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Ultra-processed foods,
diet quality, and health
using the NOVA
classification system
Food and Agriculture Organization of the United Nations
Rome, 2019
Prepared by
Carlos Augusto Monteiro
Geoffrey Cannon
Mark Lawrence
Maria Laura da Costa Louzada
and
Priscila Pereira Machado
Required citation:
Monteiro, C.A., Cannon, G., Lawrence, M., Costa Louzada, M.L. and Pereira Machado, P. 2019. Ultra-processed foods,
diet quality, and health using the NOVA classification system. Rome, FAO.
The designations employed and the presentation of material in this information product do not imply the expression of any opinion
whatsoever on the part of the Food and Agriculture Organization of the United Nations (FAO) concerning the legal or development
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of FAO, nor do they constitute a validation of the NOVA classification system.
ISBN 978-92-5-131701-3
© FAO, 2019
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Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 1 of 44
Contents
Acknowledgements 2
SECTION 1
Introduction 3
SECTION 2
The NOVA food classification system and its four food groups 6
SECTION 3
Ultra-processed foods and the nutritional quality of national diets 13
SECTION 4
Ultra-processed foods and the risk of non-communicable diseases 22
SECTION 5
Conclusions and implications 33
References 38
Annex 1 44
Page 2 of 44
Ultra-processed foods, diet quality, and health using the NOVA classification system
Acknowledgements
The report Ultra-processed foods, diet quality, and health using the NOVA classification
system was prepared by Carlos Augusto Monteiro, Geoffrey Cannon, Mark Lawrence, Maria
Laura da Costa Louzada, and Priscila Pereira Machado.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 3 of 44
SECTION 1
Introduction
The significance of industrial processing, and in particular techniques and ingredients
developed or created by modern food science and technology, on the nature of food and on
the state of human health, is generally understated. This is evident in international and national
policies and strategies designed to improve population nutrition and health, in dietary
recommendations, and in public policies and actions guided by such recommendations. Until
recently it has also been neglected in epidemiological and experimental studies concerning
diet, nutrition and health.
The nature of processing
Reports issued by UN agencies and other authoritative organisations (WHO, 2003; WCRF, 2007)
list a number of commonly consumed processed foods and drinks as certainly or probably
implicated in obesity and various chronic non-communicable diseases. These include energy-
dense food products, “fast foods”, “convenience foods”, soft drinks, sugary drinks, various
refined starchy foods, processed meat and salt-preserved foods. But such reports stop short of
examining the common factors in these foods – the nature, extent and purpose of the
processes used to make them.
National dietary guidelines issued by governments of almost all countries, now with some
exceptions (Brazilian Ministry of Health, 2014; Ministerio de Salud del Uruguay, 2016;
Ministerio de Salud Publica del Equador & FAO 2018; Ministerio de Salud del Perú 2018), do not
address how types of processing affect the nature and quality of foods. As one example, both
the official US 2010 and the 2015-2020 Dietary Guidelines for Americans reports
(USDA/DHSS, 2010; USDA/DHSS, 2015) advise reduced consumption of critical nutrients
commonly in excess in processed foods such as free sugars, sodium and trans fats, but overlook
the sources of these nutrients.
Also, attention to food additives is almost always confined to important issues of toxicity and
other forms of contamination. Little attention is given to the equally important issue of
adulteration, including the use of cosmetic food additives (notably, flavours, colours, and
emulsifiers) used to make combinations of ingredients such as cheap processed oils, refined
sugars and starches, with sodium, palatable and attractive.
The relative neglect of food processing is historically understandable. When dietary guidelines
were first compiled and published in the first half of the last century, most food was combined
with culinary ingredients and consumed in the form of dishes and meals, or was eaten as such.
But beginning in the second half of the century, branded, ready to eat, to drink or to heat ‘fast’
or ‘convenient’ packaged products became increasingly prominent in food supplies, and
displaced long established dietary patterns based on minimally processed foods and freshly
prepared dishes and meals.
Processing in itself is not the issue
Food processing in itself is not the issue. One obvious reason is that nowadays, practically all
food is processed in some sense and in some way. The term ‘processing’ (like the term
Page 4 of 44
Ultra-processed foods, diet quality, and health using the NOVA classification system
‘industry’) is very general and therefore not helpful, and so judgements of foods simply
because they are ‘processed’ are not meaningful. Further, attempts to distinguish between
different types of processing by using undefined terms such as ‘fast’, ‘convenience’, or ‘junk’
food, cannot be the basis of scientific assessment (Monteiro, 2009).
Food scientists and technologists and food manufacturers are right to emphasize the benefits
of originally ancient and also relatively novel processes such as drying, non-alcoholic
fermentation, chilling and freezing, pasteurization, and vacuum-packing. But on the other
hand, just to take two examples, evidence on the harm done by partial hydrogenation of oils is
now conclusive, and on sugaring, notably in the manufacture of soft drinks (or ‘soda’), is very
strong (de Souza et al., 2015; WHO, 2015).
Food processing and its effects on human health can be assessed and made the basis of
guidelines and thus public policies and actions only when analysis is discriminating and precise,
with terms defined, and the nature, purpose, extent and effects of processing identified and
distinguished.
Acknowledging that ‘the over-reliance on processed foods, especially energy-dense foods high
in sugar, fat and salt, is gradually displacing home-prepared meals and the consumption of
fresh fruit and vegetables in typical diets’, FAO has published a technical report to provide
guidance to countries and researchers on how to incorporate the collection of information on
processed foods into their food consumption surveys (FAO, 2015). In this guidance report, two
examples of food classifications based on food processing were described, one developed as
part of EPIC (the European Prospective Investigation into Cancer and Nutrition) (Slimani, et al.,
2009) and NOVA, a food classification system developed by researchers at the University of
Sao Paulo, Brazil (Monteiro et al., 2010).
The EPIC and NOVA systems, together with other three alternatives of food classifications
based on food processing (González-Castell, et al., 2007; Asfaw, 2011; Eicher-Miller, et al.,
2012) were compared and reviewed elsewhere (Moubarac et al, 2014). A variant of NOVA was
later proposed (Poti et al., 2015). Annex 1 lists the six existing food classifications that take into
account food processing, with references that describe their methodologies and their use.
1
The NOVA food classification system with its identification and definition of ultra-processed
foods is the one that by far has been most applied in the scientific literature (Lawrence &
Baker, 2019).
1 This report is on Ultra-processed foods, diet quality and health. Ultra-processed foods is a concept and a
term only used by the NOVA food system classification and therefore the report focuses on NOVA
classification only.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 5 of 44
NOVA classifies all foods into four groups (Monteiro et al., 2017a). One of these, termed ultra-
processed foods, is made up of snacks, drinks, ready meals and many other product types
formulated mostly or entirely from substances extracted from foods or derived from food
constituents. Ultra-processed foods are made possible by use of many types of additive,
including those that imitate or enhance the sensory qualities of foods or culinary preparations
made from foods.
The processes and the ingredients used in the manufacture of ultra-processed foods make
them highly convenient (ready-to-consume, almost imperishable) and highly attractive (hyper-
palatable) for consumers, and highly profitable (low cost ingredients, long shelf-life) for their
manufacturers.
But these processes and ingredients also make ultra-processed foods typically nutritionally
unbalanced and liable to be over-consumed and to displace all three other NOVA food groups,
all of which include foods processed in some form. These are unprocessed or minimally
processed foods, processed culinary ingredients, and processed foods (Monteiro et al., 2017a).
These other food groups are the basis of long-established dietary patterns, including those
known to promote long and healthy lives (Sho, 2001; Sofi, et al., 2010; Jung et al., 2014).
The convenience and attractiveness of ultra-processed foods as defined by NOVA and their
aggressive marketing, are among the reasons why they now amount to around or even more
than half of the total dietary energy consumed in high-income countries with less established
dietary patterns based on freshly prepared meals such as the United States of America (Baraldi
et al., 2018), Canada (Moubarac, et al., 2017), the United Kingdom of Great Britain and
Northern Island (Rauber, et al., 2018), and Australia (Machado, et al.,2019). Their sales in
middle-income countries, including those whose cultures based on freshly prepared meals
have so far survived, are growing very fast, up to ten percent per year (Monteiro et al., 2013).
The next section of this report describes in detail the NOVA food classification system and its
four food groups, and provides a practical guide to identify ultra-processed foods. Subsequent
sections list and examine the peer-reviewed literature on the impact of ultra-processed foods
for the nutritional quality of overall diets, and for health and disease. Research and policy
implications of the evidence described in these sections are discussed in the final section.
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Ultra-processed foods, diet quality, and health using the NOVA classification system
SECTION 2
The NOVA food classification system
and its four food groups
The NOVA classification system groups all foods according to the nature, extent and purposes
of the industrial processes they undergo. These involve physical, biological and chemical
techniques used after foods are separated from nature, and before they are consumed or else
made into dishes and meals.
Some foods may be consumed by themselves (examples are fruit, nuts, and milk). Others are
usually consumed as all or part of prepared dishes and meals (examples are grains, vegetables,
meat, and eggs). Others are food products used in making dishes and meals (examples are oils,
butter, sugar, and salt). Or else they are food products manufactured so as to be ready to eat,
drink or heat (examples are breads, cheeses, ham, packaged snacks, soft drinks, and pre-
prepared dishes).
NOVA classifies all foods and food products into four groups. See table 1, below, for more
details and lists of foods and food products in each of the four groups.
A description of the four NOVA food groups and a practical guide to identify ultra-processed
foods follows, adapted from Monteiro, et al., 2017a and Monteiro, et al., 2019.
|GROUP 1 |
Unprocessed and minimally processed foods
Unprocessed (or natural) foods are the edible parts of plants (such as fruit, leaves, stems,
seeds, roots) or from animals (such as muscle, offal, eggs, milk), and also fungi, algae and
water, after separation from nature. See table 1, below.
Minimally processed foods are natural foods altered by methods that include removal of
inedible or unwanted parts, and also processes that include drying, crushing, grinding,
powdering, fractioning, filtering, roasting, boiling, non-alcoholic fermentation, pasteurization,
chilling, freezing, placing in containers, and vacuum packaging. The distinction between
unprocessed and minimally processed foods is not especially significant.
These methods and processes are designed to preserve natural foods, to make them suitable
for storage, or else to make them safe or edible or more pleasant to consume. Many
unprocessed or minimally processed foods are prepared and cooked as dishes or meals in
kitchens at home or in restaurants or canteens in combination with processed culinary
ingredients and sometimes with some processed foods.
Unprocessed and minimally processed foods vary in energy density and in their content and
balance of fats, carbohydrates, proteins, and their fractions, and in vitamins, minerals and
other bioactive compounds. No single type of food can provide human beings with all
necessary energy and essential nutrients in adequate balance, except for breastmilk in the first
six months of life.
Ultra-processed foods, diet quality, and health using the NOVA classification system
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Thus in general, animal foods are good sources of various amino acids, vitamins and minerals,
but contain little or no dietary fibre. Quite often they are energy-dense and high in unhealthy
types of fat. Plant foods are usually low in energy density and good sources of dietary fibre.
Many are high in various micronutrients and bioactive compounds, and some are good sources
of amino acids.
This is why the human species has evolved as omnivorous. It explains why a great variety of
traditional and long established food systems have been developed that have in common, the
combination of plant foods with complementary nutrient profiles, such as grains (cereals) with
legumes (pulses), or roots with legumes, or grains with vegetables, and usually with modest
amounts of animal foods.
In appropriate variety and combinations, all foods in this group are the basis for healthy diets.
|GROUP 2|
Processed culinary ingredients
Processed culinary ingredients include oils, butter, lard, sugar and salt. See Table 1, below.
These are substances derived from group 1 foods or else from nature by processes such as
pressing, refining, grinding, milling, and drying. Some methods used to make processed
culinary ingredients are originally ancient. But now they usually are industrial products,
designed to make durable products suitable for use in home, restaurant and canteen kitchens
to prepare, season and cook freshly prepared dishes and meals.
