of the modified ratings with NOVA classifications and the current Australian Dietary Guidelines classifications of core (recommended foods) and discretionary (foods to limit).

METHODS

Data was cross-sectionally analysed for 25 486 products. Four approaches were compared to the original Health Star Rating: (1) five 'negative' points added to ultra-processed products (modification 1; inclusion approach); (2) ultra-processed products restricted to a maximum of 3.0 Health Stars (modification 2; capping approach); (3 and 4) same approach used for modifications 1 and 2 but only applied to products that already exceeded 10 'negative' points from existing Health Star Rating attributes (modifications 3 and 4, respectively; hybrid approaches). Alignment occurred when products (i) received <3.5 Health Stars and were NOVA group 4 (for NOVA comparison) or discretionary (for Dietary Guidelines comparison), or (ii) received ≥3.5 Health Stars and were NOVA groups 1-3 or core.

RESULTS

All Health Star Rating modifications resulted in greater alignment with NOVA (ranging from 69% to 88%) compared to the original Health Star Rating (66%). None of the modifications resulted in greater alignment to the Dietary Guidelines classifications overall (69% to 76%, compared with 77% for the original Health Star Rating), but alignment varied considerably by food category.

CONCLUSIONS

If ultra-processing were incorporated into the Australian and New Zealand Health Star Rating, consideration of ultra-processing within the broader dietary guidance framework would be essential to ensure coherent dietary messaging to Australians.

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.

County Rurality and Incidence and Prevalence of Diagnosed Diabetes in the United States

OBJECTIVE

To examine differences in the incidence and prevalence of diagnosed diabetes by county rurality.

PATIENTS AND METHODS

This observational, cross-sectional study used US Centers for Disease Control and Prevention data from 2004 through 2019 for county estimates of incidence and prevalence of diagnosed diabetes. County rurality was based on 6 levels (large central metro counties [most urban] to noncore counties [most rural]). Weighted least squares regression was used to relate rurality with diabetes incidence rates (IRs; per 1000 adults) and prevalence (percentage) in adults aged 20 years or older after adjusting for county-level sociodemographic factors (eg, food environment, health care professionals, inactivity, obesity).

RESULTS

Overall, in 3148 counties and county equivalents, the crude IR and prevalence of diabetes were highest in noncore counties. In age and sex ratio-adjusted models, the IR of diabetes increased monotonically with increasing rurality (P<.001), whereas prevalence had a weak, nonmonotonic but statistically significant increase (P=.002). Further adjustment for sociodemographic factors including food environment, health care professionals, inactivity, and obesity attenuated differences in incidence across rurality levels, and reversed the pattern for prevalence (prevalence ratios [vs large central metro] ranged from 0.98 [95% CI, 0.97 to 0.99] for large fringe metro to 0.94 [95% CI, 0.93 to 0.96] for noncore). In region-stratified analyses adjusted for sociodemographic factors including inactivity and obesity, increasing rurality was inversely associated with incidence in the Midwest and West only and inversely associated with prevalence in all regions.

CONCLUSION

The crude incidence and prevalence of diagnosed diabetes increased with increasing county rurality. After accounting for sociodemographic factors including food environment, health care professionals, inactivity, and obesity, county rurality showed no association with incidence and an inverse association with prevalence. Therefore, interventions targeting modifiable sociodemographic factors may reduce diabetes disparities by region and rurality.

Pro-vegetarian dietary patterns and mortality by all-cause and specific causes in an older Mediterranean population

PURPOSE

Pro-vegetarian (PVG) dietary patterns have shown health benefits, although the evidence concerning their association with mortality is scarce, particularly in older populations. We investigated the effect of three defined PVG patterns on all-cause, cardiovascular disease (CVD) and cancer mortality risk in an older Mediterranean population.

METHODS

We analysed baseline data from 597 adults aged 65 and older who participated in a population-based cross-sectional study, and mortality during a 12-year period. We used a validated food frequency questionnaire to estimate the adherence in tertiles to three evidence-based PVG dietary patterns: a general PVG pattern (gPVG) and two specific variations (healthful -hPVG, and unhealthful -uPVG). The gPVG pattern incorporated data from 12 food groups, consisting of 7 plant-based and 5 animal-based. The hPVG and uPVG versions included information from 18 food groups (4 food groups added and the splitting of 2 food groups). We used Cox regression to estimate hazard ratios (HR) and 95% confidence intervals (CI) adjusting for relevant covariates.

