Identifying and Estimating Ultraprocessed Food Intake in the US NHANES According to the Nova Classification System of Food Processing.

BACKGROUND: The degree of food processing may be an important dimension of diet in how it relates to health outcomes. A major challenge is standardizing food processing classification systems for commonly used datasets. OBJECTIVES: To standardize and increase transparency in its application, we describe the approach used to classify foods and beverages according to the Nova food processing classification in the 24-h dietary recalls from the 2001-2018 cycles of What We Eat in America (WWEIA), NHANES, and investigate variability and potential for Nova misclassification within WWEIA, NHANES 2017-2018 data via various sensitivity analyses. METHODS: First, we described how the Nova classification system was applied to the 2001-2018 WWEIA, NHANES data using the reference approach. Second, we calculated the percentage energy from Nova groups [1: unprocessed or minimally processed foods, 2: processed culinary ingredients, 3: processed foods, and 4: ultraprocessed foods (UPFs)] for the reference approach using day 1 dietary recall data from non-breastfed participants aged ≥1 y from the 2017-2018 WWEIA, NHANES. We then conducted 4 sensitivity analyses comparing potential alternative approaches (e.g., opting for more vs. less degree of processing for ambiguous items) to the reference approach, to assess how estimates differed. RESULTS: The energy contribution of UPFs using the reference approach was 58.2% ± 0.9% of the total energy; unprocessed or minimally processed foods contributed 27.6% ± 0.7%, processed culinary ingredients contributed 5.2% ± 0.1%, and processed foods contributed 9.0% ± 0.3%. In sensitivity analyses, the dietary energy contribution of UPFs ranged from 53.4% ± 0.8% to 60.1% ± 0.8% across alternative approaches. CONCLUSIONS: We present a reference approach for applying the Nova classification system to WWEIA, NHANES 2001-2018 data to promote standardization and comparability of future research. Alternative approaches are also described, with total energy from UPFs differing by ∼6% between approaches for 2017-2018 WWEIA, NHANES.

Ultra-processed foods consumption and diet quality among preschool children and women of reproductive age from Argentina.

OBJECTIVE: To assess the association between the consumption of ultra-processed foods (UPF) and diet quality among preschool children and women of reproductive age from Argentina. DESIGN: Cross-sectional and nationally representative survey. The food items were classified according to the NOVA system. Consumption of fruits, vegetables, legumes, nuts, seeds and wholegrains was estimated, and the energy and nutrients related to non-communicable disease (NCD) intake. Linear regression was used to assess the associations. SETTING: Argentina. PARTICIPANTS: Children aged 2-5 years (n 7022), female adolescent aged 10-19 years (n 2165) and women aged 20-49 years (n 4414). RESULTS: UPF represented more than a quarter of total energy intake, 27 % in children, 31 % in female adolescents and 26 % in women. Across all age groups, the major contributors to UPF consumption were cookies and pastries (about 6·0-7·0 %), soft drinks (about 2·7-3·7 %), candies (about 1·8-4·6 %), and juices (about 1·3-1·7 %). The consumption of fresh vegetables, fresh fruits and legumes was negatively associated with UPF consumption. A significant positive association was found between the dietary share of UPF and the dietary content of NCD-promoting nutrients such as free sugars and total saturated and trans-fats. In contrast, a significant negative association was found with the content of NCD-protective such as fibre and protein. CONCLUSIONS: UPF were associated with lower consumption of healthy foods and higher intake of nutrients related to NCD in children and women of reproductive age in Argentina. It is necessary to design food policies that simultaneously reduce the consumption of UPF while promoting the intake of fresh and whole foods to improve the dietary quality.

Ultra-processed foods drive to unhealthy diets: evidence from Chile.