In isolation, processed culinary ingredients are unbalanced, being depleted in some or most
nutrients. Other than salt, they are also energy-dense, at 400 or 900 kilocalories per 100
grams. This is around 3-6 times more than cooked grains and around 10-20 times more than
cooked vegetables.
But the key point here is that they are rarely if ever consumed by themselves. They are used in
combination with foods to make palatable, diverse, nourishing and enjoyable meals and dishes
such as stews, soups and broths, salads, breads, preserves, drinks, and desserts. Thus, oils are
used in the cooking of grains (cereals), vegetables and legumes (pulses), and meat, and are
added to salads. Table sugar is used to prepare fruit- or milk-based desserts. It is misleading to
assess their nutritional significance in isolation. They should always be assessed in combination
with foods.
Many culinary ingredients are cheap, and can be over-used. When used carefully and in small
amounts, they result in delicious dishes and meals that are nutritionally balanced, with energy
densities much lower than those of most ready-to-consume food products.
|GROUP 3|
Processed foods
These include canned or bottled vegetables or legumes (pulses) preserved in brine; whole fruit
preserved in syrup; tinned fish preserved in oil; some types of processed animal foods such as
ham, bacon, pastrami, and smoked fish; most freshly baked breads; and simple cheeses to
which salt is added. See Table 1, below.
They are made by adding salt, oil, sugar or other substances from group 2 to group 1 foods.
Processes include various preservation or cooking methods, and with breads and cheeses,
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Ultra-processed foods, diet quality, and health using the NOVA classification system
non-alcoholic fermentation.
Processing here increases the durability of group 1 foods, or modifies or enhances their
sensory qualities. Most processed foods have two or three ingredients, and are recognisable as
modified versions of group 1 foods. They are generally produced to be consumed as part of
meals or dishes, and also may be consumed by themselves as snacks. Most are highly
palatable.
As with culinary ingredients, some methods used to make processed food products are
originally ancient, and can be and are still used domestically or artisanally. But now almost all
are manufactured industrially. Processes include canning and bottling using oils, sugars or salt;
and methods of preservation such as salting, salt-pickling, smoking, and curing. The ingredients
infiltrate the foods and so the processes alter their nature.
Processed food products usually retain the basic identity and most constituents of the original
food. But when excessive oil, sugar or salt are added, they become nutritionally unbalanced.
Except for canned vegetables, their energy density ranges from moderate (around 150-250
kilocalories per 100 grams for most processed meats), to high (around 300-400 kilocalories per
100 grams for most cheeses).
Like processed culinary ingredients, they can be over-used. When used sparingly, and in the
case of processed meats also only occasionally, they also result in delicious dishes and meals
that are nutritionally balanced, also with energy densities lower than those of most ready-to-
consume food products.
|GROUP 4|
Ultra-processed foods
Ultra-processed foods are formulations of ingredients, mostly of exclusive industrial use,
typically created by series of industrial techniques and processes (hence ‘ultra-processed’).
Some common ultra-processed products are carbonated soft drinks; sweet, fatty or salty
packaged snacks; candies (confectionery); mass produced packaged breads and buns, cookies
(biscuits), pastries, cakes and cake mixes; margarine and other spreads; sweetened breakfast
‘cereals’ and fruit yoghurt and ‘energy’ drinks; pre-prepared meat, cheese, pasta and pizza
dishes; poultry and fish ‘nuggets’ and ‘sticks’; sausages, burgers, hot dogs and other
reconstituted meat products; powdered and packaged ‘instant’ soups, noodles and desserts;
baby formula; and many other types of product. See table 1, below.
Processes enabling the manufacture of ultra-processed foods involve several steps and
different industries. It starts with the fractioning of whole foods into substances including
sugars, oils and fats, proteins, starches and fibre. These substances are often obtained from a
few high-yield plant foods (such as corn, wheat, soya, cane or beet) and from puréeing or
grinding animal carcasses, usually from intensive livestock farming.
Some of these substances are then submitted to hydrolysis, or hydrogenation, or other
chemical modifications. Subsequent processes involve the assembly of unmodified and
modified food substances with little if any whole food using industrial techniques such as
extrusion, moulding and pre-frying. Colours, flavours, emulsifiers and other additives are
frequently added to make the final product palatable or hyper-palatable. Sophisticated and
attractive packaging is used, usually made of synthetic materials.
Ultra-processed foods, diet quality, and health using the NOVA classification system
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Sugar, oils and fats, and salt, used to make processed foods, are often ingredients of ultra-
processed foods, commonly in combination. Additives that prolong product duration, protect
original properties, and prevent proliferation of micro-organisms may be used in both
processed and ultra-processed foods, as well as in processed culinary ingredients, and,
infrequently, in minimally processed foods.
Ingredients characteristic of ultra-processed foods are either food substances of no or rare
culinary use, or else classes of additives whose function is to make the final product sellable,
palatable and often hyper-palatable.
Food substances of no or rare culinary use, employed in the manufacture of ultra-processed
foods, include varieties of sugars (fructose, high-fructose corn syrup, ‘fruit juice concentrates’,
invert sugar, maltodextrin, dextrose, lactose), modified oils (hydrogenated or interesterified
oils) and sources of protein (hydrolysed proteins, soya protein isolate, gluten, casein, whey
protein, and ‘mechanically separated meat’).
Classes of additives used only in the manufacture of ultra-processed foods, are flavours,
flavour enhancers, colours, emulsifiers, emulsifying salts, sweeteners, thickeners, and foaming,
anti-foaming, bulking, carbonating, gelling and glazing agents. All of them, most notably
flavours and colours, either disguise unpleasant sensory properties created by ingredients,
processes or packaging used in the manufacture of ultra-processed foods, or give the final
product intense sensory properties especially attractive to see, taste, smell and/or touch, or
both.
Processes and ingredients used for the manufacture of ultra-processed foods are designed to
create highly profitable products (low-cost ingredients, long shelf-life, powerfully branded).
Their convenience (imperishable, ready-to-consume), hyper-palatability, and ownership by
transnational corporations using pervasive advertising and promotion, give ultra-processed
foods enormous market advantages. They are therefore liable to displace all other NOVA food
groups, and to replace freshly made regular meals and dishes, with snacking any time,
anywhere.
Not all ultra-processed foods are recent or new. The first such products created and, enabled
by mass industrialisation, some commonly consumed for generations, include packaged
cookies (biscuits), preserves (jams); sauces, meat, yeast and other extracts; ice-cream,
chocolates, packaged candies (confectionery); margarines; and infant formulas.
Some of what are now ultra-processed foods were originally manufactured only with group 1
foods and salt or sugar or other substances from group 2, and thus would be classed in NOVA
group 3 as processed foods. But as now formulated most of them are ultra-processed.
Examples are commercially wrapped breads, packaged cakes and pies, and pre-prepared
animal products such as hot dogs and burgers. Packaged ready-to-heat products consumed at
home or at fast food outlets such as meat, cheese, pizza and pasta dishes, and French fries
(chips) may look much the same as home-cooked food, but their formulations and the
ingredients used in their pre-preparation render them ultra-processed.
Identifying ultra-processed foods
Food manufacturers do not have to state on food labels the processes used in their products,
and even less the purposes of these processes. Sometimes this can make it difficult to identify
ultra-processed foods with confidence.
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Ultra-processed foods, diet quality, and health using the NOVA classification system
There is of course no need to examine every food to know whether or not it is ultra-processed.
Fresh vegetables, fruit, roots and tubers are obviously not ultra-processed; nor for instance are
pasteurized milk and chilled meat. Plant oils, sugar and salt used as culinary preparations are
also not ultra-processed.
It is however not always immediately clear when some specific food products are ultra-
processed or not. Examples include breads and breakfast cereals. Here the solution is to
examine the ingredients labels that by law must be included on pre-packaged food and drink
products.
Industrial breads made only from wheat flour, water, salt and yeast are processed foods, while
those whose lists of ingredients also include emulsifiers or colours are ultra-processed. Plain
steel-cut oats, plain corn flakes and shredded wheat are minimally processed foods, while the
same foods are processed when they also contain sugar, and ultra-processed if they also
contain flavours or colours.
Generally, the practical way to identify if a product is ultra-processed is to check to see if its list
of ingredients contains at least one item characteristic of the ultra-processed food group.
These are either food substances never or rarely used in kitchens, or classes of additives whose
function is to make the final product palatable or more appealing.
Food substances not used in kitchens appear in the beginning or in the middle of the lists of
ingredients of ultra-processed foods. These include hydrolysed proteins, soya protein isolate,
gluten, casein, whey protein, ‘mechanically separated meat’, fructose, high-fructose corn
syrup, ‘fruit juice concentrate’, invert sugar, maltodextrin, dextrose, lactose, soluble or
insoluble fibre, hydrogenated or interesterified oil. The presence in the list of ingredients of
one or more of these food substances identifies a product as ultra-processed.
Classes of additive exclusively used in ultra-processed foods are at the end of lists of
ingredients, together with other additives. These include flavours, flavour enhancers, colours,
emulsifiers, emulsifying salts, artificial sweeteners, thickeners, and anti-foaming, bulking,
carbonating, foaming, gelling and glazing agents. Any example of these classes of additive, as
shown on ingredients lists also identifies a product as ultra-processed.
Information in ingredients labels is not fully standardized in all countries. But some of the most
frequently used classes of additives such as flavours, flavour enhancers, colours and
emulsifiers are usually easy to identify. They may be expressed as a class, such as flavourings
or natural flavours or artificial flavours; or their names are followed by their class, such as
‘monosodium glutamate (flavour enhancer)’, or ‘caramel colour’, or ‘soya lecithin as
emulsifier’. Other classes of additives commonly used in the manufacture of ultra-processed
foods include sweeteners like aspartame, cyclamate or compounds derived from stevia. The
UN Codex Alimentarius provides a regularly updated list of additives with their functional
classes (FAO & WHO, 2017) and an online search facility (FAO & WHO, n.d.).
The next section of this report summarises the evidence linking the consumption of ultra-
processed foods with the nutritional quality of diets.
Ultra-processed foods, diet quality, and health using the NOVA classification system
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TABLE 1. THE NOVA FOOD CLASSIFICATION SYSTEM AND ITS FOUR GROUPS DEFINED ACCORDING TO THE
EXTENT AND PURPOSE OF FOOD PROCESSING
NOVA GROUP
DEFINITION
EXAMPLES
|GROUP 1|
Unprocessed or
minimally processed
foods
Unprocessed
Edible parts of plants (fruit, seeds, leaves, stems,
roots, tubers) or of or from animals (muscle, fat,
offal, eggs, milk), and also fungi, algae, all after
separation from nature. Spring and tap water.
Minimally processed
Unprocessed foods altered by industrial processes
such as removal of inedible or unwanted parts,
drying, powdering, squeezing, crushing, grinding,
fractioning, steaming, poaching, boiling, roasting,
and pasteurization, chilling, freezing, placing in
containers, vacuum packaging, non-alcoholic
fermentation, and other methods that do not add
salt, sugar, oils or fats or other food substances to
the original food.
The main aim of these processes is to extend the life
of unprocessed foods, enabling their storage for
longer use, or to make them edible, and, often, to
make their preparation easier or more diverse.
Infrequently, minimally processed foods contain
additives that prolong product duration, protect
original properties or prevent proliferation of
microorganisms.
Fresh, squeezed, chilled, frozen, or dried fruit and
leafy and root vegetables; grains such as brown,
parboiled or white rice, corn cob or kernel, wheat
berry or grain; legumes such as beans, lentils, and
chickpeas; starchy roots and tubers such as
potatoes, sweet potatoes and cassava; fungi such
as fresh or dried mushrooms; meat, poultry, fish
and seafood, whole or in the form of steaks,
fillets and other cuts; fresh, powdered, chilled or
frozen eggs; fresh, powdered or pasteurized milk;
fresh or pasteurized fruit or vegetable juices
(with no added sugar, sweeteners or flavours);
grits, flakes or flour made from corn, wheat, oats,
or cassava; tree and ground nuts and other oily
seeds (with no added salt or sugar); herbs and
spices used in culinary preparations, such as
thyme, oregano, mint, pepper, cloves and
cinnamon, whole or powdered, fresh or dried;
fresh or pasteurized plain yoghurt; tea, coffee,
and drinking water.
