Ultra-processed foods, dietary diversity and micronutrient intakes in the Australian population.

PURPOSE: This cross-sectional study aimed to assess the association between ultra-processed foods consumption and dietary diversity and micronutrient intake in Australia. METHODS: As part of the Nutrition and Physical Activity Survey (2011-2012), 12,153 participants aged 2 years and above were recruited and interviewed. Dietary intake data were collected by two 24-h dietary recalls using the Automated Multiple-Pass Method. The NOVA classification system was used to group the food items based on the extent and purpose of industrial food processing. The mean micronutrient contents were calculated for the total diet, and for two diet fractions; one made up entirely of ultra-processed foods (NOVA group 4) and the other consisting of all non-ultra-processed foods (aggregation of NOVA food groups 1 to 3). The mean micronutrient content in the ultra-processed and non-ultra-processed food diet fractions were compared. Dietary diversity was measured using the ten Food Group Indicators (FGI) of the Food and Agriculture Organization and was defined as the sum number of FGIs per individual. Multiple linear regression models were used to assess the association between the quintiles of energy contribution of ultra-processed foods, dietary diversity, and micronutrient intake. RESULTS: A negative association was found between quintiles of energy contribution of ultra-processed foods and dietary diversity (ß = - 0.43; p < 0.001). The overall micronutrient content was lower in the diet fraction dominated by ultra-processed foods compared to the non-ultra-processed food diet fraction in the study population. The dietary contents of vitamins A, E, C, B9, B12, zinc, calcium, iron, magnesium, potassium, and phosphorus were reduced significantly with increased consumption of ultra-processed foods, even after adjustment for sociodemographic factors and dietary diversity. CONCLUSION: The quintiles of energy contribution of ultra-processed foods were negatively associated with dietary diversity and micronutrient intake in Australia.

Framing poor diet quality as malnutrition: the Brazilian National Survey on Child Nutrition (ENANI-2019).

Based on the Brazilian National Survey on Child Nutrition (ENANI-2019) results, this article reflects on the adequacy of the "malnutrition in all its forms" framework and system of classification for representing and interpreting these dietary transitions in Brazilian children. We highlight the limitations of this classification system, including the focus on health outcomes and anthropometric measures, the siloed understanding of these forms of malnutrition, the lack of relevance of the obesity category to children under 5 years old, and the failure to adequately address the various measures of poor quality diets captured by ENANI-2019. As an alternative, based on an approach developed by Gyorgy Scrinis to reframing malnutrition in all its forms, we suggest a need for frameworks that focus on describing and classifying the nature of, and changes to, dietary patterns, rather than focused on health outcomes.

Framing poor diet quality as malnutrition: the Brazilian National Survey on Child Nutrition (ENANI-2019) / Enquadrando a má qualidade da dieta como má nutrição: Estudo Nacional de Alimentação e Nutrição Infantil (ENANI-2019) / Caracterizar la mala calidad de la dieta como malnutrición: Estudio Nacional de Alimentación y Nutrición Infantil (ENANI-2019)

Based on the Brazilian National Survey on Child Nutrition (ENANI-2019) results, this article reflects on the adequacy of the "malnutrition in all its forms" framework and system of classification for representing and interpreting these dietary transitions in Brazilian children. We highlight the limitations of this classification system, including the focus on health outcomes and anthropometric measures, the siloed understanding of these forms of malnutrition, the lack of relevance of the obesity category to children under 5 years old, and the failure to adequately address the various measures of poor quality diets captured by ENANI-2019. As an alternative, based on an approach developed by Gyorgy Scrinis to reframing malnutrition in all its forms, we suggest a need for frameworks that focus on describing and classifying the nature of, and changes to, dietary patterns, rather than focused on health outcomes.

Com base nos resultados do Estudo Nacional de Alimentação e Nutrição Infantil (ENANI-2019), este artigo reflete sobre a adequação da estrutura e do sistema de classificação "má nutrição em todas as suas formas" para representar e interpretar essas transições alimentares em crianças brasileiras. Este estudo destaca as limitações desse sistema de classificação, incluindo o foco nos resultados de saúde e medidas antropométricas, o entendimento isolado dessas formas de má nutrição, a falta de relevância da categoria obesidade para crianças menores de 5 anos de idade e a incapacidade de abordar adequadamente as várias medidas de dietas de baixa qualidade identificadas pelo ENANI-2019. Como alternativa, com base em uma abordagem desenvolvida por Gyorgy Scrinis para reformular a abordagem da má nutrição em todas as suas formas, são necessárias estruturas que se concentrem em descrever e classificar a natureza e as mudanças nos padrões alimentares em vez de se concentrar nos resultados de saúde.

