Roteiro Para Elaboração de Ato Normativo Para a Categorização de Serviços de Alimentação Teórico / Script for the preparation of a regulatory act for the categorization of food services theoretical

Ainda que inovadora no Brasil, a Categorização dos serviços de alimentação já é uma realidade em outros países e cidades, principalmente as que apresentam um maior afluxo de turistas. Ela possibilita que os consumidores escolham os serviços de alimentação que se preocupam com a qualidade sanitária (BRASIL, 2013a). Com base nos programas internacionais de classificação do risco, a Agência Nacional de Vigilância Sanitária (Anvisa) decidiu criar um sistema semelhante para os serviços de alimentação no Brasil. Este sistema, teve a preocupação de minimizar o risco para Doenças Transmitidas por Alimentos (DTA). Para realizar a Categorização dos serviços de alimentação, como um projeto de governo, faz-se necessário um ato normativo que oficialize e oriente não somente a adesão a Categorização, mas todas as etapas de sua implantação. Este roteiro não tem caráter normativo e sim orientativo. As informações nele contidas são proposições com a finalidade de orientar e subsidiar estados e municípios na atuação regulatória para a Categorização de serviços de alimentação, podendo ser utilizado na íntegra ou parcialmente. Cabe ressaltar que o departamento jurídico deverá ser consultado.

Decision flowchart for food classification by the extension and purpose of industrial processing: update and practical application / Fluxograma de decisão para classificação de alimentos conforme a extensão e propósito do processamento industrial: atualização e aplicação prática

ABSTRACT Objective To describe the development and update of an instrument for food categorisation according to the extension and purpose of industrial processing, and to test its practical application. Methods After updating the instrument based on a recent publication on the NOVA classification, it was applied by five researchers to a database of 108 food items. These items are part of a database of foods announced in the health-related sections of supermarket promotional circulars. The Cohen's weighted kappa coefficient was calculated to determine intra-rater agreement; Fleiss' kappa and Kendall's coefficient were applied to determine inter-rater agreement. Results In the updated version, two classes of additives and eight substances considered by the most recent publication as specific to ultra-processed foods were added. The intra-rater agreement was 100% (p<0.001), indicating an "almost perfect" agreement; Fleiss' agreement among all raters ranged from 74% to 97% (p<0.001), which represents an agreement that ranged from "strong" to "almost perfect"; Kendall's W was higher than 0.93 (p<0.001) among all raters. Conclusion The updated instrument showed high agreement and proved to be a methodologically sound and applicable tool for the purpose of classifying foods by the extension and purpose of industrial processing.

RESUMO Objetivo Descrever o desenvolvimento e atualização de um instrumento para categorização dos alimentos de acordo com a extensão e propósito de seu processamento industrial e avaliar sua aplicação prática. Métodos Após a atualização do instrumento com base em publicação recente sobre o tema, ele foi aplicado por cinco pesquisadores em um banco de dados de 108 alimentos. Esses alimentos são parte de um banco de dados de alimentos anunciados em seções relacionadas à saúde de panfletos promocionais de supermercado. Para avaliar a concordância intra-avaliador foi calculado o kappa ponderado de Cohen e para a concordância interavaliadores foram calculados o kappa de Fleiss e o coeficiente de concordância de Kendall. Resultados Na versão atualizada foram adicionadas duas classes de aditivos e oito substâncias, consideradas pela publicação mais recente como específicas de alimentos ultraprocessados. A concordância intra-avaliador foi de 100% (p<0,001), o que indica uma concordância "quase perfeita"; a concordância de Fleiss entre todos os avaliadores variou de 74% a 97% (p<0,001), o que representa uma concordância que variou de "forte" a "quase perfeita"; a concordância de Kendall foi W >0,93 (p<0,001) entre todos os avaliadores. Conclusão O instrumento atualizado apresentou uma elevada concordância e mostrou-se uma ferramenta metodologicamente útil e aplicável quando se tem por objetivo classificar alimentos pela extensão e propósito do processamento industrial.

Use of Different Food Classification Systems to Assess the Association between Ultra-Processed Food Consumption and Cardiometabolic Health in an Elderly Population with Metabolic Syndrome (PREDIMED-Plus Cohort).

The association between ultra-processed food (UPF) and risk of cardiometabolic disorders is an ongoing concern. Different food processing-based classification systems have originated discrepancies in the conclusions among studies. To test whether the association between UPF consumption and cardiometabolic markers changes with the classification system, we used baseline data from 5636 participants (48.5% female and 51.5% male, mean age 65.1 ± 4.9) of the PREDIMED-Plus ("PREvention with MEDiterranean DIet") trial. Subjects presented with overweight or obesity and met at least three metabolic syndrome (MetS) criteria. Food consumption was classified using a 143-item food frequency questionnaire according to four food processing-based classifications: NOVA, International Agency for Research on Cancer (IARC), International Food Information Council (IFIC) and University of North Carolina (UNC). Mean changes in nutritional and cardiometabolic markers were assessed according to quintiles of UPF consumption for each system. The association between UPF consumption and cardiometabolic markers was assessed using linear regression analysis. The concordance of the different classifications was assessed with intra-class correlation coefficients (ICC3, overall = 0.51). The highest UPF consumption was obtained with the IARC classification (45.9%) and the lowest with NOVA (7.9%). Subjects with high UPF consumption showed a poor dietary profile. We detected a direct association between UPF consumption and BMI (p = 0.001) when using the NOVA system, and with systolic (p = 0.018) and diastolic (p = 0.042) blood pressure when using the UNC system. Food classification methodologies markedly influenced the association between UPF consumption and cardiometabolic risk markers.