Also includes foods made up from two or more
items in this group, such as dried mixed fruits,
granola made from cereals, nuts and dried fruit
with no added sugar, honey or oil; pasta,
couscous and polenta made with flours, flakes or
grits and water; and foods with vitamins and
minerals added generally to replace nutrients lost
during processing, such as wheat or corn flour
fortified with iron and folic acid.
|GROUP 2|
Processed culinary
ingredients
Substances obtained directly from group 1 foods or
from nature by industrial processes such as pressing,
centrifuging, refining, extracting or mining.
Used to prepare, season and cook group 1 foods.
May contain additives that prolong product
duration, protect original properties or prevent
proliferation of microorganisms.
Vegetable oils crushed from seeds, nuts or fruit
(notably olives); butter and lard obtained from
milk and pork; sugar and molasses obtained from
cane or beet; honey extracted from combs and
syrup from maple trees; starches extracted from
corn and other plants; vegetable oils with added
anti-oxidants; salt mined or from seawater, and
table salt with added drying agents.
Also includes products consisting of group 2
items, such as salted butter, and group 2 items
with added vitamins or minerals, such as iodised
salt.
Cont.
Page 12 of 44
Ultra-processed foods, diet quality, and health using the NOVA classification system
TABLE 1. Cont.
NOVA GROUP
DEFINITION
EXAMPLES
|GROUP 3|
Processed foods
Products made by adding salt, oil, sugar or other
group 2 ingredients to group 1 foods, using
preservation methods such as canning and bottling,
and, in the case of breads and cheeses, using non-
alcoholic fermentation.
Processes and ingredients here are designed to
increase the durability of group 1 foods and make
them more enjoyable by modifying or enhancing
their sensory qualities. They may contain additives
that prolong product duration, protect original
properties, or prevent proliferation of
microorganisms.
Canned or bottled vegetables and legumes in
brine; salted or sugared nuts and seeds; salted,
dried, cured, or smoked meats and fish; canned
fish (with or without added preservatives); fruit
in syrup (with or without added anti-oxidants);
freshly made unpackaged breads and cheeses.
|GROUP 4|
Ultra-processed foods
Formulations of ingredients, mostly of exclusive
industrial use, made by a series of industrial
processes, many requiring sophisticated equipment
and technology (hence ‘ultra-processed’). Processes
used to make ultra-processed foods include the
fractioning of whole foods into substances, chemical
modifications of these substances, assembly of
unmodified and modified food substances using
industrial techniques such as extrusion, moulding
and pre-frying; use of additives at various stages of
manufacture whose functions include making the
final product palatable or hyper-palatable; and
sophisticated packaging, usually with plastic and
other synthetic materials. Ingredients include sugar,
oils or fats, or salt, generally in combination, and
substances that are sources of energy and nutrients
that are of no or rare culinary use such as high
fructose corn syrup, hydrogenated or interesterified
oils, and protein isolates; classes of additives whose
function is to make the final product palatable or
more appealing such as flavours, flavour enhancers,
colours, emulsifiers, and sweeteners, thickeners,
and anti-foaming, bulking, carbonating, foaming,
gelling, and glazing agents; and additives that
prolong product duration, protect original
properties or prevent proliferation of
microorganisms.
Processes and ingredients used to manufacture
ultra-processed foods are designed to create highly
profitable products (low-cost ingredients, long shelf-
life, emphatic branding), convenient (ready-to-
consume) hyper-palatable products liable to
displace freshly prepared dishes and meals made
from all other NOVA food groups.
Adapted from Monteiro et al., 2017a.
Many ready-to-consume products such as
carbonated soft drinks; sweet or savoury
packaged snacks; chocolate, candies
(confectionery); ice-cream; mass-produced
packaged breads and buns; margarines and other
spreads; cookies (biscuits), pastries, cakes, and
cake mixes; breakfast ‘cereals’, ‘cereal’ and
‘energy’ bars; ‘energy’ drinks; milk drinks, ‘fruit’
yoghurts and ‘fruit’ drinks; ‘cocoa’ drinks;
‘instant’ sauces.
Many pre-prepared ready-to-heat products
including pies and pasta and pizza dishes; poultry
and fish ‘nuggets’ and ‘sticks’, sausages, burgers,
hot dogs, and other reconstituted meat products;
and powdered and packaged ‘instant’ soups,
noodles and desserts.
Infant formulas, follow-on milks, other baby
products; ‘health’ and ‘slimming’ products such
as meal replacement shakes and powders.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 13 of 44
SECTION 3
Ultra-processed foods and the nutritional
quality of national diets
Since the NOVA food classification system with its concept of ultra-processed foods was first
proposed in 2009, many studies have evaluated the impact of these foods on the nutritional
quality of national diets.
The main focus of these studies has been on the dietary content of nutrients associated with
non-communicable diseases (NCDs) including both NCD-promoting nutrients, such as free or
added sugars, sodium, saturated and trans fats, and also high dietary energy density, and NCD-
protective nutrients, such as protein and fibre.
Earlier studies were based on analyses of nationally-representative data sets provided by
household budget surveys while more recent studies relied mostly on national dietary surveys.
Studies using national household budget surveys
Table 2 lists the four peer-reviewed articles that have examined at national level the influence
of ultra-processed foods on the nutritional quality of total household food purchases. They are
listed in ascendant order according to the year of publication, with information on the studied
population, year of the survey, sample size, purpose of the study and main findings.
Findings reported by the articles refer to studies on data collected by nationally-
representative household surveys in Brazil (2002/3), Canada (2001), Chile (2006/7), and Spain
(1990, 2000 and 2010).
The studies in Brazil and Chile assessed the nutrient profile of total household food purchases
in each country and then compared the nutrient profile of two purchase shares: one made up
of only ultra-processed foods and the other restricted to non-ultra-processed foods. In both
countries, the ultra-processed share (or the ‘average’ ultra-processed food) was shown to be
significantly higher in NCD-promoting nutrients (free/added sugars, sodium) and in energy
density, and lower in NCD-protective nutrients (protein and fibre) than the non-ultra-
processed share (or the ‘average’ non-ultra-processed food). In Brazil, the
‘average’ ultra-processed food had also a higher content of NCD-promoting saturated fat.
The study in Canada assessed at individual level the association between household ultra-
processed food purchases and the nutrient profile of total food purchases. Increases in
household ultra-processed food purchases were significantly associated with total food
purchases higher in NCD-promoting nutrients (free sugars and sodium) and in energy density,
and lower in NCD-protecting nutrients (protein and fibre).
The study in Spain was focused on the relationship between ultra-processed food purchases
and the content of NCD-promoting added sugar in total food purchases. In 1990, in 2000 and
in 2010, increases in the ultra-processed food purchases were shown to be significantly
associated with total food purchases higher in added sugar, and with the frequency of
excessive added sugar content (≥ten percent of total energy).
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Ultra-processed foods, diet quality, and health using the NOVA classification system
The national household ultra-processed food purchases in Spain increased across the surveys
(from 11.0 percent of total energy in 1990 to 24.6 percent in 2000 and to 31.7 percent in
2010) in parallel with increases in their content of added sugar (from 8.4 percent of total
energy in 1990, to 11.2 percent in 2000 and to 13.0 percent in 2010).
Studies using national dietary surveys
Table 3 lists the fifteen peer-reviewed articles that evaluated at national level, the association
between the dietary share of ultra-processed foods and the nutritional quality of overall diets.
Articles are listed in ascendant order according to the year of publication, with information on
the studied population, year of the survey, sample size, dietary outcomes, control variables
and main findings.
Findings reported by the articles refer to studies on data collected by nationally-representative
24-hour recall/record food intake surveys undertaken between 2004 and 2014 in ten
countries: the US (four studies), the UK (two studies), Chile (two studies), Brazil, Canada,
Belgium, Colombia, Australia, Mexico, and Taiwan. Most studies included all age-groups except
infants and toddlers. One study (the one in Taiwan) was restricted to adolescents.
All studies focused on the relationship between the dietary share of ultra-processed foods and
the dietary content of nutrients associated with non-communicable diseases (NCDs). Some of
them enlarged the list of NCD-protective nutrients, adding potassium and phytoestrogens.
Four studies included a range of micronutrients other than sodium and potassium, some of
them commonly associated with undernutrition and micronutrient deficiencies, such as iron,
zinc and vitamin A. Finally, two studies examined the association between the dietary share of
ultra-processed foods and the overall quality of diets measured through nutrient-based dietary
patterns that considered the dietary content of a large range of macro and micronutrients. All
studies adjusted estimates of the association between the dietary share of ultra-processed
foods and indicators of the quality of the overall diet for demographic and socioeconomic
variables.
Ultra-processed food intake and dietary content
of NCD-promoting nutrients
Free or added sugar
Significant, direct, dose-response associations between the dietary share of ultra-processed
foods and the dietary content of free/added sugar or the probability of excessive free/added
sugar intakes (≥10 percent of total energy intake) were shown in all eight countries where
these associations were studied (USA, Brazil, UK, Chile, Canada, Colombia, Australia, and
Mexico).
For instance, the mean dietary content of free sugar in the Mexican diet ranged from 7.4
percent of total energy intake in the lower quintile of ultra-processed food intake to 17.5
percent in the upper quintile. In the US, the upper quintile of ultra-processed food intake
showed three times as many individuals with excessive added sugar intake compared to the
lower quintile (82.1 percent and 26.4 percent, respectively).
Saturated and trans fats
Significant, direct, dose-response associations between the dietary share of ultra-processed foods
and the dietary content of saturated fat or the probability of excessive saturated fat intakes (≥ten
percent of total energy intake) were found in all the ten countries.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 15 of 44
For instance, the mean dietary content of saturated fat in the Colombian diet increased from 7.3
percent of total energy intake in the lower quintile of ultra-processed intake to 10.4 percent in the
upper quintile. In Chile, the upper quintile of ultra-processed food intake showed 2.2 times as
many individuals with excessive saturated fat intake compared to the lower quintile (47.8 percent
and 21.7 percent, respectively).
The association between the intake of ultra-processed foods and the dietary content of trans fats
was only studied in Brazil, Chile and Australia. In these three countries there was a significant,
direct, dose-response association between the dietary share of ultra-processed foods and the
dietary content of trans fats or the probability of excessive trans fat intakes (≥1 percent of total
energy intake).
For instance, the mean dietary content of trans fats in the Brazilian diet increased from 0.8 percent
of total energy intake in the lower quintile of ultra-processed intake to 1.9 percent in the upper
quintile. In Chile, the upper quintile of ultra-processed food intake showed seven times as many
individuals with excessive trans fat intake compared to the lower quintile (0.9 percent and 6.6
percent, respectively).
Sodium
Significant, direct, dose-response associations between the dietary share of ultra-processed
foods and the dietary content of sodium or the probability of excessive intakes (≥2 000 mg/
2 000 kcal) were found in the UK, Australia, and Belgium.
For instance, the mean dietary content of sodium in the Australian diet increased from 2 106
mg/2 000 kcal in the lower quintile of ultra-processed intake to 2 768 mg/2 000 kcal in the
upper quintile. In the UK, the upper quintile of ultra-processed food intake showed 1.6 times
as many individuals with excessive sodium intake (2 000 mg/2 000 kcal) compared to the lower
quintile (86.7 percent and 55.8 percent, respectively).
The studies undertaken in Taiwan, Colombia, Brazil and Mexico did not consider the content of
sodium in the assessment of the dietary nutrient profile, while in studies in Chile, US and
Canada there were no significant associations between ultra-processed food intake and
dietary sodium content.
Energy density
Significant, direct, dose-response associations between the dietary share of ultra-processed
foods and energy density of diets were found in all five countries where these associations
were studied (Australia, Canada, Chile, Colombia, and Mexico).