Con base en los resultados del Estudio Nacional de Alimentación y Nutrición Infantil (ENANI-2019), este artículo reflexiona sobre la adecuación del marco y del sistema de clasificación de la "malnutrición en todas sus formas" para representar e interpretar estas transiciones dietéticas en los niños brasileños. Este estudio destaca las limitaciones de este sistema de clasificación, incluido el enfoque en los resultados de salud y las medidas antropométricas, la comprensión aislada de estas formas de malnutrición, la falta de relevancia de la categoría de obesidad para niños menores de 5 años y la incapacidad de abordar adecuadamente las diversas medidas de dietas de baja calidad identificadas por el ENANI-2019. Una alternativa sería, basándose en un enfoque desarrollado por Gyorgy Scrinis para reformular el enfoque de la malnutrición en todas sus formas, establecer estructuras que se centraran en describir y clasificar la naturaleza y los cambios en los patrones dietéticos en lugar de centrarse en los resultados de salud.

Evaluating intake levels of nutrients linked to non-communicable diseases in Australia using the novel combination of food processing and nutrient profiling metrics of the PAHO Nutrient Profile Model.

PURPOSE: To investigate intake levels of nutrients linked to non-communicable diseases in Australia using the novel combination of food processing and nutrient profiling metrics of the PAHO Nutrient Profile Model. METHODS: Dietary intakes of 12,153 participants from the Australian Health Survey (2011-12) aged 2 + years were evaluated. Food items reported during a 24 h recall were classified using the NOVA system. The Pan-American Health Organization Nutrient Profile Model (PAHO NPM) was applied to identify processed and ultra-processed products with excessive content of critical nutrients. Differences in mean intakes and prevalence of excessive intakes of critical nutrients for groups of the population whose diets were made up of products with and without excessive content in critical nutrients were examined. RESULTS: The majority of Australians consumed daily at least three processed and ultra-processed products identified as excessive in critical nutrients according to the PAHO NPM. Individuals consuming these products had higher intakes of free sugars (ß = 8.9), total fats (ß = 11.0), saturated fats (ß = 4.6), trans fats (ß = 0.2), and sodium (ß = 1788 for adolescents and adults; ß = 1769 for children 5-10 years; ß = 1319 for children aged < 5 years) (p ≤ 0.001 for all nutrients) than individuals not consuming these foods. The prevalence of excessive intake of all critical nutrients also followed the same trend. CONCLUSION: The PAHO NPM has shown to be a relevant tool to predict intake levels of nutrients linked to non-communicable diseases in Australia and, therefore, could be used to inform policy actions aimed at increasing the healthiness of food environments.

Maximising the wealth of few at the expense of the health of many: a public health analysis of market power and corporate wealth and income distribution in the global soft drink market.

BACKGROUND: Many of the harms created by the global soft drink industry that directly influence human and planetary health are well documented. However, some of the ways in which the industry indirectly affects population health, via various socio-economic pathways, have received less attention. This paper aimed to analyse the extent to which market power and corporate wealth and income distribution in the global soft drink market negatively impact public health and health equity. In doing so, the paper sought to contribute to the development of a broad-based public health approach to market analysis. A range of dimensions (e.g., market concentration; financial performance; corporate wealth and income distribution) and indicators (e.g., Herfindahl Hirschman Index; earnings relative to the industry average; effective tax rates; and shareholder value ratios) were descriptively analysed. Empirical focus was placed on the two dominant global soft drink manufacturers. RESULTS: Coca-Cola Co, and, to a lesser extent, PepsiCo, operate across an extensive patchwork of highly concentrated markets. Both corporations control vast amounts of wealth and resources, and are able to allocate relatively large amounts of money to potentially harmful practices, such as extensive marketing of unhealthy products. Over recent decades, the proportion of wealth and income transferred by these firms to their shareholders has increased substantially; whereas the proportion of wealth and income redistributed by these two firms to the public via income taxes has considerably decreased. Meanwhile, the distribution of soft drink consumption is becoming increasingly skewed towards population groups in low and middle-income countries (LMICs). CONCLUSIONS: Market power and corporate wealth and income distribution in the global soft drink market likely compound the market's maldistribution of harms, and indirectly influence health by contributing to social and economic inequalities. Indeed, a 'double burden of maldistribution' pattern can be seen, wherein the wealth of the shareholders of the market's dominant corporations, a group over-represented by a small and wealthy elite, is maximised largely at the expense of the welfare of LMICs and lower socioeconomic groups in high-income countries. If this pattern continues, the appropriate role of the global soft drink market as part of sustainable economic development will require rethinking.

