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Background: Cooking at home has been promoted as a strategy to improve diet quality; however, the association between cooking behavior and ultra-processed food intake is unknown., Objective: The objective of this study was to examine associations between frequency of cooking dinner at home and time spent cooking dinner with ultra-processed food intake., Design: Cross-sectional, nationally representative data from the 2007-2010 National Health and Nutrition Examination Survey were analyzed., Participants/setting: Participants were 9,491 adults (20 years and older) in the United States., Main Outcome Measures: The main outcome measure was the proportion of energy intake (averaged from two 24-hour dietary recalls) from the following 4 Nova food-processing groups: (1) unprocessed or minimally processed foods, (2) processed culinary ingredients, (3) processed foods, and (4) ultra-processed foods., Statistical Analyses Performed: Separate linear regression models examined associations between cooking frequency and time spent cooking dinner and proportion of energy intake from the 4 Nova food-processing groups, adjusting for sociodemographic characteristics and total energy intake., Results: Ultra-processed foods comprised >50% of energy consumed independent of cooking frequency or time spent cooking. Higher household frequency of cooking dinner and greater time spent cooking dinner were both associated with lower intake of ultra-processed foods (P trends < .001) and higher intake of unprocessed or minimally processed foods (P trends < .001) in a dose-response manner. Compared with cooking 0 to 2 times/wk, adults who cooked dinner 7 times/wk consumed a mean of 6.30% (95% CI -7.96% to -4.64%; P < .001) less energy from ultra-processed foods. Adults who spent more than 90 minutes cooking dinner consumed 4.28% less energy from ultra-processed foods (95% CI -6.08% to -2.49%; P < .001) compared with those who spent 0 to 45 minutes cooking dinner., Conclusions: Cooking at home is associated with lower consumption of ultra-processed foods and higher consumption of unprocessed or minimally processed foods. However, ultra-processed food intake is high among US adults regardless of cooking frequency., (Copyright © 2024 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Ultraprocessed foods (UPFs) comprise >50% of United States adults' energy intake, with the proportion of calories from UPFs increasing over time and the proportion of unprocessed/minimally processed foods (MPFs) decreasing over time. Whether UPFs are primarily consumed at home (AH) or away from home (AFH) is important to inform policies and messages to improve dietary quality., Objectives: We examined trends in consumption of UPFs and MPFs AH and AFH in a nationally representative sample of United States adults and within sociodemographic subgroups., Methods: Data are from 34,628 adults (aged ≥20 y) with two 24-h dietary recalls from the 2003-2018 National Health and Nutrition Examination Survey. We examined trends over time in intake from MPFs and UPFs as a proportion of total energy intake and as a proportion of AH energy intake and AFH energy intake using generalized linear models adjusted for sex, age, race/ethnicity, education, and household income. We examined differences in trends by sociodemographic subgroups using interaction terms and stratified models., Results: Overall, and for most demographic subgroups, UPFs comprised >50% of AH energy intake and >50% of AFH energy intake, with UPFs increasing and MPFs decreasing over time as a proportion of energy intake AH and AFH. The proportion of total energy intake from UPFs increased for food consumed AH (33.6%-37.1%, P-trend < 0.001), but not for UPFs consumed AFH (19.5%-18.8%, P-trend = 0.88). From 2003-2004 to 2017-2018, the proportion of total energy intake from MPFs declined for foods consumed AH (23.6%-20.8%, P-trend <0.001) and AFH (9.7%-7.5%, P-trend <0.001). Interaction terms testing differences in trends of MPF and UPF intake AH and AFH by sociodemographic subgroups were mostly nonsignificant., Conclusions: Findings highlight the ubiquity and increasing proportion of UPFs in United States adults' diets regardless of whether foods are consumed AH or AFH., (Copyright © 2024 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.)

