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OBJECTIVE: Ultraprocessed food (UPF) intake is associated with BMI, but effects on regional adipose depots or related to minimally processed food (MPF) intake are unknown. METHODS: Data included 12,297 adults in the National Health and Nutrition Examination Survey (NHANES), 2011 to 2016. This study analyzed associations between usual percentage of kilocalories from UPFs and MPFs and three adiposity indicators: supine sagittal abdominal diameter to height ratio (SADHtR, estimates visceral adiposity); waist circumference to height ratio (WHtR, estimates abdominal adiposity); and BMI, using linear and multinomial logistic regression. RESULTS: Standardized β coefficients per 10% increase in UPF intake were 0.0926, 0.0846, and 0.0791 for SADHtR, WHtR, and BMI, respectively (all p < 0.001; p > 0.26 for pairwise differences). For MPF intake, the β coefficients were −0.0901, −0.0806, and −0.0688 (all p < 0.001; p > 0.18 pairwise). Adjusted odds ratios (95% CI) for adiposity tertile 3 versus tertile 1 (comparing UPF intake quartiles 2, 3, and 4 to quartile 1) were 1.33 (1.22-1.45), 1.67 (1.43-1.95), and 2.24 (1.76-2.86), respectively, for SADHtR; 1.31 (1.19-1.44), 1.62 (1.37-1.91), and 2.13 (1.63-2.78), respectively, for WHtR; and 1.27 (1.16-1.39), 1.53 (1.31-1.79), and 1.96 (1.53-2.51), respectively, for BMI. MPF intake showed inverse associations with similar trends in association strength. CONCLUSIONS: Among US adults, abdominal and visceral adiposity indictors were positively associated with UPFs and inversely associated with MPFs.

Objective:To explore whether individuals who consume higher amounts of ultra-processed food (UPF) have more adverse mental health symptoms.Design:Using a cross-sectional design, we measured the consumption of UPF as a percentage of total energy intake in kilo-calories using the NOVA food classification system. We explored whether individuals who consume higher amounts of UPF were more likely to report mild depression, more mentally unhealthy days and more anxious days per month using multivariable analyses adjusting for potential confounding variables.Setting:Representative sample from the United States National Health and Nutrition Examination Survey between 2007 and 2012.Participants:10 359 adults aged 18+ without a history of cocaine, methamphetamine or heroin use.Results:After adjusting for covariates, individuals with the highest level of UPF consumption were significantly more likely to report at least mild depression (OR: 1·81; 95 % CI1·09, 3·02), more mentally unhealthy (risk ratio (RR): 1·22; 95 % CI 1·18, 1·25) and more anxious days per month (RR: 1·19; 95 % CI 1·16, 1·23). They were also significantly less likely to report zero mentally unhealthy (OR: 0·60; 95 % CI 0·41, 0·88) or anxious days (OR: 0·65; 95 % CI 0·47, 0·90).Conclusions:Individuals reporting higher intakes of UPF were significantly more likely to report mild depression, more mentally unhealthy and more anxious days and less likely to report zero mentally unhealthy or anxious days. These data add important information to a growing body of evidence concerning the potential adverse effects of UPF consumption on mental health.

BACKGROUND: Ultra-processed foods contribute to risks of obesity and cardiometabolic disease, and higher intakes have been observed in low-income populations in the United States. Consumption of ultra-processed foods may be particularly higher among individuals experiencing food insecurity and participating in the Supplemental Nutrition Assistance Program (SNAP). OBJECTIVES: Using data from the 2007–2016 NHANES, we examined the associations between food insecurity, SNAP participation, and ultra-processed food consumption. METHODS: The study population comprised 9190 adults, aged 20–65 y, with incomes ≤300% of the federal poverty level (FPL). Food insecurity was assessed using the Household Food Security Survey Module and SNAP participation over the past 12 mo was self-reported. Dietary intake was measured from two 24-h dietary recalls. Ultra-processed food consumption (percentage of total energy intake) was defined using the NOVA food classification system. Linear regression models were used to examine the associations between food insecurity, SNAP participation, and ultra-processed food consumption, adjusting for sociodemographic and health characteristics. RESULTS: More severe food insecurity was associated with higher intakes of ultra-processed foods (P-trend = 0.003). The adjusted means of ultra-processed food intake ranged from 52.6% for adults with high food security to 55.7% for adults with very low food security. SNAP participation was also associated with higher intakes of ultra-processed foods (adjusted mean: 54.7%), compared with income-eligible participants (adjusted mean: 53.0%). Furthermore, the association between food insecurity and ultra-processed foods was modified by SNAP participation (P-interaction = 0.02). Among income-eligible nonparticipants and income-ineligible nonparticipants, more severe food insecurity was associated with higher consumption of ultra-processed foods. Among SNAP participants, the association between food insecurity and consumption of ultra-processed foods was nonsignificant. CONCLUSION: In a nationally representative sample of adults, food insecurity and SNAP participation were both associated with higher levels of ultra-processed food consumption.

