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Objective:To investigate the association between different versions of a provegetarian food pattern (FP) and micronutrient inadequacy.Design:Cross-sectional analysis. Dietary intake was assessed at baseline through a validated 136-item FFQ. Participants were classified according to groups of different versions of a provegetarian FP: overall, healthful and unhealthful. The prevalence of inadequate intake of vitamins B1, B2, B3, B6, B12, C, A, D, E, folic acid, Zn, I, Se, Fe, Ca, K, P, Mg and Cr was evaluated using the estimated average requirement (EAR) cut-point method and the probabilistic approach. Logistic regression analyses were conducted to estimate the probability of failing to meet EAR for either ≥ 3 or ≥ 6 micronutrients.Setting:Seguimiento Universidad de Navarra (SUN) cohort.Participants:17 825 Spanish adults.Results:Overall, subjects in the highest group of the unhealthful provegetarian FP had the highest prevalence of inadequate dietary intake for every vitamin and mineral, compared to those in the lowest group. The adjusted OR of failing to meet ≥ 3 EAR (highest v. lowest group) was 0·65 (0·54, 0·69) for the overall, 0·27 (0·24, 0·31) for the healthful and 9·04 (7·57, 10·4) for the unhealthful provegetarian FP.Conclusion:A higher adherence to an overall and healthful provegetarian FP was inversely associated with the risk of failing to meet EAR values, whereas the unhealthful version was directly associated with micronutrient inadequacy. Provegetarian FP should be well planned, prioritising nutrient-dense plant foods and minimising ultra-processed and unhealthy ones.

BACKGROUND: Diets that reduce reliance on animal-source foods are recommended in some contexts. OBJECTIVES: This study aimed to compare proportions of respondents who reported following meat-reduced dietary practices (i.e., vegetarian, vegan, or pescatarian diets) and/or making efforts to reduce animal-source foods, and to examine sociodemographic correlates across 5 countries. METHODS: Online surveys were conducted in November and December 2018 and 2019 with 41,607 adults from Australia (n = 7926), Canada (n = 8031), Mexico (n = 8110), the United Kingdom (n = 9129), and the United States (n = 8411) as part of the International Food Policy Study. Respondents were asked whether they would describe themselves as vegetarian, vegan, or pescatarian, and whether they had made efforts to consume less red meat, less of all meats, or less dairy in the past year. Logistic regressions examined differences in the likelihood of each behavior between countries and sociodemographic subgroups. RESULTS: Approximately 1 in 10 respondents reported following a vegetarian, vegan, or pescatarian diet, ranging from 8.6% (Canada) to 11.7% (UK). In the past 12 months, the proportions of respondents who reported efforts to consume less red meat ranged from 34.5% (Australia) to 44.4% (Mexico), less of all meats ranged from 27.9% (US) to 35.2% (Mexico), and to consume less dairy ranged from 20.6% (UK) to 41.3% (Mexico). Respondents were more likely to report efforts to consume less animal-source products in 2019 compared to 2018 in most countries. Sociodemographic patterns varied by country; in general, women, those with higher education levels, and those in minority ethnic groups were more likely to report following meat-reduced dietary practices or efforts to consume fewer animal-source products. CONCLUSIONS: Nearly half of respondents reported following a meat-reduced diet or efforts to reduce animal-source products, with differences between countries and population subgroups. Population-level approaches and policies that support meat reduction may further reduce consumption of animal-source products.

Background Food retail environments have an influential role in shaping purchasing behavior and could contribute to improving dietary patterns at a population level. However, little is known about the level of public support for different types of initiatives to encourage healthy food choices in supermarkets, and whether this varies across countries or context. The current study aimed to explore the level of support for three potential supermarket initiatives focused on product placement across five countries, and factors that may influence this support. Methods A total of 22,264 adults from Australia, Canada, Mexico, the United Kingdom and the United States (US) provided information on support for three supermarket initiatives related to product placement (targeting product positioning: ‘checkouts with only healthy products’, ‘fewer end-of-aisle displays containing unhealthy foods or soft drinks’ or availability: ‘more shelf space for fresh and healthier foods’) as part of the online 2018 International Food Policy Study. The proportion of respondents that supported each initiative was assessed across countries, and multivariable logistic regression analyses were conducted to evaluate the influence of sociodemographic factors on support. Results The initiative that received the highest support was ‘more shelf space for fresh and healthier foods’: 72.0% [95% CI 71.3–72.7], whereas ‘checkouts with only healthy products’ received the lowest support: 48.6% [95% CI 47.8–49.4]. The level of support differed between countries (p Conclusions Most people in the assessed five countries showed a generally high level of support for three placement initiatives in supermarkets to encourage healthy food choices. Support varied by type of initiative (i.e., product positioning or availability) and was influenced by several factors related to country context and sociodemographic characteristics. This evidence could prompt and guide retailers and policy makers to take stronger action to promote healthy food choices in stores.