OBJECTIVES: To assess the consumption of ultra-processed foods and its association with the overall dietary content of nutrients related to non-communicable diseases (NCD) in the Chilean diet and to estimate the population attributable fraction of ultra-processed food consumption on the unhealthy nutrient content. DESIGN: Cross-sectional analysis of dietary data collected through a national survey (2010). SETTING: Chile. PARTICIPANTS: Chilean population aged ≥2 years (n 4920). RESULTS: In Chile, ultra-processed foods represented 28·6 % of the total energy intake. A significant positive association was found between the dietary share of ultra-processed foods and NCD-promoting nutrients such as dietary energy density (standardised regression coefficient (ß) = 0·22), content of free sugars (ß = 0·45), total fats (ß = 0·26), saturated fats (ß = 0·19), trans fats (ß = 0·09) and Na:K ratio (ß = 0·04), while a significant negative association was found with the content of NCD-protective nutrients such as K (ß = -0·19) and fibre (ß = -0·31). The content of Na (ß = 0·02) presented no significant association. Except for Na, the prevalence of inadequate intake of all nutrients (WHO recommendations) increased across quintiles of the dietary share of ultra-processed foods. With the reduction of ultra-processed foods consumption to the level seen among the 20 % lowest consumers (3·8 % (0-9·3 %) of the total energy from ultra-processed foods), the prevalence of nutrient inadequacy would be reduced in almost three-fourths for trans fats; in half for energy density (foods); in around one-third for saturated fats, energy density (beverages), free sugars and total fats; in near 20 % for fibre and Na:K ratio and in 13 % for K. CONCLUSIONS: In Chile, decreasing the consumption of ultra-processed foods is a potentially effective way to achieve the WHO nutrient goals for the prevention of diet-related NCD.

Ultra-processed food intake in association with BMI change and risk of overweight and obesity: A prospective analysis of the French NutriNet-Santé cohort.

BACKGROUND: Ultra-processed food (UPF) consumption has increased drastically worldwide and already represents 50%-60% of total daily energy intake in several high-income countries. In the meantime, the prevalence of overweight and obesity has risen continuously during the last century. The objective of this study was to investigate the associations between UPF consumption and the risk of overweight and obesity, as well as change in body mass index (BMI), in a large French cohort. METHODS AND FINDINGS: A total of 110,260 adult participants (≥18 years old, mean baseline age = 43.1 [SD 14.6] years; 78.2% women) from the French prospective population-based NutriNet-Santé cohort (2009-2019) were included. Dietary intakes were collected at baseline using repeated and validated 24-hour dietary records linked to a food composition database that included >3,500 different food items, each categorized according to their degree of processing by the NOVA classification. Associations between the proportion of UPF in the diet and BMI change during follow-up were assessed using linear mixed models. Associations with risk of overweight and obesity were assessed using Cox proportional hazard models. After adjusting for age, sex, educational level, marital status, physical activity, smoking status, alcohol intake, number of 24-hour dietary records, and energy intake, we observed a positive association between UPF intake and gain in BMI (ß Time × UPF = 0.02 for an absolute increment of 10 in the percentage of UPF in the diet, P < 0.001). UPF intake was associated with a higher risk of overweight (n = 7,063 overweight participants; hazard ratio (HR) for an absolute increase of 10% of UPFs in the diet = 1.11, 95% CI: 1.08-1.14; P < 0.001) and obesity (n = 3,066 incident obese participants; HR10% = 1.09 (1.05-1.13); P < 0.001). These results remained statistically significant after adjustment for the nutritional quality of the diet and energy intake. Study limitations include possible selection bias, potential residual confounding due to the observational design, and a possible item misclassification according to the level of processing. Nonetheless, robustness was tested and verified using a large panel of sensitivity analyses. CONCLUSIONS: In this large observational prospective study, higher consumption of UPF was associated with gain in BMI and higher risks of overweight and obesity. Public health authorities in several countries recently started to recommend privileging unprocessed/minimally processed foods and limiting UPF consumption. TRIAL REGISTRATION: ClinicalTrials.gov NCT03335644 (https://clinicaltrials.gov/ct2/show/NCT03335644).

