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Abstract

Ultra-processed foods (UPFs) are characterized by the presence of markers of ultra-processing (MUP), either additives (A-MUP) or non-additive ingredients (NA-MUP). The present study aims to characterize the MUP profile of approximately 22,000 UPFs, representative of assortments in French supermarkets. UPFs were ranked according to Siga classification within five UPF technological groups, from C01 to C3, depending on the nature and number of MUPs (MUP1 and MUP2), presence of risk-associated additives, and contents of salt, sugar and/or fat. Then, UPFs were categorized within 10 food categories. The results showed that UPFs contain more NA-MUPs than A-MUPs, on average 1.3 more by UPF. The main MUPs are NA-MUPs, i.e., refined oils (52.5 % of UPFs), extracts and natural aromas (42.7 %), synthetic aromas (26.5 %), glucose syrup (20.0 %), native starches (19.1 %), and dextrose (16.2 %). The NA-MUP/UPF and A-MUP/UPF ratios were not correlated in the 10 food categories. Among UPFs, 19 % contained only one MUP, and 31 % contained more than five MUPs. In conclusion, additives are not a sufficient marker of ultra-processing. It is proposed that NA-MUPs in UPFs should be taken into greater consideration and that foods be scored with indices based on the degree of processing, not compositional scores, which fail to filter MUPs.

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... According to a report by the European Commission, 64% of online advertisements and 75% of TV spots for food and beverages shown to children in Europe in 2017-2019 were for HFSS foods [14]. In France, 70.0% of products advertised on TV to 4-to 12-year-olds in 2018 should not be shown to children according to the criteria of the WHO Europe Nutrient Profile Model [15] and 53.3% were classified Nutri-Score groups D and E [11,16]. Moreover, advertisements targeting children mainly promote ultra-processed foods (UPFs) according to observations made around schools [17][18][19] and children's TV shows (98.9% of spots for UPFs in Argentina [20]). ...
... Characterised by the NOVA classification, our sample (n = 1155) is mainly made up of ultra-processed products (87.97%; n = 1016), and although it does not reflect a child's total diet, it suggests a strong trend in food products marketed to children, with no less than 12 categories made up entirely of UPFs. Past studies on packaging (which were not focused on children's products) found lower percentages of UPFs: 83% in supermarkets in New Zealand [66], 71% in the United States (for n = 230,156 foods and beverages) [67], 64.64% in France based on the collaborative database Open Food Facts [68], 67% [69] and 69% [70] using the SIGA method, which suggests that products marketed to children are highly ultra-processed. UPF markers are different for SIGA and NOVA (e.g., SIGA includes refined oils), but the two classifications nevertheless allow for a relevant comparison. ...
... As in our sample, UPFs have longer lists of ingredients: 13.2 components vs. 3.7 in minimally process/unprocessed foods [69], and 15.2 vs. 3.29 in NOVA group 1 and 5.89 in NOVA group 3 in our sample. The number of additives is also significantly higher in UPFs, as found in previous works [69,70]. The main UPF markers are not additives but flavourings, glucose syrup, and starch. ...
Article
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Food packaging marketing techniques which appeal to children (such as cartoon characters and brand mascots) affect children’s choices, preferences, and eating habits. Several studies have assessed the nutritional quality of food intended to children in various countries and concluded that most were high in fat, salt, and sugar (HFSS) and ultra-processed foods. The aim of this study is to analyse products intended for children over the age of 3 (foods and beverages with relevant marketing elements on the packaging) available on the French market as regards: (1) nutritional quality, based on the Nutri-Score labelling system, (2) compliance with expected nutritional profile suitable for children, according to the criteria of the WHO Europe Nutrient Profile Model, and (3) degree of processing, as defined by the NOVA classification, from packaging collected in 20 stores (hyper/supermarkets, hard-discount retail chains, and organic food stores). The marketing strategies most often used on children’s products are cartoons (97.22%; n = 1120) and mascots (77.78%; n = 896). A total of 1155 products were included in the study, most of which were sugary foods: almost a quarter of the products in the sample (23.81%; n = 275) list a sweetener as the first ingredient, and most of them (89.52%; n = 1034) contain free sugars according to the WHO definition. All the products included in our study feature marketing elements targeting on the packaging, yet 94.88% do not meet the criteria of the WHO Europe Nutrient Profile Model. Most (58.68%; n = 676) belong to Nutri-Score groups D and E, with the highest proportion in group D (39.32%; n = 453) and are ultra-processed (87.97%; n = 1016), especially through the use of flavourings and ultra-processed sugars. Using the Nutri-Score, the WHO Europe Nutrient Profile Model, and the NOVA classification, this study suggests that a significant share of pre-packaged foods marketed to children do not have an adequate nutritional profile. As such, measures are needed to regulate what marketing elements aimed at children can be included on packaging, based on these criteria.
... The Siga FP classification was formed to improve the NOVA framework. The Siga index classifies foods using the cumulative effect of a few factors such as the quantity, nature, function and degree of processing, and risk assessment of additives (sugar, salt, and fat addition) based on the scientific opinions of health agencies such as the WHO AND EFSA and the effect of these additives on the nutrient thresholds of food (27,28). The Siga framework considered the degree of transformation of the ingredients and the loss of the "matrix" effect to achieve an even more holistic and realistic classification. ...
... According to the Siga framework, UPFs are either balanced (C01), greedy (C02), or processed to limit (C1, C2, C3). It is advised that the latter be avoided or reduced to occasional indulgence due to at-risk additives, which could be harmful to human health (28). However, some preservatives play a significant role in the promotion of food safety of food by preventing the growth of molds and bacteria. ...
... There are several disadvantages of consuming some UPFs that are related to human health, such as obesity, hypertension, cardiovascular diseases, dyslipidaemia, metabolic syndrome, gastrointestinal disorders, breast cancer, depression, and allcauses high death rate (14,21,28). ...
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With increasing advocacy for plant food consumption, the sub-Saharan Africa landscape is home to diverse plant-based food commodities. The need to leverage the advantages of unprocessed/minimally processed foods (PFs) over ultra-processed foods (UPFs) is a system that requires exploitation. Most of the crops produced in the continent are either classified as traditionally or moderately PFs. However, the rise in industrialization and formalization of markets is impacting and marginalizing traditional food processing (FP). Current FP classification frameworks are briefly discussed. The level of processing of cereals, grains, fruits, vegetables, roots, and tuber crops in the continent requires intervention from nutritionists, food scientists, and scientific and governmental bodies to gain a holistic view and tackle the issue of food insecurity in Africa. This study reviews the levels of processing of African foods, challenges, and future directions.
... First, beyond only nutrients, foods are interlinked with cultural identity while playing a key role in many local economies, as highlighted by Dembska et al. [18] in their double pyramids models connecting food culture, health, and climate. These authors and others [18,[57][58][59][60][61] call attention to the need of leveraging the various dimensions of foods, which are closely related, under the so-called one-health approach [18,57]. ...
... For example, the newly developed Siga score [59] is hierarchically combined with the first degree of processing, then the food matrix effect, added salt, fat, and/or sugar, and the number of markers of ultra-processing (including some cosmetic additives and non-additive markers) [60]. To be elaborated, this score typically needs not only the food composition data, but also the list of ingredients and the presence or not of added sugar, salt, and/or fat. ...
... To be elaborated, this score typically needs not only the food composition data, but also the list of ingredients and the presence or not of added sugar, salt, and/or fat. Such a hierarchical and holistic score should be more considered, because, in the end, it is related to global (environmental and human) health [18,57,60,61]; whereas, food composition only is insufficient to address diets from the global or one-health perspective as needed (e.g., compliance with European Climate Law). ...
Article
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Food provides humans with more than just energy and nutrients addressing both vital needs and pleasure. Food habits are determined by a wide range of factors, from sensorial stimuli to beliefs, and once commanded by local and seasonal availability, are nowadays driven by mar-keting campaigns promoting unhealthy and non-sustainable foodstuffs. Top-down and bottom-up changes are transforming food systems, driven by policies on SDGs and by consumer’s con-cerns about environmental and health impacts. Food quality, in terms of taste, safety and nutri-tional value are determined by its composition, described in food composition databases (FDB). FDB are then useful resources to agronomists, food and mechanical engineers, nutritionists, marketers and others in their efforts to address at maximum human nutrient needs. In this work we analyse some relevant food composition databases (viz. purpose, type of data, ease of access, regularity of updates), inspecting information on the health and environmental nexus, as food origin, production mode as well as nutritional quality. The usefulness and limitations of food databases are discussed in what concerns sustainable diets, food “matrix effect”, missing com-pounds, safe processing and in guiding innovation in foods, as well as in shaping consumers’ perceptions and food choices.
... Compared to conventional UPFs, organic UPFs should therefore be less numerous in sales, notably because their manufacture is restricted to 48 additives among the more than 340 authorised in conventional food production at the European level (EUR-Lex 2008). In effect, numerous additives are markers of ultra-processing (A-MUPs), but there are also many nonadditive ingredient markers of ultra-processing (NA-MUPs; Davidou et al. 2021) that are not restricted to organic foods, e.g. protein and fibre isolates, glucose syrup, dextrose and refined oils. Organic foods may also be potentially subjected to drastic processes such as extrusion-cooking or puffing and are then also considered MUPs (Monteiro et al. 2019;Davidou et al. 2020). ...
