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Consumption of ultra-processed foods and health outcomes: A systematic review of epidemiological studies

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Background: Consumption of ultra-processed foods (UPFs) plays a potential role in the development of obesity and other diet-related noncommunicable diseases (NCDs), but no studies have systematically focused on this. This study aimed to summarize the evidence for the association between UPFs consumption and health outcomes. Methods: A comprehensive search was conducted in PubMed, Embase, and Web of Science to identify all relevant studies. Epidemiological studies were included, and identified studies were evaluated for risk of bias.A narrative review of the synthesized findings was provided to assess the association between UPFs consumption and health outcomes. Results: 20 studies (12 cohort and 8 cross-sectional studies) were included in the analysis, with a total of 334,114 participants and 10 health outcomes. In a narrative review, high UPFs consumption was obviously associated with an increased risk of all-cause mortality, overall cardiovascular diseases, coronary heart diseases, cerebrovascular diseases, hypertension, metabolic syndrome, overweight and obesity, depression, irritable bowel syndrome, overall cancer, postmenopausal breast cancer, gestational obesity, adolescent asthma and wheezing, and frailty. It showed no significant association with cardiovascular disease mortality, prostate and colorectal cancers, gestational diabetes mellitus and gestational overweight. Conclusions: This study indicated a positive association between UPFs consumption and risk of several health outcomes. Large-scale prospective designed studies are needed to confirm our findings.
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R E V I E W Open Access
Consumption of ultra-processed foods and
health outcomes: a systematic review of
epidemiological studies
Xiaojia Chen
1,2
, Zhang Zhang
1,2
, Huijie Yang
1,2
, Peishan Qiu
1,2
, Haizhou Wang
1,2
, Fan Wang
1,2
, Qiu Zhao
1,2*
,
Jun Fang
1,2*
and Jiayan Nie
1,2*
Abstract
Background: Consumption of ultra-processed foods (UPFs) plays a potential role in the development of obesity
and other diet-related noncommunicable diseases (NCDs), but no studies have systematically focused on this. This
study aimed to summarize the evidence for the association between UPFs consumption and health outcomes.
Methods: A comprehensive search was conducted in PubMed, Embase, and Web of Science to identify all relevant
studies. Epidemiological studies were included, and identified studies were evaluated for risk of bias.A narrative review
of the synthesized findings was provided to assess the association between UPFs consumption and health outcomes.
Results: 20 studies (12 cohort and 8 cross-sectional studies) were included in the analysis, with a total of 334,114
participants and 10 health outcomes. In a narrative review, high UPFs consumption was obviously associated with an
increased risk of all-cause mortality, overall cardiovascular diseases, coronary heart diseases, cerebrovascular diseases,
hypertension, metabolic syndrome, overweight and obesity, depression, irritable bowel syndrome, overall cancer,
postmenopausal breast cancer, gestational obesity, adolescent asthma and wheezing, and frailty. It showed no
significant association with cardiovascular disease mortality, prostate and colorectal cancers, gestational diabetes
mellitus and gestational overweight.
Conclusions: This study indicated a positive association between UPFs consumption and risk of several health
outcomes. Large-scale prospective designed studies are needed to confirm our findings.
Keywords: Ultra-processed foods, Noncommunicable diseases, Health, Systematic review
Introduction
Noncommunicable diseases (NCDs), such as cardiovas-
cular diseases, type 2 diabetes and some cancers, are col-
lectively responsible for almost 70% of all deaths
worldwide. The current prevalence of NCDs poses
devastating health outcomes and constitutes a serious
threat to global health systems. To reduce the number
of deaths caused by NCDs, a better understanding of the
potential risk factors is needed.
Unhealthy diets are recognized as a major determinant
of the occurrence of NCDs. With the increasing trend of
NCDs, a steady rise in the share of processing foods has
been seen. In the last half century food processing has
evolved greatly as a consequence of the industrialization
and globalization of food systems [1]. Negative effects on
nutritional dietary quality emerged subsequently, such as
higher content in free sugars, saturated fats, energy
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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: zhaoqiuwhu@163.com;xhfangjun@163.com;
119140546@qq.com
Xiaojia Chen, Zhang Zhang and Huijie Yang contributed equally to this
work.
1
Department of Gastroenterology, Zhongnan Hospital of Wuhan University,
No. 169, Donghu Road, Wuchang District, Wuhan 430071, Hubei Province,
China
Full list of author information is available at the end of the article
Chen et al. Nutrition Journal (2020) 19:86
https://doi.org/10.1186/s12937-020-00604-1
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density and sodium, and less content in protein, fiber
and micronutrients. It is believed that most NCDs can
be prevented by changes in diet patterns.
Ultra-processed foods (UPFs) are defined as formula-
tions of ingredients derived from foods and additives,
coupled with substances including colorings, flavorings,
sweeteners, and emulsifiers [2]. They contain little if any
intact food. Included in this definition are sugar-
sweetened beverages, sweets, ice cream, chocolates,
savoury snacks, burgers, processed meat and frozen
dishes. Compared with other food groups, UPFs are typ-
ically durable, ready to consume, low-cost and hyper-
palatable. They tend to be packaged delicately and mar-
keted concentratedly. They are characteristically fatty,
sugary or salty, energy-dense and lack of protein, dietary
fibre, micronutrients and several bioactive compounds
[35]. Furthermore, they may contain neo-formed con-
taminants derived from industrial processing, as well as
substances from additives and packaging [6,7]. Consid-
ering the association between UPFs and poorer dietary
quality, the share of UPFs has been proposed as an ef-
fective predictor of population diet quality [810].
The whole world has witnessed a dramatic transition
in food consumption patterns. Unprocessed or minim-
ally processed foods and freshly prepared meals are
gradually displaced by UPFs. The shift appeared initially
in high and middle income countries, and then world-
wide [11,12]. Transnational corporations are major fac-
tors that drive the production and sales of UPFs, along
with their convenience, branding and aggressive market-
ing [13]. These characteristics create massive market ad-
vantages for UPFs over other food groups [14]. In high
income countries, more than half of the foods consumed
are UPFs for most of the age groups, and consumption
decreases with age [15,16]. Purchase surveys and dietary
trends on UPFs consumption have been performed in
Asia and many western countries [1721]. It has been
evaluated that the energy contribution of UPFs ranged
from 25 to 60% [22].
The existing evidence indicates that displacement by
UPFs is driving a rising prevalence of obesity and other
diet-related NCDs [23]. A growing body of evidence sug-
gests that increases of UPFs in dietary proportion were
associated with a higher incidence of adverse health out-
comes [16,2442]. Decreasing the dietary share of UPFs
may notably contribute to the prevention of diet-related
NCDs [4345].
As UPFs are increasing dominantly during the past de-
cades, understanding their potential impacts on health
outcomes has become a major imperative. To date, how-
ever, this literature has not been comprehensively evalu-
ated. No reviews have been conducted on this topic
previously. To address these concerns, this systematic
review was conducted to summarize the evidence for the
association between UPFs consumption and health
outcomes.
Methods
Study design
This systematic review is completed according to the
MOOSE (Meta-analysis Of Observational Studies in Epi-
demiology) Statement [46]. We developed a protocol
with methods of the review in advance (Supplement 1).
Search strategy
The public databases of PubMed, Embase, and Web of
Science were comprehensively searched for relevant
studies published up to October 11, 2019. Broad search
strategy was used to ensure that no publications were
overlooked. The search terms were listed in Supplement
1. Studies in language other than English were excluded.
Reference lists of relevant articles and some key journals
were also hand-searched for other pertinent studies. We
considered no limitations on the publication date.
Eligibility criteria
Epidemiological studies including cohort and cross-
sectional studies were considered for further screening.
Eligibility was assessed independently by two authors
(Xiaojia Chen and Zhang Zhang). All differences were
resolved by consensus with a third author (Fan Wang).
We included studies meeting the following inclusion cri-
teria: (i) included more than 500 participants; (ii) the ex-
posure of interest was consumption of UPFs and the
outcomes of interest were any health outcomes (e.g., all-
cause mortality, cancers); (iii) reported the effect sizes of
hazard ratios (HRs), odds ratios (ORs) or relative risks
(RRs) with 95% confidence intervals (CIs). We excluded
experimental studies, reviews, letters, editorials, and ab-
stracts without full texts. When more than one studies
reported on the same cohort and outcome, we only in-
cluded the study with the longest follow-up.
