A Semi-quantitative Food Frequency Questionnaire Has Relative Validity to Identify Groups of NOVA Food Classification System Among Mexican Adults

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.

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.

Who consumes ultra-processed food? A systematic review of sociodemographic determinants of ultra-processed food consumption from nationally representative samples

Ultra-processed food (UPF) intake is associated with increased non-communicable disease risks. However, systematic reports on sociodemographic predictors of UPF intake are lacking. This review aimed to understand UPF consumption based on sociodemographic factors, using nationally representative cohorts. The systematic review was pre-registered (PROSPERO:CRD42022360199), following PRISMA guidelines. PubMed/MEDLINE searches (‘ultra-processed/ultraprocessed’ and ‘ultra-processing/ultraprocessing’) until 7 September 2022 retrieved 1131 results. Inclusion criteria included: observational, nationally representative adult samples, in English, in peer-reviewed journals, assessing the association between sociodemographics and individual-level UPF intake defined by the NOVA classification. Exclusion criteria included: not nationally representative, no assessment of sociodemographics and individual-level UPF intake defined by NOVA. Risk of bias was assessed using the Newcastle–Ottawa Scale (NOS). Fifty-five papers were included, spanning thirty-two countries. All thirteen sociodemographic variables identified were significantly associated with UPF intake in one or more studies. Significant differences in UPF intake were seen across age, race/ethnicity, rural/urbanisation, food insecurity, income and region, with up to 10–20% differences in UPF intake (% total energy). Higher UPF intakes were associated with younger age, urbanisation and being unmarried, single, separated or divorced. Education, income and socioeconomic status showed varying associations, depending on country. Multivariate analyses indicated that associations were independent of other sociodemographics. Household status and gender were generally not associated with UPF intake. NOS averaged 5·7/10. Several characteristics are independently associated with high UPF intake, indicating large sociodemographic variation in non-communicable disease risk. These findings highlight significant public health inequalities associated with UPF intake, and the urgent need for policy action to minimise social injustice-related health inequalities.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

High ultra-processed food consumption is associated with elevated psychological distress as an indicator of depression in adults from the Melbourne Collaborative Cohort Study

BACKGROUND

Few studies have tested longitudinal associations between ultra-processed food consumption and depressive outcomes. As such, further investigation and replication are necessary. The aim of this study is to examine associations of ultra-processed food intake with elevated psychological distress as a marker for depression after 15 years.

METHOD

Data from the Melbourne Collaborative Cohort Study (MCCS) were analysed (n = 23,299). We applied the NOVA food classification system to a food frequency questionnaire (FFQ) to determine ultra-processed food intake at baseline. We categorised energy-adjusted ultra-processed food consumption into quartiles by using the distribution of the dataset. Psychological distress was measured by the ten-item Kessler Psychological Distress Scale (K10). We fitted unadjusted and adjusted logistic regression models to assess the association of ultra-processed food consumption (exposure) with significant psychological distress (outcome and defined as K10 ≥ 20). We fitted additional logistic regression models to determine whether these associations were modified by sex, age and body mass index.

RESULTS

After adjusting for sociodemographic characteristics and lifestyle and health-related behaviours, participants with the highest relative intake of ultra-processed food were at increased odds of significant psychological distress compared to participants with the lowest intake (aOR: 1.23; 95%CI: 1.10, 1.38, p for trend = 0.001). We found no evidence for an interaction of sex, age and body mass index with ultra-processed food intake.

CONCLUSION

Higher ultra-processed food intake at baseline was associated with subsequent elevated psychological distress as an indicator of depression at follow-up. Further prospective and intervention studies are necessary to identify possible underlying pathways, specify the precise attributes of ultra-processed food that confer harm, and optimise nutrition-related and public health strategies for common mental disorders.

Higher Ultra-Processed Food Consumption Is Associated with Greater High-Sensitivity C-Reactive Protein Concentration in Adults: Cross-Sectional Results from the Melbourne Collaborative Cohort Study

Background: Few studies have examined associations between ultra-processed food intake and biomarkers of inflammation, and inconsistent results have been reported in the small number of studies that do exist. As such, further investigation is required. Methods: Cross-sectional baseline data from the Melbourne Collaborative Cohort Study (MCCS) were analysed (n = 2018). We applied the NOVA food classification system to data from a food frequency questionnaire (FFQ) to determine ultra-processed food intake (g/day). The outcome was high-sensitivity C-reactive protein concentration (hsCRP; mg/L). We fitted unadjusted and adjusted linear regression analyses, with sociodemographic characteristics and lifestyle- and health-related behaviours as covariates. Supplementary analyses further adjusted for body mass index (kg/m2). Sex was assessed as a possible effect modifier. Ultra-processed food intake was modelled as 100 g increments and the magnitude of associations expressed as estimated relative change in hsCRP concentration with accompanying 95% confidence intervals (95%CIs). Results: After adjustment, every 100 g increase in ultra-processed food intake was associated with a 4.0% increase in hsCRP concentration (95%CIs: 2.1−5.9%, p < 0.001). Supplementary analyses showed that part of this association was independent of body mass index (estimated relative change in hsCRP: 2.5%; 95%CIs: 0.8−4.3%, p = 0.004). No interaction was observed between sex and ultra-processed food intake. Conclusion: Higher ultra-processed food intake was cross-sectionally associated with elevated hsCRP, which appeared to occur independent of body mass index. Future prospective and intervention studies are necessary to confirm directionality and whether the observed association is causal.

Are dietary patterns becoming more processed? The effects of different dietary patterns on cognition: A review

Background: Identifying dietary patterns that promote healthy aging has become increasingly important due to changes in food processing and consumption of processed foods. Recently, the effects of these foods and unhealthy dietary patterns on cognitive function have become more widely recognized. Aim: The aim of this review is to discuss the association between various dietary patterns and cognition in older age, while also highlighting growing evidence that ultra processed food (UPF) may negatively impact healthy aging. Methods: We have performed a non-systematic literature review searches in Google Scholar electronic database with pre-defined terms relating to UPF, diet, dietary patterns, cognition and ageing. Results: The most prevalent diets in the literature include the Western, Mediterranean, Dietary Approach to Stop Hypertension (DASH), Mediterranean-DASH Intervention for Neurogenerative Delay (MIND), Japanese, Nordic, and plant-based diets. Based on the findings, higher intakes of fresh fruit and vegetables, wholegrains and oily fish are common components of dietary patterns that are positively associated with better cognitive function. In contrast, the characteristics of a Western style dietary pattern, consisting of high amounts of UPF's, are increasing in many countries even where the staple dietary pattern was identified as healthy (i.e. Japan). Conclusion: The consumption of UPF, classified by the NOVA food classification system as industrially manufactured foods containing high levels of starches, vegetable oils, sugar, emulsifiers, and foods additives, has a negative impact on the overall nutritional quality of individual diets.