Associations between ultraprocessed food consumption and total water intake in the US population.

BACKGROUND: Longitudinal studies have shown significant dose-response associations between dietary share of ultraprocessed foods and the incidence of several noncommunicable diseases and all-cause mortality. Several attributes of ultraprocessed foods are potential mechanisms for their link with health outcomes, including their typically unbalanced nutrient profile, high glycemic loads, high energy intake rate, and the presence of food additives, neoformed substances, and substances released by synthetic packaging materials. However, no studies have assessed the plausibility of reduced water intake as an additional association of diets rich in ultraprocessed foods. OBJECTIVE: To assess the association between ultraprocessed food consumption and total water intake. DESIGN: This cross-sectional secondary analysis used data from the National Health and Nutrition Examination Survey, cycles 2011 to 2016, in the United States. PARTICIPANTS/SETTINGS: This study included 24,505 participants aged ≥1 year who completed the first 24-hour dietary recall interview. MAIN OUTCOMES MEASURES: The main outcome evaluated was the mean of total water intake. STATISTICAL ANALYSIS: Crude and adjusted linear regressions were applied to investigate the association between quintiles of the dietary share of ultraprocessed foods and the total water intake. RESULTS: A significant linear reduction in the daily mean total water intake was observed across ultraprocessed food quintiles, amounting to 706 mL between the lower and the upper quintiles. Important increases across quintiles were observed for the intake of sugar-sweetened and artificially sweetened drinks, whereas important reductions occurred for unsweetened drinks, plain water, and water present in solid foods and dishes. CONCLUSIONS: Reduced total water intake and an imbalance between sources of water that favors energy-dense and nutrient-poor sources were associated with increased consumption of ultraprocessed food, suggesting that decreased total water consumption might be a negative outcome of diets rich in ultraprocessed foods. This relationship should be further investigated in longitudinal or clinical trials.

[Nutri-Score and ultra-processing: two different, complementary, non-contradictory dimensions]. / Nutri-Score y ultra-procesamiento: dos dimensiones diferentes, complementarias y no contradictorias.

INTRODUCTION: The front-of-pack nutritional labeling system Nutri-Score is sometimes under attack because it classifies as A and B certain ultra-processed foods. In fact, this is not surprising given that nutritional quality (assessed by Nutri-Score) and ultra-processing (assessed by the NOVA classification) do not cover the same "health dimensions" in foods but rather different dimensions likely to affect health through specific mechanisms. Although they cover different and complementary dimensions, there is nevertheless an overall association between the degree of processing and nutritional quality of foods. But within the group of ultra-processed foods there are differences in the number, type and doses of additives, as well as differences in nutritional quality. Therefore Nutri-Score allows, within the category of ultra-processed foods (as for all categories of the NOVA classification), to differentiate the nutritional quality of foods, which is essential in terms of health impact. Indeed, regardless of the level of food processing, it has been shown that consuming foods that are better ranked on the Nutri-Score scale is associated with a health benefit and a lower risk of chronic diseases. This is important because, even if it is recommended to reduce the consumption of ultra-processed foods, for those who do not want to or cannot avoid consuming them, for those for whom cooking is difficult (for reasons of time, ease, taste, etc.), the choice of foods better ranked on the Nutri-Score scale has a positive impact on health. Nutri-Score and ultra-transformation must be considered two different and complementary dimensions.

INTRODUCCIÓN: Al logotipo nutricional Nutri-Score se le ataca a veces porque clasifica como A y B algunos alimentos ultraprocesados. Esto no es sorprendente si se tiene en cuenta que la calidad nutricional (evaluada por Nutri-Score) y el ultraprocesamiento (evaluado por la clasificación NOVA) no abarcan las mismas "dimensiones de salud" de los alimentos, sino que cada una de ellas puede impactar en la salud por mecanismos específicos propios. Al mismo tiempo que cubren dimensiones diferentes y complementarias, sigue existiendo una asociación global entre el grado de transformación y la calidad nutricional de los alimentos. Dentro de los alimentos ultraprocesados existen diferencias en términos de número, tipo y dosis de aditivos, pero también en términos de calidad nutricional, por lo que Nutri-Score permite, dentro de la amplia categoría de productos ultraprocesados (como en todas las categorías de la clasificación NOVA), distinguir su calidad nutricional, lo que es primordial en términos de impacto sobre la salud. Cualquiera que sea el nivel de procesamiento de los alimentos, se ha demostrado que el consumo de alimentos mejor clasificados por Nutri-Score es beneficioso para la salud y tiene un menor riesgo de patologías crónicas. Esto es importante porque, incluso si se recomienda reducir el consumo de alimentos ultraprocesados, para aquellos que no quieren o no pueden evitar consumirlos o para quienes es complicado cocinar (por razones de tiempo, facilidad, preferencia, etc.) la elección de un alimento mejor clasificado en la escala Nutri-Score tiene un impacto favorable en el plano de la salud. En consecuencia, Nutri-Score y el ultraprocesamiento deben considerarse como dos dimensiones diferentes y complementarias.

Consumption of ultra-processed foods in Canada.