RESULTS

After the 12-years follow-up period, moderate adherence to hPVG pattern was associated with lower all-cause and CVD mortality whereas greater adherence to uPVG pattern was associated with higher all-cause and CVD mortality. Compared with those in the lowest tertile, participants in the second tertile of adherence to the hPVG pattern showed a significant lower risk of all-cause mortality (HR = 0.59; 95%CI: 0.43, 0.82) and CVD mortality (HR = 0.47; 0.28, 0.78). Participants in the highest tertile of adherence to the uPVG showed an increased mortality risk of all-cause (HR = 1.53; 1.07, 2.19) and CVD (HR = 2.10; 1.19, 3.70). No significant associations were found between adherence to any of the PVG dietary patterns and cancer mortality.

CONCLUSION

Moderate adherence to a healthy PVG pattern reduced the long-term mortality risk for all-cause and CVD in an older Mediterranean population, while higher adherence to an unhealthy PVG pattern increased the risk of all-cause and CVD mortality.

Ultraprocessed foods, unprocessed or minimally processed foods, and risk of frailty in a cohort of United States females

BACKGROUND

Ultraprocessed foods (UPFs) and poor diet quality have been associated with frailty but existing studies had relatively short follow-up time. It is also unclear whether the association of UPF was primarily due to its correlation with poorer diet quality.

OBJECTIVES

We examined the association between unprocessed or minimally processed foods (UMFs) and UPF and risk of frailty and explored whether the association with UPF was mainly driven by poor diet quality.

METHODS

In total, 63,743 nonfrail females aged 60+ y from the Nurses' Health Study (cohort study) were followed up for ≥26 y. Diet was assessed every 4 y by food frequency questionnaires. UPF and UMF intakes were calculated using the Nova classification. Diet quality was estimated using the Alternate Healthy Eating Index (AHEI) 2010. The association of UMF and UPF with risk of frailty was examined using multivariable adjusted Cox proportional hazard model.

RESULTS

During the follow-up period, we recorded 15,187 incident cases of frailty. The hazard ratio (HR) of frailty for the highest compared with the lowest quintile of UMFs (servings per day) was 0.86 (95% CI: 0.83, 0.95; P-trend < 0.001). However, this was no longer statistically significant after adjustment for AHEI-2010. UPFs (servings per day) was directly associated with risk of frailty, even after adjustment for AHEI-2010 (1.31; 95% CI: 1.23, 1.39; P-trend < 0.001). Among those at the highest category of the AHEI-2010, UPFs remained directly associated with frailty (HR comparing top with bottom quintile: 1.40; 95% CI:1.24, 1.57; P-trend < 0.001). For UPF components, we found a higher frailty risk with each serving per day of artificial and sugar-sweetened beverages; fat, spreads, and condiments; yogurt and dairy-based desserts; and other UPFs. However, processed whole grains were not associated with frailty.

CONCLUSIONS

Higher intake of UPF is associated with a higher risk of frailty in older females. This is not explained by a lower diet quality contributed by UPFs.

Protein and Amino Acid Adequacy and Food Consumption by Processing Level in Vegans in Brazil

Importance

Major concerns regarding individuals who adhere to a vegan diet are whether they meet protein and essential amino acid recommendations and how reliant they are on ultraprocessed foods.

Objectives

To investigate whether individuals who adhere to a vegan diet meet protein and essential amino acid recommendations and, as secondary objectives, to determine ultraprocessed food intake and potential factors associated with inadequate protein intake in this population.

Design, Setting, and Participants

This cross-sectional survey study was conducted between September 2021 and January 2023 in Brazil among male and female adults (aged 18 years or older) who adhered to a vegan diet recruited from social media platforms.

Exposure

Adherence to a vegan diet and unprocessed and minimally processed foods and ultraprocessed food consumption.

Main Outcomes and Measures

Protein and essential amino acid intake and food consumption by processing level were assessed using a 1-day food diary. Nutrient adequacy ratios were calculated by dividing nutrient intake by its recommendation (using scores truncated at 1) for each participant and then finding the mean across participants for each nutrient. The mean adequacy ratio was the mean of all nutrient adequacy ratios.