... In a recent study, we showed that NA-MUPs are more characteristic of ultra-processing than A-MUPs and that the main MUPs in conventional foods are refined oils, aromas, glucose syrup, native starches and dextrose, each of which is present in more than 15% of conventional UPFs (Davidou et al. 2021). More particularly, dextrose, glucose syrup and synthetic aromas strongly cooccur in conventional UPFs (Davidou et al. 2021). ...
... In a recent study, we showed that NA-MUPs are more characteristic of ultra-processing than A-MUPs and that the main MUPs in conventional foods are refined oils, aromas, glucose syrup, native starches and dextrose, each of which is present in more than 15% of conventional UPFs (Davidou et al. 2021). More particularly, dextrose, glucose syrup and synthetic aromas strongly cooccur in conventional UPFs (Davidou et al. 2021). Therefore, it is highly likely that such NA-MUPs are also present in organic UPFs. ...
Article
In France, around 70% of conventional industrial foods are ultra-processed, with no data for organic foods. The objectives of this study were to evaluate the percentage of ultra-processed foods (UPFs) in industrially packaged organic (n = 8,554) and conventional (n = 45,791) foods, and to describe their marker of ultra-processing (MUP) profiles. The percentage of UPFs and MUP profiles were determined with the Siga methodology. UPF percentages were 53% in organic foods and 74% in conventional foods, and there was 8% more organic UPFs in conventional stores than in organic stores. The more additive MUPs are used, the greater the quantity of nonadditive MUPs. Conventional UPFs contained twice as many total MUPs as organic UPFs. Main MUPs in organic UPFs were refined oils, extracts and natural aromas, native starches, glucose syrup, lecithins, and citric acid. Organic foods are therefore overall less ultra-processed although still containing high levels of nonadditive MUPs.
... Il a été développé par une société privée et est basé sur un modèle d'affaire incluant des accès payants à l'utilisation de ce système de classification. Présenté dans un premier article en 2018, il propose, en partant de la classification NOVA, de mieux prendre en compte la nature, la quantité, la fonction et le degré de transformation de chaque ingrédient et/ou des additifs entrant dans la formulation des aliments, ainsi que les niveaux de perte de la structure et de la composition (effet « matrice ») de la matière agricole brute mise en oeuvre [27,28]. Le système SIGA s'appuie sur la caractérisation des ingrédients industriels appelés « marqueurs d'ultra-transformation » (MUT) sur la base de connaissances techniques et réglementaires qui semblent sensiblement différentes de celles proposées dans le système NOVA et qui mériteraient d'être précisées. ...
... Le système SIGA s'appuie sur la caractérisation des ingrédients industriels appelés « marqueurs d'ultra-transformation » (MUT) sur la base de connaissances techniques et réglementaires qui semblent sensiblement différentes de celles proposées dans le système NOVA et qui mériteraient d'être précisées. Les MUTs identifiés comme les plus utilisés dans le groupe des aliments ultra-transformés, sont les huiles raffinées, les arômes naturels, les sucres hydrolysés, les arômes de synthèse et les amidons [28]. Par ailleurs, ce système intègre également les teneurs en sel, sucre et matière grasse des aliments en utilisant les seuils nutritionnels moyens proposés par la Food Standards Agency (FSA [UK]) et en divisant les groupes en sous catégories en fonction de leur niveau (audessus ou en-dessous) de ces seuils. ...
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.
... hydrogenation. Therefore, isolated purified and synthetic MUPs are compounds without matrix [150]. Therefore, in NOVA 1-3 enough of the food matrix is retained, e.g. after grinding, to benefit from the myriad molecules present in combination in these foods. ...
Article
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Purpose For decades, it has been customary to relate human health to the nutritional composition of foods, and from there was born food composition databases, composition labelling scores and the recommendation to eat varied foods. However, individuals can fully address their nutritional needs and become chronically ill. The nutrient balance of a food is only a small part of its overall health potential. In this paper, we discussed the proof of concept that the increased risk of chronic diseases worldwide is primarily associated with the degradation and artificialization of food matrices, rather than only their nutrient contents, based on the assumption that “food matrices govern the metabolic fate of nutrients”. Methods An empirico-inductive proof of concept research design has been used, based on scientific data linking the degree of food processing, food matrices and human health, notably on the glycaemic index, nutrient bioavailability, satiety potential, and synergistic effects. Results We postulate that if the nutrient content is insufficient to fully characterize the diet-global health relationship, one other dimensions is necessary, i.e., the food matrix through the degree of processing. Both matrix and nutrient composition dimensions have been included under the new concept of the 3V index for Real (Vrai), Vegetal (Végétal), and Varied (Varié) foods. The Real metric, reflecting the integrity of the initial food matrix, is the most important, followed by the Vegetal (nutrient origin) and the Varied (“composition” effect) metrics. Conclusion Concerning their effects on health, food matrix comes first, and then nutrient composition, and calorie quality matters more than calorie quantity.
... Knowing the existing evidence of the negative effect that the consumption of ultra-processed foods has on the different aspects of health [26,36,47] and the WHO recommendations to reduce the consumption of this type of food as much as possible, the front-of-pack labelling with Nutri-Score should at least be accompanied by other complementary labelling indicating the level of processing. Several tools are now available that focus on food processing [48], such as the SIGA classification [44,49], which classifies foods based on the NOVA classification and degree of processing, in addition to other factors. The application of these classifications in a label would allow consumers to know that they are choosing an ultra-processed food, and once the consumer knows this information, they could interpret the nutritional quality of the product through the Nutri-Score. ...
Article
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Front-of-pack labels can improve the ability of consumers to identify which foods are healthier, making them a useful public health tool. Nutri-Score is a front-of-pack labelling system adopted by several European countries. This system ranks foods according to their nutritional quality, but does not consider other dimensions such as the degree of food processing. The aim of this study is to compare the nutritional quality (as assessed by Nutri-Score) and the ultra-processing (as assessed by the NOVA classification) of foods in the Open Food Facts database. A simple correspondence analysis was carried out to study the relationship between the two systems. Ultra-processed foods (NOVA 4) were found in all Nutri-Score categories, ranging from 26.08% in nutritional category A, 51.48% in category B, 59.09% in category C, 67.39% in category D to up to 83.69% in nutritional category E. Given the negative effect that the consumption of ultra-processed foods has on different aspects of health, front-of-pack labelling with Nutri-Score should at least be accompanied by complementary labelling indicating the level of processing, such as the NOVA classification.
... Yet, many previously unclassified foods are often inside the phase space, indicating that they lack a dominating probability, hence the assignment of a single NOVA class is somewhat arbitrary ( Figure 2B). The detection of this ambiguity is a strength of FoodProX, reflecting the observation that a four-class classification does not accurately capture the nutrient variability characterized by different food processing methods and intensities [33]. For example, while the classifier confidently assigns "Raw Onion" to NOVA 1 (p 1 = 0.9651), and "Onion rings ...
Article
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The dietary and health impacts of ultra-processed foods can be understood across the nutri-biochemical, food and dietary pattern levels. Each level reveals distinct dimensions and characteristics that can inform our scientific analysis and policy responses accordingly.
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This systematic review and meta‐analysis investigated the association between consumption of ultraprocessed food and noncommunicable disease risk, morbidity and mortality. Forty‐three observational studies were included (N = 891,723): 21 cross‐sectional, 19 prospective, two case‐control and one conducted both a prospective and cross‐sectional analysis. Meta‐analysis demonstrated consumption of ultraprocessed food was associated with increased risk of overweight (odds ratio: 1.36; 95% confidence interval [CI], 1.23‐1.51; P < 0.001), obesity (odds ratio: 1.51; 95% CI, 1.34‐1.70; P < 0.001), abdominal obesity (odds ratio: 1.49; 95% CI, 1.34‐1.66; P < 0.0001), all‐cause mortality (hazard ratio: 1.28; 95% CI, 1.11‐1.48; P = 0.001), metabolic syndrome (odds ratio: 1.81; 95% CI, 1.12‐2.93; P = 0.015) and depression in adults (hazard ratio: 1.22; 95% CI, 1.16‐1.28, P < 0.001) as well as wheezing (odds ratio: 1.40; 95% CI, 1.27‐1.55; P < 0.001) but not asthma in adolescents (odds ratio: 1.20; 95% CI, 0.99‐1.46; P = 0.065). In addition, consumption of ultraprocessed food was associated with cardiometabolic diseases, frailty, irritable bowel syndrome, functional dyspepsia and cancer (breast and overall) in adults while also being associated with metabolic syndrome in adolescents and dyslipidaemia in children. Although links between ultraprocessed food consumption and some intermediate risk factors in adults were also highlighted, further studies are required to more clearly define associations in children and adolescents. Study registration Prospero ID: CRD42020176752.