BACKGROUND: A larger share of ultra-processed foods and drinks (UPF) in the diet is increasingly linked with poor diet quality, weight gain and elevated risk of diet-related chronic disease. This study used 2015 national-level data, the most recent available, to characterize the intake of UPF among Canadians and to examine changes since 2004. DATA AND METHODS: The 2004 and 2015 Canadian Community Health Surveys provided 24-hour dietary recall data for Canadians aged 2 or older. All food and drink items were classified according to type of food processing using the NOVA classification. The mean energy contribution of UPF (as a percentage of total daily energy intake) was compared across survey years for the overall population and for eight age-sex groups. The National Cancer Institute's methodology was used to assess the distribution of usual energy contributed by UPF. RESULTS: On average, UPF contributed 47.8% (95% CI: 47.3% to 48.3%) of total daily energy in 2004 and 45.7% (95% CI: 45.0% to 46.4%) in 2015 among the overall population, and more than half of total daily energy among children and adolescents. Both the mean energy contribution of UPF and their usual energy distribution shifted downward since 2004 for all age-sex groups, except among adults aged 55 or older. The energy contributions of soft drinks, fruit juices and fruit drinks declined, particularly among children and adolescents. Ultra-processed breads contributed more energy in 2015 for nearly all age-sex groups. DISCUSSION: As in 2004, the overall dietary share of UPF in Canada remained high in 2015, but intakes of some UPF, particularly beverages, declined. The energy contribution of UPF remained highest among children and adolescents, and increased among adults aged 55 or older.

Addressing Challenges with the Categorization of Foods Processed at Home: A Pilot Methodology to Inform Consumer-Facing Guidance.

The objective of this study was to inform consumer-facing dietary guidance by (1) adapting the current University of North Carolina at Chapel Hill (UNC) food processing framework to include a home processing (HP) component and (2) pilot testing the adapted version using a nationally representative sample of foods consumed in the U.S. The UNC framework was adapted to include guidelines for categorizing home-prepared (HP) foods. The original UNC and adapted HP frameworks were used to code dietary recalls from a random sample of National Health and Nutrition Examination Survey (2015-2016 cycle) participants (n = 100; ages 2-80 years). Percent changes between the UNC and HP adapted frameworks for each processing category were calculated using Microsoft Excel, version 16.23. Participants were 56% female, 35% non-Hispanic white (mean age = 31.3 ± 23.8). There were 1,376 foods with 651 unique foods reported. Using the HP compared to the UNC framework, unprocessed/minimally processed foods declined by 11.7% (UNC: 31.0% vs. HP: 27.4%); basic processed foods increased by 116.8% (UNC: 8.2% vs. HP: 17.8%); moderately processed foods increased by 16.3% (UNC: 14.2% vs. HP: 16.6%); and highly processed foods decreased by 17.8% (UNC: 46.5% vs. HP: 38.2%). Home-prepared foods should be considered as distinct from industrially produced foods when coding dietary data by processing category. This has implications for consumer-facing dietary guidance that incorporates processing level as an indicator of diet quality.

Association between Heat-Induced Chemical Markers and Ultra-Processed Foods: A Case Study on Breakfast Cereals.

Nutritional composition and neo-formed contaminant content in ultra-processed foods, amongst other factors, may contribute to increasing overall risk of non-communicable diseases and cancer. Commercial breakfast cereals (n = 53) were classified according to the NOVA approach as un-/minimally processed (NOVA-1, 11%), processed (NOVA-3, 30%), and ultra-processed (NOVA-4, 59%) foods. Acrylamide and hydroxymethylfurfural (HMF) content as heat-induced chemical markers was taken from our research team database. The NutriScore was used as the nutritional profiling system. Samples were distributed between groups A (19%), B (13%), C (38%), and D (30%). No statistically significant differences in acrylamide and HMF were found across the NutriScore groups. Sugar content was the only nutritional descriptor found to be significantly different between processed (11.6 g/100 g) and ultra-processed (23.1 g/100 g) breakfast cereal groups. Sugar content correlated with acrylamide (p < 0.001) and HMF (p < 0.0001). Acrylamide and HMF contents were not significantly higher in the NOVA-4 group when compared with the NOVA-3 group. However, trends towards higher acrylamide and HMF content are observed, amounting to a change of 75 µg/kg and 13.3 mg/kg in processed breakfast cereals, and 142 µg/kg and 32.1 mg/kg in ultra-processed breakfast cereals, respectively. Thus, the NOVA classification may not reflect the extent of the thermal treatment applied to the breakfast cereal but the type and amount of ingredients incorporated. Ultra-processed breakfast cereal does not predict significantly higher toxicological concern based on acrylamide content than processed breakfast cereals; a clear trend is seen whose contributing factors should be further studied.

Food consumption by degree of processing and cardiometabolic risk: a systematic review.

Processed and ultra-processed foods (UPF) consumption has been associated with development of noncommunicable chronic diseases (NCD). This systematic review aims to summarise and discuss evidence of the relationship between food consumption according to degree of food processing and cardiometabolic risk. Data search was conducted in databases as PubMed, Bireme and Science Direct until July 2018. Studies have shown a positive association of UPF consumption with excess body weight, hypertension, dyslipidemia and metabolic syndrome features. However, disparities found in the studies analysed regarding dietary assessment, confounding factors and differences in food classifications makes comparisons between studies difficult. In conclusion, current evidences indicate the need to monitor UPF intake in global population. However, more studies are necessary to interpret better these associations with similar methodologies used in the studies. As well as longitudinal analyses can help to improve comparisons between outcomes and establish cause-effect relationship between UPF intake and cardiometabolic risk.