The impact of acculturation to the US environment on the dietary share of ultra-processed foods among US adults.

This study examined the association between measures of acculturation to the US environment including place of birth, and language spoken at home and proportion of life in the US among foreign-born, in relation to the dietary contribution of ultra-processed foods. Ultra-processed foods, as defined by the NOVA food classification system, are formulations of macronutrients (starches, sugars, fats and protein isolates) with little, if any, whole food and often with added flavors, colors, emulsifiers and other cosmetic additives. We studied 14,663 participants from the National Health and Nutrition Examination Survey 2011-2016, aged 20+ years, who completed a 1-day 24-h dietary recall. Food items were classified using NOVA into ultra-processed or non-ultra-processed foods. Linear regression models adjusted for age, sex, family income, education and race/ ethnicity, showed significant associations between general acculturation measures and dietary contribution of ultra-processed foods. Foreign-born adults consumed less ultra-processed foods than US-born adults (45 vs. 58%, p < 0.001). Within foreign-born adults, ultra-processed food consumption increased with English permeation at home from 40% among individuals speaking non-English languages only to 50% among those speaking English only (p for linear trend <0.001). In addition, ultra-processed food consumption increased from 41% among foreign-born adults who spent less than 30% of their life in the US to 48% among those who lived in the US for more than 50% of their lives (p for linear trend <0.001). Race/ethnicity emerged as an important effect modifier for the observed associations.

Dietary share of ultra-processed foods and metabolic syndrome in the US adult population.

This study sought to examine the relationship between dietary share of ultra-processed foods and metabolic syndrome among US adults. We studied 6, 385 participants from the cross-sectional National Health and Nutrition Examination Survey 2009-2014, aged 20+ years, with blood tests under fasting conditions and at least one 24-hour dietary recall. Food items were classified according to the extent and purpose of industrial food processing. Ultra-processed foods (UPF) are formulations of many ingredients, mostly of exclusive industrial use, that result from a sequence of industrial processes (hence ultra-processed). Metabolic Syndrome (MetS) was defined according to the 2009 Joint Scientific Statement as meeting three or more of the following criteria: (1) elevated waist circumference (2) elevated fasting plasma glucose (3) elevated blood pressure (4) elevated triglycerides (5) reduced high-density lipoprotein (HDL-C). Poisson regression models with robust variance adjusted for age, sex, race/ethnicity, family income, education, physical activity and smoking showed significant linear association between the dietary contribution of UPF and the prevalence of MetS (a 10% increase in contribution was associated with a 4% prevalence increase) (prevalence ratio -PR- = 1.04; 95% CI 1.02, 1.07). A dietary UPF contribution of >71% (5th population quintile) was associated with 28% higher prevalence of MetS compared to a contribution below 40% (1st population quintile) (PR = 1.28; 95% CI 1.09, 1.50). The association was stronger in young adults (PR between upper and lower quintiles = 1.94; 95% CI 1.39, 2.72) and decreased with age. These findings add to the growing evidence that UPF consumption is associated with diet-related non-communicable diseases.

Ultra-processed foods: what they are and how to identify them.

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).

Association between ultra-processed food consumption and the nutrient profile of the Colombian diet in 2005.

OBJECTIVE: To evaluate the consumption of ultra-processed food and drink products and its association with the nutrient profile of the Colombian diet in 2005. MATERIALS AND METHODS: Food consumption based on 24-hour dietary records from 38 643 men and women was classified into four NOVA groups according to the extent and purpose of food processing. RESULTS: Ultra-processed food and drink products represented 15.9% of the total energy daily intake, compared to 63.3% from minimally processed food, 15.8% from processed culinary ingredients, and 4.9% from processed food. Non-ultra-processed food items had a healthier nutritional profile compared to ultra-processed items in terms of contribution to total calories from protein, carbohydrates, total fat, saturated fat, free sugar, fiber and energy density. CONCLUSIONS: Ultra-processed food products have a less healthy nutrient profile than non-ultra-processed ones. An increase in the consumption of these foods must be prevented within Colombia.