Background: Molar sums are often used to quantify total phthalate exposure, but they do not capture patterns of exposure to multiple phthalates., Objective: To introduce an exposure burden score method for quantifying exposure to phthalate metabolites and examine the association between phthalate burden scores and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR)., Methods: We applied item response theory (IRT) to data from 3474 adults aged 20-60 years in the 2013-2018 National Health and Examination Survey (NHANES) to quantify latent phthalate exposure burden from 12 phthalate metabolites. We compared model fits of three IRT models that used different a priori groupings (general phthalate burden; low molecular weight (LMW) and high molecular weight (HMW) burdens; and LMW, HMW and DEHP burden), and used the best fitting model to estimate phthalate exposure burden scores. Regression models assessed the covariate-adjusted association between phthalate burden scores and HOMA-IR. We compared findings to those using molar sums. In secondary analyses, we examined how the IRT model could be used for data harmonization when a subset of participants are missing some phthalate metabolites, and accounted for measurement error of the phthalate burden scores in estimating associations with HOMA-IR through a resampling approach using plausible value imputation., Results: A three correlated factors model (LMW, HMW and DEHP burdens) provided the best fit. One interquartile range (IQR) increase in DEHP burden score was associated with 0.094 (95% CI: 0.022, 0.164, p = 0.010) increase in log HOMA-IR, co-adjusted for LMW and HMW burden scores. Findings were consistent when using log molar sums. Associations of phthalate burden and insulin resistance were also consistent when participants were simulated to be missing some phthalate metabolites, and when we accounted for measurement error in estimating burden scores., Conclusion: Both phthalate molar sums and burden scores are sensitive to associations with insulin resistance. Phthalate burden scores may be useful for data harmonization., (© 2023. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Purpose: Ultra-processed food may play a role in facilitating snacking behavior because of their convenience and low satiety potential. This study aimed to describe the association between consumption of ultra-processed foods and frequency of snacking., Methods: We analyzed data from 46,164 participants (≥ 10 years old) in the 2017-2018 Brazilian Household Budget Survey. Dietary data were collected by 24-h dietary recalls over one or two days for each participant. We estimated energy intake, ultra-processed food consumption, and level of snacking. We measured the association between ultra-processed food consumption and level of snacking using multinomial logistic regression, stratified by age group (adolescents, 10-19 years old; adults, 20-64 years old; elders, 65 or older)., Results: We found a statistically significant tendency of increased daily energy intake and consumption of snacks and that ultra-processed food consumption was positively associated with the level of snacking for all age groups. For adolescents, adults, and elders in the highest quintile of ultra-processed food consumption as a share of their entire diet, the relative risk ratio (95% CI) of having more than two snacks per day compared to no snacks was 14.21 (9.09-22.21), 4.44 (3.54-5.57), and 4.21 (2.67-6.64), respectively, when compared to the lowest quintile., Conclusion: Higher consumption of ultra-processed food was associated with snacking behavior, and the strength of this association was stronger among adolescents. Efforts to mitigate ultra-processed food attributes that facilitate snacking should be incorporated into strategies to promote healthier food choices, especially among adolescents., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Consumption of ultra-processed food (UPF) has been associated with several chronic diseases and poor diet quality. It is reasonable to speculate that the consumption of UPF negatively associates with flavonoid dietary intake; however, this assumption has not been previously examined. The present study aims to assess association between the dietary contribution of UPF and flavonoid intake in the US population aged 0 years and above. We performed a cross-sectional analysis of dietary data collected by 24-h recalls from 7640 participants participating in the National Health and Nutrition Examination Survey 2017-2018. Foods were classified according to the Nova classification system. The updated US Department of Agriculture (USDA) Database for the Flavonoid Content of Selected Foods (Release 3.3) database was used to estimate total and six classes of flavonoid intakes. Flavonoid intakes were compared across quintiles of dietary contribution of UPF (% of total energy intake) using linear regression models. The total and five out of six class flavonoid intakes decreased between 50 and 70 % across extreme quintiles of the dietary contribution of UPF ( P for linear trend < 0·001); only isoflavones increased by over 260 %. Our findings suggest that consumption of UPF is associated with lower total and five of six class flavonoid intakes and with higher isoflavone intakes, supporting previous evidence of the negative impact of UPF consumption on the overall quality of the diet and health outcomes.

Introduction: Dietary quality is poor and intake of ultraprocessed foods (UPFs) is high among children and adolescents in the United States. Low dietary quality and high UPF intake are associated with obesity and higher risk of diet-related chronic diseases. It is unknown whether household cooking behavior is related to improved dietary quality and lower consumption of UPFs among US children and adolescents. Methods: Nationally representative data from the 2007-2010 National Health and Nutrition Examination Survey ( n  = 6032 children and adolescents ≤19 years of age) were used to examine the relationships between household cooking frequency of evening meals and children's dietary quality and UPF intake using multivariate linear regression models adjusted for sociodemographics. Two 24-hour diet recalls were used to assess UPF intake and dietary quality [Healthy Eating Index-2015 (HEI-2015)]. Food items were categorized according to Nova classification to obtain the UPF percent of total energy intake. Results: A higher household frequency of cooking dinner was associated with lower UPF intake and higher overall dietary quality. Compared to children in households cooking dinner 0-2 times per week, children in households cooking dinner 7 times/week had lower intake of UPFs [β = -6.30, 95% confidence interval (CI) -8.81 to -3.78, p  < 0.001] and marginally higher HEI-2015 scores (β = 1.92, 95% CI -0.04 to 3.87, p  = 0.054). The trends toward lower UPF intake ( p -trend <0.001) and higher HEI-2015 scores ( p -trend = 0.001) with increasing cooking frequency were significant. Conclusions: In this nationally representative sample of children and adolescents, more frequent cooking at home was associated with lower intake of UPFs and higher HEI-2015 scores.