A growing body of evidence shows that consumption of ultra-processed foods (UPF) is associated with a higher risk of cardiometabolic diseases, which, in turn, have been linked to depression. This suggests that UPF might also be associated with depression, which is among the global leading causes of disability and disease. We prospectively evaluated the relationship between UPF consumption and the risk of depression in a Mediterranean cohort. We included 14,907 Spanish university graduates [mean (SD) age: 36.7 year (11.7)] initially free of depression who were followed up for a median of 10.3 years. Consumption of UPF (industrial formulations made mostly or entirely from substances derived from foods and additives, with little, if any, intact food), as defined by the NOVA food classification system, was assessed at baseline through a validated semi-quantitative 136-item food-frequency questionnaire. Participants were classified as incident cases of depression if they reported a medical diagnosis of depression or the habitual use of antidepressant medication in at least one of the follow-up assessments conducted after the first 2 years of follow-up. Cox regression models were used to assess the relationship between UPF consumption and depression incidence. A total of 774 incident cases of depression were identified during follow-up. Participants in the highest quartile of UPF consumption had a higher risk of developing depression [HR (95% CI) 1.33 (1.07–1.64); p trend = 0.004] than those in the lowest quartile after adjusting for potential confounders. In a prospective cohort of Spanish university graduates, we found a positive association between UPF consumption and the risk of depression that was strongest among participants with low levels of physical activity.

We aimed to investigate the relationship between the pre-gestational consumption of ultra-processed foods (UPF) and the risk of gestational diabetes (GDM). We carried out a prospective study among 3730 Spanish women of the SUN cohort who reported at least one pregnancy after baseline recruitment. Cases of GDM were identified among women with a confirmed diagnosis of GDM. UPF consumption was assessed through a validated, semi-quantitative food frequency questionnaire and the frequency of UPF consumption was categorized in tertiles. We identified 186 cases of GDM. In the pooled sample, we did not observe a significant association of UPF with the risk of GDM. When we stratified by age, the multivariate OR for the third tertile of UPF consumption compared with the lowest one was 2.05 (95% CI 1.03, 4.07) in women aged ≥30 years at baseline (Ptrend = 0.041). The association remained significant in a sensitivity analysis after changing many of our assumptions and adjusting for additional confounders. No association between a higher UPF consumption and GDM risk was observed in women aged 18–29 years. The pre-gestational UPF consumption may be a risk factor for GDM, especially in women aged 30 years or more. Confirmatory studies are needed to validate these findings.