Data extraction
Both authors independently reviewed full-texts of the
eligible studies and extracted data using a standardized
collection form. All differences were resolved by consen-
sus. Information extracted from each study was as fol-
lows: first author, year of publication, study design,
study period and area, study population, number of par-
ticipants, exposure assessment, outcome measures and
categories, comparison, effect sizes (HRs, ORs, and RRs)
with 95% CIs. All kinds of measures of exposures and
outcomes were allowed. There was also no limitation on
outcome categories.
Chen et al. Nutrition Journal (2020) 19:86 Page 2 of 10
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Quality assessment
Risk of bias was evaluated by two reviewers independ-
ently. All differences were resolved by consensus. We
assessed the quality of cohort studies with the
Newcastle-Ottawa Scale (NOS) and cross-sectional stud-
ies with the JBI Critical Appraisal Checklist [47,48]. Risk
of bias of each eligible study was evaluated according to
a series of methodological features: (i) sampling of par-
ticipants and their representativeness of the population;
(ii) assessment of exposure to UPFs; (iii) ascertainment
of health outcomes; (iv) adjustment for potential con-
founders; (v) demonstration was mentioned that out-
come of interest was not present at start of study. In
general, cohort studies scoring 6 were considered as
high quality, while cross-sectional studies with 5yes
were rated as high quality.
Data synthesis
In light of the overall low number of studies, variance of
exposures and outcomes measurement, no quantitative
meta-analysis was conducted. To systematically synthesize
findings across included studies, a narrative synthesis ap-
proach was chosen. We tabulated study characteristics
and classified studies into groups according to different
health outcomes. The evidence was synthesized to provide
useful insights for the association of interest.
Results
Study selection and characteristics
The search strategy identified 1165 records. 563 articles
were screened by titles and abstracts after duplicates
removed. Of the 55 full-texts assessed for eligibility, 20
published epidemiological studies (12 cohort and 8
cross-sectional studies) were included into the system-
atic review, with a total of 334,114 participants and 10
diseases (Fig. 1). An overview of the characteristics of in-
cluded studies was provided in Table 1. All studies were
published between 2015 and 2019, with a sample size
ranging from 785 to 109,104. Six studies were conducted
in Spain, while 5 in France, 4 in Canada, 3 in America
and 2 in Brazil. The median follow-up ranged from 3.5
to 19 years in cohort studies. The mean age of partici-
pants was between 28 and 69 years, exclusive of the un-
known one [41]. The female proportion ranged from 49
to 100%. Of the 20 eligible studies, 4 focused on all-
cause mortality [2427], 2 on cardiocerebrovascular dis-
eases [28,29], 2 on metabolic syndrome [30,31], 5 on
overweight and obesity [16,3235], 2 on mental health
diseases [36,37]. The remaining 5 studies respectively
investigated gastrointestinal diseases [38], cancers [39],
pregnancy outcome [40], respiratory diseases [41], and
geriatric diseases [42].
Quality assessment
The quality assessment was listed in Supplement 2. Co-
hort studies scored ranging from 6 to 9. A maximum of
9 points could be awarded to each cohort study: 4 for se-
lection, 2 for comparability, and 3 for outcome. Two co-
hort studies represented the highest quality. The most
common bias risk was incomplete representativeness.
Volunteers [25,28,36,38,39] and university graduates
[29,35,37] tended to be more health-conscious and had
Fig. 1 Flowchart of literature search
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Table 1 Characteristics of included studies
First author,
year
Study design Study period, area Study population, age Sample
size
Exposure measures Health outcome Outcome measures Comparison Effect size (95% CI)
Rico-Campà,
2019 [24]
Prospective
cohort study
19992014, Spain University graduates,
20-91y
19,899 FFQ All-cause mortality Medical records,
database
Q4 vs. Q1 HR: 1.62 (1.13, 2.33)
Schnabel,
2019 [25]
Prospective
cohort study
20092017, France Adults participants,
45y
44,551 Dietary records,
interview,
biomarkers
All-cause mortality Clinical data Q4 vs. Q1 HR: 1.25 (0.99, 1.57)
Blanco-Rojo,
2019 [26]
Prospective
cohort study
20082016, Spain Adult participants, 18y 11,898 Questionnaire All-cause mortality Computerized search Q4 vs. Q1 HR: 1.44 (1.01, 2.07)
Kim, 2019 [27] Prospective
cohort study
19882011, USA Adult participants, 20y 11,898 Dietary records,
questionnaire
All-cause mortality
Cardiovascular
disease mortality
Database Q4 vs. Q1 HR: 1.30 (1.08, 1.57)
HR: 1.13 (0.74, 1.71)
Srour, 2019
[28]
Prospective
cohort study
20092018, France Adult participants, 18y 105,159 Dietary records,
interview,
biomarkers
All cardiovascular
diseases
Coronary heart
diseases
Cerebrovascular
diseases
Questionnaire,
medical records,
database
Q4 vs. Q1 HR: 1.23 (1.04, 1.45)
HR: 1.18 (0.93, 1.52)
HR: 1.23 (1.00, 1.53)
Mendonça,
2017 [29]
Prospective
cohort study
19992015, Spain University graduates, 20-91y 14,790 FFQ Hypertension Self-reported,
clinical data
T3 vs. T1 HR: 1.21 (1.06, 1.37)
Melo, 2018
[41]
Cross-
sectional
study
2012, Brazil 9th graders, NC 109,104 Questionnaire Asthma
Wheezing
Questionnaire Q5 vs. Q1 OR: 1.27 (1.15, 1.41)
OR: 1.42 (1.35, 1.50)
Schnabel,
2018 [38]
Prospective
cohort study
20082018, France Adult participants, 18y 33,343 Dietary records,
questionnaire
Functional
gastrointestinal
disorders
Questionnaire,
medical history,
symptoms
Q4 vs. Q1 OR: 1.25 (1.12, 1.39)
Adjibade,
2019 [36]
Prospective
cohort study
20092018, France Adult volunteers, 18y 26,730 Dietary records Depression Clinical data Q4 vs. Q1 HR: 1.30 (1.15, 1.47)
Gómez-
Donoso, 2018
[37]
Prospective
cohort study
19992016, Spain University graduates, NC 14,907 FFQ Depression Questionnaire,
clinical interview
Q4 vs. Q1 HR: 1.33 (1.07, 1.64)
Steele, 2019
[30]
Cross-
sectional
study
20092014, USA Adult participants, 20y 6385 Interview Metabolic
syndrome
Interviews, health
examination
Q5 vs. Q1 OR: 1.28 (1.09, 1.50)
Lavigne-
Robichaud,
2018 [31]
Cross-
sectional
study
20052009,
Canada
Adult participants, 18y 811 Dietary records Metabolic
syndrome
Clinical data Q5 vs. Q1 OR: 1.90 (1.14, 3.17)
Juul, 2018 [32] Cross-
sectional
study
20052014, USA Adults participants, 2064y 15,977 Interview Overweight
Obesity
Abdominal obesity
Clinical data Q5 vs. Q1 OR: 1.48 (1.25, 1.76)
OR: 1.53 (1.29, 1.81)
OR: 1.62 (1.39, 1.89)
Louzada, 2015
[33]
Cross-
sectional
study
20082009, Brazil Individuals, 10y 30,243 Dietary records Overweight
Obesity
Clinical data Q5 vs. Q1 OR: 1.26 (0.95, 1.69)
OR: 1.98 (1.23, 3.12)
Mendonca, Prospective 19992012, Spain University graduates, 8451 FFQ Overweight Self-reported Q4 vs. Q1 HR: 1.26 (1.10, 1.45)
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Table 1 Characteristics of included studies (Continued)
First author,
year
Study design Study period, area Study population, age Sample
size
Exposure measures Health outcome Outcome measures Comparison Effect size (95% CI)
2016 [35] cohort study middle-aged
Nardocci,
2019 [16]
Cross-
sectional
study
20042005,
Canada
Adult participants, 18y 19,363 Dietary records Obesity Clinical data (32%
self-reported)
Q5 vs. Q1 OR: 1.32 (1.05, 1.57)
Silva, 2018
[34]
Cross-
sectional
study
20082010, Brazil Civil servants from universities and
research organizations, 3564y
8977 FFQ Overweight
Obesity
Clinical data Q4 vs. Q1 OR: 1.31 (1.13, 1.51)
OR: 1.41 (1.18, 1.69)
Fiolet, 2018
[39]
Prospective
cohort study
20092017, France Adult volunteers, 18y 104,980 Dietary records Overall cancer
Prostate cancer
Colorectal cancer
Breast cancer
Questionnaire,
medical records,
database
Q4 vs. Q1 HR: 1.23 (1.08, 1.40)
HR: 0.93 (0.61, 1.40)
HR: 1.23 (1.08, 1.40)
HR: 1.13 (0.89, 1.42)
Sartorelli, 2019
[40]
Cross-
sectional
study
20112012, Brazil. Adult women, 20y 785 Dietary records Obesity
Overweight
Gestational
diabetes mellitus
Clinical data T3 vs. T1 OR: 3.06 (1.27, 3.37)
OR: 1.17 (0.75, 1.82)
OR: 0.82 (0.49, 1.36)
Sandoval-
Insausti, 2019
[42]
Prospective
cohort study
20082012, Spain Individuals, 60y 1822 Interview Frailty Clinical data Q4 vs. Q1 OR: 3.67 (2.00, 6.73)
Abbreviation:FFQ food frequency questionnaire, HR hazard ratio, OR odds ratio, Qquartile or quintile, Ttertile, NC not clear
Chen et al. Nutrition Journal (2020) 19:86 Page 5 of 10
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healthier dietary habits, leading to a lack of representa-
tiveness of the general population. Considering the
chronic development of NCDs, the insufficient follow-up
was another source of bias risk [39,42].