Association of body image (dis)satisfaction and perception with food consumption according to the NOVA classification: Pró-Saúde Study.

The literature on body image and food consumption has generally focused on isolated food items, while overlooking the growing role of ultra-processed foods in the overall diet. The objective of this study was to assess the association of body image (dis)satisfaction and perception with food consumption, according to the NOVA classification, which takes into account the extent and purpose of industrial food processing. A silhouette scale developed considering the Brazilian adults' Body Mass Index was used to assess body image (dis)satisfaction and perception. Food consumption was evaluated using a Food Frequency Questionnaire, and its items were categorized into three groups: unprocessed or minimally-processed foods and culinary preparations; processed foods; ultra-processed foods. The association was assessed using linear regression models. A total of 514 of Brazilian university employees were evaluated. Women dissatisfied due to excess weight consumed less unprocessed or minimally-processed foods and culinary preparations (-6.6, 95% CI: -10.7; -2.5) and more ultra-processed foods (3.7, 95% CI: 0.1; 7.2) compared to satisfied. Women that overestimated their body size consumed less unprocessed or minimally-processed food and culinary preparations (-4.2, 95% CI: -7.3; -1.1), compared to those who had not distorted body image. Food consumption appears to be more strongly associated with body image (dis)satisfaction than with perception. An association was established between body image dissatisfaction and unhealthy eating habits. This relation deserves public health attention since it may contribute to the development of chronic diseases and reduce the quality of life and body image assessment could be adopted by nutritionists and other health professionals in their practice.

Exploring the understanding of the term "ultra-processed foods" by young consumers.

Low diet quality has been associated with high consumption of highly processed foods. An effective educational campaign should aim at replacing ultra-processed foods by minimally processed and unprocessed foods. The objective of this study was to explore the understanding of young consumers of the term ultra-processed foods. A study was carried out with 181 young consumers from two different countries (Argentina and Ecuador). They were asked to explain what they understood by ultra-processed foods and to list foods they considered ultra-processed. Text and content analysis were conducted on participant's responses. Participants understand ultra-processed foods as those highly processed containing many artificial ingredients. The un-natural and unhealthful dimension was also stressed on their definitions. The most relevant food items that elicit the term ultra-processed foods were processed meats, soft drinks, and canned products. However, some food items not considered ultra-processed (meat, milk, ingredients) were misclassified as ultra-processed foods. This implies that a clear definition of the term ultra-processed food should be included in any strategy aimed at curbing today's high consumption of ultra-processed foods.

Sedentary behavior and consumption of ultra-processed foods by Brazilian adolescents: Brazilian National School Health Survey (PeNSE), 2015. / Comportamento sedentário e consumo de alimentos ultraprocessados entre adolescentes brasileiros: Pesquisa Nacional de Saúde do Escolar (PeNSE), 2015.

The aim of this cross-sectional study was to investigate the association between sedentary behavior and consumption of ultra-processed foods (UPF) among Brazilian adolescents. The study used data from the 2015 edition of the Brazilian National School Health Survey (PeNSE). Daily consumption of at least one group of UPF was the outcome, and the principal exposure was daily time spent in sedentary behavior (hours spent sitting, except for time sitting at school). We calculated prevalence rates, prevalence ratios, and 95% confidence intervals (95%CI). The analyses were adjusted for gender, age, skin color, maternal schooling, household assets index, major geographic region, and school's administrative jurisdiction (public versus private). Forty percent of the schoolchildren reported daily consumption of at least one group of UPF (39.7%; 95%CI: 39.2-40.3), while 68.1% (95%CI: 67.7-68.7) reported > 2 hours/day of sedentary behavior. Among schoolchildren with sedentary behavior > 2 hours/day, prevalence of daily consumption of UPF was 42.8% (95%CI: 42.1-43.6%), higher than among those without sedentary behavior (29.8%; 95%CI: 29.0-30.5%). Longer time spent in sedentary behavior was associated with higher prevalence of consumption of UPF (p-value for linear trend < 0.001). Strategies to promote healthy eating and decrease sedentary behavior, as well as regulation of advertising for UPF, are necessary to prevent unhealthy lifestyles from persisting into adulthood.

Estudo transversal com o objetivo de investigar a associação entre comportamento sedentário e consumo de alimentos ultraprocessados (AUP) em adolescentes brasileiros. Foram utilizados dados da Pesquisa Nacional de Saúde do Escolar (PeNSE) realizada em 2015. O consumo diário de pelo menos um grupo de AUP representou o desfecho, e a exposição principal foi o tempo diário de comportamento sedentário (horas em atividades sentado, excluído o tempo dispendido na escola). Foram calculadas prevalências, razões de prevalências e intervalos de 95% de confiança (IC95%). As análises foram ajustadas para sexo, idade, cor da pele, escolaridade materna, índice de bens, região geográfica e dependência administrativa da escola. Cerca de 40% dos escolares reportaram consumo diário de pelo menos um grupo de AUP (39,7%; IC95%: 39,2-40,3) e 68,1% (IC95%: 67,7-68,7) referiram > 2 horas/dia de comportamento sedentário. Entre os escolares com comportamento sedentário > 2 horas/dia, a prevalência de consumo diário de AUP foi de 42,8% (IC95%: 42,1-43,6%), maior do que entre os sem comportamento sedentário (29,8%; IC95%: 29,0-30,5%). Quanto maior o tempo de comportamento sedentário, maior a prevalência de consumo de AUP (valor de p para tendência linear < 0,001). Estratégias que promovam a alimentação saudável e a diminuição de comportamentos sedentários, bem como regulamentações da publicidade de AUP, tornam-se necessárias a fim de evitar que estilos de vida não saudáveis perdurem à idade adulta.