Background Ultra-processed foods are associated with both sugar intake and noncommunicable diseases. We aimed to assess whether the intake of ultra-processed food is associated with periodontal disease and whether this association, if present, is dependent on non-communicable diseases. Methods This analysis used data from cycles 2009-2010, 2011-2012 and 2013-2014 of the National Health and Nutrition Examination Survey (NHANES), including participants aged 30 years or older. Dietary recalls were categorized according to the NOVA classification, and total contribution of ultra-processed foods to daily energy intake (%E) was calculated. Cases of periodontitis were defined as moderate or severe according to the CDC working group criteria for use in population surveillance of periodontitis. Adjustment variables to estimate total and direct associations were defined with direct acyclic graphs. Odds ratios were estimated with logistic regression for moderate/severe periodontitis and severe periodontitis, and ordinal logistic regression for the trichotomised outcome. Analyses were done using NHANES fasting subsample weights. Results Sample participants numbered 4809 (52.2% female), with a mean age of 52.1 years (SE, 0.3). The prevalence of periodontal disease was 27.8% for moderate and 6.5% for severe cases. Mean %E from ultra-processed foods was 54.4 (SE, 0.5). No significant crude, direct or total association between ultra-processed %E and periodontal disease was found. Conclusion Intake of ultra-processed foods is not associated with periodontal disease in US non-institutionalized adults over 30 years old, whether directly or by mediation. This article is protected by copyright. All rights reserved.

OBJECTIVE To assess whether proportional contribution of unprocessed or minimally processed, processed or ultra-processed foods to daily energy intake is associated with dental caries in US adults. METHODS This secondary cross-sectional analysis included adults aged 20 to 59 years old with complete oral examinations, using data gathered from cycles 2011-2012 and 2013-2014 of the continuous National Health and Nutrition Examination Survey (NHANES). Dietary recall data were categorized according to the NOVA classification into four groups: unprocessed or minimally processed foods (Group 1), processed culinary ingredients (Group 2), processed foods (Group 3) and ultra-processed foods (Group 4). The proportional contribution of each of these groups to mean daily energy intake was calculated and then cut into quartiles (Group 1, Group 3 and Group 4) or tertiles (Group 2). Two separate measures were used to assess dental caries: the decayed, missing, filled teeth (DMFT) index and, after exclusion of edentulous participants, prevalence of untreated caries. Poisson regression was used to model DMFT, while logistic regression was used to model the prevalence of untreated dental caries. Models were calculated for each NOVA group. All models were controlled for age, gender, race/ethnicity, level of education, income, access to oral health services, body mass index, smoking status and total energy intake. Analyses took into account NHANES sampling weights. RESULTS We analysed data from 5720 individuals, of whom 123 (2.2%) were edentulous. Mean DMFT was 9.7 (± 0.2), while the prevalence of untreated dental caries was 26.0%. Mean daily energy intake was 2170 kcal (± 17). Mean contribution to overall daily energy intake was 28.6% (± 0.5) for G1 foods, 4.3% (± 0.1) for G2 foods, 10.1% (± 0.2) for G3 foods and 56.9% (± 0.5) for G4 foods. A higher intake of G3 was associated with lower DMFT at the fourth quartile (0.89; 95%: CI 0.81-0.96), while a higher intake of G4 was associated with a higher DMFT at the fourth quartile (1.10; 95% CI: 1.04-1.16). In the adjusted models for untreated dental caries, no statistically significant associations were found with any of the NOVA groups. CONCLUSION Higher proportional intake of NOVA groups is only weakly associated with dental caries. Widespread exposure to a highly ultra-processed diet may explain these weak associations.