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Increasing evidence suggests that high consumption of ultra-processed foods (UPF) is associated with an increase in non-communicable diseases , overweight and obesity. The present study systematically reviewed all observational studies that investigated the association between UPF consumption and health status. A comprehensive search of MEDLINE, Embase, Scopus, Web of Science and Google Scholar was conducted, and reference lists of included articles were checked. Only cross-sectional and prospective cohort studies were included. At the end of the selection process, twenty-three studies (ten cross-sectional and thirteen prospective cohort studies) were included in the systematic review. As regards the cross-sectional studies, the highest UPF consumption was associated with a significant increase in the risk of overweight/obesity (þ39 %), high waist circumference (þ39 %), low HDL-cholesterol levels (þ102 %) and the metabolic syndrome (þ79 %), while no significant associations with hypertension, hyperglycaemia or hypertriacylglycerolaemia were observed. For prospective cohort studies evaluating a total population of 183 491 participants followed for a period ranging from 3·5 to 19 years, highest UPF consumption was found to be associated with increased risk of all-cause mortality in five studies (risk ratio (RR) 1·25, 95 % CI 1·14, 1·37; P < 0·00001), increased risk of CVD in three studies (RR 1·29, 95 % CI 1·12, 1·48; P = 0·0003), cerebrovascular disease in two studies (RR 1·34, 95 % CI 1·07, 1·68; P = 0·01) and depression in two studies (RR 1·20, 95 % CI 1·03, 1·40; P = 0·02). In conclusion, increased UPF consumption was associated, although in a limited number of studies, with a worse cardiometabolic risk profile and a higher risk of CVD, cerebrovascular disease, depression and all-cause mortality.
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We examined the association between the consumption of ultra-processed foods and adiposity in a nationally representative sample of the UK adult population. We studied 6,143 participants (19 to 96 years, 51.6% female) sampled by the UK National Diet and Nutrition Survey (2008–16). Food items reported in four-day food diary were classified according to the NOVA system. Multiple linear and logistic regressions were used to evaluate associations between the dietary contribution of ultra-processed foods (sex-specific quartile and continuous) and Body Mass Index (BMI), Waist Circumference (WC) and obesity (BMI>30kg/m²) and abdominal obesity (men: WC≥102cm, women: WC≥88cm) status. Models were adjusted for sociodemographic and lifestyle characteristics. In multivariable analyses, the highest consumption of ultra-processed food was associated with 1.66 kg/m² higher BMI (95%CI 0.96–2.36), 3.56 cm greater WC (95%CI 1.79–5.33) and 90% higher odds for being obese (OR = 1.90, 95%CI 1.39–2.61), compared with the lowest consumption. A 10% increase in the consumption of ultra-processed foods was associated with an increase of 0.38 kg/m² in BMI (95%CI 0.20–0.55), 0.87 cm in WC (95%CI 0.40–1.33) and 18% higher odds of being obese (OR = 1.18, 95%CI 1.08–1.28). The consumption of ultra-processed food was associated with an increase in BMI, WC and prevalence of obesity in both sexes. A dose response relationship was observed in both sexes, with a 10% increase in the consumption of ultra-processed foods being associated with a 18% increase in the prevalence of obesity in men and a 17% increase in women. Higher consumption of ultra-processed food is associated with greater adiposity in the UK adult population. Policy makers should consider actions that promote consumption of unprocessed or minimally processed foods and reduce consumption of ultra-processed foods.
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Background: More than 330 food additives (e.g. artificial sweeteners, emulsifiers, dyes) are authorized in Europe, with a great variability of use across food products. Objective: The objective of this study was to investigate the distribution and co-occurrence of food additives in a large-scale database of foods and beverages available on the French market. Design: The open access crowdsourced Open Food Facts database (https://world.openfoodfacts.org/) was used to retrieve the composition of food and beverage products commonly marketed on the French market (n = 126,556), based on the ingredients list. Clustering of food additive variables was used in order to determine groups of additives frequently co-occurring in food products. The clusters were confirmed by network analysis, using the eLasso method. Results: Fifty-three-point eight percent of food products contained at least 1 food additive and 11.3% at least 5. Food categories most likely to contain food additives (in more than 85% of food items) were artificially sweetened beverages, ice creams, industrial sandwiches, biscuits and cakes. The most frequently used food additives were citric acid, lecithins and modified starches (>10,000 products each). Some food additives with suspected health effects also pertained to the top 50: sodium nitrite, potassium nitrate, carrageenan, monosodium glutamate, sulfite ammonia caramel, acesulfame K, sucralose, (di/tri/poly) phosphates, mono- and diglycerides of fatty acids, potassium sorbate, cochineal, potassium metabisulphite, sodium alginate, and bixin (>800 food products each). We identified 6 clusters of food additives frequently co-occurring in food products. Conclusions: Food additives are widespread in industrial French products and some clusters of additives frequently co-occurring in food products were identified. These results pave the way to future etiological studies merging composition data to food consumption data to investigate their association with chronic disease risk, in particular potential 'cocktail effects'.
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The qualitative NOVA classification of foods according to their degree of processing is widely used worldwide by researchers. NOVA defines ultra-processed foods (UPFs) by the presence of processed industrial and cosmetic ingredients and additives to modify the sensory properties (aroma, taste, colour and texture) of the reconstituted food. Some drastic processes directly applied to food are also markers of ultra-processing. However, in the intent to develop an elaborated tool for industries and retailers, the Siga classification was developed by combining the four holistic NOVA groups with four new more reductionist subgroups considering the impact of processing on the food/ingredient matrix; the contents of added salt, sugar and fat; the nature and number of markers of ultra-processing (MUPs); and the levels of at-risk additives for health (groups are unprocessed, A0; minimally processed foods, A1; culinary ingredients, A2; balanced, B1/C0.1; greedy, B2/C0.2; processed/ultra-processed foods; and UPFs with more than one MUP, C1). The Siga algorithm was used to characterize 24 932 packaged foods in French supermarkets (baby foods and alcohol excluded), which were representative of the packaged food assortments. The main results showed that two-thirds of the products were ultra-processed. Products with more than one MUP (C1) corresponded to the most represented category, accounting for 54% of the products. Among foods with more than five ingredients, 75% were UPFs. Considering all products, the average numbers of ingredients, MUPs and at-risk additives were 10.1, 2.6 and 0.5, respectively. Among food categories, some contained a high percentage of UPFs: 94, 95, 95, 81, 80, and 87% for salted meats, cooked dishes, flavoured yogurts/white cheeses, energy and gourmet bars, breakfast cereals, and vegetarian dishes, respectively. Finally, the Siga algorithm presents a useful tool for improving the health potential of packaged food and for decision-making on search engine optimization (SEO) policy and assortment management in supermarkets.
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Background: Ultra-processed food consumption is a risk factor for obesity and has a negative environmental impact. Food companies spend billions of dollars on advertisements each year to increase the consumption of ultra-processed food. In Australia, USA, and New Zealand, most food advertisements around schools and in train stations promote ultra-processed food, but no similar studies have been conducted in Sweden. The aim of this study was to explore the proportion of ultra-processed food advertisements in two districts of Stockholm, Sweden with low vs. high socioeconomic status (SES). Methods: Two independent researchers (per area) mapped all advertisements, including storefronts, in two Stockholm districts. During consecutive days, all advertisements were photographed in Skärholmen (low SES district), and Östermalmstorg (high SES district), on the streets inside and outside the subway stations, as well as inside and outside of local shopping malls. Advertisements promoting food products were identified and a trained dietician categorized whether they promoted ultra-processed foods. Chi-Square test was conducted to test for differences in the proportion of ultra-processed food advertisements between the two study areas. Results: In total, 4092 advertisements were photographed in Skärholmen (n = 1935) and Östermalm (n = 2157). 32.8% of all advertisements promoted food, while 65.4% of food advertisements promoted ultra-processed foods. A significantly higher proportion of ultra-processed food advertisements out of total food advertisements was identified in the low SES area, irrespective of the researcher taking the pictures (74.6% vs. 61.8%, p < 0.001 and 70.4% vs. 54.8%, p = 0.001). There was no significant difference in the proportion of food advertisements out of total advertisements between the two areas. Conclusions: This study provides initial evidence about the scale and the differences in exposure to food advertisements across areas in Stockholm. The observed high proportion of ultra-processed food advertisements is concerning and is in sharp contrast to the Swedish dietary guidelines that recommend reduced consumption of such foods. Based on our results, residents in low SES areas might be more exposed to ultra-processed food advertisements than those in high SES areas in Stockholm. If such findings are confirmed in additional areas, they should be considered during the deployment of food advertisement regulatory actions.
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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 evaluate the association of ultra-processed food (UPF) consumption with gains in weight and waist circumference, and incident overweight/obesity, in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohort. Design We applied FFQ at baseline and categorized energy intake by degree of processing using the NOVA classification. Height, weight and waist circumference were measured at baseline and after a mean 3·8-year follow-up. We assessed associations, through Poisson regression with robust variance, of UPF consumption with large weight gain (1·68 kg/year) and large waist gain (2·42 cm/year), both being defined as ≥90th percentile in the cohort, and with incident overweight/obesity. Setting Brazil. Participants Civil servants of Brazilian public academic institutions in six cities ( n 11 827), aged 35–74 years at baseline (2008–2010). Results UPF provided a mean 24·6 ( sd 9·6) % of ingested energy. After adjustment for smoking, physical activity, adiposity and other factors, fourth (>30·8 %) v . first (<17·8 %) quartile of UPF consumption was associated (relative risk (95 % CI)) with 27 and 33 % greater risk of large weight and waist gains (1·27 (1·07, 1·50) and 1·33 (1·12, 1·58)), respectively. Similarly, those in the fourth consumption quartile presented 20 % greater risk (1·20 (1·03, 1·40)) of incident overweight/obesity and 2 % greater risk (1·02; (0·85, 1·21)) of incident obesity. Approximately 15 % of cases of large weight and waist gains and of incident overweight/obesity could be attributed to consumption of >17·8 % of energy as UPF. Conclusions Greater UPF consumption predicts large gains in overall and central adiposity and may contribute to the inexorable rise in obesity seen worldwide.