Estudio transversal con el objetivo de investigar la asociación entre el comportamiento sedentario y el consumo de alimentos ultraprocesados (AUP) en adolescentes brasileños. Se utilizaron datos de la Encuesta Nacional de Salud del Escolar (PeNSE), realizada en 2015. El consumo diario de por lo menos un grupo de AUP representó el resultado, y la exposición principal fue el tiempo diario de comportamiento sedentario (horas en actividades sentado, excluido el tiempo transcurrido en la escuela). Se calcularon las prevalencias, razones de prevalencias e intervalos de 95% de confianza (IC95%). Los análisis se ajustaron por sexo, edad, color de la piel, escolaridad materna, índice de bienes, región geográfica y dependencia administrativa de la escuela. Cerca de un 40% de los escolares informaron un consumo diario de por lo menos un grupo de AUP (39,7%; IC95%: 39,2-40,3) y 68,1% (IC95%: 67,7-68,7) informaron > 2 horas/día de comportamiento sedentario. Entre los escolares con un comportamiento sedentario > 2 horas/día, la prevalencia de consumo diario de AUP fue de un 42,8% (IC95%: 42,1-43,6%), mayor que entre quienes no tenían comportamiento sedentario (29,8%; IC95%: 29,0-30,5%). Cuanto mayor es el tiempo de comportamiento sedentario, mayor la prevalencia de consumo de AUP (valor de p para tendencia lineal < 0,001). Estrategias que promuevan la alimentación saludable y la disminución de comportamientos sedentarios, así como una regulación de la publicidad de AUP, fueron necesarias, a fin de evitar que estilos de vida no saludables perduren en la edad adulta.

Consumption of ultra-processed foods and socioeconomic position: a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

The objective of the study was to estimate the contribution of ultra-processed foods to total caloric intake and investigate whether it differs according to socioeconomic position. We analyzed baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil 2008-2010; N = 14.378) and data on dietary intake using a food frequency questionnaire, assigning it into three categories: unprocessed or minimally processed foods and processed culinary ingredients, processed foods, and ultra-processed foods. We measured the associations between socioeconomic position (education, per capita household income, and occupational social class) and the percentage of caloric contribution of ultra-processed foods, using generalized linear regression models adjusted for age and sex. Unprocessed or minimally processed foods and processed culinary ingredients contributed to 65.7% of the total caloric intake, followed by ultra-processed foods (22.7%). After adjustments, the percentage of caloric contribution of ultra-processed foods was 20% lower among participants with incomplete elementary school when compared to postgraduates. Compared to individuals from upper income classes, the caloric contribution of ultra-processed foods was 10%, 15% and 20% lower among the ones from the three lowest income, respectively. The caloric contribution of ultra-processed foods was also 7%, 12%, 12%, and 17% lower among participants in the lowest occupational social class compared to those from high social classes. Results suggest that the caloric contribution of ultra-processed foods is higher among individuals from high socioeconomic positions with a dose-response relationship for the associations.

The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing.

Given evident multiple threats to food systems and supplies, food security, human health and welfare, the living and physical world and the biosphere, the years 2016-2025 are now designated by the UN as the Decade of Nutrition, in support of the UN Sustainable Development Goals. For these initiatives to succeed, it is necessary to know which foods contribute to health and well-being, and which are unhealthy. The present commentary outlines the NOVA system of food classification based on the nature, extent and purpose of food processing. Evidence that NOVA effectively addresses the quality of diets and their impact on all forms of malnutrition, and also the sustainability of food systems, has now accumulated in a number of countries, as shown here. A singular feature of NOVA is its identification of ultra-processed food and drink products. These are not modified foods, but formulations mostly of cheap industrial sources of dietary energy and nutrients plus additives, using a series of processes (hence 'ultra-processed'). All together, they are energy-dense, high in unhealthy types of fat, refined starches, free sugars and salt, and poor sources of protein, dietary fibre and micronutrients. Ultra-processed products are made to be hyper-palatable and attractive, with long shelf-life, and able to be consumed anywhere, any time. Their formulation, presentation and marketing often promote overconsumption. Studies based on NOVA show that ultra-processed products now dominate the food supplies of various high-income countries and are increasingly pervasive in lower-middle- and upper-middle-income countries. The evidence so far shows that displacement of minimally processed foods and freshly prepared dishes and meals by ultra-processed products is associated with unhealthy dietary nutrient profiles and several diet-related non-communicable diseases. Ultra-processed products are also troublesome from social, cultural, economic, political and environmental points of view. We conclude that the ever-increasing production and consumption of these products is a world crisis, to be confronted, checked and reversed as part of the work of the UN Sustainable Development Goals and its Decade of Nutrition.