Nutritional marketing of plant-based meat-analogue products: an exploratory study of front-of-pack and website claims in the USA.

OBJECTIVE: To explore how some of the largest food companies involved in producing alternative proteins (AP) use health and nutrition claims to market their products. DESIGN: We identified the largest food manufacturers, meat processors and AP companies selling plant-based AP products in the USA. Using publicly available data, we analysed the voluntary health and nutrition claims made on front-of-pack labels (FOPL) and company webpages. We also analysed company websites for further nutrition and health-related statements about their products or AP more generally. Claim classification was guided by the INFORMAS (International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring, and Action Support) taxonomy for health-related food labelling. SETTING: USA. PARTICIPANTS: Not applicable. RESULTS: 1394 health and nutrition-related FOPL claims were identified on 216 products, including 685 nutrition claims and 709 'other health-related' claims. No FOPL health claims were identified. Most nutrient claims were for nutrients associated with meat, with 94 % of products carrying a protein claim and 30 % carrying a cholesterol claim. 74 % of products carried a GMO-free claim, and 63 % carried a plant-based claim. On their websites, some companies expanded on these claims or discussed the health benefits of specific ingredients. CONCLUSIONS: Companies involved in this category appear to be using nutritional marketing primarily to position their products in relation to meat. There is a focus on nutrient and ingredient claims, with discussion of processing largely avoided. The findings highlight the challenges companies face in positioning AP products as healthy against the backdrop of debates about ultra-processed foods.

Ultra-processed food consumption and obesity in the Australian adult population.

BACKGROUND: Rapid simultaneous increases in ultra-processed food sales and obesity prevalence have been observed worldwide, including in Australia. Consumption of ultra-processed foods by the Australian population was previously shown to be systematically associated with increased risk of intakes of nutrients outside levels recommended for the prevention of obesity. This study aims to explore the association between ultra-processed food consumption and obesity among the Australian adult population and stratifying by age group, sex and physical activity level. METHODS: A cross-sectional analysis of anthropometric and dietary data from 7411 Australians aged ≥20 years from the National Nutrition and Physical Activity Survey 2011-2012 was performed. Food consumption was evaluated through 24-h recall. The NOVA system was used to identify ultra-processed foods, i.e. industrial formulations manufactured from substances derived from foods and typically added of flavours, colours and other cosmetic additives, such as soft drinks, confectionery, sweet or savoury packaged snacks, microwaveable frozen meals and fast food dishes. Measured weight, height and waist circumference (WC) data were used to calculate the body mass index (BMI) and diagnosis of obesity and abdominal obesity. Regression models were used to evaluate the association of dietary share of ultra-processed foods (quintiles) and obesity indicators, adjusting for socio-demographic variables, physical activity and smoking. RESULTS: Significant (P-trend ≤ 0.001) direct dose-response associations between the dietary share of ultra-processed foods and indicators of obesity were found after adjustment. In the multivariable regression analysis, those in the highest quintile of ultra-processed food consumption had significantly higher BMI (0.97 kg/m2; 95% CI 0.42, 1.51) and WC (1.92 cm; 95% CI 0.57, 3.27) and higher odds of having obesity (OR = 1.61; 95% CI 1.27, 2.04) and abdominal obesity (OR = 1.38; 95% CI 1.10, 1.72) compared with those in the lowest quintile of consumption. Subgroup analyses showed that the trend towards positive associations for all obesity indicators remained in all age groups, sex and physical activity level. CONCLUSION: The findings add to the growing evidence that ultra-processed food consumption is associated with obesity and support the potential role of ultra-processed foods in contributing to obesity in Australia.

Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers.