For instance, the mean energy density of the solid fraction of the Canadian diet increased from
1.9 kcal/g in the lower quintile of ultra-processed intake to 3.2 kcal/g in the upper quintile. In
Chile there was a significant direct association between the dietary share of ultra-processed
foods and the energy density of drinks (from 0.17 kcal/ml in the lower quintile of ultra-
processed food intake to 0.33 kcal/ml in the upper quintile). In Australia, the proportion of
people with dietary energy density above the recommendation (≥2.25kcal/g) increased from 2
percent to 25 percent, from the lower to the upper quintile of ultra-processed food intake.
Ultra-processed food intake and dietary content of NCD-protective nutrients
Protein
Significant, inverse, dose-response associations between the dietary share of ultra-processed
Page 16 of 44
Ultra-processed foods, diet quality, and health using the NOVA classification system
foods and the dietary content of protein were found in all countries, except in Belgium and
Australia where this association was not investigated. Furthermore, in the US, one direct
association between the dietary share of ultra-processed foods and the total energy intake
was documented, partially mediated by the lower protein content of ultra-processed foods.
Fibre
Significant, inverse, dose-response associations between the dietary share of ultra-processed
foods and the dietary content of fibre or the probability of insufficient intakes (<25g/2 000
kcal) were found in all eight countries where these associations were studied (US, Brazil, UK,
Canada, Chile, Colombia, Australia, and Mexico).
For instance, the dietary content of fibre in the Colombian diet decreased from 25.6 g/2 000
kcal in the lower quintile of ultra-processed intake to 17.2 g/2 000 kcal in the upper quintile. In
Chile, the upper quintile of ultra-processed food intake showed twice as many individuals with
insufficient fibre intake compared to the lower quintile (86.3 percent and 46.9 percent,
respectively).
Potassium
Significant, inverse, dose-response associations between the dietary share of ultra-processed
foods and the dietary content of potassium or the probability of insufficient intakes (≤3 510
mg/2 000 kcal) were found in all seven countries where these associations were studied (US,
Brazil, Canada, Chile, UK, Australia, and Taiwan).
For instance, the dietary content of potassium in the Taiwanese diet decreased from 2 178
mg/2 000 kcal in the lower quintile of ultra-processed intake to 1 810 mg/2 000 kcal in the
upper quintile. In the UK, the upper quintile of ultra-processed food intake showed 1.6 times
as many people with insufficient potassium intake compared to the lower quintile (92.3
percent and 56.1 percent, respectively). In Chile there was a significant direct association
between the dietary share of ultra-processed foods and sodium/potassium ratio.
Phytoestrogens
A significant, inverse, dose-response association between the dietary share of ultra-processed
foods and a biomarker of the intake of NCD-protective phytoestrogens, the urinary
concentration of these food compounds, was found in one study undertaken in the USA.
Ultra-processed food intake and the general dietary
content of micronutrients
The association between the intake of ultra-processed foods and the dietary content of
micronutrients other than sodium and potassium was studied in four countries.
Significant, inverse, dose-response associations between the dietary share of ultra-processed
foods and the mean dietary content of several micronutrients were found in the US (vitamins
A, C, D and E, and calcium, magnesium, phosphorus and zinc), in Brazil (vitamins D, E, B12,
niacin, pyridoxine, and copper, iron, magnesium, phosphorus, selenium and zinc), in Canada
(vitamins A, C, D, E, B12, niacin, thiamine, riboflavin, and calcium, iron, magnesium,
phosphorus and zinc) and in Taiwan (vitamins A, C, D, B6, niacin, thiamine, magnesium,
calcium and iron). Only in Brazil, increases in the dietary share of ultra-processed foods were
positively related with increases in the dietary content of calcium.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 17 of 44
Ultra-processed food intake and nutrient-based dietary patterns
The association between the intake of ultra-processed foods and nutrient-based dietary
patterns was studied in the US and in Brazil.
In the US, there was a significant dose-response inverse association between the dietary share
of ultra-processed foods and a ‘healthy’ dietary pattern, richer in fibre, potassium, magnesium
and vitamin C, with less added sugar and saturated fat.
In Brazil, there was a significant dose-response inverse association between the dietary share
of ultra-processed foods and a ‘healthy’ dietary pattern, richer in protein and micronutrients,
with less free sugars. A significant dose-response direct association was found with an
‘unhealthy’ dietary pattern with more total, saturated and trans fats, and less fibre.
In sum, the evidence from analyses of nationally-representative data sets collected in 11
countries from 2001 to 2015 shows that the displacement of non-ultra-processed by ultra-
processed foods is consistently associated with an overall deterioration of the nutritional
quality of diets.
This has several important implications for public health including a clear potential to increase
the risk of several non-communicable diseases. This potential will be assessed in the next
section of this report with examination of the peer-reviewed literature on the association
between the dietary share of ultra-processed foods and the risk of these diseases.
Page 18 of 44
Ultra-processed foods, diet quality, and health using the NOVA classification system
TABLE 2. PEER-REVIEWED LITERATURE ON HOUSEHOLD ULTRA-PROCESSED FOOD PURCHASES AND THE
NUTRIENT PROFILE OF TOTAL FOOD PURCHASES (2011-2018)*
AUTHOR AND YEAR
STUDIED POPULATION
PURPOSE OF THE
STUDY
MAIN FINDINGS
Monteiro et al., 2011
Brazilian households in
11 metropolitan regions
in 2002/3 (n=13 848)
To compare the nutrient
profile of purchased ultra-
processed and non-ultra-
processed foods
Compared to non-ultra-processed foods, ultra-
processed foods had higher energy density, higher
content of added sugar, saturated fat, and sodium,
and lower content of fibre.
Moubarac et al., 2013
Canadian households in
2001 (n=5 643)
To assess the association
between purchase of ultra-
processed foods and the
nutrient profile of total
food purchases
Increases in the purchase share of ultra-processed
foods were significantly associated with total food
purchases higher in energy density, free sugar and
sodium, and lower in fibre and protein.
Crovetto et al., 2014
Chilean households in
2006/7 (n= 10 096)
To compare the nutrient
profile of purchased ultra-
processed and non-ultra-
processed foods
Compared to non-ultra-processed foods, ultra-
processed foods had higher energy density, free
sugar and sodium, and lower in fibre and protein.
Latasa et al., 2018
Spanish households in
1990, 2000 and 2010
(n=2 012; 33 730; and 22
116, respectively)
To assess the association
between purchase of ultra-
processed foods and the
content of added sugar in
total food purchases
In each of the three surveys, increases in the
purchase share of ultra-processed foods were
associated with total food purchases higher in
added sugar and more likely to exceed the upper
limit of ten percent of total energy. Across the
surveys, there were parallel increases in the
purchase share of ultra-processed foods and in the
content of added sugar in total food purchases.
*Including only nationally-representative studies.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 19 of 44
TABLE 3. PEER-REVIEWED LITERATURE ON ULTRA-PROCESSED FOOD INTAKE AND THE NUTRIENT PROFILE OF
THE OVERALL DIET (2015-2019)*
AUTHOR
AND YEAR
STUDIED
POPULATION
DIETARY
OUTCOMES
CONTROL
VARIABLES
MAIN
FINDINGS
Adams &
White, 2015
UK adult
population in
2008-12 (n=2
174)
Protein, carbohydrate,
fat, saturated fat, free
sugar, sodium and
fibre
Gender, occupational
social class, age and
percentage of energy
from alcohol.
Increases in the dietary share of ultra-processed
foods were associated with diets higher in free
sugar, saturated fat and sodium, and lower in
fibre and protein.
Steele et al.,
2016
US population
aged 1 year or
older in 2009-
2010 (n=9 317)
Added sugar
Age, sex,
race/ethnicity, family
income, and
educational
attainment.
Increases in the dietary share of ultra-processed
foods were associated with diets higher in added
sugar. The upper quintile of ultra-processed
consumption showed three times as many
individuals with excessive added sugar intake
(≥ten percent of total energy intake) compared to
the lower quintile.
Moubarac et
al., 2017
Canadian
population aged
2 years or older
in 2004 (n= 33
694)
Energy density,
protein, free sugar,
saturated fat, sodium,
potassium, calcium,
zinc, iron, magnesium,
phosphorus, vitamins
A, B6, B12, C, D,
thiamine, riboflavin,
niacin, fibre
Age, sex, educational
attainment, relative
family revenue.
Increases in the dietary share of ultra-processed
foods were associated with diets with higher in
energy density, free sugars and saturated fat, and
lower in protein, fibre, vitamins A, C, D, B6 and
B12, niacin, thiamine, riboflavin, zinc, iron,
magnesium, calcium, phosphorus and potassium.
Steele et al.,
2017a
US population
aged 1 year or
older in 2009-
2010 (n=9 317)
Protein,
carbohydrates, added
sugars, fats, saturated
fats, sodium, vitamins
A, C, D, and E, iron,
zinc, potassium,
phosphorus,
magnesium, calcium,
and fibre
Age, sex,
race/ethnicity, family
income, and
educational attainment
Increases in the dietary share of ultra-processed
foods were associated with diets higher in added
sugar and saturated fat, and lower in protein,
fibre, vitamins A, C, D, and E, zinc, potassium,
phosphorus, magnesium, and calcium. An inverse
dose–response association was found between
the dietary share of ultra-processed foods and
the overall dietary quality measured through a
nutrient balanced-pattern PCA-derived factor
score characterized by being richer in fibre,
potassium, magnesium and vitamin C, and having
less saturated fat and added sugars.
Louzada et
al., 2017
Brazilian
population aged
10 years or older
in 2008/9 (n=32
898)
Protein, carbohydrate,
free sugar, total,
saturated and trans
fat, fibre, vitamins A,
B6, B12, C, D and E,
niacin, riboflavin,
thiamine, zinc, iron,
magnesium,
manganese, copper,
selenium, phosphorus,
calcium and potassium
Age, sex, ethnicity, per
capita household
income, region,
urban/rural status, and
education.
Increases in the dietary share of ultra-processed
foods were associated with diets lower in
protein, fibre, vitamins D, E, B6 and B12, niacin,
zinc, iron, magnesium, copper, selenium,
phosphorus and potassium, and higher in free
sugars, and total, saturated and trans fats.
Quintiles of the dietary share of ultra-processed
food were inversely associated with two healthy
nutrient-based dietary patterns derived from
principal component analyses (one richer in
protein and micronutrients, and poorer in free
sugars, and the second richer in vitamins), and
directly associated with a unhealthy pattern
richer in total, saturated and trans fats, and
having less dietary fibre.
Cont.
Page 20 of 44
Ultra-processed foods, diet quality, and health using the NOVA classification system
TABLE 3. Cont.
AUTHOR
AND YEAR
STUDIED
POPULATION
DIETARY
OUTCOMES
CONTROL
VARIABLES
MAIN
FINDINGS
Steele et al.,
2017b
US population
aged 6 years or
older in 2009-
2010 (n=2 692)
Phytoestrogens
Age, sex,
race/ethnicity, family
income, education,
BMI, physical activity,
smoking status,
normalized by
creatinine, and
difference between
recommended and
actual energy intake.
Increases in the dietary share of ultra-processed
foods were associated with diets with higher
urinary concentrations (a proxy for the diet
content) of enterodiol and enterolactone.
Steele et al.,
2017c
US population
aged 2 years or
older in 2009-
2010 (n=9 042)
Protein and energy
intake
Age and gender strata
corresponding to those
used to define energy
and protein
requirements,
race/ethnicity, family,
income, education.
The dietary share of ultra-processed foods was
inversely related to the relative diet content in
protein and positively related with total energy
intake. Due to the increase in total energy intake
with the increase in ultra-processed food intake,
the absolute protein intake remained relatively
constant across quintiles.
Cediel et al.,
2017
Chilean
population aged
2 years or older
in 2010 (n=4 920)
Added sugar
Age, urban/rural
residence, geographic
region, family income.
Increases in the dietary share of ultra-processed
foods were associated with diets higher in added
sugar. The upper quintile of ultra-processed
consumption showed three times as many
individuals with excessive added sugar intake
(≥ten percent of total energy intake) compared to
the lower quintile.