Cross-sectional studies achieved 5 to 8 yes. Three
studies were unclear whether the measurement of the
condition was assessed according to the objective and
standard criteria [30,31,41]. Three studies applied in-
complete statistical analysis [31,34,40]. The methods of
exposures [33,40] or outcomes [15,41] measurement
were short of validity and reliability, which led to bias
risk. However, all the eligible studies made adequate ad-
justments for potential confounding factors. Generally,
all included studies had a good methodological quality.
Study results
The results were synthesized in Table 1, comprising
study design, study setting, samples, exposures, out-
comes, and effect sizes. A narrative synthesis of our find-
ings is as follows.
All-cause mortality
Four cohort studies investigated the association between
UPFs consumption and risk of all-cause mortality [24
27]. Despite diverse methods of exposures assessment,
all studies reported a significant positive association, in-
dicating that high consumption of UPFs was associated
with an increased hazard for all-cause mortality. Three
of them conducted sensitivity analyses and results did
not substantially change, showing the strength of the as-
sociation [24,25,27]. Rico-Campà et al. and Schnabel
et al. found that cancer was the main cause of death.
However, Kim et al. reported null association with car-
diovascular disease mortality, which is surprising.
Cardiocerebrovascular diseases
Two cohort studies investigated the association between
UPFs consumption and risk of cardiocerebrovascular
diseases [28,29]. Srour et al. focused on the overall of
cardiovascular diseases, and Mendonca et al. on hyper-
tension. Even after adjustment for potential confounding
factors, it was found that high UPFs consumption in-
creased the risk of overall cardiovascular diseases (HR:
1.23, 95% CI: 1.04 to 1.45), coronary heart diseases risk
(HR: 1.18, 95% CI: 0.93 to 1.52), cerebrovascular diseases
risk (HR: 1.23, 95% CI: 1.00 to 1.53), and hypertension
(HR: 1.21, 95% CI: 1.06 to 1.37). Results from sensitivity
analyses did not substantially change.
Respiratory diseases
One cross-sectional study investigated the association
between UPFs consumption and risk of asthma and
wheezing among the Brazilian adolescents [41]. It found
a positive association between UPFs consumption and
risk of asthma (OR: 1.27, 95% CI: 1.15 to 1.41) and
wheezing (OR: 1.42, 95% CI: 1.35 to 1.50). In addition,
the direct association was stronger among male adoles-
cents, those who did not consume fruits and vegetables
regularly, non-smokers, with parents who did not smoke,
and those living in non-capital cities.
Gastrointestinal diseases
One cohort study investigated the association between
UPFs consumption and risk of functional gastrointestinal
disorders [38]. In a sample of French adults, it was found
that high UPFs consumption increased the risk of irrit-
able bowel syndrome (IBS) (OR: 1.25, 95% CI: 1.12 to
1.39) and concomitant functional dyspepsia (OR: 1.25,
95% CI: 1.05 to 1.47). No associations were observed be-
tween UPFs consumption and functional dyspepsia alone
without concomitant IBS, indicating the indispensable
role of IBS in the positive association.
Mental health diseases
Two cohort studies investigated the association between
UPFs consumption and risk of depression [36,37]. Both
reported a positive association even after extensive ad-
justment. The fourth quartile had a significantly in-
creased risk compared to the lowest quartile. Similar
results were observed after sensitivity analyses, confirm-
ing the robustness of the association.
Metabolic syndrome
Two cross-sectional studies investigated the association
between UPFs consumption and risk of metabolic syn-
drome [30,31]. Both reported a significant positive asso-
ciation, suggesting the growing evidence of associations
between UPFs consumption and several diet-related
NCDs. In addition, Steele et al. observed that the associ-
ation was stronger among young adults and decreased
with age.
Overweight and obesity
Four cross-sectional studies [16,3234] and one pro-
spective cohort study [35] investigated the association
between UPFs consumption and risk of overweight
(BMI 25 kg/m
2
) and obesity (BMI 30 kg/m
2
). Three
studies reported a positive association for overweight
[32,33,35] and four studies for obesity [16,3234]. Fur-
thermore, Juul et al. found a positive association between
high UPFs consumption and abdominal obesity (OR:
1.62, 95% CI: 1.39 to 1.89). Stronger effects were ob-
served among women, partly due to sex-related differ-
ences in food choices [32,33]. The evidence strongly
supported the role of increased UPFs consumption in
the obesity epidemic worldwide.
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Cancers
One cohort study investigated the association between
UPFs consumption and risk of cancers [39]. After a rela-
tively short median follow-up of 5 years, this volunteer-
based study suggested a positive association between
UPFs consumption and overall cancer risk (HR: 1.23,
95% CI: 1.08 to 1.40) and postmenopausal breast cancer
risk (HR: 1.38, 95% CI: 1.05 to 1.81). No significant asso-
ciation was observed for prostate, colorectal, overall
breast and premenopausal breast cancers. However, a
direct association about overall breast cancer risk was
obtained when UPFs consumption was regarded as a
continuous variable.
Pregnancy outcome
One cross-sectional study investigated the association
between UPFs consumption and risk of several preg-
nancy outcomes [40]. This study was conducted among
adult women with singleton pregnancies. It detected a
positive association between UPFs consumption and
pregnant obesity (OR: 3.06, 95% CI: 1.27 to 3.37), but no
significant association was observed in gestational dia-
betes mellitus (OR: 0.82, 95% CI: 0.49 to 1.36) and over-
weight (OR: 1.17, 95% CI: 0.75 to 1.82).
Geriatric diseases
One cohort study investigated the association between
UPFs consumption and risk of incident frailty in the old
adults [42]. With a relatively short median follow-up of
3.5 years, this study suggested a positive association be-
tween UPFs consumption and frailty risk (OR: 3.67, 95%
CI: 2.00 to 6.73). Similar results were observed in sensi-
tivity analyses.
Discussion
To the best of our knowledge, this is the first systematic
review of available epidemiological evidence on the asso-
ciation between UPFs consumption and health out-
comes. We identified 12 cohort and 8 cross-sectional
studies, and found that there was a positive association
between UPFs consumption and risk of all-cause mortal-
ity, overall cardiovascular diseases, coronary heart dis-
eases, cerebrovascular diseases, hypertension, metabolic
syndrome, overweight and obesity, depression, irritable
bowel syndrome, overall cancer, postmenopausal breast
cancer, gestational obesity, adolescent asthma and
wheezing, and frailty. It showed no obvious association
with cardiovascular disease mortality, prostate and colo-
rectal cancer, gestational diabetes mellitus and gesta-
tional overweight.