Objetivo: Cuantificar el impacto de reducir el consumo de carnes rojas y procesadas sobre la mortalidad cardiovascular y la mortalidad total de la población adulta española, basado en 5 revisiones publicadas. Participantes y mediciones principales: Se define la exposición como el consumo de ≥ 3 raciones/ semana de carnes rojas o procesadas, y se consideran cuatro escenarios de población expuesta (30-60%). Con datos del Instituto Nacional de Estadística, se calcula la mortalidad ponderada en población española de 40-80 años y, utilizando los riesgos relativos (RR) y los intervalos de confianza (IC) al 95% publicados en 5 revisiones (RR = 0,88; IC 95%: 0,84-0,93 para mortalidad por todas las causas y RR = 0,92; IC 95%: 0,90-0,93 para la mortalidad cardiovascular), se calculó la tasa de mortalidad en expuestos y no expuestos. Multiplicando esas tasas por el número de expuestos, se obtuvo el número de muertes atribuibles. Resultados: Asumiendo un 60% de población española de 40-80 años expuesta, el número de muertes anuales de causa cardiovascular que se podrían evitar consumiendo < 3 raciones/semana de carnes rojas o procesadas con un IC 95% está entre 2.112 y 3.055. Si la población expuesta fuese un 30% se podrían evitar entre 1.079 y 1.577 muertes. Conclusiones: Incluso bajo el supuesto más conservador, el beneficio poblacional de reducir el consumo de carnes rojas o procesadas sobre la mortalidad cardiovascular y total sería muy importante. Las conclusiones de las revisiones mencionadas contradicen sus propios resultados y contribuyen a un estado de confusión que representa un daño a la salud pública., Objective: Quantify the impact of reducing the consumption of red/processed meats on cardio-vascular mortality and all-cause mortality of the Spanish adult population based in 5 revisionspublished.Participants and main measurements: We defined exposure as consumption of ≥ 3 ser-vings/week of red or processed meats and considered four possible scenarios of exposedpopulation (30%-60%). Based on data from the Spanish National Statistics Institute, we cal-culated the weighted mortality between 40 and 80 years. Using the relative risks (RR) and 95%confidence intervals (CI) published by the referred revisions (RR = 0.88; IC 95%: 0.84-0.93 forall-cause mortality and RR = 0.92; IC 95%: 0.90-0.93 for cardiovascular mortality), we calcula-ted the expected mortality rate in both exposed and unexposed categories. By multiplying theserates by the number of exposed individuals, we estimated the attributable number of yearlydeaths.Results: If 60% of the population was exposed, with a 95% CI, the number of cardiovasculardeaths that could be averted each year if population consumed < 3 servings/week of red orprocessed meats was between 2.112 and 3.055. If was exposed that 30%, the difference in theyearly number of potentially averted deaths was between 1.079 and 1.577.Conclusions: Even under the most conservative assumption, the benefit, at the population level,of reducing red or processed meats consumption < 3 servings/week on cardiovascular mortalityis important. The conclusions of the recently published reviews contradicted their own resultsand contributed to a state of confusion that can create substantial harm for public health.

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.

Background & aims Front-of-pack nutrition labelling is a key public health policy that can be adopted as part of a comprehensive set of measures to promote healthy diets. The Nutri-Score, a five-colour summary label based on a modified version of the British Food Standards Agency Nutrient Profiling System (FSAm-NPS), is being considered for implementation in several European countries including Spain. This study aimed to prospectively assess the association between the FSAm-NPS and mortality rate in a Spanish cohort of university graduates. Methods Analyses included 20 503 participants (mean [SD] age: 38 [12] years) from the SUN cohort. Dietary intake was assessed at baseline and after 10-years of follow-up with a validated semi-quantitative food-frequency questionnaire. The FSAm-NPS was calculated for each food/beverage based on their amount of energy, saturated fat, sugar, sodium, fibre, protein, fruits, vegetables, legumes, nuts, rapeseed, walnut and olive oils per 100 g of product. The FSAm-NPS Dietary Index (DI) was computed as an energy-weighted mean of the FSAm-NPS scores of all foods and beverages consumed by each participant. Multivariable-adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality according to baseline and updated FSAm-NPS DI scores. Results Over a median follow-up of 10.9 years, 407 participants died. A higher baseline FSAm-NPS DI score, reflecting consumption of foods with lower nutritional quality and hence less favourable Nutri-Score rating, was directly associated with all-cause mortality (HR Q4 versus Q1 = 1.82; 95% CI: 1.34 to 2.47; p-trend

Background & aims: Given the enormous health, economic and societal consequences of the obesity pandemic, identifying effective primary prevention strategies represents a global priority. The aim of this study was to provide evidence on the association between adherence to a food-based score reflecting a set of targeted, well-informed, simple dietary recommendations and the incidence of overweight/obesity. Methods: A total of 11,349 initially free of overweight/obesity young adults (mean [SD] age: 34.7 y [10.7]), were followed up biennially during a median of 9.3 years. The Dietary Obesity-Prevention Score (DOS) was created based on a priori evidence of foods associated with weight changes. The DOS positively weighted the consumption of vegetables, fruits, legumes, yogurt, nuts, fish, and a ratio of vegetable to animal protein; whereas the consumption of red meat, processed meat, saturated animal fat, refined grains, ultra-processed food, sugary beverages, beer and spirits were inversely weighted. Energy-adjusted tertiles of each item were used to build the DOS, ranging from 14 (lowest adherence) to 42 points (highest adherence). Adherence to the DOS was calculated at baseline and after 10 years of follow-up. We assessed both incident overweight/obesity (BMI ≥25 kg/m2) and average yearly weight changes in grams per year (g/y). Results: During 104,887 person-years, 2153 incident cases of overweight/obesity were identified. A higher adherence to the DOS at baseline was significantly associated with lower risk of future development of overweight/obesity [multivariable-adjusted HR (95% CI) for the highest vs. lowest quintile = 0.63 (0.54–0.74)], with a significant linear dose–response relationship (p for trend < 0.001). When the analyses were updated with repeated measures, the results were similar and remained statistically significant. Consistently, increases in average yearly weight gain were significantly lower with better adherence to the DOS. Conclusions: In this Mediterranean cohort of university graduates, a higher adherence to a food-based score was significantly associated with lower risk of overweight/obesity and lower average annual weight gain. These findings may help counsel patients regarding dietary risks and raise awareness of weight gain before the onset of overweight/obesity. Refereed/Peer-reviewed