Results

Of 1014 participants who completed the survey, 774 individuals (median [IQR] age, 29 [24-35] years; 637 female [82.3%]) were confirmed as adhering to a vegan diet and provided adequate food recalls, among whom 558 individuals reported body weight and so had relative protein and amino acid intake values available. The median (IQR) body mass index (calculated as weight in kilograms divided by height in meters squared) of participants was 22.6 (20.3-24.8). The nutrient adequacy ratio of protein was 0.93 (95% CI, 0.91-0.94); for essential amino acids, ratios ranged from 0.90 (95% CI, 0.89-0.92) for lysine to 0.98 (95% CI, 0.97-0.99) for phenylalanine and tyrosine. The mean adequacy ratio for protein and all amino acids was 0.95 (95% CI, 0.94-0.96). The median intake level was 66.5% (95% CI, 65.0%-67.9%) of total energy intake for unprocessed and minimally processed food and 13.2% (95% CI, 12.4%-14.4%) of total energy intake for ultraprocessed food. Adjusted logistic regression models showed that consuming protein supplements (odds ratio [OR], 0.06 [95% CI 0.02-0.14]; P < .001) or textured soy protein (OR, 0.32 [95% CI, 0.17-0.59]; P < .001) was associated with decreased odds of inadequate protein intake. Higher ultraprocessed food intake levels were also associated with decreased odds of inadequate protein intake (eg, fourth vs first quartile of intake: OR, 0.16 [95% CI, 0.07-0.33]; P < .001), and higher unprocessed and minimally processed protein intake levels were associated with increased odds of inadequate protein intake (eg, fourth vs first quartile of intake: OR, 12.42 [95% CI, 5.56-29.51]; P < .001).

Conclusions and Relevance

In this study, most individuals who adhered to a vegan diet attained protein and essential amino acid intake recommendations, largely based their diet of unprocessed and minimally processed food, and had a significantly lower proportion of ultraprocessed food intake compared with previous reports. Participants consuming less ultraprocessed food were more likely to have inadequate protein intake, suggesting a significant reliance on ultraprocessed proteins for this population.

Ultra-processed food consumption and increased risk of metabolic syndrome in Korean adults: A cross-sectional analysis of the KNHANES 2016-2020

OBJECTIVE

This study aimed to investigate the association between ultra-processed food (UPF) intake and the risk for metabolic syndrome (MetS) in Korean adults.

METHODS

The study consisted of 22 688 Korean adults ≥19 y of age from the Korea National Health and Nutrition Examination Survey (KNHANES) 2016-2020. The NOVA classification categorizes foods according to the nature, extent, and purpose of industrial processing. MetS was defined based on the National Cholesterol Education Program Adult Treatment Panel III criteria and a modified waist circumference cut-off for Korean adults. We estimated the usual percent total food intake from UPFs. We used multivariate logistic regression to assess the association between UPFs and risk for MetS, adjusted for age, sex, education level, income level, smoking status, alcohol drinking, physical activity, and total energy intake. We further analyzed the association of UPFs with each component of MetS.

RESULTS

The median usual percent total food intake from UPFs was 22%, and the midpoint of intake ranged from 3% (quartile 1) to 48% (quartile 4). The group with the highest UPF consumption had a 19% higher risk for developing MetS than the lowest quartile of UPF consumption (odds ratio [OR],1.19; 95% confidence interval [CI], 1.06-1.33; Ptrend = 0.006). In analysis of the relationship between UPF intake and MetS components, a higher UPF was associated with an increased risk for hypertension (OR, 1.13; 95% CI, 1.01-1.26; Ptrend = 0.037) and abdominal obesity (OR, 1.19; 95% CI, 1.07-1.33; Ptrend = 0.001), but had no significant association with other components (hyperglycemia, hypertriacylglycerolmia, and low high-density lipoprotein cholesterol, all P > 0.05).

CONCLUSION

Higher UPF contribution to total daily food intake is associated with an increased risk for MetS, particularly with a higher risk for hypertension and abdominal obesity.

Ultra-processed foods and human health: An umbrella review and updated meta-analyses of observational evidence

BACKGROUND & AIMS

Ultra-processed food (UPF) intake has increased sharply over the last few decades and has been consistently asserted to be implicated in the development of non-communicable diseases. We aimed to evaluate and update the existing observational evidence for associations between ultra-processed food (UPF) consumption and human health.

METHODS

We searched Medline and Embase from inception to March 2023 to identify and update meta-analyses of observational studies examining the associations between UPF consumption, as defined by the NOVA classification, and a wide spectrum of health outcomes. For each health outcome, we estimated the summary effect size, 95% confidence interval (CI), between-study heterogeneity, evidence of small-study effects, and evidence of excess-significance bias. These metrics were used to evaluate evidence credibility of the identified associations.

RESULTS

This umbrella review identified 39 meta-analyses on the associations between UPF consumption and health outcomes. We updated all meta-analyses by including 122 individual articles on 49 unique health outcomes. The majority of the included studies divided UPF consumption into quartiles, with the lowest quartile being the reference group. We identified 25 health outcomes associated with UPF consumption. For observational studies, 2 health outcomes, including renal function decline (OR: 1.25; 95% CI: 1.18, 1.33) and wheezing in children and adolescents (OR: 1.42; 95% CI: 1.34, 1.49), showed convincing evidence (Class I); and five outcomes were reported with highly suggestive evidence (Class II), including diabetes mellitus, overweight, obesity, depression, and common mental disorders.