Among the included studies, different methods were
applied to estimate intake of UPFs. In some studies por-
tion sizes were estimated using validated photographs.
They calculated energy and weight relative to total food
intake according to specific food composition databases.
Some studies calculated daily intake by multiplying the
portion size by the frequency of consumption, which
had been proved validated. A majority of included stud-
ies evaluated intake as the percentage to total energy
while the others selected weight proportion. The appli-
cation of energy proportion contributed to reduction of
variation due to body size, metabolic efficiency, and
physical activity [33]. Weight proportion was taken into
account for UPFs that did not provide any energy intake
such as artificially sweetened drinks, and factors related
to food processing [38]. Although methods vary, UPFs
intake was all modeled as quantiles (e.g., tertiles, quar-
tiles and quintiles). We selected effect estimates adjusted
by the most factors for the highest versus the lowest
consumption levels, which made them comparable. In
light of the increasing concern of UPFs, further research
is needed to set standard methods for UPFs intake
estimation.
Despite different ways to estimate intake of UPFs, all
the studies conducted food classification using the
NOVA system, except one [33]. Louzada et al. divided
foods into three groups according to the degree of pro-
cessing, which was also consistent with the NOVA sys-
tem. NOVA, a food classification system which classifies
foods into four groups according to the nature, extent
and purpose of industrial processing, has now been ap-
plied globally [49]. Groups are as follows: (i) Unpro-
cessed or minimally processed foods; (ii) Processed
culinary ingredients; (iii) Processed foods; (iv) Ultra-
processed foods. Instead of focusing on nutrient com-
position of the diet, it takes into consideration all phys-
ical, chemical and biological methods used during the
food productive process [50]. The NOVA system has
been used to describe population dietary patterns, assess
changes in the dietary share of UPFs, and analyze the as-
sociation of the dietary share with nutrient profile and
with health outcomes [50]. It will contribute to the pre-
vention of NCDs and the improvement of public health
worldwide [51]. Nevertheless, when using the NOVA
system to make dietary recommendations, it should be
considered that some foods are difficult to classify [2].
Further research is needed to promote the application of
this food classification system.
Considering the synergistic health-related effects of
foods, it is of great importance to study dietary patterns
instead of single foods or nutrients. UPFs consumption
is increasing dominantly across the globe, especially in
Western countries. It is consistent with the increased
burden of NCDs attributable to unhealthy diets. The role
of some specific UPFs has been assessed, such as proc-
essed meats and sweetened beverages, showing positive
associations with NCDs [52,53]. In line with our find-
ings, previous studies reported an inverse association
Chen et al. Nutrition Journal (2020) 19:86 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
between higher diet quality and risk of all-cause, cardio-
vascular disease, and cancer mortality [5456]. Adher-
ence to healthier diet patterns, which are characterized
by a high consumption of unprocessed or minimally
processed foods, was promoted to prevent NCDs. De-
crease of cardiovascular disease burden with a healthier
food system was observed in two modelling studies [57,
58]. A review of systematic reviews found that grain
products and tea were protective, while processed meats
and soft drinks tended to increase the risk [59]. Existing
meta-analyses demonstrated that an optimal intake of
several food groups could decrease the risk of coronary
heart disease, stroke and heart failure [60]. Overall, UPFs
consumption should be limited in prevention of NCDs.
The mechanism is multi-faceted. First, UPFs consump-
tion is usually accompanied with high intake of fats, cal-
ories, sugars and salt, and low intake of micronutrients
and fibre. The poor quality of dietary nutrients leads to
the development of NCDs [61]. Processing, especially
heat treatments, food additives and food packaging, can
generate carcinogenicity and genotoxicity [25]. UPFs
consumption increases added sugar intake, which is as-
sociated with obesity and several other health outcomes
[19,21,62,63]. Moreover, higher intake of UPFs induces
changes in gut microbiota, serum C-reactive protein
levels and lipoprotein profiles [6467]. Displacement of
unprocessed or minimally processed foods might play a
potential role in decreased diet quality [37]. However, it
still remains unclear what plays a leading role in the as-
sociation. A better understanding of what really matters
and how various aspects contribute to the effects is
highly needed.
Our study has strengths. To our knowledge, this is the
most comprehensive systematic review of the topic to
date. We carried out extensive literature research. The
occurrence of selection bias was reduced greatly due to
the prospective design of all the cohort studies. Large
number of participants might compensate for the inad-
equate number of studies of each health outcome. All
the eligible studies made adequate adjustments of the
potential confounding factors. In general, we provide
strong implications for dietary policies and guidelines.
Several limitations should also be acknowledged. First,
most cohort studies recruited university graduates or
volunteers as study objects, who tended to be more
health-conscious and had a lower UPFs consumption
than the general population. This probably resulted in
an underestimation of the association of interest. Sec-
ond, as occurrence of some health outcomes took a long
time, such as carcinogenic processes, the median follow-
up was relatively inadequate. Besides, complete detection
of outcomes could not be guaranteed. Third, epidemio-
logical studies could not exclude reverse causality and
residual confoundings. For cross-sectional studies,
probability existed that participants changed their diet-
ary habits after the occurrence of diseases. It tended to
cause an underestimation of the results. Fourth, some
misclassification in the NOVA system could not be ruled
out. Ways applied for dietary assessment were not spe-
cifically designed for NOVA classification and UPFs con-
sumption yet. However, substantial differences between
the highest and the lowest group might reduce the bias
to a great extent. It is also worth mentioning that no
quantitative meta-analysis was conducted, which we
hoped to be overcome with further research. Given eth-
ical issues of conducting randomized controlled trials of
risk factors, more well-designed epidemiological studies
are needed to confirm these findings.
There are significant public health implications in our
study. To date, prevention and control of NCDs are be-
coming a growing concern. UPFs are beginning to be
recognized as an emerging health risk. The positive asso-
ciation between UPFs consumption and adverse health
outcomes provides insights into dietary policies and
guidelines. Encouraging a decrease in UPFs consumption
and an increase in the proportion of unprocessed or
minimally processed foods are a direct way to resolve
the issue. Food taxation and surveillance on food mar-
keting still play a vital role. Dietary guidelines, in accord-
ance with the shift of the global food system and health,
are a necessity to slow the prevalence of NCDs.
Conclusion
This study indicated a positive association between UPFs
consumption and risk of several health outcomes. Our
results encouraged a decrease in UPFs consumption and
an increase in the proportion of unprocessed or minim-
ally processed foods, such as fruits and vegetables. Con-
sidering diet-related risk factors, we provided insights
into NCDs occurrence and prevention. Large-scale pro-
spective designed studies are needed to confirm our
findings and to better understand the relative effects of
various aspects in UPFs.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12937-020-00604-1.
Additional file 1: Supplyment 1: Supplementary Text 1. Review
protocol.
Additional file 2: Supplyment 2: Supplementary Table 1. Quality of
cohort studies according to the Newcastle-Ottawa Scale (NOS). Supple-
mentary Table 2. Quality of cross-sectional studies according to the JBI
Critical Appraisal Checklist.
Abbreviations
UPFs: Ultra-processed foods; NCDs: Noncommunicable diseases;
CIs: Confidence intervals; HRs: Hazard ratios; ORs: Odds ratios; RRs: Relative
risks
Chen et al. Nutrition Journal (2020) 19:86 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Acknowledgments
The authors thank the staff of the Department of Gastroenterology,
Zhongnan Hospital of Wuhan University, for their guidance and support.
Authorscontributions
XC, ZZ, HY conceived and designed the study. XC, ZZ, HY, PQ acquired data.
XC, ZZ, HY, HW, FW analyzed data and interpreted results. XC, ZZ, HY wrote
the paper. QZ, JF, JN reviewed and edited the manuscript. All authors read
and approved the final manuscript.
Funding
National Key R&D Program of China (2017YFC0112302).
Availability of data and materials
The datasets supporting the conclusions of this article are included within
the article and its additional files.
Ethics approval and consent to participate
All included studies underwent institutional review board approval. All
participants provided informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Gastroenterology, Zhongnan Hospital of Wuhan University,
No. 169, Donghu Road, Wuchang District, Wuhan 430071, Hubei Province,
China.