Consumption of ultra-processed foods and socioeconomic position: a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health / O consumo de alimentos ultraprocessados e nível socioeconômico: uma análise transversal do Estudo Longitudinal de Saúde do Adulto, Brasil / Consumo de comida ultraprocesada y nivel socioeconómico: un análisis transversal del Estudio Longitudinal Brasileño sobre Salud en la Edad Adulta

The objective of the study was to estimate the contribution of ultra-processed foods to total caloric intake and investigate whether it differs according to socioeconomic position. We analyzed baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil 2008-2010; N = 14.378) and data on dietary intake using a food frequency questionnaire, assigning it into three categories: unprocessed or minimally processed foods and processed culinary ingredients, processed foods, and ultra-processed foods. We measured the associations between socioeconomic position (education, per capita household income, and occupational social class) and the percentage of caloric contribution of ultra-processed foods, using generalized linear regression models adjusted for age and sex. Unprocessed or minimally processed foods and processed culinary ingredients contributed to 65.7% of the total caloric intake, followed by ultra-processed foods (22.7%). After adjustments, the percentage of caloric contribution of ultra-processed foods was 20% lower among participants with incomplete elementary school when compared to postgraduates. Compared to individuals from upper income classes, the caloric contribution of ultra-processed foods was 10%, 15% and 20% lower among the ones from the three lowest income, respectively. The caloric contribution of ultra-processed foods was also 7%, 12%, 12%, and 17% lower among participants in the lowest occupational social class compared to those from high social classes. Results suggest that the caloric contribution of ultra-processed foods is higher among individuals from high socioeconomic positions with a dose-response relationship for the associations.

O estudo teve como objetivo estimar a contribuição dos alimentos ultraprocessados à ingestão calórica total e investigar se essa contribuição difere de acordo com nível socioeconômico. Analisamos os dados da linha de base do Estudo Longitudinal de Saúde do Adulto-Brasil (ELSA-Brasil 2008-2010; N = 14.378) e os de ingestão alimentar, usando um questionário sobre frequência de consumo alimentar, em três categorias: alimentos não processados ou minimamente processados e ingredientes culinários processados, alimentos processados e alimentos ultraprocessados. Estimamos as associações entre nível socioeconômico (escolaridade, renda domiciliar per capita e classe social ocupacional) e o percentual da contribuição calórica dos ultraprocessados, usando modelos lineares generalizados, ajustados por idade e sexo. Os alimentos não processados ou minimamente processados e ingredientes culinários processados representaram 65,7% da ingestão calórica total, seguidos pelos ultraprocessados (22,7%). Depois dos ajustes, a contribuição dos ultraprocessados foi 20% mais baixa entre participantes com ensino fundamental incompleto, quando comparados aos indivíduos com pós-graduação. Quando comparados aos indivíduos das classes de renda mais alta, a contribuição calórica dos ultraprocessados foi 10%, 15% e 20% mais baixa entre aqueles pertencentes aos três quintis de renda mais baixos, respectivamente. Além disso, a contribuição calórica dos ultraprocessados foi 7%, 12%, 12% e 17% mais baixa entre os participantes da classe social ocupacional mais baixa, comparados aos das classes sociais mais altas. Os resultados sugerem que a contribuição calórica dos alimentos ultraprocessados é mais alta entre os indivíduos de nível socioeconômico mais alto, com gradiente de dose e resposta nas associações.

El objetivo del estudio fue estimar la contribución de las comidas ultraprocesadas en la ingesta total calórica e investigar si difiere según el nivel socioeconómico. Analizamos datos de referencia, procedentes del Estudio Longitudinal Brasileño sobre Salud en la Edad Adulta (ELSA-Brasil 2008-2010; N = 14.378) y datos de la ingesta nutricional, usando un cuestionario de frecuencia sobre comidas, asignándole tres categorías: comida sin procesar o mínimamente procesada e ingredientes culinarios procesados, comidas procesadas, y comidas ultraprocesadas. Medimos las asociaciones entre el nivel socioeconómico (educación, ingreso por hogar per cápita, y clase ocupacional social) y el porcentaje de la contribución calórica de la comida ultraprocesada, usando modelos de regresión lineal generalizada, ajustados por edad y sexo. Las comidas sin procesar o mínimamente procesadas con ingredientes culinarios procesados contribuyeron al 65,7% del total de la ingesta calórica, seguidos de la comida ultraprocesada (22,7%). Tras los ajustes, el porcentaje de la contribución calórica de la comida ultraprocesada fue un 20% menor entre los participantes con la escuela elemental incompleta, cuando se compararon con los postgraduados. Comparados con los individuos de las clases con ingresos superiores, la contribución calórica de las comidas ultraprocesadas fue un 10%, 15% y 20% menor entre quienes pertenecían a las tres categorías de ingresos más bajas, respectivamente. La contribución calórica de la comida ultraprocesada fue también un 7%, 12%, 12%, y 17% más baja entre los participantes en el nivel ocupacional social más bajo, comparados con aquellos de las clases sociales altas. Los resultados sugieren que la contribución calórica de la comida ultraprocesada es más alta entre quienes proceden de niveles socioeconómicos más altos con una relación dosis-respuesta para las asociaciones establecidas.