Provegetarian diets (i.e., preference for plant-derived foods but not exclusion of animal foods) have been associated with a reduced risk of long-term weight gain and could be more easily embraced than strict vegetarian diets. However, not all plant-derived foods are equally healthy. In the &ldquo, Seguimiento Universidad de Navarra&rdquo, (SUN) cohort, we prospectively evaluated the association between different provegetarian food patterns and the incidence of overweight/obesity in 11,554 participants with initial body mass index &lt, 25 kg/m2. A provegetarian food pattern (FP) was built by assigning positive scores to plant foods and reverse scores to animal foods. A healthful and an unhealthful provegetarian FP, which distinguished between healthy (fruits/vegetables/whole grains/nuts/legumes/olive oil/coffee) and less-healthy plant foods (fruit juices/potatoes/refined grains/pastries/sugary beverages), were also built. A total of 2320 new cases of overweight or obesity were identified after a median follow-up of 10.3 years. Higher baseline conformity with the overall provegetarian FP was inversely associated with overweight/obesity (HR comparing extreme quintiles: 0.85, 95% CI: 0.75 to 0.96, p-trend: 0.014). This association was stronger for the healthful FP (HR: 0.78, 95% CI: 0.67 to 0.90, p-trend: &lt, 0.001) and was not apparent for the unhealthful FP (HR: 1.07, 95% CI: 0.92 to 1.23, p-trend: 0.551). In a large prospective cohort of relatively young adults, better conformity with a healthy provegetarian diet was associated with a reduced long-term risk of overweight/obesity, whereas no consistent trend was found for a FP that emphasized less-healthy plant foods.

Background: Ultra-processed foods (UPFs) consumption has increased in the past decade. Because of its nutritional composition, evidence suggests a potential association between UPFs consumption and higher risk of all-cause mortality. No prospective study has investigated this relationship. Methods: We evaluated the association between UPFs consumption and the risk of mortality in a dynamic, prospective Spanish cohort of university graduates, the "Seguimiento Universidad de Navarra" (SUN) study. We used data from 19,897 participants followed-up between December 1999 and February 2014 for a median of 10·4 years with a retention rate of 90·9%. UPFs consumption (defined as food and drink products ready to eat, drink, or heat and made predominantly or entirely from processed items extracted or refined from whole foods or synthesized in the laboratory) was assessed with the use of a validated semi-quantitative 136-item foodfrequency questionnaire (FFQ). We adjusted UPFs consumption for energy intake using the residuals method. Participants were classified according to their energy-adjusted UPFs consumption into quartiles. Cox proportional hazards models were used to estimate adjusted Hazards Ratio (HR) and 95% confidence intervals (CI) for all-cause mortality. Findings: We registered 335 deaths in 198,556 persons-years of follow-up. Participants in the highest quartile of UPFs consumption had a higher risk for all-cause mortality compared to those in the first quartile (multivariable-adjusted HR=1·62; 95% CI: 1·13-2·32) with a significant dose-response trend (p for linear trend=0·005). For each additional serving of UPFs consumption, mortality relatively increased by 9% (HR=1·09; 95% CI: 1·02-1·17). Interpretation: UPFs consumption was associated with an increased risk for all-cause mortality in a prospective cohort of Spanish middle-aged adult university graduates. Further longitudinal studies are needed to confirm our results. Funding Statement: The SUN Project has been supported by the Spanish Government-Instituto de Salud Carlos III, and the European Regional Development Fund (FEDER) (RD 06/0045, PI14/01798, PI14/01764, PI17/01795), the Navarra Regional Government, and the University of Navarra. Declaration of Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Ethics Approval Statement: The Institutional Review Board (IRB) of the University of Navarra approved the protocol and the methods used to obtain consent of participants, conforming to the principles embodied in the Declaration of Helsinki. The SUN project was registered at clinicaltrials.gov as NCT02669602.