CONCLUSIONS

High UPF consumption is associated with an increased risk of a variety of chronic diseases and mental health disorders. At present, not a single study reported an association between UPF intake and a beneficial health outcome. These findings suggest that dietary patterns with low consumption of UPFs may render broad public health benefits.

Association of ultra-processed food consumption with all cause and cause specific mortality: population based cohort study

OBJECTIVE

To examine the association of ultra-processed food consumption with all cause mortality and cause specific mortality.

DESIGN

Population based cohort study.

SETTING

Female registered nurses from 11 US states in the Nurses' Health Study (1984-2018) and male health professionals from all 50 US states in the Health Professionals Follow-up Study (1986-2018).

PARTICIPANTS

74 563 women and 39 501 men with no history of cancer, cardiovascular diseases, or diabetes at baseline.

MAIN OUTCOME MEASURES

Multivariable Cox proportional hazard models were used to estimate hazard ratios and 95% confidence intervals for the association of ultra-processed food intake measured by semiquantitative food frequency questionnaire every four years with all cause mortality and cause specific mortality due to cancer, cardiovascular, and other causes (including respiratory and neurodegenerative causes).

RESULTS

30 188 deaths of women and 18 005 deaths of men were documented during a median of 34 and 31 years of follow-up, respectively. Compared with those in the lowest quarter of ultra-processed food consumption, participants in the highest quarter had a 4% higher all cause mortality (hazard ratio 1.04, 95% confidence interval 1.01 to 1.07) and 9% higher mortality from causes other than cancer or cardiovascular diseases (1.09, 1.05 to 1.13). The all cause mortality rate among participants in the lowest and highest quarter was 1472 and 1536 per 100 000 person years, respectively. No associations were found for cancer or cardiovascular mortality. Meat/poultry/seafood based ready-to-eat products (for example, processed meat) consistently showed strong associations with mortality outcomes (hazard ratios ranged from 1.06 to 1.43). Sugar sweetened and artificially sweetened beverages (1.09, 1.07 to 1.12), dairy based desserts (1.07, 1.04 to 1.10), and ultra-processed breakfast food (1.04, 1.02 to 1.07) were also associated with higher all cause mortality. No consistent associations between ultra-processed foods and mortality were observed within each quarter of dietary quality assessed by the Alternative Healthy Eating Index-2010 score, whereas better dietary quality showed an inverse association with mortality within each quarter of ultra-processed foods.

CONCLUSIONS

This study found that a higher intake of ultra-processed foods was associated with slightly higher all cause mortality, driven by causes other than cancer and cardiovascular diseases. The associations varied across subgroups of ultra-processed foods, with meat/poultry/seafood based ready-to-eat products showing particularly strong associations with mortality.

Excluding whole grain-containing foods from the Nova ultraprocessed food category: a cross-sectional analysis of the impact on associations with cardiometabolic risk measures

BACKGROUND

Whole grain (WG) consumption is linked with a reduced risk of chronic disease. However, the recommendations of the Nova classification system tend to contradict this evidence as high WG-containing foods, such as bread and cereals, are considered ultraprocessed, and intake is discouraged.

OBJECTIVES

This study aimed to explore associations of cardiometabolic risk measures with ultraprocessed food (UPF) intake as classified by Nova compared with when foods with ≥25% and ≥50% WG are removed from the Nova UPF category.

METHODS

A cross-sectional analysis of the 2015-18 National Health and Nutrition Examination Survey. Nova was used to identify UPFs, and the WG Initiative's definition of a WG food and front-of-pack labeling requirements was used to identify high WG foods. Regression models were used to explore impacts on the association of UPF intake (quintiles) and cardiometabolic risk measures when high WG foods were excluded from the Nova UPF category.

RESULTS

Participants in the highest quintile of UPF intake had significantly higher weight [83.6 kg (0.8)], BMI (in kg/m2) [30.6 (0.3)], waist circumference [103.1 cm (0.6)], and weight-to-height ratio [0.63 (0.003)] compared to those in the lowest quintile (P < 0.0001 for all). The same was found when foods with ≥25% and ≥50% WG were removed. Positive associations for C-reactive protein were found when ≥25% and ≥50% WG-containing foods were removed only [2.32 mg/L (0.1), P = 0.0209; 2.37 mg/L (0.1), P = 0.0179, respectively]. Participants in the highest quintile had significantly lower total cholesterol after adjustment when foods with ≥50% WG were removed [4.98 mmol/L (0.04), P = 0.0292]. Adjusted R2 values remained relatively unchanged across each approach for all outcomes.