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This is a report published by the Food and Agriculture Organization of the United Nations. Jose Graziano da Silva, outgoing FAO director-general, says: ‘Glad to see FAO report on NOVA classification and ultra-processed food, by Carlos Monteiro and the NUPENS/USP team [ showing] consistent evidence on how the consumption of ultra-processed food causes obesity and many chronic non-communicable diseases’. Carlos Monteiro adds: ‘this is the first time that the peer-reviewed literature linking ultra-processed food intake to diet quality and to risk of non-communicable diseases has been brought together and analysed. This report as published by FAO is a great step forward'. The report examines the peer-reviewed literature on the effects of ultra-processed foods on diet quality and on 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. 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 and dietary fibre. The results from the studies on health outcomes show plausible, significant, 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 a randomised controlled trial conducted by the US National Institutes of Health. These findings are all fully referenced in the report. Carlos Monteiiro adds: 'The conclusion is clear. Governments at all levels now need to agree and enact statutory including fiscal policies that support and protect enjoyment of freshly prepared meals. Worldwide, these are based on minimally processed foods and include processed culinary ingredients and processed foods. This means enormous opportunities for the food industry as a whole including producers of fresh foods, especially co-operative and family farmers that still produce most food all over the world, and also for producers of processed culinary ingredients and processed foods. At the same time, statutory measures must make ultra-processed foods, which are as great a menace to public health as tobacco, less attractive, affordable and available’. ISBN 978-92-5-131701-3
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Background: There is cumulative recognition that increases in the dietary share of ultra-processed foods result in deterioration of the nutritional quality of the overall diet and adverse health outcomes. Objective: The purpose of this study was to assess the consumption of ultra-processed foods and to examine its association with added sugar content in the diet of US children aged 2 to 19 years. Methods: We classified all food items according to the NOVA food classification system and looked at the consumption of ultra-processed foods, measured as percentage of total energy intake. We assessed dietary added sugar content by estimating its contribution to total energy intake and the proportion of individuals with diets exceeding the recommended limit of 10% of total energy intake from added sugars. We also examined the proportion of those who surpassed twice that limit. Gaussian and Poisson regressions estimated the association between consumption of ultra-processed foods and estimates of added sugar content. Results: Ultra-processed foods contributed to 65% of total energy intake and to 92% of energy from added sugars in the diet of US children. The mean percent energy provided by added sugars in the observed period was 14.3%. Most individuals (70.9%) had diets exceeding the recommended limit of added sugar (<10% of total energy intake), and 18.4% of the population had diets surpassing twice the recommended level (20% of total energy intake). A 5.5% point increase in the dietary share of ultra-processed foods determined a 1 percentage point increase in the dietary content of added sugars, with stronger adjusted associations among younger children. Conclusions: Public health efforts to reduce added sugars in the diet of US children must put greater emphasis on decreasing the consumption of ultra-processed foods.
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Objectives: To draw advocacy lessons from actions undertaken by public health groups to assist the development of Australia and New Zealand's Health Star Rating (HSR) front‐of‐pack nutrition labelling system. Methods: The advocacy approaches undertaken by the Public Health Association of Australia leading up to the time of the adoption of the HSR is examined using a 10 step advocacy framework. Key roles in advocacy planning and implementation are described, along with coordinating efforts by health and consumer groups during the HSR development processes. Results: HSR aims to support consumers to make informed choices to protect from diet‐related diseases, including obesity. The HSR launched despite a number of major obstacles, owing to a strategic, coordinated advocacy effort undertaken by a guiding coalition. Conclusions: Actions to improve nutrition are often highly contested, particularly if the desired outcome competes with commercial interests. However, by deploying a structured approach to public health advocacy it is possible to influence government despite opposition from commercial interests. Implications for public health: A shared vision and a coordinated effort by public health professionals enabled advocates to overcome undue commercial influence.
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Background: The NOVA food classification scheme divides foods into ultra-processed, processed, unprocessed, and culinary ingredients. Ultra-processed foods contribute >60% of energy to diets in the US. Objective: To characterize ultra-processed foods by energy density, nutrient density, and monetary cost. Methods: The 384 component foods of Fred Hutch (FHCRC) food frequency questionnaire (FFQ), were assigned to 4 NOVA categories and to 7 USDA MyPyramid food groups. Energy density was kcal/g. Nutrient density was measured using the Nutrient Rich Food index NRF9.3. Food prices were collected in local supermarkets from 2004 to 2016. Analyses examined time trends in food prices by NOVA category and by USDA food group. Results: The ultra-processed classification captured mostly grains (91%), fats and sweets (73%), dairy (71%), and beans, nuts and seeds (70%), but only 36% of meat, poultry and fish, 26% of vegetables, and 20% of fruit. Compared to unprocessed foods, ultra-processed foods had lower nutrient density (NRF9.3 per 100 kcal: 21.2 vs. 108.5),higher energy density (mean (SD): 2.2 vs. 1.10 in kcal/g), and lower per calorie cost (0.55 vs. 1.45 in $/100 kcal). Ultra-processed foods did not increase in price as much as unprocessed foods over the 12 year period. Conclusion: Ultra-processed foods tend to be energy-dense, low-cost, and nutrient-poor. Low energy cost could be one mechanism linking ultra-processed foods with negative health outcomes. Food-based Dietary Guidelines may need to address food processing in relation to economic aspects of food choice.
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We investigated whether ultra-processed foods affect energy intake in 20 weight-stable adults, aged (mean ± SE) 31.2 ± 1.6 years and BMI = 27 ± 1.5 kg/m2. Subjects were admitted to the NIH Clinical Center and randomized to receive either ultra-processed or unprocessed diets for 2 weeks immediately followed by the alternate diet for 2 weeks. Meals were designed to be matched for presented calories, energy density, macronutrients, sugar, sodium, and fiber. Subjects were instructed to consume as much or as little as desired. Energy intake was greater during the ultra-processed diet (508 ± 106 kcal/day; p = 0.0001), with increased consumption of carbohydrate (280 ± 54 kcal/day; p < 0.0001) and fat (230 ± 53 kcal/day; p = 0.0004), but not protein (-2 ± 12 kcal/day; p = 0.85). Weight changes were highly correlated with energy intake (r = 0.8, p < 0.0001), with participants gaining 0.9 ± 0.3 kg (p = 0.009) during the ultra-processed diet and losing 0.9 ± 0.3 kg (p = 0.007) during the unprocessed diet. Limiting consumption of ultra-processed foods may be an effective strategy for obesity prevention and treatment.
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Commentary in World Nutrition. Policies to control and prevent the pandemic of obesity and related conditions and diseases have failed. This is because the efficient causes of the pandemic have not yet been agreed. We state here that its outstanding immediate cause is the increased and rapidly increasing consumption of ultra-processed foods, which displace unprocessed or minimally processed foods and freshly prepared dishes and meals, most conspicuously now in middle-and lower-income countries. The underlying cause of this is the phenomenal rise since the 1980s of the transnational corporations whose huge profits depend on the use of cheap ingredients and arrays of additives made into ultra-processed food. The scale and power of the transnationals, which tend towards oligopoly, and their penetration of middle and lower-income countries, have been accelerated by global political and economic agreements that have deregulated trade and allowed capital flow that opens countries to penetration by foreign businesses. Food is essential for life and health, but there is no need to consume ultra-processed foods. In this sense, they are similar to tobacco products. The same statutory policies and programmes that are applied to smoking should be adapted to limit and reduce consumption of ultra-processed foods. Revenue from taxation should be used to protect local food producers and retailers, to promote healthy and sustainable diets, and to ensure food security for vulnerable populations. Overall, a Framework Convention on Food Systems, promulgated by the relevant United Nations agencies as agreed by UN member states, supported by professional and civil society organisations and social movements, is needed. This will be designed to create healthy food systems and supplies and thus healthy diets that also are beneficial socially, culturally, economically and environmentally.
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A number of phenomenal global catastrophes confront humanity. Six of these are ‘superbugs’ resistant to antimicrobial drugs; cigarettes and other use of tobacco; alcohol abuse; climate disruption; gross inequities; and the pandemic of obesity and diseases of which obesity is a leading cause, notably diabetes, and also cardiovascular diseases and a number of common cancers. These dreadful calamities are similar in various ways. None are natural. All are disastrous socially and economically as well as personally. All are predicted to get worse and even irreversibly uncontrollable, with the partial exception of cigarette smoking, which has decreased in many countries. There is however one difference. The causes of the first five phenomena mentioned here are known beyond reasonable doubt, and public policies and actions that would reduce the devastation they cause are generally agreed beyond reasonable argument. But this is not the case with pandemic obesity and related diseases. Their causes are still debated, and their remedies disputed. The purpose of this background paper is to help to clarify the causes of the pandemic obesity and to propose solutions in line with these causes. (Background paper for the Prince Mahidol conference, session on commercial determinants of chronic diseases, Bangkok, Thailand, February 2019).