Rauber et al.,
2018
UK population
aged 1.5 year or
older in 2008-
2014 (n=9 364)
Protein, carbohydrate,
free sugar, saturated
fat, fibre, sodium, and
potassium
Age, sex, ethnicity, and
income
Increases in the dietary share or ultra-processed
foods were associated with diets higher in free
sugars and saturated fat, and lower in fibre,
protein and potassium. The prevalence of people
exceeding the upper limits recommended for
free sugars and sodium increased by 85 percent
and 55 percent, respectively, from the lowest to
the highest ultra-processed food quintile.
Vandevijvere
et al., 2018
Belgian
population aged
from 3 to 64
years in 2014/5
(n=3 146)
Sodium, saturated fat
and trans fat
Age and sex
Increases in the dietary share of ultra-processed
foods were associated with higher risk of diets
with excessive content in sodium and saturated
fat.
Cont.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 21 of 44
TABLE 3. Cont.
AUTHOR
AND YEAR
STUDIED
POPULATION
DIETARY
OUTCOMES
CONTROL
VARIABLES
MAIN
FINDINGS
Chen et al.,
2018
Taiwanese
adolescents aged
16-18 years in
2011 (1 274)
Protein, carbohydrate,
total, saturated,
monounsaturated and
polyunsaturated fats,
vitamins A, E, D, B1,
B2, B6, B2, niacin,
potassium,
magnesium, calcium,
iron and dietary quality
evaluated with the
Youth Healthy Eating
Index–Taiwan
Gender, grade, locality,
major caregivers,
household income,
household expenditure,
mother’s education,
smoking, alcohol
drinking, and BMI,
percentages of energy
intake in unprocessed
and minimally
processed foods,
processed foods and
total energy intake.
Increases in the energy intake of ultra-processed
foods were associated with diets higher in
saturated fat, and lower in protein, vitamins A, C,
D, B1, and B6, niacin, potassium, magnesium,
calcium, and iron as well as with an increased risk
of poor dietary quality (ten percent increase in
ultra-processed food intake=OR:1.33; CI 95
percent 1.16 to 1.52).
Parra et al.,
2019
Colombian
population aged
from 1 to 64
years in 2005
(n=38 643)
Energy density,
protein, free sugar,
saturated fat, and fibre
Age, sex, zone and
regions of residency,
socioeconomic status
and education
Increases in the dietary share of ultra-processed
foods were associated with diets higher in energy
density, free sugars, and saturated fat, and lower
in protein and fibre.
Machado et
al., 2019
Australian
population aged
2 years or older
in 2011-2012
(n=12 153)
Energy density, free
sugar, saturated and
trans fats, fibre,
sodium, and potassium
Age, sex, educational
attainment, socio-
economic status and
geographical location
Increases in the dietary share of ultra-processed
foods were associated with higher energy
density, free sugars, sodium, and saturated and
trans fats, and lower in fibre and potassium. The
prevalence of non-recommended intake levels of
all studied nutrients increased linearly across
quintiles of ultra-processed food intake, notably
from 22 percent to 82 percent for free sugars,
from 6 percent to 11 percent for trans-fat, and
from 2 percent to 25 percent for dietary energy
density, from the lowest to the highest ultra-
processed food quintile.
Marrón-
Ponce et al.,
2019
Mexican
population aged
1 year and older
in 2012
(n= 10 087)
Energy density,
protein, added sugar,
saturated fat, and fibre
Age, residence area,
region, socioeconomic
status, education
Increases in the dietary share of ultra-processed
foods were associated with diets higher in energy
density, added sugars and saturated fat, and
lower in protein and fibre.
Cediel et al.,
2019
Chilean
population aged
2 years or older
in 2010 (n=4 920)
Energy density, free
sugar, saturated and
trans fats, fibre,
sodium, and potassium
Age, urban/rural
residence, geographic
region, family income.
Increases in the dietary share of ultra-processed
foods were associated with diets higher in energy
density, free sugars, saturated and trans fats, and
sodium/potassium ratio, and lower in fibre and
potassium.
*Including only nationally-representative studies.
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Ultra-processed foods, diet quality, and health using the NOVA classification system
SECTION 4
Ultra-processed foods and the risk of
non-communicable diseases
This section evaluates the peer-reviewed literature on the association between the dietary
share of ultra-processed foods and the risk of various diet-related non-communicable diseases
(NCDs).
Table 3 lists twenty-six peer-reviewed articles examining the association between ultra-
processed food exposures and NCDs outcomes, most of them (22 out of 26) undertaken in
adults. These articles are restricted to those that reported findings from ecological studies
where countries were the unit of analysis, cross-sectional studies based on nationwide
population samples, and any cohort study or randomized controlled trial. Articles are listed in
ascendant order according to the year of publication, with information on the studied
population, year of the survey, sample size, study design, exposure, NCD outcomes, control
variables and main findings.
In the ecological studies, the exposure to ultra-processed foods was measured either by the
share of ultra-processed foods in national household food purchases or by annual changes in
national per capita sales of ultra-processed foods while the dietary content of ultra-processed
foods was used in the individual-based studies.
Studied NCD outcomes included obesity and related factors (values of or changes in weight,
body mass index, waist circumference, skinfolds, percentage of body fat); cardiovascular
health (hypertension, dyslipidaemia, metabolic syndrome, and cardiovascular diseases -
overall, coronary heart diseases and cerebrovascular disease); cancer (overall, breast, prostate,
and colorectal cancer); depression; asthma and wheezing; gastrointestinal disorders, frailty
syndrome, and also all-cause, cardiovascular, and cancer mortality.
All observational studies adjusted their estimates on the association between ultra-processed
food exposure and NCD outcomes for several potential confounders, in most studies for more
than ten. These include various demographic and socioeconomic variables (all studies),
physical activity (except the two studies on young children and the study on the frailty
syndrome, where physical activity is part of the outcome), smoking (except one study with
adolescents) and variables on health antecedents related to the outcome.
A synthesis follows of the findings reported by the four studies undertaken in children and
adolescents and the twenty-two studies in adults.
Children and adolescents
Following the selection criteria above, two studies on ultra-processed food consumption and
NCD outcomes among children were found, and two among adolescents, all in Brazil.
The two studies on children were based on a follow-up for four years of a small cohort of 3-4
year-old children of low socioeconomic status. After adjustment for potential confounders,
they found that ultra-processed food intake at preschool age was positively associated with
increases from preschool to school age in cholesterol and LDL cholesterol, and in waist
circumference.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 23 of 44
One of the studies among adolescents examined a large nationally-representative sample of
Brazilian 9th graders. After adjustment for potential confounders, it found a cross-sectional
positive dose-response association between a score of ultra-processed food consumption and
self-reported occurrence of asthma and wheezing.
The other study among adolescents followed for three years a cohort of students enrolled in
the 1st year of high school in six schools in the metropolitan area of Rio de Janeiro. After
adjustment for potential confounders, it did not find any association between consumption of
ultra-processed foods and trajectories of body mass index and percentage of body fat mass.
Adults
The twenty-two studies on ultra-processed food exposures and NCD outcomes among adults
include ecological studies, national cross-sectional studies, longitudinal studies and one
randomized controlled trial. One ecological study involved nineteen European countries, and
the other eighty countries from different world regions. National cross-sectional studies were
undertaken in the US (two studies), France (two studies), Brazil, Canada and the UK.
Longitudinal studies were based on the follow-up of middle-aged or older adults in Spain (the
SUN project study, and the SENIOR-Enrica study); of adults in France (the French NutriNet-
Santé study), of adults or pregnant women in the US (the NHANES III follow-up study, and the
St. Louis Women’s Health Center study), and of adults in Brazil (the ELSA cohort study). The
randomized controlled cross-over trial was undertaken by the US National Institutes of Health
(NIH) with participants recruited in the United States.
A synthesis follows of the main findings of these studies grouped according to the studied NCD
outcome.
Obesity
The association between ultra-processed food exposures and obesity or obesity-related
outcomes among adults was examined by the two ecological studies, by five national cross-
sectional studies (Brazil, the US, France, Canada and the UK), and by three longitudinal studies
(the SUN project study, the St. Louis Women’s Health Center study, and the ELSA cohort
study). After adjustment for potential confounders, significant positive associations were
shown in the two ecological studies, in four of the five national cross-sectional studies, and in
the three cohort studies.
The NIH randomized controlled trial has confirmed the association between ultra-processed
food exposure and obesity-related outcomes. It shows that when exposed to ad libitum ultra-
processed diets (81.3 percent of total energy from ultra-processed foods) participants
consumed on average 508 kcal more per day than when exposed to ad libitum diets with no
ultra-processed foods, and that at the end of two weeks participants increased 0.9 kg
consuming the ultra-processed diet and decreased 0.9 kg consuming the non-ultra-processed
diet. The ultra-processed and the non-ultra-processed diets offered to participants were
matched for total energy, energy density, macronutrients, sugar, sodium and fibre.
Significant direct dose-response associations between the dietary share of ultra-processed
foods and obesity after adjusting for potential confounders were found in still unpublished
cross-sectional studies undertaken on representative samples of the adult population of
Australia (Priscila Machado, personal communication) and of the UK (Fernanda Rauber,
personal communication).
Page 24 of 44
Ultra-processed foods, diet quality, and health using the NOVA classification system
Cardiovascular and metabolic diseases
Studies on the association between the intake of ultra-processed foods and cardiovascular,
and metabolic diseases include one national cross-sectional study on metabolic syndrome
undertaken in the US adult population, one longitudinal study on hypertension from the
Navarra SUN cohort, and another longitudinal study on coronary heart diseases,
cerebrovascular diseases and all cardiovascular diseases from the French NutriNet cohort.
After adjustment for potential confounders, the three studies found significant positive dose-
response associations between the dietary share of ultra-processed foods and all studied
cardiovascular health outcomes. The associations found in the French NutriNet cohort
remained significant after control for saturated fat, sodium and sugar intakes.
One new longitudinal study from the NutriNet-Santé cohort, still unpublished, found
significant direct dose-response associations between the dietary share of ultra-processed
foods and the incidence of type 2 diabetes even with the control for saturated fat, sodium,
sugar and fibre intakes (Bernard Srour, personal communication).
Cancer
Dietary share of ultra-processed foods and incidence of cancer was examined in the French
NutriNet-Santé study. After adjustment for potential confounders, significant direct
associations were found for overall and breast cancer (but not for prostate and colorectal
cancer). This association remained significant after control for total fat, sodium and
carbohydrate intake.
Depression
Association between the intake of ultra-processed foods and the incidence of depression was
examined in the French NutriNet-Santé study, and also the SUN Navarra cohort study. After
adjustment for potential confounders, significant direct dose-response associations between
the dietary share of ultra-processed foods and incidence of depression were shown in both
studies. In the French study, the association remained significant after control for total fat,
sodium, and carbohydrate intakes.
Gastrointestinal disorders
The cross-sectional association between the intake of ultra-processed foods and
gastrointestinal disorders was investigated in the French NutriNet-Santé study. After control
for potential confounders, a direct dose-response association was found between the dietary
share of ultra-processed foods and the risk of irritable bowel syndrome and functional
dyspepsia.
Frailty
The longitudinal association between the intake of ultra-processed foods and incidence of the
frailty syndrome (or presence of three or more of the following five phenotypic criteria:
exhaustion after small efforts, muscle weakness, low physical activity, slow walking speed, and
unintentional weight loss) was investigated in the Seniors-ENRICA cohort study. After control
for potential confounders, a direct dose-response association was found between the dietary
share of ultra-processed foods and the risk of frailty syndrome.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 25 of 44
Mortality
The association between the intake of ultra-processed foods and all-cause mortality was
investigated by three cohort studies the NHANES III follow-up, the SUN project and the French
NutriNet-Santé. After adjustment for potential confounders, the three studies all found
significant direct dose-response associations between the dietary share of ultra-processed
foods and death risk due to all causes. Probably due to lack of statistical power, no significant
association was found for disease-specific mortality including cardiovascular mortality
(investigated by the NHANES III follow study and the SUN project study) and cancer mortality
(investigated only by the SUN project study).