Understanding the drivers and dynamics of global ultra-processed food (UPF) consumption is essential, given the evidence linking these foods with adverse health outcomes. In this synthesis review, we take two steps. First, we quantify per capita volumes and trends in UPF sales, and ingredients (sweeteners, fats, sodium and cosmetic additives) supplied by these foods, in countries classified by income and region. Second, we review the literature on food systems and political economy factors that likely explain the observed changes. We find evidence for a substantial expansion in the types and quantities of UPFs sold worldwide, representing a transition towards a more processed global diet but with wide variations between regions and countries. As countries grow richer, higher volumes and a wider variety of UPFs are sold. Sales are highest in Australasia, North America, Europe and Latin America but growing rapidly in Asia, the Middle East and Africa. These developments are closely linked with the industrialization of food systems, technological change and globalization, including growth in the market and political activities of transnational food corporations and inadequate policies to protect nutrition in these new contexts. The scale of dietary change underway, especially in highly populated middle-income countries, raises serious concern for global health.

Comparison of methodological quality between the 2007 and 2019 Canadian dietary guidelines.

OBJECTIVE: With significant shifts in the dietary recommendations between the 2007 and 2019 Canadian dietary guidelines, such as promoting plant-based food intake, reducing highly processed food intake and advocating the practice of food skills, we compared their differences in guideline development methods. DESIGN: Two reviewers used twenty-five guided criteria to appraise the methods used to develop the most recent dietary guidelines against those outlined in the 2014 WHO Handbook for Guideline Development. SETTING: Canada. PARTICIPANTS: 2007 and 2019 dietary guidelines. RESULTS: We found that the 2019 guidelines were more evidence-based and met 80 % (20/25) of the WHO criteria. For example, systematic reviews and health organisation authoritative reports, but not industry reports, constituted the evidence base for the dietary recommendations. However, recommendations on food sustainability and food skill practice were driven primarily by stakeholders' interests. By contrast, less information was recorded about the process used to develop the 2007 guidelines, resulting in 24 % (6/25) consistency with the WHO standards. CONCLUSIONS: Our analysis suggests that a more transparent and evidence-based approach is used to develop the 2019 Canadian dietary guidelines and that method criteria should support further incorporation of nutrition priorities (food sustainability and food skills) in future dietary guideline development.

The politics of voluntary self-regulation: insights from the development and promotion of the Australian Beverages Council's Commitment.

OBJECTIVE: To analyse the evolution of the soft drink industry's use of self-regulation as a response to obesity and examine the motivations driving its development and the strategies used to promote it to policy makers. DESIGN: We used a data set of industry documents published by the Australian Beverages Council (ABC) between 1998 and 2016. We analysed how the ABC voiced its political motivations about self-regulation and what internal nutrition policies it developed prior to its public launch of self-regulation. We also analysed two promotional strategies: funding research and writing policy submissions. SETTING: Australia. RESULTS: Between 1998 and 2006, the ABC shifted from a defensive strategy that denied the role of its products in obesity to more conciliatory strategy that emphasised the role of the soft drink industry in solutions to obesity. The ABC deliberately timed the launch of its self-regulation to coincide with an international public health congress. Following its launch, the ABC funded research demonstrating the efficacy of self-regulation and wrote submissions to government nutrition policies arguing that further regulation was unnecessary. CONCLUSIONS: The soft drink industry uses self-regulation to bolster its reputation and influence nutrition policy. Strategic timing plays a key role in the political influence of self-regulation.

Ultra-processed food consumption drives excessive free sugar intake among all age groups in Australia.

OBJECTIVE: To analyze the contribution of ultra-processed foods to the intake of free sugars among different age groups in Australia. METHODS: Dietary intakes of 12,153 participants from the National Nutrition and Physical Activity Survey (2011-12) aged 2+ years were evaluated. Food items collected through two 24-h recalls were classified according to the NOVA system. The contribution of each NOVA food group and their subgroups to total energy intake was determined by age group. Mean free sugar content in diet fractions made up exclusively of ultra-processed foods, or of processed foods, or of a combination of un/minimally processed foods and culinary ingredients (which includes table sugar and honey) were compared. Across quintiles of the energy contribution of ultra-processed foods, differences in the intake of free sugars, as well as in the prevalence of excessive free sugar intake (≥ 10% of total energy) were examined. RESULTS: Ultra-processed foods had the highest energy contribution among children, adolescents and adults in Australia, with older children and adolescents the highest consumers (53.1% and 54.3% of total energy, respectively). The diet fraction restricted to ultra-processed items contained significantly more free sugars than the two other diet fractions. Among all age groups, a positive and statistically significant linear association was found between quintiles of ultra-processed food consumption and both the average intake of free sugars and the prevalence of excessive free sugar intake. CONCLUSION: Ultra-processed food consumption drives excessive free sugar intake among all age groups in Australia.

Ultra-processed foods and recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from a nationally representative cross-sectional study.