Objective: To assess the prospective association of two diet quality scores based on the Nova food classification with BMI gain., Design: The NutriNet-Brasil cohort is an ongoing web-based prospective study with continuous recruitment of participants aged ≥ 18 years since January 2020. A short 24-h dietary recall screener including 'yes/no' questions about the consumption of whole plant foods (WPF) and ultra-processed foods (UPF) was completed by participants at baseline. The Nova-WPF and the Nova-UPF scores were computed by adding up positive responses regarding the consumption of thirty-three varieties of WPF and twenty-three varieties of UPF, respectively. Participants reported their height at baseline and their weight at both baseline and after approximately 15 months of follow-up. A 15-month BMI (kg/m 2 ) increase of ≥5 % was coded as BMI gain., Setting: Brazil., Participants: 9551 participants from the NutriNet-Brasil cohort., Results: Increasing quintiles of the Nova-UPF score were linearly associated with higher risk of BMI gain (relative risk Q5/Q1 = 1·34; 95 % CI 1·15, 1·56), whereas increasing quintiles of the Nova-WPF score were linearly associated with lower risk (relative risk Q5/Q1 = 0·80; 95 % CI 0·69, 0·94). We identified a moderate inverse correlation between the two scores (-0·33) and a partial mediating effect of the alternative score: 15 % for the total effect of the Nova-UPF score and 25 % for the total effect of the Nova-WPF score., Conclusions: The Nova-UPF and Nova-WPF scores are independently associated with mid-term BMI gain further justifying their use in diet quality monitoring systems.

Our objective was to convene interdisciplinary experts from government, academia, and industry to develop a Research Roadmap to identify research priorities about processed food intake and risk for obesity and cardiometabolic diseases (CMD) among United States populations. We convened attendees at various career stages with diverse viewpoints in the field. We held a "Food Processing Primer" to build foundational knowledge of how and why foods are processed, followed by presentations about how processed foods may affect energy intake, obesity, and CMD risk. Breakout groups discussed potential mechanistic and confounding explanations for associations between processed foods and obesity and CMD risk. Facilitators created research questions (RQs) based on key themes from discussions. Different breakout groups convened to discuss what is known and unknown for each RQ and to develop sub-RQs to address gaps. Workshop attendees focused on ultra-processed foods (UPFs; Nova Group 4) because the preponderance of evidence is based on this classification system. Yet, heterogeneity and subjectivity in UPF classification was a challenge for RQ development. The 6 RQs were: 1) What objective methods or measures could further categorize UPFs, considering food processing, formulation, and the interaction of the two? 2) How can exposure assessment of UPF intake be improved? 3) Does UPF intake influence risk for obesity or CMDs, independent of diet quality? 4) What, if any, attributes of UPFs influence ingestive behavior and contribute to excess energy intake? 5) What, if any, attributes of UPFs contribute to clinically meaningful metabolic responses? 6) What, if any, external environmental factors lead people to consume high amounts of UPFs? Uncertainty and complexity around UPF intake warrant further complementary and interdisciplinary causal, mechanistic, and methodological research related to obesity and CMD risk to understand the utility of applying classification by degree of processing to foods in the United States., (Published by Elsevier Inc.)