In sum, consistent evidence accumulated by studies with different design, undertaken in a
great number of countries, shows that the displacement of non-ultra-processed by ultra-
processed foods increases the risk of obesity and several other diet-related non-
communicable diseases, and also premature mortality.
Ultra-processed foods, diet quality and health using the NOVA classification system
Page 26 of 444
TABLE 4. PEER-REVIEWED LITERATURE ON ULTRA-PROCESSED FOOD INTAKE AND NCDS OUTCOMES (2015-2019)*.
AUTHOR AND YEAR
STUDIED POPULATION
STUDY DESIGN
EXPOSURE
NCDS OUTCOMES
CONTROL VARIABLES
MAIN FINDINGS
Louzada et al., 2015
Brazilian population
aged 10 years or older in
2008/9 (n=32 898)
Cross-sectional
Dietary
energy share
of ultra-
processed
foods
Obesity and
obesity-related
outcomes
Age, sex, race, region, urbanity, education,
income, smoking status, physical activity,
fruits, vegetables and beans intakes.
Participants in the highest quintile of
ultra-processed food consumption had
higher BMI (0.95 kg/m²; 95 percent CI
0.43 to 1.48), and higher odds of being
obese (OR: 1.97; 95 percent CI 1.26,
3.09) compared with those in the
lowest quintile.
Adams & White, 2015
UK adult population in
2008-12 (n=2 174)
Cross-sectional
Dietary
energy share
of ultra-
processed
foods
Obesity and
obesity-related
outcomes
Gender, occupational social class, age and
percentage of energy derived from alcohol.
Dietary share of ultra-processed foods
(continuous) was not significantly
associated with BMI (β=0.02; CI 95
percent -0.02 to 0.07), or obesity (OR:
1.01; CI 95 percent 1.00 to 1.02).
Rauber et al., 2015
Children in Brazil (n=345)
aged 3-4 years at
baseline (2001/2) and 7-
8 years at follow-up
(2005/6)
Cohort
Dietary
energy share
of ultra-
processed
foods
Changes in
lipid
concentrations
Sex, birth weight, family income, maternal
schooling, BMI-for-age z-scores and total
energy intake at age 7-8.
Ultra-processed food consumption at
preschool age was significantly
associated with a higher increase in total
cholesterol (β 0.430; P = 0.046) and LDL
cholesterol (β 0.369; P = 0.047) from
preschool to school age.
Mendonça et al., 2016
Middle-aged adults in
Spain with a median
follow-up of 8.9 years
(n=8 541) (Seguimiento
Universidad de Navarra
(SUN) project
1999/2012)
Cohort
Consumption
of ultra-
processed
foods
(servings/d).
Incidence of
overweight/
obesity
Sex, age, marital status, educational status,
physical activity, television watching, siesta
sleep, smoking status, snacking between
meals, following a special diet at baseline,
baseline BMI, and consumption of fruit and
vegetables.
Participants in the highest quartile of
consumption of ultra-processed foods
had a higher risk of developing
overweight/obesity compared to those
in the lowest quartile of consumption
(HR: 1.26; 95 percent CI 1.10, 1.45).
Mendonça et al., 2017
Middle-aged adults in
Spain with a median
follow-up of 9.1 years
(n=14 790)
(Seguimiento
Universidad de Navarra
(SUN) project
1999/2012)
Cohort
Consumption
of ultra-
processed
foods
(servings/d).
Incidence of
hypertension
Sex, age, physical activity, hours of TV
watching, baseline body mass index,
smoking status, use of analgesics, following
a special diet at baseline, family history of
hypertension, hypercholesterolemia,
alcohol consumption, total energy intake,
olive oil intake, and consumption of fruits
and vegetables.
Participants in the highest tertile of
consumption of ultra-processed foods
were at higher risk of developing
hypertension than those in the lowest
tertile (HR: 1.21; 95 percent CI 1.06,
1.37).
*Including only ecological studies where countries were the unit of analysis, national cross-sectional studies, and any cohort study or randomized controlled trial.
Cont.
Ultra-processed foods, diet quality and health using the NOVA classification system
Page 27 of 44
44
TABLE 4. Cont.
AUTHOR AND YEAR
STUDIED POPULATION
STUDY DESIGN
EXPOSURE
NCDS OUTCOMES
CONTROL VARIABLES
MAIN FINDINGS
Monteiro et al., 2017b
European countries,
1991-2008 (n=19)
Ecological
Dietary
energy from
ultra-
processed
foods in
household
food
availability
Obesity
prevalence
among adults
Countries’ GDP per capita, squared GDP
per capita, difference in years between the
estimates on obesity and availability of
ultra-processed foods, measurement
method of obesity (self-reported or
directly measured), prevalence of physical
inactivity and of smoking.
Each percentage point increase in the
household availability of ultra-processed
foods resulted in an increase of 0.25 (CI
95 percent 0.05 to 0.45) percentage
points in obesity prevalence.
Rohatgi et al., 2017
Pregnant adult women
followed during
pregnancy and their
new-borns in the US in
2013/4 (n=45)
(St. Louis Women’s
Health Center Study)
Cohort
Dietary
energy share
of ultra-
processed
foods
Gestational
weight gain,
and new-born
skinfolds and
body fat
percentage
For maternal outcomes: age, race, weight
status, socioeconomic status, average daily
energy and fat intake, and percent of time
spent in moderate physical activity. For
neonatal outcomes: those referred
maternal variables plus gestational age at
which neonatal measurements were taken.
Each percentage point increase in the
dietary share of ultra-processed foods
was associated with a 1.3 kg (CI 95
percent 0.3 to 2.4) increase in
gestational weight, as well as with a 0.22
mm (CI 95 percent 0.005 to 0.4) increase
in thigh skinfold, 0.14 (CI 9 percent
percent 0.02 to 0.3) mm in subscapular
skinfold, and 0.62 (CI 95 percent 0.04 to
1.2) percentage points of total body
adiposity in the neonate.
Julia et al., 2018
French adult population
in 2009-2014 (n=74 470)
(French NutriNet-Santé
study)
Cross-sectional
Dietary share
of ultra-
processed
foods (g)
Obesity
Sex, age, household income, marital status,
education, residence (urban/rural), and
smoking status.
A higher dietary share of ultra-processed
foods was significantly associated with
overweight and obesity (P<0.0001)
Juul et al., 2018
US population aged
20-64 years in 2005-
2014 (n=15 977)
Cross-sectional
Dietary
energy share
of ultra-
processed
foods
Obesity and
obesity-related
outcomes
Age, sex, educational attainment,
race/ethnicity, ratio of family income to
poverty, marital status, smoking and
physical activity level.
Participants in the highest quintile of
consumption of ultra-processed foods
had higher BMI (1.61 kg/m²; 95 percent
CI 1.11 to 2.10) and waist circumference
(4.07 cm; 95 percent CI 2.94 to 5.19), and
higher odds of having obesity (OR: 1.53;
95 percent CI 1.29, 1.81), excess weight
(OR: 1.48; 95 percent CI 1.25 to 1.76),
and abdominal obesity (OR: 1.62; 95
percent CI 1.39 to 1.89) compared with
those in the lowest quintile.
Cont.
Ultra-processed foods, diet quality and health using the NOVA classification system
Page 28 of 44 44
TABLE 4. Cont.
AUTHOR AND YEAR
STUDIED POPULATION
STUDY DESIGN
EXPOSURE
NCDS OUTCOMES
CONTROL VARIABLES
MAIN FINDINGS
Nardocci et al., 2018
Canadian population
aged 18 years or older
in 2004 (n=19,363)
Cross-sectional
Dietary
energy share
of ultra-
processed
foods
Obesity and
obesity-related
outcomes
Sex, age, education, income, physical
activity, smoking status, immigrant status,
zone of residence, total energy reporting
group, and measurement type (self-
reported or directly measured).
A ten-percentage point increase in the
relative energy intake from ultra-
processed foods increased the odds of
being obese (OR: 1.05; 95 percent CI
1.01 to 1.08) or overweight (OR: 1.03; 95
percent CI 1.01 to 1.07). Participants in
the highest quintile of consumption of
ultra-processed foods had higher odds
of being obese (OR: 1.32; 95 percent CI
1.05 to 1.57) compared with those in the
lowest quintile.
Melo et al., 2018
Brazilian 9th graders
population (median
age: 14 y) in 2012
(n=109,104)
Cross-sectional
Ultra-
processed
food intake
score.
Asthma and
wheezing
Sex, age, mother’s education level, parents
as smokers, having smoked in the past 30
days, alcohol consumption in the past 30
days, school type, geographical region,
municipality of residence, and physical
activity level.
Participants in the highest quintile of
ultra-processed food intake score had
higher odds of having asthma (OR: 1.27;
95 percent CI 1.15, 1.41) or wheezing
(OR: 1.42; 95 percent CI 1.35 to 1.50),
compared with those in the lowest
quintile.
Fiolet et al., 2018
Adults aged 18 years
or older in France
with a median follow-
up of 5 years
(n=104,980) (French
NutriNet-Santé study
2009/13)
Cohort
Dietary share of
ultra-processed
foods (g)
Incidence of
overall, breast,
prostate and
colorectal cancer
Age (timescale), sex, energy intake without
alcohol, number of 24 hour dietary records,
smoking status, educational level, physical
activity, height, body mass index, alcohol
intake, family history of cancers, and
Western dietary pattern; breast cancer
models were additionally adjusted for
menopausal status, hormonal treatment
for menopause, oral contraception, and
number of children.
Participants in the highest quartile of
consumption of ultra-processed foods
had a higher risk of developing overall
cancer (1.21; 95 percent CI 1.06 to 1.38)
and postmenopausal breast cancer (HR:
1.38; 95 percent CI 1.06 to 1.81).
Additional analyses show that these
associations remain significant even
with adjustment for total fat, sodium
and carbohydrate intake.
Cont.
Ultra-processed foods, diet quality and health using the NOVA classification system
Page 29 of 44
44
TABLE 4. Cont.
AUTHOR AND YEAR
STUDIED POPULATION
STUDY DESIGN
EXPOSURE
NCDS OUTCOMES
CONTROL VARIABLES
MAIN FINDINGS
Schnabel et al., 2018
Adults aged 18 years
or older in France
with a median follow-
up of 5 years
(n=33,343) (French
NutriNet-Santé study
2009/13)
Cross-sectional
Dietary share
of ultra-
processed
foods (g)
Functional gastro-
intestinal disorders
(FGiDs: irritable
bowel syndrome,
functional
constipation,
functional
diarrhoea, and
functional
dyspepsia)
Sex, age, income level, education level,
marital status, residence, BMI, physical
activity, smoking status, energy intake,
season of food records, time between food
record and FGiDs questionnaire,
adherence with national dietary
recommendations (index).
Participants in the highest quartile of
consumption of ultra-processed foods
had a higher risk of irritable bowel
syndrome (OR: 1.25; 95 percent CI 1.12
to 1.39) and functional dyspepsia (OR:
1.25; CI 95 percent 1.05 to 1.47).
Cunha et al., 2018
High school students in
Brazil with a median
follow-up of 3 years
(n=1,035) (Adolescent
Nutritional Assessment
Longitudinal Study -
ELANA 2010/12)
Cohort
Dietary energy
share of ultra-
processed foods
BMI and body fat
percentage
trajectories
during follow-up
Age (timescale), type of school, sex, physical
activity, and energy intake underreporting.
There was no significant difference in BMI
trajectories according to baseline ultra-
processed food consumption (p=0.07 for
the interaction term between age and
quartiles of ultra-processed food
consumption). Similar results for body fat
percentage trajectories.
Vandevijvere et al.,
2019
Countries in the
Euromonitor annual
food sales database and
with NCD-RisC group
sex-stratified annual BMI
estimates for adults
aged ≥18 years in the
period 2002-2014 (n=80)
Ecological,
longitudinal
Annual changes in
national per
capita sales of
ultra-processed
foods
BMI trajectory in
the studied period
National per capita income, education,
population living in urban areas, mean
fruit and vegetable consumption in 2005,
the tertile of the mean GINI‐index, and,
indirectly, physical activity.