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The present commentary contains a clear and simple guide designed to identify ultra-processed foods. It responds to the growing interest in ultra-processed foods among policy makers, academic researchers, health professionals, journalists and consumers concerned to devise policies, investigate dietary patterns, advise people, prepare media coverage, and when buying food and checking labels in shops or at home. Ultra-processed foods are defined within the NOVA classification system, which groups foods according to the extent and purpose of industrial processing. Processes enabling the manufacture of ultra-processed foods include the fractioning of whole foods into substances, chemical modifications of these substances, assembly of unmodified and modified food substances, frequent use of cosmetic additives and sophisticated packaging. Processes and ingredients used to manufacture ultra-processed foods are designed to create highly profitable (low-cost ingredients, long shelf-life, emphatic branding), convenient (ready-to-consume), hyper-palatable products liable to displace all other NOVA food groups, notably unprocessed or minimally processed foods. A practical way to identify an ultra-processed product is to check to see if its list of ingredients contains at least one item characteristic of the NOVA ultra-processed food group, which is to say, either food substances never or rarely used in kitchens (such as high-fructose corn syrup, hydrogenated or interesterified oils, and hydrolysed proteins), or classes of additives designed to make the final product palatable or more appealing (such as flavours, flavour enhancers, colours, emulsifiers, emulsifying salts, sweeteners, thickeners, and anti-foaming, bulking, carbonating, foaming, gelling and glazing agents).
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Background: The consumption of ultra-processed foods is associated with diminished dietary quality and adverse health outcomes. The Australian Health Star Rating (HSR) is a nutrient-based front-of-pack (FOP) labelling system that assesses the 'healthiness' of foods on a scale of 0.5 to 5 stars based on their content of 'risk' and 'positive' nutrients. This study aimed to analyse the use of health stars on new packaged food products entering the Australian marketplace by level of food processing. Methods: The Mintel Global New Product Database (GNPD) was searched to identify the number of stars displayed on the labels of all new packaged food products participating in the HSR system released into the Australian retail food supply between 27 June 2014 (the endorsement date) and 30 June 2017. Products were categorised by the four NOVA food processing categories: unprocessed and minimally processed (MP), processed culinary ingredients (PCI), processed (P), and ultra-processed (UP), and the distribution of the star ratings within each category was compared and analysed. Results: The majority of new food products displaying an HSR were UP (74.4%), followed by MP (12.5%), P (11.6%), and PCI (1.5%). The median HSR of MP products (4.5) was significantly higher than the median of P (4) and UP products (3.5) (all p < 0.05). In all NOVA categories HSR profiles were distributed towards higher star ratings, and the majority (77%) of UP products displayed an HSR ≥ 2.5. Conclusions: The HSR is being displayed on a substantial proportion of newly released UP foods. Technical weaknesses, design flaws and governance limitations with the HSR system are resulting in 3 out of 4 instances of these UP foods displaying at least 2.5 so-called 'health' stars. These findings add further evidence to concerns that the HSR system, in its current form, is misrepresenting the healthiness of new packaged food products and creating a risk for behavioural nutrition.
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Objectives To assess the association between consumption of ultra-processed foods and obesity in the Canadian population. Methods Cross-sectional study including 19,363 adults aged 18 years or more from the 2004 Canadian Community Health Survey, cycle 2.2. Ultra-processed food intake was estimated using daily relative energy intake of ultra-processed food (% of total energy intake) from data obtained by 24-h food recalls. Obesity was assessed using body mass index (BMI ≥ 30 kg/m²). Univariate and multivariate linear regressions were performed to describe ultra-processed food consumption according to socio-economic and demographic variables, and multivariate logistic regression was performed to verify the association between ultra-processed food consumption and obesity, adjusting for potential confounders, including socio-demographic factors, physical activity, smoking, immigrant status, residential location, and measured vs self-reported weight and height. Results Ultra-processed foods make up almost half (45%) of the daily calories consumed by Canadian adults. Consumption of these foods is higher among men, younger adults, those with fewer years of formal education, smokers, those physically inactive, and Canadian-born individuals. Ultra-processed food consumption is positively associated with obesity. After adjusting for confounding factors, individuals in the highest quintile of ultra-processed food consumption were 32% more likely of having obesity compared to individuals in the first quintile (predicted OR = e0.005 × 56 = 1.32; 95% CI = 1.05–1.57). Conclusion Canadians would benefit from reducing consumption of ultra-processed foods and beverages and increasing consumption of freshly prepared dishes made from unprocessed or minimally processed foods.
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Background To improve nutritional status and prevent chronic nutrition-related diseases, international organizations have recommended the use of multiple strategies, including front-of-package nutrition labelling (FOPL). In France, the Nutri-Score has been selected by health authorities in March 2017. However, to be effective in purchasing situations, the label needs to be well understood, which may be influenced by label format and sociodemographic characteristics. This study aimed at investigating the objective understanding of the Nutri-Score compared to other label formats, and more particularly among specific at-risk populations. Methods The objective understanding of four FOPLs—namely Nutri-Score, Multiple Traffic Lights (MTL), the simplified nutrition labelling system (SENS), and modified Reference Intakes (mRIs)—was investigated in a sample from the NutriNet-Santé French cohort (n = 3,751). Logistic regression mixed models were computed to assess the association of the four FOPLs, compared to a “no label” situation, on the consumers’ ability to rank products according to their overall nutritional quality. Objective understanding was also investigated according to sociodemographic and lifestyle characteristics. Results Compared to a “no label” situation, all FOPLs were significantly associated to an increase in consumers’ ability to classify the products correctly, with wide disparities in results according to formats. The best performance was observed for the Nutri-Score (OR = 20.33(17.68–23.37)), followed by SENS (OR = 9.57(8.50–10.77)), MTL (OR = 3.55(3.20–3.93)) and mRIs (OR = 1.53(1.39–1.69)). This ranking was similar among all sub-populations and the ORs associated to the Nutri-Score were over 10, whichever the sub-group considered. Women, younger people, non-smokers, individuals with higher educational level and those with children had a higher capacity to identify healthier products (all P≤0.05). Conclusion Nutri-Score, with a summarized graded and color-coded format, using semantic colours, is associated to a higher objective understanding than monochrome and nutrient-specific labels. Furthermore, though objective understanding may differ according to individual characteristics of subjects, the magnitude of effect of the Nutri-Score largely outweighed this effect, even in the at-risk populations.
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Objective To describe the number of processed and ultra-processed food (PUPF) advertisements (ads) targeted to children on Argentinean television (TV), to analyse the advertising techniques used and the nutritional quality of the foods advertised, and to determine the potential exposure of children to unhealthy food advertising in our country. Design Five free-to-air channels and the three most popular children’s cable networks were recorded from 07.00 to 22.00 hours for 6 weeks. Ads were classified by target audience, type of product, advertised food categories and advertising strategies used. The NOVA system was used to classify food products according to industrial food processing level. Nutritional quality was analysed using the Pan American Health Organization’s nutrient profile model. Setting Buenos Aires, Argentina. Results are considered applicable to most of the country. Subjects The study did not involve human subjects. Results Of the sample of food ads, PUPF products were more frequently advertised during children’s programmes (98·9 %) v . programmes targeted to the general audience (93·7 %, χ² =45·92, P <0·01). The top five food categories were desserts, dairy products, non-alcoholic sugary beverages, fast-food restaurants, and salty snacks. Special promotions and the appearance of cartoon characters were much more frequent in ads targeting children. Argentinean children are estimated to be exposed to sixty-one ads for unhealthy PUPF products per week. Conclusions Our study showed that Argentinean children are exposed to a high number of unhealthy PUPF ads on TV. The Argentinean Government should build on this information to design and implement a comprehensive policy to reduce exposure to unhealthy food marketing that includes TV and other communication channels and places.
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Objective To assess the consumption of ultra-processed foods and analyse its association with the content of added sugars in the Chilean diet. Design Cross-sectional study of national dietary data obtained through 24 h recalls and classified into food groups according to the extent and purpose of food processing (NOVA classification). Setting Chile. Subjects A probabilistic sample of 4920 individuals (aged 2 years or above) studied in 2010 by a national dietary survey (Encuesta Nacional de Consumo Alimentario). Results Ultra-processed foods represented 28·6 ( se 0·5) % of total energy intake and 58·6 ( se 0·9) % of added sugars intake. The mean percentage of energy from added sugars increased from 7·7 ( se 0·3) to 19·7 ( se 0·5) % across quintiles of the dietary share of ultra-processed foods. After adjusting for several potential sociodemographic confounders, a 5 percentage point increase in the dietary share of ultra-processed foods determined a 1 percentage point increase in the dietary content of added sugars. Individuals in the highest quintile were three times more likely (OR=2·9; 95 % CI 2·4, 3·4) to exceed the 10 % upper limit for added sugars recommended by the WHO compared with those in the lowest quintile, after adjusting for sociodemographic variables. This association was strongest among individuals aged 2–19 years (OR=3·9; 95 % CI 2·7, 5·9). Conclusions In Chile, ultra-processed foods are important contributors to total energy intake and to the consumption of added sugars. Actions aimed at limiting consumption of ultra-processed foods are being implemented as effective ways to achieve WHO dietary recommendations to limit added sugars and processed foods, especially for children and adolescents.