Comportamento sedentário e consumo de alimentos ultraprocessados entre adolescentes brasileiros: Pesquisa Nacional de Saúde do Escolar (PeNSE), 2015 / Comportamiento sedentario y consumo de alimentos ultraprocesados entre adolescentes brasileños: Encuesta Nacional de Salud del Escolar (PeNSE), 2015 / Sedentary behavior and consumption of ultra-processed foods by Brazilian adolescents: Brazilian National School Health Survey (PeNSE), 2015

Estudo transversal com o objetivo de investigar a associação entre comportamento sedentário e consumo de alimentos ultraprocessados (AUP) em adolescentes brasileiros. Foram utilizados dados da Pesquisa Nacional de Saúde do Escolar (PeNSE) realizada em 2015. O consumo diário de pelo menos um grupo de AUP representou o desfecho, e a exposição principal foi o tempo diário de comportamento sedentário (horas em atividades sentado, excluído o tempo dispendido na escola). Foram calculadas prevalências, razões de prevalências e intervalos de 95% de confiança (IC95%). As análises foram ajustadas para sexo, idade, cor da pele, escolaridade materna, índice de bens, região geográfica e dependência administrativa da escola. Cerca de 40% dos escolares reportaram consumo diário de pelo menos um grupo de AUP (39,7%; IC95%: 39,2-40,3) e 68,1% (IC95%: 67,7-68,7) referiram > 2 horas/dia de comportamento sedentário. Entre os escolares com comportamento sedentário > 2 horas/dia, a prevalência de consumo diário de AUP foi de 42,8% (IC95%: 42,1-43,6%), maior do que entre os sem comportamento sedentário (29,8%; IC95%: 29,0-30,5%). Quanto maior o tempo de comportamento sedentário, maior a prevalência de consumo de AUP (valor de p para tendência linear < 0,001). Estratégias que promovam a alimentação saudável e a diminuição de comportamentos sedentários, bem como regulamentações da publicidade de AUP, tornam-se necessárias a fim de evitar que estilos de vida não saudáveis perdurem à idade adulta.

Estudio transversal con el objetivo de investigar la asociación entre el comportamiento sedentario y el consumo de alimentos ultraprocesados (AUP) en adolescentes brasileños. Se utilizaron datos de la Encuesta Nacional de Salud del Escolar (PeNSE), realizada en 2015. El consumo diario de por lo menos un grupo de AUP representó el resultado, y la exposición principal fue el tiempo diario de comportamiento sedentario (horas en actividades sentado, excluido el tiempo transcurrido en la escuela). Se calcularon las prevalencias, razones de prevalencias e intervalos de 95% de confianza (IC95%). Los análisis se ajustaron por sexo, edad, color de la piel, escolaridad materna, índice de bienes, región geográfica y dependencia administrativa de la escuela. Cerca de un 40% de los escolares informaron un consumo diario de por lo menos un grupo de AUP (39,7%; IC95%: 39,2-40,3) y 68,1% (IC95%: 67,7-68,7) informaron > 2 horas/día de comportamiento sedentario. Entre los escolares con un comportamiento sedentario > 2 horas/día, la prevalencia de consumo diario de AUP fue de un 42,8% (IC95%: 42,1-43,6%), mayor que entre quienes no tenían comportamiento sedentario (29,8%; IC95%: 29,0-30,5%). Cuanto mayor es el tiempo de comportamiento sedentario, mayor la prevalencia de consumo de AUP (valor de p para tendencia lineal < 0,001). Estrategias que promuevan la alimentación saludable y la disminución de comportamientos sedentarios, así como una regulación de la publicidad de AUP, fueron necesarias, a fin de evitar que estilos de vida no saludables perduren en la edad adulta.

The aim of this cross-sectional study was to investigate the association between sedentary behavior and consumption of ultra-processed foods (UPF) among Brazilian adolescents. The study used data from the 2015 edition of the Brazilian National School Health Survey (PeNSE). Daily consumption of at least one group of UPF was the outcome, and the principal exposure was daily time spent in sedentary behavior (hours spent sitting, except for time sitting at school). We calculated prevalence rates, prevalence ratios, and 95% confidence intervals (95%CI). The analyses were adjusted for gender, age, skin color, maternal schooling, household assets index, major geographic region, and school's administrative jurisdiction (public versus private). Forty percent of the schoolchildren reported daily consumption of at least one group of UPF (39.7%; 95%CI: 39.2-40.3), while 68.1% (95%CI: 67.7-68.7) reported > 2 hours/day of sedentary behavior. Among schoolchildren with sedentary behavior > 2 hours/day, prevalence of daily consumption of UPF was 42.8% (95%CI: 42.1-43.6%), higher than among those without sedentary behavior (29.8%; 95%CI: 29.0-30.5%). Longer time spent in sedentary behavior was associated with higher prevalence of consumption of UPF (p-value for linear trend < 0.001). Strategies to promote healthy eating and decrease sedentary behavior, as well as regulation of advertising for UPF, are necessary to prevent unhealthy lifestyles from persisting into adulthood.

Processed and ultra-processed food consumption among children aged 13 to 35 months and associated factors.

The aim of this study was to evaluate the consumption of processed and ultra-processed foods among children aged 13-35 months and its associated factors. We studied 1,185 children within the BRISA cohort in São Luís, Maranhão State, Brazil. The food consumption was investigated using a 24-hour recall, and the percentages of daily caloric intake and nutrients were estimated by food groups according to "NOVA" classification. We chose to categorize children belonging to the upper tertile of the distribution as having a high consumption of processed and ultra-processed food products. The Poisson regression model with robust variance estimation using a hierarchical modeling approach was used to calculate the prevalence ratios (PRs) of variables associated with high consumption of processed and ultra-processed food products. The mean energy intake was 1,226Kcal/day. After adjustments, there was a higher proportion of high consumption of processed and ultra-processed food products among children whose mothers had < 12 years of education and among children who were older than 16 months. Mothers with low schooling and children older than 16 months should be the targets of interventions aimed at reducing consumption of these food products and preventing adverse health outcomes in later life.