To estimate beef consumption and its influence on carbon and water footprints, as well as to improve the nutritional quality of the Brazilian diet.The amount of beef and other foods consumed was evaluated by two 24-hour food records in a representative sample of the Brazilian population ≥ 10 years of age (n = 32,853) from 2008 to 2009. The environmental impact of the diet considered the coefficients of the carbon footprint (gCO2 and/kg) and the water footprint (liters/kg) of the foods, as well as their nutritional quality considering the nutrient composition of each food associated with the prevention of nutritional deficiencies or the increase/decrease in chronic disease risk. Linear and logistic regression models, crude and adjusted for sex, age, education, income, region, and area, were used to respectively study the association of fifths of the caloric contribution of beef with the environmental impacts of the diet and inadequate nutrient intake.Carbon and water footprints and protein, iron, zinc, vitamin B12, saturated fat, and sodium contents were higher in the fraction of the diet composed of beef, whereas fiber and added sugar contents were higher in the fraction composed by the other foods. Dietary beef contribution was directly associated with the carbon and water footprints of the diet and the risk of saturated fat and sodium excess, besides fiber insufficiency, inversely associated with the risk of protein, iron, zinc, and vitamin B12 insufficiency.Reducing beef consumption in Brazil would also reduce the carbon and water footprints of the diet, as well as the risk of chronic diseases related to food. Therefore, in order not to increase the risk of nutritional deficiencies, monitoring the increased intake of other foods rich in protein, iron, zinc, and vitamin B12 is suggested.

OBJECTIVE To study the association between ultra-processed food consumption and carbon and water footprints of the Brazilian diet. METHODS Cross-sectional analysis on data collected in 2008–2009 on a probabilistic sample of the Brazilian population aged ≥ 10 years (n = 32,886). Individual food intake was assessed using two 24-hour food records, on non-consecutive days. The environmental impact of individual diets was calculated by multiplying the amount of each food by coefficients that quantify the atmospheric emissions of greenhouse gases in grams of carbon dioxide equivalent (carbon footprint) and freshwater use in liters (water footprint), both per gram or milliliter of food. The two coefficients consider the food life cycle ‘from farm to fork.’ Crude and adjusted linear regression models and tests for linear trends assessed the association between the ultra-processed food contribution to total energy intake (quintiles) and the diet carbon and water footprints. Potential confounders included age, sex, education, income, and region. Total energy intake was assessed as a potential mediation variable. RESULTS In the crude models, the dietary contribution of ultra-processed foods was linearly associated with the carbon and water footprints of the Brazilian diet. After adjustment for potential confounders, the association remained significant only regarding the diet water footprint, which increased by 10.1% between the lowest and highest quintile of the contribution of ultra-processed foods. Additional adjustment for total energy intake eliminated this association indicating that the dietary contribution of ultra-processed foods increases the diet water footprint by increasing energy intake. CONCLUSIONS The negative impact of ultra-processed foods on the diet water footprint, shown for the first time in this study, adds to the negative impacts of these foods, already demonstrated regarding dietary nutrient profiles and the risk for several chronic non-communicable diseases. This reinforces the recommendation to avoid ultra-processed foods made in the official Brazilian Dietary Guidelines and increasingly in dietary guidelines of other countries.

OBJECTIVE: To estimate the carbon footprint of the Brazilian diet and of sociodemographic strata of this population. METHODS: Carbon footprint of the diet was estimated based on data from two 24-hour diet records, obtained in 2008 and 2009, from a probabilistic sample of the Brazilian population aged 10 years and over (n = 34,003) and on environmental impact coefficients of food and culinary preparations consumed in Brazil (gCO2e/kg). Means with 95% confidence intervals of food consumption (kcal/person/day) and the carbon footprint of the diet (gCO2e/person/day and in gCO2e/2,000kcal) were calculated for the population as a whole and for strata according to sex, age, income, education, macro-regions and Federative Unit. Linear regression models were used to identify significant differences (p < 0.05) in the dietary carbon footprint of different sociodemographic strata. RESULTS: The average carbon footprint of the Brazilian diet was 4,489gCO2e/person/day. It was higher for males, for the age group from 20 to 49 years and for the North and Midwest regions, and tended to increase with income and education. The pattern of association of footprint with sociodemographic variables did not change substantially with adjustment for differences in the amount of food consumed, except for a reduction in the relative excess of the footprint among males and an increase in the relative excess of the footprint in the Midwest region. CONCLUSION: The carbon footprint of the Brazilian diet exceeds by about 30% the footprint of the human diet, which could simultaneously meet the nutritional requirements of a healthy diet and the global goal of containing the increase in the planet's average temperature. The pattern of association of this footprint with sociodemographic variables can help identify priority targets for public actions aimed at reducing the environmental impacts of food consumption in Brazil. RESUMO OBJETIVO: Estimar a pegada de carbono da dieta brasileira e de estratos sociodemográficos dessa população. MÉTODOS: A pegada de carbono da dieta foi estimada com base nos dados de dois registros alimentares de 24 horas, obtidos em 2008 e 2009, de uma amostra probabilística da população brasileira com 10 ou mais anos de idade (n = 34.003) e em coeficientes de impacto ambiental de alimentos e preparações culinárias consumidos no Brasil (gCO2e/kg). Médias com intervalos de confiança de 95% do consumo alimentar (kcal/pessoa/dia) e da pegada de carbono da dieta (gCO2e/pessoa/dia e em gCO2e/2.000kcal) foram calculadas para o conjunto da população e para estratos segundo sexo, idade, renda, escolaridade, macrorregiões e Unidade Federativa. Modelos de regressão linear foram utilizados para identificar diferenças significativas (p < 0,05) na pegada de carbono da dieta de diferentes estratos sociodemográficos. RESULTADOS: A pegada média de carbono da dieta brasileira foi de 4.489gCO2e/pessoa/dia. Foi maior para o sexo masculino, para a faixa etária de 20 a 49 anos e para as regiões Norte e Centro-Oeste, e tendeu a aumentar com a renda e a escolaridade. O padrão de associação da pegada a variáveis sociodemográficas não se alterou substancialmente com o ajuste para diferenças na quantidade consumida de alimentos, exceto por uma redução no excesso relativo da pegada entre homens e pelo aumento no excesso relativo da pegada na região Centro-Oeste. CONCLUSÃO: A pegada de carbono da dieta brasileira excede em cerca de 30% a pegada da dieta humana que poderia atender, simultaneamente, os requisitos nutricionais de uma dieta saudável e a meta global de contenção do aumento da temperatura média do planeta. O padrão de associação dessa pegada às variáveis sociodemográficas pode auxiliar na identificação de alvos prioritários para ações públicas que visem a reduzir os impactos ambientais do consumo alimentar no Brasil.