OBJECTIVES: We assessed the population impact of the joint effect of the Mediterranean Diet (MedDiet) and physical activity (PA) in a Spanish cohort. METHODS: We used data from the SUN (“Seguimiento Universidad de Navarra) study, a dynamic cohort of university graduates. We used a MedDiet score (MDS) of 0–9 points and PA score of 0–8 points. Adjusted multivariable Cox regression models were used to study the individual and joint effects of the MedDiet and PA on all-cause mortality. To assess adherence to MDS, PA, or the combination of both, the highest tertiles of each served as references. P-values for interaction were calculated for the Relative Risk due to Interaction (RERI) and the attributable proportion due to interaction. We calculated the population attributable risk (PAR) and the rate advancement period (RAP) as the aging effect attributable to the lowest combination of MDS and PA score. RESULTS: We recruited 20,127 participants, 61.5% female and 37 years-old mean age. After a mean follow-up of 10.9 months, 347 deaths were confirmed. The lowest adherence to PA was associated with a 69% increased risk of all-cause mortality compared with the highest tertile (95%CI;1.32–2.17). MDS, as a continuous variable, was also inversely significantly associated with total mortality. The joint effect showed a trend towards an increased risk for all-cause mortality. Using the highest MedDiet and PA as reference, the HR for death in participants with lowest adherence to both was 2.08 (1.28–3.37). We observed a positive but non-significant additive interaction between MedDiet and PA (RERI for the lowest MedDiet and PA = 0.54, (95% CI;0.64–1.72, P = 0.367). We estimated that 48% (95%CI; −0.33–1.30) of the joint effect was attributable to the interaction between MedDiet and PA. The RAP for participants with the lowest tertiles of both MedDiet and PA was 10 years (95% CI: 2.97–17.13). An estimated 28% (95% CI: 11%–43%) of all premature deaths may have been prevented if all participants exhibited high MedDiet and PA levels. CONCLUSIONS: A combination of poor MedDiet adherence and low PA levels account for almost 30% of all-cause mortality. Public health interventions combining both diet and PA could have a substantial impact at the population level. FUNDING SOURCES: Spanish Government-Instituto de Salud Carlos III, European Fund for Regional & Economic Development, CIBER-OBN, Navarra Government. SUPPORTING TABLES, IMAGES AND/OR GRAPHS

Objective To evaluate the association between consumption of ultra-processed foods and all cause mortality. Design Prospective cohort study. Setting Seguimiento Universidad de Navarra (SUN) cohort of university graduates, Spain 1999-2018. Participants 19 899 participants (12 113 women and 7786 men) aged 20-91 years followed-up every two years between December 1999 and February 2014 for food and drink consumption, classified according to the degree of processing by the NOVA classification, and evaluated through a validated 136 item food frequency questionnaire. Main outcome measure Association between consumption of energy adjusted ultra-processed foods categorised into quarters (low, low-medium, medium-high, and high consumption) and all cause mortality, using multivariable Cox proportional hazard models. Results 335 deaths occurred during 200 432 persons years of follow-up. Participants in the highest quarter (high consumption) of ultra-processed foods consumption had a higher hazard for all cause mortality compared with those in the lowest quarter (multivariable adjusted hazard ratio 1.62, 95% confidence interval 1.13 to 2.33) with a significant dose-response relation (P for linear trend=0.005). For each additional serving of ultra-processed foods, all cause mortality relatively increased by 18% (adjusted hazard ratio 1.18, 95% confidence interval 1.05 to 1.33). Conclusions A higher consumption of ultra-processed foods (>4 servings daily) was independently associated with a 62% relatively increased hazard for all cause mortality. For each additional serving of ultra-processed food, all cause mortality increased by 18%. Study registration ClinicalTrials.gov NCT02669602 .

OBJECTIVES: Provegetarian diets (i.e., preference for plant-derived foods) have been associated with a reduced risk of long-term weight gain and could be more easily embraced than strict vegetarian diets. However, not all plant-derived foods are equally healthy. The objective was to identify the association between provegetarian food patterns and the incidence of overweight/obesity. METHODS: The analysis included 11,554 participants with a baseline BMI