Objective: This paper describes the first web-based self-completed 24-h recall designed to categorise food intake according to Nova groups - Nova24h - and its agreement with a reference tool in estimating the dietary relative contribution of the four Nova food groups (% of total energy intake)., Design: Comparisons of estimates of dietary relative contributions of Nova groups obtained by Nova24h and one standard interviewer-led 24-h recall., Setting: Nationwide adult cohort study in Brazil., Participants: The subjects were 186 participants of the NutriNet Brasil Cohort Study ( n 186)., Results: No statistically significant differences were observed between the Nova24h and the reference tool mean contributions of unprocessed or minimally processed foods (52·3 % v . 52·6 %), processed culinary ingredients (11·6 % v . 11·9 %), processed foods (17·1 % v . 14·7 %) and ultra-processed foods (19·0 % v . 20·9 %). Intraclass correlation coefficients between individual estimates obtained for each Nova group showed moderate to good agreement (0·54-0·78). Substantial or almost perfect agreement between the tools was seen regarding the ability to rank participants according to quintiles of contribution of each Nova group (PABAK 0·69-0·81)., Conclusions: Nova24h is a suitable tool for estimating the dietary relative energy contribution of Nova food groups in the NutriNet Brasil cohort. New studies are necessary to verify its adequacy in other populations.

Background: The effect of ultra-processed foods (UPF) on NAFLD remains unclear. Related evidence for adult NAFLD is limited and no study has yet evaluated UPF's impact on NAFLD in adolescence., Methods: We used data from the National Health and Nutrition Examination Survey (2017-2018) with 806 adolescents and 2734 adults. UPF intake was estimated using dietary data from two 24-hour dietary recalls. NAFLD was defined by transient elastography. Logistic regression was used to estimate the multivariable OR and 95% CI for associations between UPF and NAFLD with survey weight adjustments., Results: The mean UPF intake was 812 g/d in adolescents and 823 g/d in adults. A total of 12.4% of the adolescents and 35.6% of the adults had NAFLD. Higher UPF intake was associated with higher odds of NAFLD in both adolescents (OR Quintile 5 vs. Quartile 1 = 2.34, 95% CI, 1.01, 5.41; ptrend = 0.15) and adults (OR Quintile 5 vs. Quintile 1 = 1.72, 95% CI, 1.01, 2.93; ptrend = 0.002). In adults, ~68% and 71% of the association between UPF intake and NAFLD was mediated by body mass index and waist circumference (all p-values < 0.001), respectively. The results were similar for adolescents but not statistically significant. A higher UPF intake was associated with lower levels of serum albumin and higher levels of C-reactive protein in adults., Conclusions: Higher UPF intake was linked to higher NAFLD odds in both adolescents and adults, mainly because of elevated body fatness. If confirmed, reducing UPF intake may help prevent NAFLD in both adolescents and adults., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Study of Liver Diseases.)

Background: High intake of ultra-processed foods (UPFs) is associated with increased risk of chronic disease; thus, it is important to understand how UPFs influence diet quality early in life., Objectives: We describe complementary foods and beverages (CFBs) according to the Nova Classification System of Food Processing for infants and toddlers in the United States and estimate how Nova groups and subgroups contribute to energy and select nutrients and food groups., Methods: We used day 1 24-h recall from infants and toddlers aged 6-23 mo from the cross-sectional, nationally representative 2013-18 National Health and Nutrition Examination Survey (n = 1140). We estimated contributions of Nova groups and subgroups to energy and select nutrients and food groups consumed as CFBs (excluding human milk and formula) using the population ratio with weighted survey commands in SAS., Results: For infants and toddlers in the United States, 42 ± 0.9% (mean ± standard error of the mean) of energy intake from CFBs came from unprocessed/minimally processed foods (U/MPFs) and 45 ± 0.8% from UPFs. U/MPFs contributed most to nutrient intakes (except iron, zinc, and sodium); ≥20% of all selected nutrients was from UPFs. UPFs contributed most to iron (75 ± 1.0%) and zinc (48 ± 1.3%); breakfast cereals were the top source. Most fruit, vegetables, and dairy were from U/MPFs. More than 80% of total grains, whole grains, refined grains, and added sugars were UPFs., Conclusions: U/MPFs support healthy dietary intake of infants and toddlers in the United States, whereas UPFs contribute meaningfully to nutrients and food groups to be encouraged (iron, zinc, and whole grains), as well as some that should be limited (added sugars and sodium). More research is needed to better understand the utility and sensitivities of using Nova for providing dietary guidance for infants and toddlers in the United States., (Published by Elsevier Inc.)