2
Hubei Clinical Center & Key Lab of Intestinal & Colorectal Diseases,
Wuhan, China.
Received: 27 January 2020 Accepted: 12 August 2020
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... UPFs are products that have undergone a series of industrial processes, including physical, biological, or chemical processes, coupled with the use of additives such as colorings, emulsifiers, and preservatives [5][6][7]. A privilege of this industry is providing hyper-palatable products that are easy to advertise and can last on store shelves or kitchen cabinets as long as possible with the least amount of expense, therefore gaining maximum profits [3]. ...
... The rise in the consumption of UPFs, including "fast foods", "soft and sugary drinks", "processed meats", and other types of "ready-to-consume" foods, has been linked to the risk of obesity and many other NCDs such as cardiovascular disease, hypertension, and depression [8]. UPFs are characteristically poor in nutritional compounds and high in non-nutritive components [3,5,9]. In addition, the use of several additives may cause multiple health issues, and the packaging may also contain harmful substances [6]. ...
... NOVA classifies foods based on the degree and purpose of industrialized processing into four categories ( Figure 1): (i) unprocessed/minimally processed foods, (ii) processed culinary ingredients, (iii) processed foods, and (iv) ultra-processed foods [13]. The latter, ultra-processed foods (UPFs), are products that have been manufactured by different types of industrial processes, including physical, biological, or chemical processes, such as hydrogenation, extrusion, and pre-frying, coupled with the use of "cosmetic additives" such as colorings, flavorings, sweeteners, and emulsifiers [5][6][7]. Cosmetic additives are low-cost ingredients that have rarely or never been used in kitchens. The presence of at least one cosmetic additive in any product's ingredients list, which by law must be included in food labels, identifies it as ultra-processed [13]. ...
Article
Full-text available
Studying the factors that cause diabetes and conducting clinical trials has become a priority, particularly raising awareness of the dangers of the disease and how to overcome it. Diet habits are one of the most important risks that must be understood and carefully applied to reduce the risk of diabetes. Nowadays, consuming enough home-cooked food has become a challenge, particularly with modern life performance, pushing people to use processed foods. Ultra-processed food (UPF) consumption has grown dramatically over the last few decades worldwide. This growth is accompanied by the increasing prevalence of non-communicable diseases (NCDs) such as cardiovascular diseases, hypertension, and type 2 diabetes. UPFs represent three main health concerns: (i) they are generally high in non-nutritive compounds such as sugars, sodium, and trans fat and low in nutritional compounds such as proteins and fibers, (ii) they contain different types of additives that may cause severe health issues, and (iii) they are presented in packages made of synthetic materials that may also cause undesirable health side-effects. The association between the consumption of UPF and the risk of developing diabetes was discussed in this review. The high consumption of UPF, almost more than 10% of the diet proportion, could increase the risk of developing type 2 diabetes in adult individuals. In addition, UPF may slightly increase the risk of developing gestational diabetes. Further efforts are needed to confirm this association; studies such as randomized clinical trials and prospective cohorts in different populations and settings are highly recommended. Moreover, massive improvement in foods’ dietary guidelines to increase the awareness of UPF and their health concerns is highly recommended.
... While the evidence to support the efficacy of organic foods in preventing diseases might be scarce, comparative studies have established that societies that consume processed foods in high quantities report a higher prevalence of lifestyle conditions than societies that consume organic foods. In a systematic review of epidemiological studies conducted by Chen et al. (2020), high consumption of ultra-processed foods contributed significantly to the high prevalence of obesity, diabetes, cancer, strokes, and heart attacks. The study also established that the prevalence of lifestyle diseases was significantly low in areas where people consumed less processed foods and more organic foods. ...
... However, other studies have revealed the health problems associated with the high consumption of processed foods. For instance, researchers such as Chen et al. (2020) found a close link between the high consumption of ultra-processed foods and the increasing prevalence of obesity, diabetes, and cancer in many societies. With more studies establishing a link between the consumption of organic foods and better health outcomes, it is predicted that many people will switch to organic foods and beverages in the future. ...
Article
This paper identifies attributes of hotels in Cyprus that domestic consumers are either willing to make extra payments for, or they can actually do without. These findings can be useful in revitalizing businesses in the hospitality sector which the COVID-19 pandemic has forced to either scale down or cease their operations. This revitalization of the hospitality industry may be achieved if the hotel units maintain and enhance the attributes which domestic consumers prefer and, at the same time, they scale down or completely remove attributes which internal tourists find either indifferent or unwelcome. The latter measure may also succeed in cutting down the operational costs of the Cypriot hotels to a more manageable level.
... Many ready-to-eat or ready-to-heat foods and drinks are high in added sugars, sodium, saturated fats, and refined carbohydrates. Excessive consumption of these nutrients and ultra-processed foods increases the risk of obesity and related NCDs [13][14][15][16][17][18][19][20][21][22][23][24][25]. Indeed, a growing literature including both a large randomized controlled trial and over 45 longitudinal cohort studies linked ultra-processed food with increased risk of overweight/obesity, diet-related NCDs, and total and heart disease-linked mortality [16,26]. ...
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Policies to require front-of-package labels (FOPLs) on packaged foods may help Indian consumers to better identify foods high in nutrients of concern, including sugar, saturated fat, and sodium, and discourage their consumption, which are outcomes that are critical for preventing rises in diet-related non-communicable disease. The objective was to test whether FOPLs helped Indian consumers identify “high-in” packaged foods and reduce intentions to purchase them. We conducted an in-person randomized experiment (n = 2869 adults between ages 18 and 60 years old) in six states of India in 2022. Participants were randomized to one of five FOPLs: a control label (barcode), warning label (octagon with “High in [nutrient]”), Health Star Rating (HSR), Guideline Daily Amount (GDA), or traffic light label. Participants then viewed a series of packaged foods high in sugar, saturated fat, or sodium with the assigned FOPL, and rated product perceptions and label reactions. Fewer than half of participants in the control group (39.1%) correctly identified all products high in nutrient(s) of concern. All FOPLs led to an increase in this outcome, with the biggest differences observed for the warning label (60.8%, p < 0.001), followed by the traffic light label (54.8%, p < 0.001), GDA (55.0%, p < 0.001), and HSR (45.0%, p < 0.01). While no FOPLs led to a reduction in intentions to purchase the packaged foods, the overall pattern of results suggested that warning labels are the most effective FOPL to help Indian consumers identify unhealthy foods.
... This is one example of the complex two-way nature of the interactions among consumers, food environments and the whole food system [13,14]. This widespread consumption of ultra-processed food products is particularly concerning since it has been associated with several adverse health outcomes, including overweight, obesity, increased cardio-metabolic risk, cancer, type II diabetes, cardiovascular diseases, irritable bowel syndrome, depression, frailty conditions and all-cause mortality [31,32]. Sweet pastries and confectionery were the most frequently purchased street foods, which is in line with their high popularity among Bosnians [33,34]. ...
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This study aimed to describe street food and takeaway food purchasing patterns in Sarajevo and Banja Luka, throughout the day and by city location. A cross-sectional evaluation of street food and takeaway food customers was conducted in 2017. All eligible vending sites (n = 348) in the vicinity of selected markets and bus stops were included. Data on the food items purchased, and time and geographic location of the purchases were collected. A total of 755 customers purchased 929 food items. Takeaway venues showed higher customer influx (5.0 vs. 2.0 customers observed per 10 min of observation, p < 0.001) and buying rates (6.7 vs. 2.0 items bought per 10 min of observation, p < 0.001; 1.5 vs. 1.0 items bought per customer, p < 0.001) than street food sites. These rates were higher in city peripheries for street food venues, and in city centres for takeaway establishments. The purchase of industrial food products prevailed throughout the day in street food venues, whereas most takeaway purchases comprised homemade foods, with or without industrial beverages. The proportion of customers buying foods and beverages together was higher in takeaway venues (15.3% vs. 6.0%, p < 0.001), especially during lunchtime and in city centres. In street food vending sites, sweet and savoury snacks seemed to be preferred in the afternoon, whereas in takeaway food establishments, savoury pastries and main dishes were mostly purchased at breakfast or lunch, and bread during the morning. Soft drinks and industrial juices were frequently purchased in both types of vending site and at all hours of the day, particularly in the afternoon. Our findings provide an overview of street food and takeaway food buying habits and consumer demands in these cities, reflecting local food culture and dietary behaviours. The identification of the meal contexts and city sub-regions in which specific purchasing practices emerge point to potential priority targets. These insights can be useful when designing interventions adapted to the specificities of these food environments and the food habits of customers.