Increases in ultra-processed foods
volume sales/capita were significantly
and positively associated with
population‐level BMI trajectories.
Steele et al., 2019
US adult population
aged 20 years or older in
2009-2014 (n=6,385)
Cross-sectional
Dietary energy
share of ultra-
processed foods
Metabolic
Syndrome
Age, sex, race/ethnicity, income-to-poverty,
educational attainment, smoking status and
physical activity level.
Participants in the highest quintile of
ultra-processed food consumption had
higher odds of having metabolic syndrome
(OR: 1.28; 95 percent CI 1.09, 1.50)
compared with those in the lowest
quintile.
Cont.
Ultra-processed foods, diet quality and health using the NOVA classification system
Page 30 o f 44 44
TABLE 4. Cont.
AUTHOR AND YEAR
STUDIED POPULATION
STUDY DESIGN
EXPOSURE
NCDS OUTCOMES
CONTROL VARIABLES
MAIN FINDINGS
Costa et al., 2019
Children in Brazil (n=307)
aged 3-4 years at
baseline (2001/2) and 7-
8 years at follow-up
(2005/6)
Cohort
Dietary energy
share of ultra-
processed foods
Changes in
anthropometric
and glucose
metabolism
indicators
Sex, pre-pregnancy BMI, birth weight,
breastfeeding, family income, maternal
schooling and total screen duration.
Ultra-processed food consumption at
preschool age was associated with a
significant increase in waist circumference
from preschool to school age (β 0.07; P =
0.035), but not with changes in glucose
metabolism.
Kim et al., 2019
US adult population
aged 20y or older with a
median follow-up of 19
years (n= 11,898)
(National Health and
Nutrition Examination
Survey 1988/94)
Cohort
Consumption of
ultra-processed
foods (times/day)
All-cause and
cardiovascular
disease mortality
Age, sex, race/ethnicity, total energy intake,
poverty level, education level, smoking
status, physical activity, alcohol intake, BMI,
hypertension status, total cholesterol and
estimated glomerular filtration rate.
Participants in the highest quartile of
frequency of ultra-processed food
consumption were at higher risk of all-
cause mortality (HR: 1.30; 95 percent CI
1·08, 1·57). No significant association was
found for cardiovascular mortality
Schnabel et al., 2019
Adults (≥ 45y old) in
France with a median
follow-up of 7.1 years
(n=44,551) (French
NutriNet-Santé study
2009/17)
Cohort
Dietary share of
ultra-processed
foods (g)
All-cause
mortality
Sex, age, income level, education level,
marital status, residence, BMI, physical
activity level, smoking status, energy intake,
alcohol intake, season of food records, first-
degree family history of cancer or
cardiovascular diseases, number of food
records, and adherence with national dietary
recommendations (index).
Ultra-processed food intake was
associated with a higher risk of all-cause
mortality (HR for an absolute increment of
10 in the percentage of ultra-processed
foods in the diet = 1.14, 95 percent Cl =
1.04 to 1.27).
Rico-Campà et al., 2019
Adults aged 20-91 years
in Spain with a median
follow-up of 10.4 years
(n=19,899) (Seguimiento
Universidad de Navarra
(SUN) project
1999/2014)
Cohort
Quartiles of the
energy adjusted
ultra-processed
food
consumption.
All-cause
mortality
Age, sex, marital status, baseline body mass
index, total energy intake, smoking status,
family history of cardiovascular disease,
alcohol consumption, cardiovascular disease,
cancer, or diabetes at baseline, hypertension
at baseline, self-reported
hypercholesterolemia at baseline,
depression at baseline, educational level,
snacking, following a special diet at baseline,
physical activity, and lifelong cumulative
exposure to smoking.
Participants in the highest quarter of ultra-
processed foods consumption were at
higher risk of all-cause mortality than
those in the lowest quarter (HR 1.62, 95
percent CI 1.13 to 2.33). No significant
association was found for cardiovascular
and cancer mortality.
Cont.
Ultra-processed foods, diet quality and health using the NOVA classification system
Page 31 of 44
44
TABLE 4. Cont.
AUTHOR AND YEAR
STUDIED POPULATION
STUDY DESIGN
EXPOSURE
NCDS OUTCOMES
CONTROL VARIABLES
MAIN FINDINGS
Srour et al., 2019
Adults (≥18y old) in
France with a median
follow-up of 5.2 years
(n=105,159) (French
NutriNet-Santé study
2009/18)
Cohort
Dietary share of
ultra-processed
foods (g)
Incidence of
overall
cardiovascular
diseases and
coronary heart,
and
cerebrovascular
diseases
Age (timescale), sex, energy intake, number
of 24-hour dietary records, smoking status,
educational level, physical activity, body
mass index, alcohol intake, and family
history of cardiovascular disease, baseline
prevalent type 2 diabetes, dyslipidaemia,
hypertension, and hypertriglyceridemia as
well as treatments for these conditions.
Participants in the highest quarter of ultra-
processed foods consumption were at
higher risk of overall cardiovascular
disease (HR: 1.23, 95 percent CI 1.04 to
1.45) than those in the lowest quarter.
Each percentage point increase in the
dietary share of ultra-processed foods
results in 1.12 (95 percent CI 1.02 to 1.24)
higher risk of coronary heart diseases, and
1.11 (95 percent CI 1.01 to 1.21) higher
risk of cerebrovascular disease. Additional
analyses show persistent significant
associations with adjustment for saturated
fat, sodium and sugar intake.
Sandoval-Insausti et al.,
2019
Adults (≥60y old) in
Spain with a median
follow-up of 3.5 years
(n=1,822) (Seniors-
ENRICA – Study on
Nutrition and
Cardiovascular risk
factors, 2008/2012)
Cohort
Dietary energy
share of ultra-
processed foods.
Incidence of
frailty
Sex, age, education, marital status, tobacco
consumption, former-drinker status,
diagnose of chronic respiratory disease,
coronary disease, stroke,
osteoarthritis/arthritis, cancer, depression
requiring treatment, and number of
medications used.
Participants in the highest quartile of
ultra-processed foods consumption were
at higher risk of frailty than those in the
lowest quintile (OR: 3.67, 95 percent CI
2.00 to 6.73).
Gómez-Donoso et al.,
2019
Middle-aged adults in
Spain with a median
follow-up of 10.3 years
(n=14,907) (Seguimiento
Universidad de Navarra
(SUN) project
1999/2014)
Cohort
Energy-adjusted
dietary share of
ultra-processed
foods (g)
Incidence of
depression
Age (timescale), sex, baseline BMI, total
energy intake, physical activity, smoking
status, marital status, living alone,
employment status, working hours per
week, health-related career, years of
education, adherence to Trichopoulou’s
MeDiet Score, and baseline self-perception
of competitiveness, anxiety, and
dependence levels.
Participants in the highest quartile of
ultra-processed foods consumption had
a higher risk of developing depression
than those in the lowest quartile (HR:
1.33; 95 percent CI 1.07-1.64).
Cont.
Ultra-processed foods, diet quality and health using the NOVA classification system
Page 32 of
TABLE 4. Cont.
AUTHOR AND YEAR
STUDIED POPULATION
STUDY DESIGN
EXPOSURE
NCDS OUTCOMES
CONTROL VARIABLES
MAIN FINDINGS
Adjibade et al., 2019
Adults (≥18y old) in
France with a median
follow-up of 5.4 years
(n=26,730) (French
NutriNet-Santé study
2009/18)
Cohort
Dietary share of
ultra-processed
foods (g)
Incidence of
depression
Age, sex, BMI, marital status, educational
level, occupational categories, household
income per consumption unit, residential
area, number of 24-h dietary records,
inclusion month, energy intake without
alcohol, alcohol intake, smoking status, and
physical activity.
Participants in the highest quartile of
ultra-processed foods consumption had
a higher risk of developing depressive
symptoms than those in the lowest
quartile (HR: 1.30; 95 percent CI 1.15 to
1.47). Additional analyses show that
these associations remain significant
with adjustment for total fat, sodium and
carbohydrate intake, and a diet quality
index.
Canhada et al., 2019
Adults (≥35y old) in
Brazil with a median
follow-up of 3.8 years
(Longitudinal Study of
Adult Health (ELSA-
Brasil).
Cohort
Dietary energy
share of ultra-
processed foods
Changes in
anthropometri
c indicators
and incidence
of overweight/
obesity
Age, sex, colour/race, income, school
achievement, smoking and physical activity
Participants in the highest quartile of
consumption of ultra-processed foods
had a greater risk of large weight gain
(>1.68 kg/year) and waist circumference
gain (>2.42 cm/year) (RR: 1.30; 95
percent CI 1.10 to 1.54, and RR: 1.33; 95
percent CI 1.12 to 1.57, respectively),
and higher risk of developing
overweight/obesity compared to those
in the lowest quartile of consumption
(HR: 1.29; 95 percent CI 1.08 to 1.53).
Hall et al., 2019
US adult voluntaries with
a mean age of 31.2 years
(n=20) (NIH study)
In-patient,
randomized
controlled cross-
over trial
Ad libitum offer
for two weeks of
either ultra-
processed diets
(83 percent of
energy from
ultra-processed
foods, on
average) or diets
with no ultra-
processed foods
Daily energy
intake, and
weight and fat
mass change
The ultra-processed and the non-ultra-
processed diets were matched for presented
calories, energy density, macronutrients,
sugar, sodium, and fibre
Energy intake was greater during exposure
to the ultra-processed diet (508 ± 106
kcal/day). Participants gained, on average,
0.9 ± 0.3 kg during the ultra-processed
diet, most being of fat mass. Participants
lost, on average, 0.9 ± 0.3 kg during the
diet with no ultra-processed foods.
44
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 33 of 44
SECTION 5
Conclusions and implications
This report has listed and examined the peer-reviewed literature on the effects of ultra-
processed foods on both diet quality and health. Papers on the effects on diet quality reported
results from nineteen nationally-representative studies. Papers on health outcomes reported
results from nine nationwide cross-sectional studies, sixteen longitudinal studies and one
randomized controlled trial.
Taken together, the results from the studies on diet quality show significant and graded
associations between the dietary share of ultra-processed foods and dietary nutrient profiles
prone to non-communicable diseases, including high or excessive content of free or added
sugar, saturated and trans fats, and sodium, and also high dietary energy density; and low or
insufficient content of protein, fibre and potassium.
Furthermore, the results from the studies on health outcomes show plausible, significant and
graded associations between the dietary share of ultra-processed foods and the occurrence or
incidence of several non-communicable diseases, including obesity and obesity-related
outcomes, cardiovascular and metabolic diseases, breast and all cancers, depression,
gastrointestinal disorders, frailty in the elderly, and also premature mortality. In the case of
short-term increases in body weight and fat, this is solidly supported by the randomised
controlled trial conducted by the US National Institutes of Health (Hall, et al., 2019).
The significance of food processing
The significance of food processing, and in particular of ultra-processed food, is now generally
recognized. In May 2019 Francis Collins, director of the US Government National Institutes of
Health (NIH), in response to the NIH randomised controlled trial (Hall at al., 2019) stated: “It
appears that a good place to start in reaching or maintaining a healthy weight is to work to
eliminate or at least reduce ultra-processed foods in your diet in favour of a balanced variety
of unprocessed, nutrient-packed foods” (Collins, 2019).
In July 2019 authors from the US National Cancer Institute and the World Cancer Research
Fund/American Cancer Research Fund announced that their recommendation to limit
consumption of “fast foods” in order to protect against cancer would be changed, “as there is
currently no standard way to categorize or define cut-points for it” and instead “our solution
was to create an adapted version of the NOVA classification system to create an ‘ultra-
processed foods’ (UPFs) variable” (Shams-White, et al., 2019).