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).

Accumulating evidence links ultra-processed foods to poor diet quality and chronic diseases. Understanding dietary trends is essential to inform priorities and policies to improve diet quality and prevent diet-related chronic diseases. Data are lacking, however, for trends in ultra-processed food intake.We examined US secular trends in food consumption according to processing level from 2001 to 2018.We analyzed dietary data collected by 24-h recalls from adult participants (aged19 y; N = 40,937) in 9 cross-sectional waves of the NHANES (2001-2002 to 2017-2018). We calculated participants' intake of minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods as the relative contribution to daily energy intake (%kcal) using the NOVA framework. Trends analyses were performed using linear regression, testing for linear trends by modeling the 9 surveys as an ordinal independent variable. Models were adjusted for age, sex, race/ethnicity, education level, and income. Consumption trends were reported for the full sample and stratified by sex, age groups, race/ethnicity, education level, and income level.Adjusting for changes in population characteristics, the consumption of ultra-processed foods increased among all US adults from 2001-2002 to 2017-2018 (from 53.5 to 57.0 %kcal; P-trend 0.001). The trend was consistent among all sociodemographic subgroups, except Hispanics, in stratified analyses. In contrast, the consumption of minimally processed foods decreased significantly over the study period (from 32.7 to 27.4 %kcal; P-trend 0.001) and across all sociodemographic strata. The consumption of processed culinary ingredients increased from 3.9 to 5.4 %kcal (P-trend 0.001), whereas the intake of processed foods remained stable at ∼10 %kcal throughout the study period (P-trend = 0.052).The current findings highlight the high consumption of ultra-processed foods in all parts of the US population and demonstrate that intake has continuously increased in the majority of the population in the past 2 decades.

Objective:The majority of groceries purchased by US households are industrially processed, yet it is unclear how processing level influences diet quality. We sought to determine if processing level is associated with diet quality of grocery purchases.Design:We analysed grocery purchasing data from the National Household Food Acquisition and Purchase Survey 2012–2013. Household grocery purchases were categorized by the NOVA framework as minimally processed, processed culinary ingredients, processed foods or ultra-processed foods. The energy share of each processing level (percentage of energy; %E) and Healthy Eating Index-2015 (HEI-2015) component and total scores were calculated for each household’s purchases. The association between %E from processed foods and ultra-processed foods, respectively, and HEI-2015 total score was determined by multivariable linear regression. Foods purchased by households with the highest v. lowest ultra-processed food purchases and HEI-2015 total score v. ≥60 were compared using linear regression.Setting:USA.Participants:Nationally representative sample of 3961 households.Results:Processed foods and ultra-processed foods provided 9·2 (se 0·3) % and 55·8 (se 0·6) % of purchased energy, respectively. Mean HEI-2015 score was 54·7 (se 0·4). Substituting 10 %E from minimally processed foods and processed culinary ingredients for ultra-processed foods decreased total HEI-2015 score by 1·8 points (β = −1·8; 95 % CI −2·0, −1·5). Processed food purchases were not associated with diet quality. Among households with high ultra-processed food purchases, those with HEI-2015 score Conclusions:Increasing purchases of minimally processed foods, decreasing purchases of ultra-processed foods and selecting healthier foods at each processing level may improve diet quality.

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 (