... Our results are in line with the increasing availability and consumption of ultraprocessed foods and beverages that is happening in the region, arising from quick economic and technological development, as well as globalization, which have been transforming food systems in Asian LMIC (39,40). The consumption of ultra-processed foods and beverages have been increasingly recognized as a risk factor for a set of adverse health effects, including overweight, obesity, cancer, type II diabetes, cardiovascular diseases and allcause mortality (41,42), being also associated to lower dietary quality by providing excessive amounts of fat, sugar, and/or sodium in an energy-dense and nutrient-poor food matrix (43). This is particularly concerning since excess weight, as well as Values in bold represent statistically significant differences according to Pearson's Chi-squared test with a significance level of 0.05. ...
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Street food makes a significant contribution to the diet of many dwellers in low- and middle-income countries and its trade is a well-developed activity in the central Asian region. However, data on its purchase and nutritional value is still scarce. This study aimed to describe street food purchasing patterns in central Asia, according to time and place of purchase. A multicentre cross-sectional study was conducted in 2016/2017 in the main urban areas of four central Asian countries: Dushanbe (Tajikistan), Bishkek (Kyrgyzstan), Ashgabat (Turkmenistan) and Almaty (Kazakhstan). Street food markets (n = 34) and vending sites (n = 390) were selected by random and systematic sampling procedures. Data on the purchased foods and beverages were collected by direct observation. Time and geographic location of the purchases was registered, and their nutritional composition was estimated. A total of 714 customers, who bought 852 foods, were observed. Customers' influx, buying rate and purchase of industrial food were higher in city centers compared to the outskirts (median: 4.0 vs. 2.0 customers/10 min, p < 0.001; 5.0 vs. 2.0 food items/10 min, p < 0.001; 36.2 vs. 28.7%, p = 0.004). Tea, coffee, bread and savory pastries were most frequently purchased in the early morning, bread, main dishes and savory pastries during lunchtime, and industrial products in the mid-morning and mid-afternoon periods. Energy and macronutrient density was highest at 11:00–12:00 and lowest at 09:00–10:00. Purchases were smaller but more energy-dense in city centers, and higher in saturated and trans-fat in the peripheries. This work provides an overview of the street food buying habits in these cities, which in turn reflect local food culture. These findings from the main urban areas of four low- and middle-income countries which are currently under nutrition transition can be useful when designing public health interventions customized to the specificities of these food environments and their customers.
... Los estudios en Brasil, Colombia, Chile, México, EE.UU., Reino Unido, Canadá y Australia han demostrado que el aumento de la ingesta de ultraprocesados se asocia con dietas nutricionalmente desequilibradas 16,17,18,19,20,21,22,23,24,25 . Por lo que han sido propuestos como indicadores de la calidad de la alimentación 10 , y también se asociaron con sobrepeso y obesidad 26,27,28,29 , diabetes tipo 2 30 , hipertensión 31 , dislipemias, enfermedades coronarias, accidente cerebrovascular 32,33,34 , cáncer de mama 35 y otras enfermedades crónicas relacionadas con la alimentación 36,37 . Por todas estas razones, la evaluación de su consumo se ha convertido en una prioridad en la agenda de investigación de epidemiología nutricional. ...
Article
Growing evidence of the global transition in food systems exists, affecting the availability, accessibility, affordability, and convenience of highly processed foods. This study aimed to evaluate the apparent consumption of energy, saturated fat, added sugars, and sodium according to the degree of food processing in Argentina from 1996 to 2018 and according to income level. This is a descriptive and cross-sectional study with data on food and beverage expenditures and income from the National Household Expenditure Survey for years 1996-1997, 2004-2005, 2012-2013, and 2017-2018, including more than 20,000 households in each period. The apparent daily consumption of energy, saturated fat, added sugars, and sodium per adult for: (1) minimally processed foods; (2) processed culinary ingredients; (3) processed foods; and (4) ultra-processed products, was calculated for each period and according to per capita income quintile in each household. Descriptive statistical analysis was performed. Reductions in the proportion of energy and all nutrients evaluated from minimally processed foods, culinary ingredients and processed foods were observed, as well as an increase in the consumption of ultra-processed products. One also observes a greater share from ultra-processed foods as household income increases but with decreasing differences over time. Therefore, future strategies in Argentina should promote the consumption of minimally processed foods and discourage the availability and accessibility of ultra-processed ones, especially for the most vulnerable groups.
... Le système NOVA est de plus en plus utilisé pour explorer les relations entre la consommation d'aliments « ultratransformés » et la qualité du régime alimentaire ou les effets sur la santé [10]. En outre, les institutions inscrivent parfois NOVA dans leurs politiques de santé publique. ...
Article
Résumé La classification NOVA répartit les aliments en quatre groupes (de 1, peu transformé à 4, le plus transformé). Sa fiabilité et sa reproductibilité ont été très peu explorées alors qu’elle est très utilisée. Nous avons étudié la cohérence entre utilisateurs (environ 170 professionnels) de l’affectation de 120 aliments du commerce et 111 aliments génériques dans les groupes NOVA. La cohérence des affectations (κ de Fleiss) était de 0,32 (aliments du commerce) et 0,34 (aliments génériques). Des clusters d’aliments présentant des distributions d’affectations similaires ont été définis par classification hiérarchique. Parmi les aliments du commerce, un cluster réunissait 90 aliments très largement affectés à NOVA4 (91 % des affectations) et, parmi les aliments génériques, trois clusters contenaient des aliments principalement affectés à NOVA 1 (79 %), NOVA2 (75 %) et NOVA4 (70 %), respectivement. Les affectations étaient particulièrement hétérogènes pour 30 aliments du commerce et 28 aliments génériques (25 % du total dans les deux cas). Les critères actuels de la classification NOVA ne permettent pas d’affecter de manière non ambiguë un aliment à un groupe. Ce système doit être amélioré, en raison de son utilisation en recherche et dans les politiques publiques.
... Le système NOVA est de loin le plus utilisé [20]. Dans sa version actuelle, il propose de regrouper les aliments en quatre catégories [21]. ...
Article
Résumé La part des aliments transformés dans les régimes alimentaires n’a cessé de croître ces dernières décennies. Ils répondent aux attentes et besoins des modes de vie contemporains, et couvrent une grande part des besoins nutritionnels. Toutefois, de nombreuses études épidémiologiques ont pu identifier des liens entre la consommation d’aliments dits « ultra » ou « très » transformés et la santé. Ces études s’appuient sur des systèmes de classement des aliments selon leur niveau de transformation. Cet article s’appuie sur une analyse de la littérature et vise à présenter les différents systèmes de classement, ainsi que les limites de ces derniers Neuf classifications sont discutées et comparées. Si certaines sont décrites avec des règles plus précises, aucune de ces classifications ne s’appuie sur un réel algorithme et ne propose pas non plus de classement « officiel » que les utilisateurs pourraient utiliser comme « gold standard », expliquant pour partie le manque de robustesse de ces classifications. Par ailleurs, aucun consensus ne semble se dégager sur les facteurs déterminant le niveau de transformation d’un aliment, montrant le besoin d’un travail interdisciplinaire afin de proposer un système de classification robuste et universel des aliments selon leur niveau de transformation.