Processed and ultra-processed food consumption among children aged 13 to 35 months and associated factors / Consumo de alimentos processados e ultraprocessados e fatores associados em crianças entre 13 e 35 meses de idade / Consumo de alimentos procesados y ultraprocesados y factores asociados en niños entre 13 y 35 meses de edad

Abstract: The aim of this study was to evaluate the consumption of processed and ultra-processed foods among children aged 13-35 months and its associated factors. We studied 1,185 children within the BRISA cohort in São Luís, Maranhão State, Brazil. The food consumption was investigated using a 24-hour recall, and the percentages of daily caloric intake and nutrients were estimated by food groups according to "NOVA" classification. We chose to categorize children belonging to the upper tertile of the distribution as having a high consumption of processed and ultra-processed food products. The Poisson regression model with robust variance estimation using a hierarchical modeling approach was used to calculate the prevalence ratios (PRs) of variables associated with high consumption of processed and ultra-processed food products. The mean energy intake was 1,226Kcal/day. After adjustments, there was a higher proportion of high consumption of processed and ultra-processed food products among children whose mothers had < 12 years of education and among children who were older than 16 months. Mothers with low schooling and children older than 16 months should be the targets of interventions aimed at reducing consumption of these food products and preventing adverse health outcomes in later life.

Resumo: O estudo teve como objetivo avaliar o consumo de alimentos processados e ultraprocessados por crianças entre 13 e 35 meses de idade e fatores associados. Estudamos 1.185 crianças da coorte BRISA em São Luís, Maranhão, Brasil. O consumo alimentar foi investigado com um recordatório de 24 horas, e os percentuais de ingestão diária de calorias e nutrientes foram estimados por grupos de alimentos de acordo com a classificação "NOVA". Optamos por categorizar as crianças pertencentes ao tercil superior da distribuição como tendo consumo elevado de produtos alimentícios processados e ultraprocessados. Foi utilizado um modelo de regressão Poisson com estimativa robusta de variância com modelagem hierárquica para calcular as razões de prevalência (RPs) das variáveis associadas ao consumo elevado de produtos alimentícios processados e ultraprocessados. A ingestão calórica média era 1.226Kcal/dia. Após os ajustes, houve uma proporção maior de consumo elevado de produtos alimentícios processados e ultraprocessados entre crianças cujas mães tinham menos de 12 anos de escola e entre crianças com mais de 16 meses de idade. As mães com baixa escolaridade e crianças acima de 16 meses devem ser alvos de intervenções para reduzir o consumo desses produtos alimentícios e prevenir os desfechos de saúde adversos na adolescência e idade adulta.

Resumen: El objetivo de este estudio fue evaluar el consumo de alimentos procesados y ultraprocesados por parte de niños entre 13 y 35 meses de edad y sus factores asociados. Estudiamos a 1.185 niños de la cohorte BRISA en São Luís, Maranhão, Brasil. El consumo alimentario fue investigado con un recordatorio de 24 horas, y los porcentajes de ingesta diaria de calorías y nutrientes fueron estimados por grupos de alimentos, de acuerdo con la clasificación "NOVA". Optamos por categorizar a los niños pertenecientes al tercil superior de la distribución como de consumo elevado de productos alimenticios procesados y ultraprocesados. Se utilizó un modelo de regresión Poisson de estimativa robusta de variancia con modelaje jerárquico para calcular las razones de prevalencia (RPs) de las variables asociadas al consumo elevado de productos alimenticios procesados y ultraprocesados. La ingesta calórica media era 1.226Kcal/día. Tras los ajustes, hubo una proporción mayor de consumo elevado de productos alimenticios procesados y ultraprocesados entre niños, cuyas madres contaban con menos de 12 años de escuela y entre niños con más de 16 meses de edad. Las madres con baja escolaridad y niños por encima de 16 meses deben ser objetivo de intervenciones para reducir el consumo de esos productos alimenticios y prevenir desenlaces de salud adversos en la adolescencia y edad adulta.

General Template for the FMEA Applications in Primary Food Processing.

Data on the hazards involved in the primary steps of processing cereals, fruit and vegetables, milk and milk products, meat and meat products, and fats and oils are compiled with a wide-ranging literature survey. After determining the common factors from these data, a general FMEA template is offered, and its use is explained with a case study on pasteurized milk production.

[Food prices in Brazil: prefer cooking to ultra-processed foods]. / Preço dos alimentos no Brasil: prefira preparações culinárias a alimentos ultraprocessados.

This study aims to describe the prices of food groups consumed in Brazil considering the nature, extent, and purpose of their processing. Data were obtained from the Brazilian Household Budget Survey for 2008-2009. The mean prices of the groups (natural, cooking ingredients, processed, and ultra-processed) and their respective food subgroups were estimated for Brazil according to income, region, and area. Natural products and cooking ingredients showed lower prices per calorie when compared to the other groups, suggesting an economic advantage to preparing meals at home when compared to replacing them with ultra-processed foods. Families with the highest income paid the highest prices for their food, while families in the Northeast and North regions and rural areas paid the lowest. While fresh foods (meat, milk, fruit, and vegetables) tend to cost more than ultra-processed foods, dry grains (like rice and beans) are a more economical alternative for adopting healthy eating practices.