CONCLUSIONS

Foods high in WG may not significantly contribute to the deleterious associations previously observed between UPF intake and cardiometabolic risk factors. Consideration of their contribution to healthful dietary patterns and diet quality in the United States population should be made prior to the endorsement of Nova.

Metabolomic and transcriptomic reveal flavonoid biosynthesis and regulation mechanism in Phlomoides rotata from different habitats

Phlomoides rotata is a traditional medical plant at 3100-5200 m altitude in the Tibet Plateau. In this study, flavonoid metabolites were investigated in P. rotata from Henan County (HN), Guoluo County (GL), Yushu County (YS), and Chengduo County (CD) habitats in Qinghai. The level of kaempferol 3-neohesperidoside, sakuranetin, and biochanin A was high in HN. The content of limocitrin and isoquercetin was high in YS. The levels of ikarisoside A and chrysosplenol D in GL were high. Schaftoside, miquelianin, malvidin chloride, and glabrene in CD exhibited high levels. The results showed a significant correlation between 59 flavonoids and 29 DEGs. Eleven flavonoids increased with altitude. PAL2, UFGT6, COMT1, HCT2, 4CL4, and HCT3 genes were crucial in regulating flavonoid biosynthesis. Three enzymes CHS, 4CL, and UFGT, were crucial in regulating flavonoid biosynthesis. This study provided biological and chemical evidence for the different uses of various regional plants of P. rotata.

Development of the VEGANScreener, a Tool for a Quick Diet Quality Assessment among Vegans in Europe

BACKGROUND

Plant-based diets are not inherently healthy. Similar to omnivorous diets, they may contain excessive amounts of sugar, sodium, and saturated fats, or lack diversity. Moreover, vegans might be at risk of inadequate intake of certain vitamins and minerals commonly found in foods that they avoid. We developed the VEGANScreener, a tool designed to assess the diet quality of vegans in Europe.

METHODS

Our approach combined best practices in developing diet quality metrics with scale development approaches and involved the following: (a) narrative literature synthesis, (b) evidence evaluation by an international panel of experts, and (c) translation of evidence into a diet screener. We employed a modified Delphi technique to gather opinions from an international expert panel.

RESULTS

Twenty-five experts in the fields of nutrition, epidemiology, preventive medicine, and diet assessment participated in the first round, and nineteen participated in the subsequent round. Initially, these experts provided feedback on a pool of 38 proposed items from the literature review. Consequently, 35 revised items, with 17 having multiple versions, were suggested for further consideration. In the second round, 29 items were retained, and any residual issues were addressed in the final consensus meeting. The ultimate screener draft encompassed 29 questions, with 17 focusing on foods and nutrients to promote, and 12 addressing foods and nutrients to limit. The screener contained 24 food-based and 5 nutrient-based questions.

CONCLUSIONS

We elucidated the development process of the VEGANScreener, a novel diet quality screener for vegans. Future endeavors involve contrasting the VEGANScreener against benchmark diet assessment methodologies and nutritional biomarkers and testing its acceptance. Once validated, this instrument holds potential for deployment as a self-assessment application for vegans and as a preliminary dietary screening and counseling tool in healthcare settings.

Precision Food Composition Data as a Tool to Decipher the Riddle of Ultra-Processed Foods and Nutritional Quality

BACKGROUND

Epidemiology supports a link between ultra-processed foods (UPFs) and health, mediated mainly through the clustering of foods with suboptimal nutrient profiles within UPFs. However, successful NOVA categorization requires access to a food's ingredient list, which we hypothesized can impact both UPF identification and the link between processing and composition.

METHODS

Foods (n = 4851) in the HelTH branded food composition database were classified as NOVA1-4, with or without using the ingredient lists (generic and branded approach, respectively), to identify differences in NOVA classification (chi-square test) and the estimated average nutritional composition of each NOVA group (Kruskal-Willis U test).

RESULTS

Using the ingredients list increased UPF identification by 30%. More than 30% of foods commonly assumed to be minimally processed (NOVA1-plain dairy, frozen vegetables, etc.) were reclassified as UPFs when using ingredient lists. These reclassified foods, however, had nutritional compositions comparable to NOVA1 foods and better than UPFs for energy, fat, sugars, and sodium (p < 0.001). In fact, UPFs did not show a uniform nutritional composition covering foods from Nutri-Score A (~10%) to Nutri-Score E (~20%).

CONCLUSIONS

The assumption that all UPFs have the same unfavorable nutritional composition is challenged when NOVA is applied using the appropriate branded food composition database.