Article
Atherosclerotic cardiovascular disease (ASCVD) is epidemic throughout the world and is etiologic for such acute cardiovascular events as myocardial infarction, ischemic stroke, unstable angina, and death. ASCVD also impacts risk for dementia, chronic kidney disease peripheral arterial disease and mobility, impaired sexual response, and a host of other visceral impairments that adversely impact the quality and rate of progression of aging. The relationship between low-density lipoprotein cholesterol (LDL-C) and risk for ASCVD is one of the most highly established and investigated issues in the entirety of modern medicine. Elevated LDL-C is a necessary condition for atherogenesis induction. Basic scientific investigation, prospective longitudinal cohorts, and randomized clinical trials have all validated this association. Yet despite the enormous number of clinical trials which support the need for reducing the burden of atherogenic lipoprotein in blood, the percentage of high and very high-risk patients who achieve risk stratified LDL-C target reductions is low and has remained low for the last thirty years. Atherosclerosis is a preventable disease. As clinicians, the time has come for us to take primordial prevention more seriously. Despite a plethora of therapeutic approaches, the large majority of patients at risk for ASCVD are poorly or inadequately treated, leaving them vulnerable to disease progression, acute cardiovascular events, and poor aging due to loss of function in multiple visceral organs. Herein we discuss the need to greatly intensify efforts to reduce risk, decrease disease burden, and provide more comprehensive and earlier risk assessment to optimally prevent ASCVD and its complications. Evidence is presented to support that treatment should aim for far lower goals in cholesterol management, should take into account many more factors than commonly employed today and should begin significantly earlier in life.
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This study summarized the association between ultra-processed food (UPF) consumption and dental caries in children and adolescents through a systematic review and meta-analysis. The search of PubMed, Cochrane, Web of Science, and Scopus databases using the “PECOS” strategy retrieved 1,462 eligible articles. Only studies with humans aged ≤ 19 years old; that assessed groups of any UPF or specific UPF items; that measured dental caries as the decayed, filled, and missing surfaces or teeth indexes, based on the World Health Organization criteria; cross-sectional, case-control, cohort and all types of interventions that examined the adjusted association between UPF consumption and dental caries were included. All studies received qualitative evaluation. Meta-analysis using random-effects models combined multivariable-adjusted odd ratio (OR) for case-control and cross-sectional studies and risk ratio (RR) for longitudinal studies of the highest versus lowest category of UPF consumption. Forty-two studies were included in the qualitative synthesis and 27 in the meta-analysis. The pooled RR was 1.71 (95% CI 1.31-2.24), and the pooled OR was 1.55 (95% CI 1.37-1.75). The highest OR was found among participants who had dental caries prevalence >70% (OR=3.67, 95% CI 2.16; 6.23). Better evidence quality was found among cohort studies that evaluated children <6 years old. The findings suggest that higher UPF consumption is associated with greater dental caries in children and adolescents. Public health efforts to reduce UPF consumption are needed to improve the oral health of children and adolescents.
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Objectives To describe dietary sources of free sugars in different age groups of the UK population considering food groups classified according to the NOVA system and to estimate the proportion of excessive free sugars that could potentially be avoided by reducing consumption of their main sources. Design and setting Cross-sectional data from the UK National Diet and Nutrition Survey (2008–2014) were analysed. Food items collected using a 4-day food diary were classified according to the NOVA system. Participants 9364 individuals aged 1.5 years and above. Main outcome measures Average dietary content of free sugars and proportion of individuals consuming more than 10% of total energy from free sugars. Data analysis Poisson regression was used to estimate the associations between each of the NOVA food group and intake of free sugars. We estimated the per cent reduction in prevalence of excessive free sugar intake from eliminating ultra-processed foods and table sugar. Analyses were stratified by age group and adjusted for age, sex, ethnicity, survey year, region and equivalised household income (sterling pounds). Results Ultra-processed foods account for 56.8% of total energy intake and 64.7% of total free sugars in the UK diet. Free sugars represent 12.4% of total energy intake, and 61.3% of the sample exceeded the recommended limit of 10% energy from free sugars. This percentage was higher among children (74.9%) and adolescents (82.9%). Prevalence of excessive free sugar intake increased linearly across quintiles of ultra-processed food consumption for all age groups, except among the elderly. Eliminating ultra-processed foods could potentially reduce the prevalence of excessive free sugar intake by 47%. Conclusion Our findings suggest that actions to reduce the ultra-processed food consumption generally rich in free sugars could lead to substantial public health benefits.
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Objective: To assess the prospective association between ultra-processed food consumption and all-cause mortality and to examine the effect of theoretical iso-caloric non-processed foods substitution. Patients and methods: A population-based cohort of 11,898 individuals (mean age 46.9 years, and 50.5% women) were selected from the ENRICA study, a representative sample of the noninstitutionalized Spanish population. Dietary information was collected by a validated computer-based dietary history and categorized according to their degree of processing using NOVA classification. Total mortality was obtained from the National Death Index. Follow-up lasted from baseline (2008-2010) to mortality date or December 31th, 2016, whichever was first. The association between quartiles of consumption of ultra-processed food and mortality was analyzed by Cox models adjusted for the main confounders. Restricted cubic-splines were used to assess dose-response relationships when using iso-caloric substitutions. Results: Average consumption of ultra-processed food was 385 g/d (24.4% of the total energy intake). After a mean follow-up of 7.7 years (93,599 person-years), 440 deaths occurred. The hazard ratio (and 95% CI) for mortality in the highest versus the lowest quartile of ultra-processed food consumption was 1.44 (95% CI, 1.01-2.07; P trend=.03) in percent of energy and 1.46 (95% CI, 1.04-2.05; P trend=.03) in grams per day per kilogram. Isocaloric substitution of ultra-processed food with unprocessed or minimally processed foods was associated with a significant nonlinear decrease in mortality. Conclusion: A higher consumption of ultra-processed food was associated with higher mortality in the general population. Furthermore, the theoretical iso-caloric substitution ultra-processed food by unprocessed or minimally processed foods would suppose a reduction of the mortality risk. If confirmed, these findings support the necessity of the development of new nutritional policies and guides at the national and international level. Trial registration: clinicaltrials.gov Identifier: NCT01133093.
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Background: Studying dietary patterns may provide insights into the potential effects of red and processed meat on health outcomes. Purpose: To evaluate the effect of dietary patterns, including different amounts of red or processed meat, on all-cause mortality, cardiometabolic outcomes, and cancer incidence and mortality. Data Sources: Systematic search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and ProQuest Dissertations & Theses Global from inception to April 2019 with no restrictions on year or language. Study Selection: Teams of 2 reviewers independently screened search results and included prospective cohort studies with 1000 or more participants that reported on the association between dietary patterns and health outcomes. Data Extraction: Two reviewers independently extracted data, assessed risk of bias, and evaluated the certainty of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. Data Synthesis: Eligible studies that followed patients for 2 to 34 years revealed low- to very-low-certainty evidence that dietary patterns lower in red and processed meat intake result in very small or possibly small decreases in all-cause mortality, cancer mortality and incidence, cardiovascular mortality, nonfatal coronary heart disease, fatal and nonfatal myocardial infarction, and type 2 diabetes. For all-cause, cancer, and cardiovascular mortality and incidence of some types of cancer, the total sample included more than 400 000 patients; for other outcomes, total samples included 4000 to more than 300 000 patients. Limitation: Observational studies are prone to residual confounding, and these studies provide low- or very-low-certainty evidence according to the GRADE criteria. Conclusion: Low- or very-low-certainty evidence suggests that dietary patterns with less red and processed meat intake may result in very small reductions in adverse cardiometabolic and cancer outcomes.
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Objective This study aimed to describe the consumption of ultra-processed foods in Australia and its association with the intake of nutrients linked to non-communicable diseases (NCDs). Design Cross-sectional study. Setting National Nutrition and Physical Activity Survey (2011-2012). Participants 12,153 participants aged 2+ years. Main outcome measures Average dietary content of nutrients linked to NCDs and the prevalence of intake outside levels recommended for the prevention of NCDs. Data analysis Food items were classified according to the NOVA system, a classification based on the nature, extent and purpose of industrial food processing. The contribution of each NOVA food group and their subgroups to total energy intake was calculated. Mean nutrient content of ultra-processed food and non-ultra-processed food fractions of the diet were compared. Across quintiles of the energy contribution of ultra-processed foods, differences in the intake of nutrients linked to NCDs as well as in the prevalence of intakes outside levels recommended for the prevention of NCDs were examined. Results Ultra-processed foods had the highest dietary contribution (42.0% of energy intake), followed by unprocessed or minimally processed foods (35.4%), processed foods (15.8%) and processed culinary ingredients (6.8%). A positive and statistically significant linear trend was found between quintiles of ultra-processed food consumption and intake levels of free sugars (standardised β 0.43, p<0.001); total (β 0.08, p<0.001), saturated (β 0.18, p<0.001) and trans fats (β 0.10, p<0.001); sodium (β 0.21, p<0.001) and diet energy density (β 0.41, p<0.001), while an inverse relationship was observed for dietary fibre (β -0.21, p<0.001) and potassium (β -0.27, p<0.001). The prevalence of non-recommended intake levels of all studied nutrients increased linearly across quintiles of ultra-processed food intake, notably from 22% to 82% for free sugars, from 6% to 11% for trans fat and from 2% to 25% for dietary energy density, from the lowest to the highest ultra-processed food quintile. Conclusion The high energy contribution of ultra-processed foods impacted negatively on the intake of non-ultra-processed foods and on all nutrients linked to NCDs in Australia. Decreasing the dietary share of ultra-processed foods would substantially improve the diet quality in the country and help the population achieve recommendations on critical nutrients linked to NCDs.