Importance: Although consumption of ultraprocessed food has been linked to higher risk of cardiovascular disease, metabolic syndrome, and obesity, little is known about the association of consumption of ultraprocessed foods with cognitive decline., Objective: To investigate the association between ultraprocessed food consumption and cognitive decline in the Brazilian Longitudinal Study of Adult Health., Design, Setting, and Participants: This was a multicenter, prospective cohort study with 3 waves, approximately 4 years apart, from 2008 to 2017. Data were analyzed from December 2021 to May 2022. Participants were public servants aged 35 to 74 years old recruited in 6 Brazilian cities. Participants who, at baseline, had incomplete food frequency questionnaire, cognitive, or covariate data were excluded. Participants who reported extreme calorie intake (<600 kcal/day or >6000 kcal/day) and those taking medication that could negatively interfere with cognitive performance were also excluded., Exposures: Daily ultraprocessed food consumption as a percentage of total energy divided into quartiles., Main Outcomes and Measures: Changes in cognitive performance over time evaluated by the immediate and delayed word recall, word recognition, phonemic and semantic verbal fluency tests, and Trail-Making Test B version., Results: A total of 15 105 individuals were recruited and 4330 were excluded, leaving 10 775 participants whose data were analyzed. The mean (SD) age at the baseline was 51.6 (8.9) years, 5880 participants (54.6%) were women, 5723 (53.1%) were White, and 6106 (56.6%) had at least a college degree. During a median (range) follow-up of 8 (6-10) years, individuals with ultraprocessed food consumption above the first quartile showed a 28% faster rate of global cognitive decline (β = -0.004; 95% CI, -0.006 to -0.001; P = .003) and a 25% faster rate of executive function decline (β = -0.003, 95% CI, -0.005 to 0.000; P = .01) compared with those in the first quartile., Conclusions and Relevance: A higher percentage of daily energy consumption of ultraprocessed foods was associated with cognitive decline among adults from an ethnically diverse sample. These findings support current public health recommendations on limiting ultraprocessed food consumption because of their potential harm to cognitive function.

Objective: To estimate beef consumption and its influence on carbon and water footprints, as well as to improve the nutritional quality of the Brazilian diet., Methods: 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., Results: 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., Conclusion: 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 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., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: Ultra-processed foods are associated with both sugar intake and non-communicable 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 to 2010, 2011 to 2012, and 2013 to 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 directed acyclic graphs. Odds ratios were estimated with logistic regression for moderate/severe periodontitis and severe periodontitis, and ordinal logistic regression for the trichotomized outcome. Analyses were performed 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., (© 2021 American Academy of Periodontology.)

Background: 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., Objectives: We examined US secular trends in food consumption according to processing level from 2001 to 2018., Methods: We analyzed dietary data collected by 24-h recalls from adult participants (aged >19 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., Results: 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)., Conclusions: 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., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

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., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

This randomised clinical trial aimed to evaluate the effect of a pro-breast-feeding (BF) and healthy complementary feeding intervention performed during infants' first months of life on ultraprocessed food (UPF) consumption at 4-7 years. We enrolled 323 teenage mothers and their infants from South Brazil, 163 allocated to the intervention group and 160 to the control group. Intervention consisted of sessions on BF and healthy complementary feeding promotion and was carried out in the maternity ward and at home after delivery. Food consumption was assessed using three 24-h food recalls at child's age of 4-7 years. Foods were classified according to NOVA classification. Dietary contribution of UPF was adjusted for intra-individual variability by the SPADE method and categorised into tertiles. We used Poisson regression models with robust variance, adjusted for confounders, to estimate the effect of the intervention and duration of BF on the risk of high consumption of UPF. Our final analysis included 194 children, with mean age of 6·1 (sd 0·5) years. Mean dietary contribution of UPF was 38 % in the intervention group and 42·7 % in the control group, from total daily intakes. Results adjusted for BF duration, propensity score, income and total energy content demonstrated that the intervention reduced the risk of high consumption of UPF by 35 % (relative risk 0·65, 95 % CI 0·43, 0·98). BF duration was not associated with UPF consumption. The intervention was effective in reducing the risk of high UPF consumption at the age of 4-7 years.

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., (© 2019 World Obesity Federation.)

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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 <40 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 <40 purchased less minimally processed plant-foods than households with HEI-2015 score ≥60., 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.

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).