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Dietary fibre-induced faecal bulking and hydration are important contributors to large bowel function and health, and are affected by the dietary fibre structure. To determine faecal bulk-related parameters for vegetable dietary fibres with retained structure, cold water fragmentation of vegetables was used to make minimally processed vegetable fibres (MPVF) from swede, broccoli and asparagus. A valid adult rat model was used to subject the fibres to processes of hind gut fermentation and faecal accumulation similar to those in humans. All the MPVFs had high faecal bulking indexes (FBIs, mean ± sem: wheat bran (reference), 100 ± 6.0; asparagus 168 ± 5.7; swede 135 ± 6.1; broccoli 135 ± 5.9; broccoli rind 205 ± 10.4), and caused large increases in the theoretical colonic water load at 10 g per 100 g diet (increase over baseline (%): wheat bran, 137 ± 8.3; asparagus, 236 ± 25, swede 193 ± 8.8; broccoli 228 ± 12; broccoli rind 223 ± 8.5). Faecal bulking by MPVFs was much greater than by fermentable extracted polysaccharides such as pectin and raftilose, or by commercial fibres made from highly processed cell walls. The results show natural, non-degraded vegetable fibres with retained botanical structure have beneficial effects not provided by structure-less fermentable dietary fibres. Dietary fibre-deficient diets supplemented with prebiotics cannot, therefore, adequately substitute for varied diets containing adequate vegetables, fruits and wholegrain cereals in which fermentation is associated with enough retained structure to conserve physicochemical properties of benefit to colonic function.
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Objectives To investigate the contribution of ultra-processed foods to the intake of added sugars in the USA. Ultra-processed foods were defined as industrial formulations which, besides salt, sugar, oils and fats, include substances not used in culinary preparations, in particular additives used to imitate sensorial qualities of minimally processed foods and their culinary preparations. Design Cross-sectional study. Setting National Health and Nutrition Examination Survey 2009–2010. Participants We evaluated 9317 participants aged 1+ years with at least one 24 h dietary recall. Main outcome measures Average dietary content of added sugars and proportion of individuals consuming more than 10% of total energy from added sugars. Data analysis Gaussian and Poisson regressions estimated the association between consumption of ultra-processed foods and intake of added sugars. All models incorporated survey sample weights and adjusted for age, sex, race/ethnicity, family income and educational attainment. Results Ultra-processed foods comprised 57.9% of energy intake, and contributed 89.7% of the energy intake from added sugars. The content of added sugars in ultra-processed foods (21.1% of calories) was eightfold higher than in processed foods (2.4%) and fivefold higher than in unprocessed or minimally processed foods and processed culinary ingredients grouped together (3.7%). Both in unadjusted and adjusted models, each increase of 5 percentage points in proportional energy intake from ultra-processed foods increased the proportional energy intake from added sugars by 1 percentage point. Consumption of added sugars increased linearly across quintiles of ultra-processed food consumption: from 7.5% of total energy in the lowest quintile to 19.5% in the highest. A total of 82.1% of Americans in the highest quintile exceeded the recommended limit of 10% energy from added sugars, compared with 26.4% in the lowest. Conclusions Decreasing the consumption of ultra-processed foods could be an effective way of reducing the excessive intake of added sugars in the USA.
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Objectives: The aim of this study was to evaluate the relationship between the consumption of ultra-processed foods and obesity indicators among Brazilian adults and adolescents. Methods: We used cross-sectional data on 30,243 individuals aged ≥10years from the 2008-2009 Brazilian Dietary Survey. Food consumption data were collected through 24-h food records. We classified food items according to characteristics of food processing. Ultra-processed foods were defined as formulations made by the food industry mostly from substances extracted from foods or obtained with the further processing of constituents of foods or through chemical synthesis, with little if any whole food. Examples included candies, cookies, sugar-sweetened beverages, and ready-to-eat dishes. Regression models were fitted to evaluate the association of the consumption of ultra-processed foods (% of energy intake) with body-mass-index, excess weight, and obesity status, controlling for socio-demographic characteristics, smoking, and physical activity. Results: Ultra-processed foods represented 30% of the total energy intake. Those in the highest quintile of consumption of ultra-processed foods had significantly higher body-mass-index (0.94kg/m(2); 95% CI: 0.42,1.47) and higher odds of being obese (OR=1.98; 95% CI: 1.26,3.12) and excess weight (OR=1.26; 95% CI: 0.95,1.69) compared with those in the lowest quintile of consumption. Conclusion: Our findings support the role of ultra-processed foods in the obesity epidemic in Brazil.
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to evaluate the relationship between the consumption of ultra-processed foods and obesity indicators among Brazilian adults and adolescents. We used cross-sectional data on 30,243 individuals aged ≥10 years from the 2008-2009 Brazilian Dietary Survey. Food consumption data were collected through 24-hour food records. We classified food items according to characteristics of food processing. Ultra-processed foods were defined as formulations made by the food industry mostly from substances extracted from foods or obtained with the further processing of constituents of foods or through chemical synthesis, with little if any whole food. Examples included candies, cookies, sugar-sweetened beverages, and ready-to-eat dishes. Regression models were fitted to evaluate the association of the consumption of ultra-processed foods (% of energy intake) with body-mass-index, excess weight, and obesity status, controlling for socio-demographic characteristics, smoking, and physical activity. Ultra-processed foods represented 30% of the total energy intake. Those in the highest quintile of consumption of ultra-processed foods had significantly higher body-mass-index (0.94 kg/m(2); 95%CI: 0.42,1.47) and higher odds of being obese (OR=1.98; 95%CI: 1.26,3.12) and excess weight (OR=1.26; 95%CI: 0.95,1.69) compared with those in the lowest quintile of consumption. Our findings support the role of ultra-processed foods in the obesity epidemic in Brazil. Copyright © 2015. Published by Elsevier Inc.
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To examine the availability of packaged food products in New Zealand supermarkets by level of industrial processing, nutrient profiling score (NPSC), price (energy, unit and serving costs) and brand variety. Secondary analysis of cross-sectional survey data on packaged supermarket food and non-alcoholic beverages. Products were classified according to level of industrial processing (minimally, culinary and ultra-processed) and their NPSC. Packaged foods available in four major supermarkets in Auckland, New Zealand. Packaged supermarket food products for the years 2011 and 2013. The majority (84 % in 2011 and 83 % in 2013) of packaged foods were classified as ultra-processed. A significant positive association was found between the level of industrial processing and NPSC, i.e. ultra-processed foods had a worse nutrient profile (NPSC=11��63) than culinary processed foods (NPSC=7��95), which in turn had a worse nutrient profile than minimally processed foods (NPSC=3��27), P<0��001. No clear associations were observed between the three price measures and level of processing. The study observed many variations of virtually the same product. The ten largest food manufacturers produced 35 % of all packaged foods available. In New Zealand supermarkets, ultra-processed foods comprise the largest proportion of packaged foods and are less healthy than less processed foods. The lack of significant price difference between ultra- and less processed foods suggests ultra-processed foods might provide time-poor consumers with more value for money. These findings highlight the need to improve the supermarket food supply by reducing numbers of ultra-processed foods and by reformulating products to improve their nutritional profile.
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Associations between food and beverage groups and the risk of diet-related chronic disease (DRCD) have been the subject of intensive research in preventive nutrition. Pooled/meta-analyses and systematic reviews (PMASRs) aim to better characterize these associations. To date, however, there has been no attempt to synthesize all PMASRs that have assessed the relationship between food and beverage groups and DRCDs. The objectives of this review were to aggregate PMASRs to obtain an overview of the associations between food and beverage groups (n = 17) and DRCDs (n = 10) and to establish new directions for future research needs. The present review of 304 PMASRs published between 1950 and 2013 confirmed that plant food groups are more protective than animal food groups against DRCDs. Within plant food groups, grain products are more protective than fruits and vegetables. Among animal food groups, dairy/milk products have a neutral effect on the risk of DRCDs, while red/processed meats tend to increase the risk. Among beverages, tea was the most protective and soft drinks the least protective against DRCDs. For two of the DRCDs examined, sarcopenia and kidney disease, no PMASR was found. Overweight/obesity, type 2 diabetes, and various types of cardiovascular disease and cancer accounted for 289 of the PMASRs. There is a crucial need to further study the associations between food and beverage groups and mental health, skeletal health, digestive diseases, liver diseases, kidney diseases, obesity, and type 2 diabetes.