Also in July 2019, the Pan American Health Organization of the World Health Organization
published Ultra-processed Food and Drink Products in Latin America: Sales, Sources, Nutrient
Profiles and Policy Implications. (PAHO, 2019). The report takes into account the present
national official dietary guidelines of Brazil (Brazilian Ministry of Health, 2014); Uruguay
(Ministerio de Salud del Uruguay, 2016); Ecuador (Ministerio de Salud Pública del Equador &
FAO 2018); and Peru (Ministerio de Salud del Perú, 2018), all of which recommend freshly
prepared meals and avoidance of ultra-processed foods. In its final section on
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Ultra-processed foods, diet quality, and health using the NOVA classification system
‘recommendations’ the report states:
The initiatives to promote healthy eating and healthy nutrition environments already
implemented in some Latin American countries are supported by the analyses,
findings and conclusions of this report. Concerted actions led by governments,
specific to national circumstances, are needed in all Latin American countries.
To counteract displacement of hand-made dishes made from fresh or minimally
processed food by ultra- processed products, established food systems need to be
preserved, family farmers supported, and healthy food preparation and cooking
promoted, including in schools.
Public health policies and market incentives are needed, in order to make
unprocessed and minimally processed food, and freshly prepared dishes and meals,
more valued, and more available and affordable. Fresh and minimally processed
foods that are staples in long-established diets, such as grains, roots, tubers, legumes
and other plant foods should have generally affordable and stable prices.
Unhealthy products need to be the subject of statutory regulatory measures. Some
ultra-processed products are shown in this report to be especially problematic. These
include carbonated soft drinks, sweet and savoury snacks, biscuits (cookies),
confectionery, and cakes, pastries and desserts.
These 2019 statements follow conclusions published by authoritative bodies in previous years.
In September 2016, the Global Panel on Agriculture and Food Systems for Nutrition, an
independent expert group one of whose members was José Graziano da Silva, FAO Director-
General 2012-2019, published its Foresight report on Food Systems and Diets: Facing the
Challenges of the 21st Century (GLOPAN, 2016). This
includes important recommendations and advice for leaders at the most senior levels
in countries and international organizations [and] constitute a stark warning for all
countries... the situation is set to worsen dramatically over the next 20 years as
powerful drivers of change such as population growth, climate change and
urbanization converge on food systems… If the direction of current policies remains
the same, then estimates suggest that by 2030, the number of overweight and obese
people will have increased from 1.33 billion in 2005 to 3.28 billion, around one third
of the projected global population. This is a major concern as no country to date has
successfully reversed growth in obesity once it has been allowed to develop.
Specific reference is made to production and consumption of ultra-processed food and drink
products as a reason for the rise in obesity:
In 2000, sales of ultra-processed foods and beverages in the upper-middle-income
countries were one third of those in the high-income countries. Fifteen years later,
they were more than half… The term ‘ultra-processed’ was coined to refer to
industrial formulations manufactured from substances derived from foods or
synthesized from other organic sources. They typically contain little or no whole
foods, are ready-to-consume or heat up, and are fatty, salty or sugary and depleted in
dietary fibre, protein, various micronutrients and other bioactive compounds.
Examples include: sweet, fatty or salty packaged snack products, ice cream, sugar-
sweetened beverages, chocolates, confectionery, French fries, burgers and hot dogs,
and poultry and fish nuggets.
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 35 of 44
The report, which ends with an annex listing all types of ultra-processed food products, goes
on to state:
Sales of ultra-processed food and sugar-sweetened beverages are growing. This
growth is almost exclusively found in lower-middle income and upper-middle-income
countries... Sales of ultra-processed foods in East and South East Asia are expected to
approach those of high-income countries by 2035.
In January 2019, The Lancet published The Global Syndemic of Obesity, Undernutrition, and
Climate Change (Swinburn et al., 2019). This was the product of a three-year Lancet project in
which 43 authors from a broad range of disciplines from 14 countries were engaged, led by the
University of Auckland, the US George Washington University, and the World Obesity
Federation. This in effect endorses the WHO/FAO and Foresight reports:
The main reason for the increase in the prevalence of obesity and overweight is the
inability of food systems to deliver healthy diets. The consumption of industrialized
and processed foods that are high in trans fats, sugar, salt, and chemical additives is
growing in most countries.... This type of consumption occurs mainly in urban settings
and upper-middle income and high-income countries, although the negative impacts
of food insecurity on diet quality also exist in low-income, middle-income, and high-
income countries alike…
The manufacture of ultra-processed foods and sugary drinks is based on inexpensive
commodity ingredients such as sugar, flours, and oils, often with multiple preservatives,
colourings, and flavourings. These products are typically energy-dense and nutrient-poor,
and offer excessive amounts of energy, fat, sugar, or sodium. Examples include snack
products such as chips or crisps, ready-to-eat cereals, sugary drinks, and confectionery.
By design, these products are highly palatable, cheap, ubiquitous, and contain
preservatives that offer a long shelf life. These features, combined with aggressive
industry marketing strategies, contribute to excessive consumption and make these
products highly profitable for the food, beverage, and restaurant industry sectors that
are dominant actors in the global food system.
The environmental impact of ultra-processed food is also indicated, with Australia as an
example:
In Australia, ultra-processed food consumption is estimated to contribute to more
than a third of the total diet-related environmental effects; 35 percent of water use,
39 percent of energy use, 33 percent of carbon dioxide equivalents, and 35 percent of
land use. If dietary trends continue, per-capita greenhouse-gas emissions from empty
calories are estimated to nearly double by 2050. Therefore, reduction of ultra-
processed food consumption is a priority for reducing the environmental effects of
the food system.
Research implications
The evidence presented in sections 3 and 4 of this report shows that ultra-processed food
intake is consistently associated with both dietary nutrient profiles prone to NCDs, and
increased risk of these diseases. Nonetheless, more research is needed.
More epidemiological research is especially needed on the impact of ultra-processed food
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Ultra-processed foods, diet quality, and health using the NOVA classification system
intake on the health and well-being of infants, children and adolescents including its effects on
both diet-related chronic NCDs and also on undernutrition and micronutrient deficiencies.
More cohort studies on obesity, diabetes, cardiovascular diseases, various types of cancer and
other diseases will enable meta-analyses of their association with ultra-processed food intake
and estimation of disease-specific pooled relative risks. Ideally, ethics permitting, more
randomized controlled trials should assess the impact of ultra-processed foods on energy
intake, weight increase and other disease biomarkers.
A review of animal studies on the effects of ultra-processed foods on the gut microbiome has
identified that common ingredients of these products, such as artificial sweeteners and
emulsifiers, and substances generated by high-temperature extrusion, create a gut
environment favouring microbes that promote low-grade inflammation associated with
obesity and several diseases (Zinocker & Lindseth, 2018). Here more experimental and
epidemiological research is needed.
More experimental and epidemiological research is needed on the behavioural effects of ultra-
processed foods, and their role in appetite, craving, over-consumption, and quasi-addictive
behaviour.
Systematic research is also needed on the various benefits of freshly prepared meals; on
overall well-being and positive human health; and on the social, cultural, economic, political
and environmental significance of the nature, extent and purposes of food processing, as set
out in the NOVA classification. This implies “joined-up” teamwork involving investigators from
all relevant disciplines, with appropriate methodologies, conducted in different countries.
One specific need is thorough careful examination of the cost in time and money of dietary
patterns based on ultra-processed food as well as those based on preparation or acquisition of
fresh meals. It is commonly said that modern living allows little time for cooking. But for many
people, cooking is a constructive use of leisure time. It is also often said that ultra-processed
foods are cheaper than freshly prepared meals. But this varies in different countries, and
depends on what foods are used to make meals and on culinary skills, and does not include the
value of freshly prepared meals as insurance against diseases and disabilities that are
expensive and also time-consuming to treat.
Finally, continuous research on research is needed, as shown in sections 3 and 4 of this report
and as pioneered by the World Cancer Research Fund/ American Institute for Cancer Research
in their ground-breaking and very influential reports. (WCRF/AICR, 2007, 2009). Updated lists,
digests and analyses of completed epidemiological and experimental research on ultra-
processed foods and human health should be regularly made available.
Policy implications
Public policies and actions designed to promote freshly prepared meals and to restrict and
reduce manufacture and consumption of ultra-processed foods, can and should be in various
ways similar to those recommended for achieving healthy eating outlined in the United
Nations Framework for Action, Decade of Action on Nutrition (FAO & WHO, 2014) and the UN
Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020
(WHO, 2013).
Public policies and actions should protect long-established production, manufacture,
distribution, sale and consumption of healthy food. This will involve systematic examination of
Ultra-processed foods, diet quality, and health using the NOVA classification system
Page 37 of 44
the behavioural, social, cultural, economic, political and environmental purposes and effects of
food systems and supplies and dietary patterns.
Other specific public policies and actions, to involve statutory including fiscal measures, should
give special priority to the health of infants, children and adolescents, and to the support of
cooperative, small and family farmers and producers of fresh foods. They should ensure that
staple healthy foods are affordable by and available to all, when appropriate by fixed prices,
and encourage and protect cultures and dietary patterns based on freshly prepared meals.
Many policies and programmes designed to reorientate food systems and supplies and dietary
patterns have already been discussed, reviewed and published by UN agencies and by national
governments. These can and should contribute to actions that fully take into account the
nature, extent and purpose of food processing, designed always to protect the overall
immediate and indefinite good health and well-being of populations, the living and physical
world, and the planet.
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Ultra-processed foods, diet quality, and health using the NOVA classification system
ANNEX 1
Food processing classification systems: originators,
where developed/applied, and references that
describe their methods and applications
ORIGINATORS
WHERE
DEVELOPED/APPLIED
REFERENCES TO METHODS AND APPLICATIONS
Researchers from the
National Institute of Public
Health (NIPH), Mexico
Mexico/Mexico
González-Castell, et al., 2007. Contribution of processed foods to the
energy, macronutrient and fiber intakes of Mexican children aged 1
to 4 years. Salud Publica Mex., 49(5):345–56.
Researchers from the
International Agency for
Research on Cancer (IARC)
and the European
Prospective Investigation
into Cancer and Nutrition
(EPIC)
Europe/Europe
Slimani, et al., 2009. Contribution of highly industrially processed
foods to the nutrient intakes and patterns of middle-aged
populations in the European Prospective Investigation into Cancer
and Nutrition study. Eur. J. Clin. Nutr., 63 (Suppl. 4):S206–25.
Chajes, et al., 2011. Ecological-level associations between highly
processed food intakes and plasma phospholipid elaidic acid
concentrations: results from a cross-sectional study within the
European prospective investigation into cancer and nutrition (EPIC).
Nutr. Cancer, 63(8):1235–50.
Researchers from the
University of São Paulo,
Brazil
Brazil/Global
Monteiro, et al., 2010. A new classification of foods based on the
extent and purpose of their processing. Cad. Saúde Pública,
26(11):2039-2049
Monteiro, et al., 2017a. The UN Decade of Nutrition, the NOVA food
classification and the trouble with ultra-processing. Public Health
Nutrition, 21(1): 5-17.
NOVA has been used by over 80 studies conducted in many countries.
Some of these studies are described in Monteiro et al., 2017a and
some are reviewed in Section 3 and 4 of this report.
International Food
Information Council (IFIC),
US
US/US
Eicher-Miller, et al., 2012. Contributions of processed foods to dietary
intake in the US from 2003-2008: A report of the Food and Nutrition
Science Solutions Joint Task Force of the Academy of Nutrition and
Dietetics, American Society for Nutrition, Institute of Food
Technologists, and International Food Information Council. J. Nutr.,
142:2065S–2072S.
Eicher-Miller, et al., 2015. Processed Food Contributions to Energy
and Nutrient Intake Differ among US Children by Race/Ethnicity.
Nutrients, 7:10076–10088.
Research from the
International Food Policy
Research Institute (IFPRI)
Guatemala/
Guatemala
Asfaw, 2011. Does consumption of processed foods explain
disparities in the body weight of individuals? The case of Guatemala.
Health Econ., 20(2):184–95.
Researchers from the
University of North Carolina
at Chapel Hill, US
US/US
Poti, et al., 2015. Is the degree of food processing and convenience
linked with the nutritional quality of foods purchased by US
households? Am. J. Clin. Nutr., 101:1251–1262.