Ultra-processed foods provide 58 % of energy intake and 89 % of added sugars in the American diet. Nevertheless, the association between ultra-processed foods and excess weight has not been investigated in a US sample. The present investigation therefore aims to examine the association between ultra-processed foods and excess weight in a nationally representative sample of US adults. We performed a cross-sectional analysis of anthropometric and dietary data from 15 977 adults (20-64 years) participating in the National Health and Nutrition Examination Survey 2005-2014. Dietary data were collected by 24-h recall. Height, weight and waist circumference (WC) were measured. Foods were classified as ultra-processed/non-ultra-processed according to the NOVA classification. Multivariable linear and logistic regression was used to evaluate the association between ultra-processed food consumption (% energy) and BMI, WC and odds of BMI≥25 kg/m2, BMI≥30 kg/m2 and abdominal obesity (men: WC≥102 cm, women: WC≥88 cm). Prevalence of BMI≥25 kg/m2, BMI≥30 kg/m2 and abdominal obesity was 69·2, 36·1 and 53·0 %, respectively. Consuming ≥74·2 v. ≤36·5 % of total energy from ultra-processed foods was associated with 1·61 units higher BMI (95 % CI 1·11, 2·10), 4·07 cm greater WC (95 % CI 2·94, 5·19) and 48, 53 and 62 % higher odds of BMI≥25 kg/m2, BMI≥30 kg/m2 and abdominal obesity, respectively (OR 1·48; 95 % CI 1·25, 1·76; OR 1·53; 95 % CI 1·29, 1·81; OR 1·62; 95 % CI 1·39, 1·89, respectively; P for trend<0·001 for all). A significant interaction between being female and ultra-processed food consumption was found for BMI (F 4,79=4·89, P=0·002), WC (F 4,79=3·71, P=0·008) and BMI≥25 kg/m2 (F 4,79=5·35, P<0·001). As the first study in a US population, our findings support that higher consumption of ultra-processed food is associated with excess weight, and that the association is more pronounced among women.

Objectives: To compare ultra-processed food consumption across sociodemographic groups and over time (2007-2008, 2009-2010, 2011-2012) in the USA., Design: Cross-sectional study., Setting: National Health and Nutrition Examination Survey (NHANES) 2007-2012., Participants: All individuals aged ≥2 years with at least one 24-hour dietary recall were included (n=23 847)., Main Outcome Measures: Average dietary contribution of ultra-processed foods (expressed as a percentage of the total caloric value of the diet), obtained after classifying all food items according to extent and purpose of industrial food processing using NOVA classification., Data Analysis: Linear regression was used to evaluate the association between sociodemographic characteristics or NHANES cycles and dietary contribution of ultra-processed foods., Results: Almost 60% of calories consumed in the period 2007-2012 came from ultra-processed foods. Consumption of ultra-processed foods decreased with age and income level, was higher for non-Hispanic whites or non-Hispanic blacks than for other race/ethnicity groups and lower for people with college than for lower levels of education, all differences being statistically significant. Overall contribution of ultra-processed foods increased significantly between NHANES cycles (nearly 1% point per cycle), the same being observed among males, adolescents and high school education-level individuals., Conclusions: Ultra-processed food consumption in the USA in the period 2007-2012 was overall high, greater among non-Hispanic whites or non-Hispanic blacks, less educated, younger, lower-income strata and increased across time., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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.

Background: Although AIDS is less frequent following HIV-2 than HIV-1 infection, it is unclear whether the clinical picture and clinical course of AIDS are similar in the two infections., Objectives: To compare the pattern of AIDS-defining events, CD4 cell count at the time of AIDS diagnosis, survival from time of AIDS, and CD4 cell count near time of death in HIV-1 and HIV-2-infected patients., Methods: Adult patients with AIDS who attended the clinics of the MRC in The Gambia were enrolled. AIDS was diagnosed according to the expanded World Health Organization case definition for AIDS surveillance (1994)., Results: Three hundred and forty-one AIDS patients with HIV-1 and 87 with HIV-2 infection were enrolled. The most common AIDS-defining events in both infections were the wasting syndrome and pulmonary tuberculosis. The median CD4 cell count at AIDS was 109 cells/microl in HIV-1 and 176 in HIV-2 (P = 0.01) and remained significantly higher in HIV-2 after adjustment for age and sex (P = 0.03). The median time to death was 6.3 months in HIV-1 and 12.6 months in HIV-2-infected patients (P = 0.03). In a multivariable analysis adjusting for age, sex and CD4 cell count, the mortality rates of HIV-1 and HIV-2-infected patients were similar (P = 0.25). The median CD4 cell count near time of death was 62 and 120 cells/microl in HIV-1 and HIV-2-infected patients, respectively (P = 0.02)., Conclusions: HIV-2 patients have a higher CD4 cell count at the time of AIDS, and a longer survival after AIDS. The mortality after an AIDS diagnosis is more influenced by CD4 cell count than HIV type.