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Production and consumption of industrially processed food and drink products have risen in parallel with the global increase in overweight and obesity and related chronic non-communicable diseases. The objective of this study was to analyze the relationship between household availability of processed and ultra-processed products and the prevalence of excess weight (overweight plus obesity) and obesity in Brazil. The study was based on data from the 2008-2009 Household Budget Survey involving a probabilistic sample of 55,970 Brazilian households. The units of study were household aggregates (strata), geographically and socioeconomically homogeneous. Multiple linear regression models were used to assess the relationship between the availability of processed and ultra-processed products and the average of Body Mass Index (BMI) and the percentage of individuals with excess weight and obesity in the strata, controlling for potential confounders (socio-demographic characteristics, percentage of expenditure on eating out of home, and dietary energy other than that provided by processed and ultra-processed products). Predictive values for prevalence of excess weight and obesity were estimated according to quartiles of the household availability of dietary energy from processed and ultra-processed products. The mean contribution of processed and ultra-processed products to total dietary energy availability ranged from 15.4% (lower quartile) to 39.4% (upper quartile). Adjusted linear regression coefficients indicated that household availability of ultra-processed products was positively associated with both the average BMI and the prevalence of excess weight and obesity, whereas processed products were not associated with these outcomes. In addition, people in the upper quartile of household consumption of ultra-processed products, compared with those in the lower quartile, were 37% more likely to be obese. Greater household availability of ultra-processed food products in Brazil is positively and independently associated with higher prevalence of excess weight and obesity in all age groups in this cross-sectional study.
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The rapid nutrition transition occurring in Latin America has resulted in a sharp increase of childhood overweight and obesity. Recent evidence has shown that food and beverage advertising has a great influence on children’s eating behavior. This population has become a key target market for the ultra-processed foods and beverages industry, which is marketing products in an aggressive way. Evidence shows that Latin American countries have poor regulation of ultra-processed foods and beverages advertising, where the discourse of self-regulation still prevails over statutory regulations. The following commentary explores how advertising might play an important role in developing unhealthy dietary patterns and obesity in Latin American children, as well as the urgent need for government action and the involvement of civil society to tackle this public health issue.
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Hyperphosphatemia has been identified in the past decade as a strong predictor of mortality in advanced chronic kidney disease (CKD). For example, a study of patients in stage CKD 5 (with an annual mortality of about 20%) revealed that 12% of all deaths in this group were attributable to an elevated serum phosphate concentration. Recently, a high-normal serum phosphate concentration has also been found to be an independent predictor of cardiovascular events and mortality in the general population. Therefore, phosphate additives in food are a matter of concern, and their potential impact on health may well have been underappreciated. We reviewed pertinent literature retrieved by a selective search of the PubMed and EU databases (www.zusatzstoffe-online.de, www.codexalimentarius.de), with the search terms "phosphate additives" and "hyperphosphatemia." There is no need to lower the content of natural phosphate, i.e. organic esters, in food, because this type of phosphate is incompletely absorbed; restricting its intake might even lead to protein malnutrition. On the other hand, inorganic phosphate in food additives is effectively absorbed and can measurably elevate the serum phosphate concentration in patients with advanced CKD. Foods with added phosphate tend to be eaten by persons at the lower end of the socioeconomic scale, who consume more processed and "fast" food. The main pathophysiological effect of phosphate is vascular damage, e.g. endothelial dysfunction and vascular calcification. Aside from the quality of phosphate in the diet (which also requires attention), the quantity of phosphate consumed by patients with advanced renal failure should not exceed 1000 mg per day, according to the guidelines. Prospective controlled trials are currently unavailable. In view of the high prevalence of CKD and the potential harm caused by phosphate additives to food, the public should be informed that added phosphate is damaging to health. Furthermore, calls for labeling the content of added phosphate in food are appropriate.
Article
Numerous studies have reported the association of ultra-processed foods with excess body weight; however, the nature and extent of this relation has not been clearly established. This systematic review was conducted to analyze the currently documented evidence regarding the association between ultra-processed food with overweight and obesity. A literature search was performed using multiple literature databases for relevant articles published prior to November 2019. Random effects model, namely the DerSimonian–Laird method, was applied to pool effect sizes. The potential sources of heterogeneity across studies were explored using the Cochrane Q test. Fourteen studies (one cohort study and thirteen cross-sectional studies) were included in this review. A significant association was identified between ultra-processed food intake and overweight (pooled effect size: 1.02; 95% confidence interval (95% CI): 1.01, 1.03, p < 0.001) and obesity (pooled effect size: 1.26; 95% CI: 1.13, 1.41, p < 0.001). Our findings revealed a positive association between ultra-processed foods and excess body weight. Future studies with longitudinal designs and adequate control for confounding factors are required to clarify whether ultra-processed food intake alters anthropometric parameters and leads to obesity.
Article
Background: Telomere length (TL) is a marker of biological age that may be affected by dietary factors through oxidation and inflammation mechanisms. In addition, ultra-processed food (UPF) consumption has increased worldwide and it has been associated with the risk of developing several diseases. Objectives: We aimed to evaluate the association between UPF consumption and the risk of having short telomeres in an elderly population of the Seguimiento Universidad de Navarra (SUN) Project. Methods: This is a cross-sectional study of 886 participants (645 men and 241 women) aged 57-91 y recruited from the SUN Project (Spain, 1999-2018). TL was measured from saliva samples by real-time qPCR at baseline and UPF consumption was collected using a validated 136-item FFQ and classified according to the NOVA system. We evaluated the association between consumption of energy-adjusted UPF categorized into quartiles (low, medium-low, medium-high, and high consumption) and the risk of having short telomeres (<20th percentile) using logistic regression models. Results: Those participants with the highest UPF consumption had almost twice the odds of having short telomeres compared with those with the lowest consumption (adjusted OR: 1.82; 95% CI: 1.05, 3.22; P-trend = 0.03). Conclusions: A higher consumption of UPF (>3 servings/d) was associated with higher risk of having shorter telomeres in an elderly Spanish population of the SUN Project.This trial was registered at clinicaltrials.gov as NCT02669602.
Article
Background: The concept of ultra-processed foods (UPFs) is new, and it was proposed for the first time in 2009 as group 4 of the NOVA classification to address the degree of food processing. UPFs include not only “junk foods” but also foods marketed as healthy, such as light, vegan, organic, or gluten-free products. UPFs are characterized by the presence of highly-processed/purified “cosmetic” ingredients and/or additives to restore and/or exacerbate organoleptic properties, i.e., taste, aroma, color and texture. Substantial industrial processing techniques, e.g., puffing, extrusion cooking, and/or extreme fractioning/refining that greatly breakdown the food matrix, may also be markers of ultra-processing. The UPF concept has been consistently criticized for being an overly heterogeneous concept, and the NOVA classification has been criticized for being qualitative only and too imprecise. Scope and approach: This review is intended to discuss the UPF concept from a holistic perspective and to analyze the scientific soundness of criticisms about UPFs and NOVA. The UPF concept is first defined; then, its primary nutritional characteristics are described, followed by their association with health based on human studies. Key findings and conclusions: UPF criticisms differ between holistic and reductionist perspectives. In a holistic concept, reductionist researchers view the proposed definition of UPF as an imprecise, vague and heterogeneous technological group. However, from a holistic perspective, the UPF concept has serious advantages, such as broad and common deleterious health attributes (i.e., the loss of “matrix” effect, empty calories, poorly satiating, hyperglycemic and containing artificial compounds foreign to the human body).
Article
The Australian Government’s voluntary Health Star Rating (HSR) system has potential to provide a user-friendly approach to help shoppers choose healthier packaged food options. However, despite evidence that it is dietary imbalances and excesses that are the predominant causes of diet-related noncommunicable diseases and obesity, the star-rating system’s design is based on a reductionist (nutrient) world view of nutrition science which is not a fit-for-purpose solution to the cause of the problem. As a result, the HSR system frequently is inadvertently contradicting Australian Dietary Guidelines (ADG) recommendations, and promoting the marketing of discretionary and ultraprocessed foods. This perspective article looks at how the HSR system could be reformed to complement the ADG and stresses the overriding priority is to position it within, and not be a distraction from, a comprehensive national nutrition policy if dietary risk factors are to be effectively tackled.
Article
We propose an empirical study of French sales in conventional food retailing and in specialised organic stores for 2012. We examine the plant or animal origin of food products, as an indicator of the environmental and health impacts of sales, and their degree of processing, as an indicator of their health impact. The results indicate that sales of organic food products are more plant-based and less processed in specialised organic stores than in conventional retail stores, two criteria for a better health and environmental impact. In conventional stores, organic sales are more plant-based and less processed than conventional sales. Organic sales in conventional stores show some specificity, having the highest share of particular product ranges lacking a clear health or environmental impact, such as processed culinary ingredients or unprocessed or minimally processed animal products. Building a typology of buyers in conventional stores, we find that even purchases by buyers with the highest organic purchase intensity in conventional stores are less plant-based and more processed than average purchases in specialised organic stores. Our results characterise to what extent some of the holistic environmental and health impacts of organic agriculture are lower in conventional retail stores than in specialised organic stores in France in 2012.