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Background: There may be a direct association between consumption of ultra-processed foods and C-reactive protein (CRP) levels, under the assumption that the high glycemic index of these food products could stimulate the entire chronic inflammation cascade, along with an indirect association mediated by obesity. The types of food consumed, including ultra-processed products, strongly influence obesity, and are also associated with higher serum CRP levels. Objective: Our aim was to investigate whether the caloric contribution of ultra-processed foods to diet is associated with CRP levels, independent of body mass index (BMI). Design and setting: Cross-sectional analysis on the Longitudinal Study of Adult Health (ELSA-Brasil) baseline cohort (2008-2010). Methods: Dietary information, obtained through a food frequency questionnaire, was used to estimate the percentage of energy contribution from ultra-processed food to individuals' total caloric intake. CRP levels were the response variable. Sex-specific associations were estimated using generalized linear models with gamma distribution and log-link function. Results: Ultra-processed food accounted for 20% of total energy intake. Among men, after adjustments for sociodemographic characteristics, there was no association between ultra-processed food intake and CRP levels. Among women, after adjustment for sociodemographic characteristics, smoking and physical activity, the highest tercile of ultra-processed food intake was associated with mean CRP levels that were 14% higher (95% confidence interval: 1.04-1.24) than those of the lowest tercile. However, after considering BMI, this association lost statistical significance. Conclusion: Our findings suggest that the positive association of ultra-processed food consumption with CRP levels among women seems to be mediated by the presence of adiposity.
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Background: Ultra-processed foods are highly palatable and can be consumed anywhere at any time, but typically have a poor nutritional profile. Therefore, their contribution to total energy intake has been proposed as an indicator for studying overall dietary quality. Objective: The aim of this study was to investigate the associations between the energy contribution from ultra-processed foods and the intake of nutrients related to chronic non-communicable diseases in Mexico. Design: This study used a secondary analysis of cross-sectional data from the 2012 Mexican National Health and Nutrition Survey. Participants/setting: This study included participants aged 1 year and older (n=10,087) who had completed a 1-day 24-hour recall. Main outcome measures: Intake from added sugar (% kcal), total fat (% kcal), saturated fat (% kcal), protein (% kcal), dietary fiber (g/1,000 kcal), and dietary energy density (kcal/g) were measured. Statistical analysis: Multiple linear regression models adjusted for sociodemographic variables were fitted to assess the association between quintiles of energy contribution from ultra-processed foods and nutrient intake. Results: Mean reported energy contribution from ultra-processed foods to the Mexican population's diet ranged from 4.5% kcal in quintile 1 (Q1) to 64.2% kcal in quintile 5 (Q5). An increased energy contribution from ultra-processed foods was positively associated with intake from added sugar (Q1: 7.4% kcal; Q5: 17.5% kcal), total fat (Q1: 30.6% kcal; Q5: 33.5% kcal) and saturated fat (Q1: 9.3% kcal; Q5: 13.2% kcal), as well as dietary energy density (Q1: 1.4 kcal/g; Q5: 2.0 kcal/g) (P≤0.001); and inversely associated with intake from protein (Q1: 15.1% kcal; Q5: 11.9% kcal) and dietary fiber (Q1: 16.0 g/1,000 kcal; Q5: 8.4 g/1,000 kcal) (P≤0.001). Conclusions: In the Mexican population, an increased energy contribution from ultra-processed foods was associated with a lower dietary quality with regard to intake of nutrients related to chronic non-communicable diseases. Future research is needed to identify barriers to eating a variety of unprocessed and minimally processed foods for the Mexican population, as well as effective public health strategies and policies to overcome these barriers.
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Objective To assess the prospective associations between consumption of ultra-processed foods and risk of cardiovascular diseases. Design Population based cohort study. Setting NutriNet-Santé cohort, France 2009-18. Participants 105 159 participants aged at least 18 years. Dietary intakes were collected using repeated 24 hour dietary records (5.7 for each participant on average), designed to register participants’ usual consumption of 3300 food items. These foods were categorised using the NOVA classification according to degree of processing. Main outcome measures Associations between intake of ultra-processed food and overall risk of cardiovascular, coronary heart, and cerebrovascular diseases assessed by multivariable Cox proportional hazard models adjusted for known risk factors. Results During a median follow-up of 5.2 years, intake of ultra-processed food was associated with a higher risk of overall cardiovascular disease (1409 cases; hazard ratio for an absolute increment of 10 in the percentage of ultra-processed foods in the diet 1.12 (95% confidence interval 1.05 to 1.20); P<0.001, 518 208 person years, incidence rates in high consumers of ultra-processed foods (fourth quarter) 277 per 100 000 person years, and in low consumers (first quarter) 242 per 100 000 person years), coronary heart disease risk (665 cases; hazard ratio 1.13 (1.02 to 1.24); P=0.02, 520 319 person years, incidence rates 124 and 109 per 100 000 person years, in the high and low consumers, respectively), and cerebrovascular disease risk (829 cases; hazard ratio 1.11 (1.01 to 1.21); P=0.02, 520 023 person years, incidence rates 163 and 144 per 100 000 person years, in high and low consumers, respectively). These results remained statistically significant after adjustment for several markers of the nutritional quality of the diet (saturated fatty acids, sodium and sugar intakes, dietary fibre, or a healthy dietary pattern derived by principal component analysis) and after a large range of sensitivity analyses. Conclusions In this large observational prospective study, higher consumption of ultra-processed foods was associated with higher risks of cardiovascular, coronary heart, and cerebrovascular diseases. These results need to be confirmed in other populations and settings, and causality remains to be established. Various factors in processing, such as nutritional composition of the final product, additives, contact materials, and neoformed contaminants might play a role in these associations, and further studies are needed to understand better the relative contributions. Meanwhile, public health authorities in several countries have recently started to promote unprocessed or minimally processed foods and to recommend limiting the consumption of ultra-processed foods. Study registration ClinicalTrials.gov NCT03335644 .
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Objective: To evaluate the association between consumption of ultra-processed foods and all cause mortality. Design: Prospective cohort study. Setting: Seguimiento Universidad de Navarra (SUN) cohort of university graduates, Spain 1999-2018. Participants: 19 899 participants (12 113 women and 7786 men) aged 20-91 years followed-up every two years between December 1999 and February 2014 for food and drink consumption, classified according to the degree of processing by the NOVA classification, and evaluated through a validated 136 item food frequency questionnaire. Main outcome measure: Association between consumption of energy adjusted ultra-processed foods categorised into quarters (low, low-medium, medium-high, and high consumption) and all cause mortality, using multivariable Cox proportional hazard models. Results: 335 deaths occurred during 200 432 persons years of follow-up. Participants in the highest quarter (high consumption) of ultra-processed foods consumption had a higher hazard for all cause mortality compared with those in the lowest quarter (multivariable adjusted hazard ratio 1.62, 95% confidence interval 1.13 to 2.33) with a significant dose-response relation (P for linear trend=0.005). For each additional serving of ultra-processed foods, all cause mortality relatively increased by 18% (adjusted hazard ratio 1.18, 95% confidence interval 1.05 to 1.33). Conclusions: A higher consumption of ultra-processed foods (>4 servings daily) was independently associated with a 62% relatively increased hazard for all cause mortality. For each additional serving of ultra-processed food, all cause mortality increased by 18%.