OBJECTIVE: This study aimed to describe the consumption of ultra-processed foods in Australia and its association with the intake of nutrients linked to non-communicable diseases (NCDs). DESIGN: Cross-sectional study. SETTING: National Nutrition and Physical Activity Survey (2011-2012). PARTICIPANTS: 12,153 participants aged 2+ years. MAIN OUTCOME MEASURES: Average dietary content of nutrients linked to NCDs and the prevalence of intake outside levels recommended for the prevention of NCDs. DATA ANALYSIS: Food items were classified according to the NOVA system, a classification based on the nature, extent and purpose of industrial food processing. The contribution of each NOVA food group and their subgroups to total energy intake was calculated. Mean nutrient content of ultra-processed food and non-ultra-processed food fractions of the diet were compared. Across quintiles of the energy contribution of ultra-processed foods, differences in the intake of nutrients linked to NCDs as well as in the prevalence of intakes outside levels recommended for the prevention of NCDs were examined. RESULTS: Ultra-processed foods had the highest dietary contribution (42.0% of energy intake), followed by unprocessed or minimally processed foods (35.4%), processed foods (15.8%) and processed culinary ingredients (6.8%). A positive and statistically significant linear trend was found between quintiles of ultra-processed food consumption and intake levels of free sugars (standardised ß 0.43, p<0.001); total (ß 0.08, p<0.001), saturated (ß 0.18, p<0.001) and trans fats (ß 0.10, p<0.001); sodium (ß 0.21, p<0.001) and diet energy density (ß 0.41, p<0.001), while an inverse relationship was observed for dietary fibre (ß -0.21, p<0.001) and potassium (ß -0.27, p<0.001). The prevalence of non-recommended intake levels of all studied nutrients increased linearly across quintiles of ultra-processed food intake, notably from 22% to 82% for free sugars, from 6% to 11% for trans fat and from 2% to 25% for dietary energy density, from the lowest to the highest ultra-processed food quintile. CONCLUSION: The high energy contribution of ultra-processed foods impacted negatively on the intake of non-ultra-processed foods and on all nutrients linked to NCDs in Australia. Decreasing the dietary share of ultra-processed foods would substantially improve the diet quality in the country and help the population achieve recommendations on critical nutrients linked to NCDs.

Ultra-processed foods and the limits of product reformulation.

The nutritional reformulation of processed food and beverage products has been promoted as an important means of addressing the nutritional imbalances in contemporary dietary patterns. The focus of most reformulation policies is the reduction in quantities of nutrients-to-limit - Na, free sugars, SFA, trans-fatty acids and total energy. The present commentary examines the limitations of what we refer to as 'nutrients-to-limit reformulation' policies and practices, particularly when applied to ultra-processed foods and drink products. Beyond these nutrients-to-limit, there are a range of other potentially harmful processed and industrially produced ingredients used in the production of ultra-processed products that are not usually removed during reformulation. The sources of nutrients-to-limit in these products may be replaced with other highly processed ingredients and additives, rather than with whole or minimally processed foods. Reformulation policies may also legitimise current levels of consumption of ultra-processed products in high-income countries and increased levels of consumption in emerging markets in the global South.

Study sponsorship and the nutrition research agenda: analysis of randomized controlled trials included in systematic reviews of nutrition interventions to address obesity.

OBJECTIVE: To categorize the research topics covered by a sample of randomized controlled trials (RCT) included in systematic reviews of nutrition interventions to address obesity; to describe their funding sources; and to explore the association between funding sources and nutrition research topics. DESIGN: Cross-sectional study. SUBJECTS: RCT included in Cochrane Reviews of nutrition interventions to address obesity and/or overweight. RESULTS: Two hundred and thirteen RCT from seventeen Cochrane Reviews were included. Funding source and authors' conflicts of interest were disclosed in 82·6 and 29·6 % of the studies, respectively. RCT were more likely to test an intervention to manipulate nutrients in the context of reduced energy intake (44·2 % of studies) than food-level (11·3 %) and dietary pattern-level (0·9 %) interventions. Most of the food industry-sponsored studies focused on interventions involving manipulations of specific nutrients (66·7 %). Only 33·1 % of the industry-funded studies addressed dietary behaviours compared with 66·9 % of the non-industry-funded ones (P=0·002). The level of food processing was poorly considered across all funding sources. CONCLUSIONS: The predominance of RCT examining nutrient-specific questions could limit the public health relevance of rigorous evidence available for systematic reviews and dietary guidelines.