Article
The inclusion of more attention-grabbing and easily interpretable front-of-pack (FOP) nutrition information is one of the public policies that can be implemented to empower consumers to identify unhealthful food products and to make more informed food choices. The aim of the present work was to evaluate the influence of two FOP nutrition labelling schemes - the traffic light labelling and the warning scheme - on consumer food purchases when facing a health goal. The study was conducted with 1182 people from Montevideo (Uruguay), recruited using a Facebook advertisement. Participants were randomly allocated to one of three between-subjects experimental conditions: (i) a control condition with no FOP nutrition information, (ii) FOP nutrition information using a modified version of the traffic light system including information about calorie, saturated fat, sugars and salt content per portion, and (iii) FOP nutrition information using the Chilean warning system including separate signs for high calorie, saturated fat, sugars and salt content. Respondents were asked to imagine that they had to purchase food in order to prepare a healthy dinner for themselves and their family, using the website of an online grocery store. Results showed that FOP nutrition information effectively improved the average healthfulness of choice compared to the control condition, both in terms of the average nutritional composition of the purchased products and expenditure in specific product categories. No relevant differences between the effect of the traffic light and the warning system were found.
Article
Background: Plant-based diets are recommended for coronary heart disease (CHD) prevention. However, not all plant foods are necessarily beneficial for health. Objectives: This study sought to examine associations between plant-based diet indices and CHD incidence. Methods: We included 73,710 women in NHS (Nurses' Health Study) (1984 to 2012), 92,329 women in NHS2 (1991 to 2013), and 43,259 men in Health Professionals Follow-up Study (1986 to 2012), free of chronic diseases at baseline. We created an overall plant-based diet index (PDI) from repeated semiquantitative food-frequency questionnaire data, by assigning positive scores to plant foods and reverse scores to animal foods. We also created a healthful plant-based diet index (hPDI) where healthy plant foods (whole grains, fruits/vegetables, nuts/legumes, oils, tea/coffee) received positive scores, whereas less-healthy plant foods (juices/sweetened beverages, refined grains, potatoes/fries, sweets) and animal foods received reverse scores. To create an unhealthful PDI (uPDI), we gave positive scores to less-healthy plant foods and reverse scores to animal and healthy plant foods. Results: Over 4,833,042 person-years of follow-up, we documented 8,631 incident CHD cases. In pooled multivariable analysis, higher adherence to PDI was independently inversely associated with CHD (hazard ratio [HR] comparing extreme deciles: 0.92; 95% confidence interval [CI]: 0.83 to 1.01; p trend = 0.003). This inverse association was stronger for hDPI (HR: 0.75; 95% CI: 0.68 to 0.83; p trend <0.001). Conversely, uPDI was positively associated with CHD (HR: 1.32; 95% CI: 1.20 to 1.46; p trend <0.001). Conclusions: Higher intake of a plant-based diet index rich in healthier plant foods is associated with substantially lower CHD risk, whereas a plant-based diet index that emphasizes less-healthy plant foods is associated with higher CHD risk.
Article
Objective Concerns have been raised about the potential health impact of ultra-processed foods (UPF) in the diet. Our objective was to investigate the contribution of UPF in the diet in a large French population and its association with sociodemographic factors and dietary patterns. Design Cross-sectional analysis of dietary data from 74 470 participants in the web-based NutriNet-Santé cohort. UPF were identified in repeated 24 h records and the proportion (in weight) of UPF in the total diet (UPFp) was computed for each participant. Associations of sociodemographic characteristics and UPFp in quartiles were assessed using multivariate multinomial logistic regression. Food group consumption and nutrient intakes across quartiles of UPFp were estimated using linear regression adjusted for sociodemographic factors and energy intake. Setting France. Results UPF contributed 18·4 % of the foods consumed in weight and 35·9 % of total energy intake. Higher UPFp consumption was independently associated with male gender, younger age, lower education, smoking, and overweight and obesity (all P <0·0001). Participants in the highest UPFp quartile consumed lower amounts of fruit and vegetables (difference between quartile 4 and quartile 1 of UPFp, Δ=−180·3 g/d) and higher amounts of sweet products (Δ=68·5 g/d) and soft drinks (Δ=98·6 g/d; all P <0·0001). They had higher intakes of energy (Δ=610 kJ/d (145·7 kcal/d)) and added sugar (Δ=17·1 g/d), and lower intakes of fibre (Δ=−4·04 g/d), β-carotene (Δ=−1019·6 μg/d) and Ca (Δ=−87·8 mg/d; all P <0·0001). Conclusions UPF represent an important part of the diet in adults from the French general population and are associated with unbalanced nutritional intakes.
Article
To investigate how consumption of ultra-processed foods has changed in Sweden in relation to obesity. Nationwide ecological analysis of changes in processed foods along with corresponding changes in obesity. Trends in per capita food consumption during 1960-2010 were investigated using data from the Swedish Board of Agriculture. Food items were classified as group 1 (unprocessed/minimally processed), group 2 (processed culinary ingredients) or group 3 (3·1, processed food products; and 3·2, ultra-processed products). Obesity prevalence data were pooled from the peer-reviewed literature, Statistics Sweden and the WHO Global Health Observatory. Nationwide analysis in Sweden, 1960-2010. Swedish nationals aged 18 years and older. During the study period consumption of group 1 foods (minimal processing) decreased by 2 %, while consumption of group 2 foods (processed ingredients) decreased by 34 %. Consumption of group 3·1 foods (processed food products) increased by 116 % and group 3·2 foods (ultra-processed products) increased by 142 %. Among ultra-processed products, there were particularly large increases in soda (315 %; 22 v. 92 litres/capita per annum) and snack foods such as crisps and candies (367 %; 7 v. 34 kg/capita per annum). In parallel to these changes in ultra-processed products, rates of adult obesity increased from 5 % in 1980 to over 11 % in 2010. The consumption of ultra-processed products (i.e. foods with low nutritional value but high energy density) has increased dramatically in Sweden since 1960, which mirrors the increased prevalence of obesity. Future research should clarify the potential causal role of ultra-processed products in weight gain and obesity.
Article
Food might contain residues of agricultural chemicals (e.g. pesticides), additives (e.g. colourants) and/or natural toxins (e.g. solanine in potatoes) which present health risks to consumers. The risks of such residues, additives and natural toxins are generally low (i.e. acceptable) when considered in isolation. However, an average meal is likely to contain a cocktail of residues, additives and/or natural toxins that might have additive or synergistic effects. This review explores potential cocktail effects with reference to two case examples, organophosphorus pesticides (OPs) and xenoestrogens, and concludes that we should extend our thinking to encompass interactions between residues, additives and natural toxins when assessing food risk.
Article
This paper is the first to make a systematic review and assessment of the literature that attempts methodically to incorporate food processing into classification of diets. The review identified 1276 papers, of which 110 were screened and 21 studied, derived from five classification systems. This paper analyses and assesses the five systems, one of which has been devised and developed by a research team that includes co-authors of this paper. The quality of the five systems is assessed and scored according to how specific, coherent, clear, comprehensive and workable they are. Their relevance to food, nutrition and health, and their use in various settings, is described. The paper shows that the significance of industrial food processing in shaping global food systems and supplies and thus dietary patterns worldwide, and its role in the pandemic of overweight and obesity, remains overlooked and underestimated. Once food processing is systematically incorporated into food classifications, they will be more useful in assessing and monitoring dietary patterns. Food classification systems that emphasize industrial food processing, and that define and distinguish relevant different types of processing, will improve understanding of how to prevent and control overweight, obesity and related chronic non-communicable diseases, and also malnutrition. They will also be a firmer basis for rational policies and effective actions designed to protect and improve public health at all levels from global to local.
Article
Epidemiological studies associate whole grain consumption with a reduced risk of many diseases. This paper focuses on the antioxidant component of cereal dietary fibre starting from its chemical structure, bioavailability and biological meaning. By the critical assessment of the intervention studies performed using cereal bran and whole grains, the hypothesis that the slow and continuous release in the gut of the dietary fibre bound antioxidants determines the health benefits, is illustrated. In the last part of the work, new perspectives and technological possibilities to enhance the health potential of this cereal component are also highlighted.
Table CIQUAL. Composition nutritionnelle des aliments
  • Centre Anses
ANSES, Centre d'information sur la qualité des aliments, 2017. Table CIQUAL. Composition nutritionnelle des aliments. Retrieved July 30, 2020 from the Ciqual database home Page: http://www.afssa.fr/TableCIQUAL/.
Consumption of ultra-processed foods and its association with added sugar content in the diets of US children
  • Daniela Neri
  • .-S Monteiro
  • Carlos Augusto
  • Renata Levy
  • Bertazzi
Daniela Neri, E.M.-S., Monteiro, Carlos Augusto, Levy, Renata Bertazzi, 2019. Consumption of ultra-processed foods and its association with added sugar content in the diets of US children, NHANES 2009-2014. Ped. Obes. 14, e12563.
Pillars of the Nutrition Transition: the Global Impacts of Ultra-processed Foods and Beverages on Overweight and Obesity and National Nutrient Supplies. The Graduate School of Washington University
  • J Eaton
Eaton, J., 2020. Pillars of the Nutrition Transition: the Global Impacts of Ultra-processed Foods and Beverages on Overweight and Obesity and National Nutrient Supplies. The Graduate School of Washington University, St. Louis, Missouri. PhD thesis.