OBJETIVO: Evaluar el consumo de alimentos y bebidas ultraprocesadas y su asociación con el perfil nutricional dentro de la Encuesta Nacional de Nutrición de 2005 en Colombia. MATERIAL Y MÉTODOS: El consumo de alimentos basados en registros alimentarios de 24 horas de 38 643 individuos se clasificó en cuatro grupos de NOVA. RESULTADOS: Los productos de alimentos y bebidas ultraprocesados representaron 15.9% de la ingesta diaria total de energía, en comparación con 63.3% de los alimentos mínimamente procesados, 15.8% de los ingredientes culinarios procesados y 4.9% de los procesados. Los alimentos mínimamente procesados tenían un perfil nutricional más saludable en comparación con los artículos ultraprocesados en términos de contribución a las calorías totales, de proteínas, carbohidratos, grasa total, grasa saturada, azúcar libre, densidad de fibra y densidad de energía. CONCLUSIONES: Los alimentos ultraprocesados tienen un perfil nutricional menos saludable que los alimentos no procesados.

Association Between Ultra-Processed Food Consumption and Functional Gastrointestinal Disorders: Results From the French NutriNet-Santé Cohort.

OBJECTIVES: Ultra-processed foods (UPF) consumption has increased over the last decades and is raising concerns about potential adverse health effects. Our objective was to assess the association between UPF consumption and four functional gastrointestinal disorders (FGIDs): irritable bowel syndrome (IBS), functional constipation (FC), functional diarrhea (FDh), and functional dyspepsia (FDy), in a large sample of French adults. METHODS: We analyzed dietary data of 33,343 participants from the web-based NutriNet-Santé cohort, who completed at least three 24 h food records, prior to a Rome III self-administered questionnaire. Proportion (in weight) of UPF in the diet (UPFp) was computed for each subject. The association between UPFp quartiles and FGIDs was estimated by multivariable logistic regression. RESULTS: Participants included in the analysis were mainly women (76.4%), and the mean age was 50.4 (SD = 14.0) years. UPF accounted for 16.0% of food consumed in weight, corresponding to 33.0% of total energy intake. UPF consumption was associated with younger age, living alone, lower incomes, higher BMI, and lower physical activity level (all p < 0.0001). A total of 3516 participants reported IBS (10.5%), 1785 FC (5.4%), 1303 FDy (3.9%), and 396 FDh (1.1%). After adjusting for confounding factors, an increase in UPFp was associated with a higher risk of IBS (aOR Q4 vs. Q1 [95% CI]: 1.25 [1.12-1.39], p-trend < 0.0001). CONCLUSIONS: This study suggests an association between UPF and IBS. Further longitudinal studies are needed to confirm those results and understand the relative impact of the nutritional composition and specific characteristics of UPF in this relationship.

Ultra-processed food consumption and excess weight among US adults.

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.

Ultra-processed foods, protein leverage and energy intake in the USA.

OBJECTIVE: Experimental studies have shown that human macronutrient regulation minimizes variation in absolute protein intake and consequently energy intake varies passively with dietary protein density ('protein leverage'). According to the 'protein leverage hypothesis' (PLH), protein leverage interacts with a reduction in dietary protein density to drive energy overconsumption and obesity. Worldwide increase in consumption of ultra-processed foods (UPF) has been hypothesized to be an important determinant of dietary protein dilution, and consequently an ecological driving force of energy overconsumption and the obesity pandemic. The present study examined the relationships between dietary contribution of UPF, dietary proportional protein content and the absolute intakes of protein and energy. DESIGN: National representative cross-sectional study. SETTING: National Health and Nutrition Examination Survey 2009-2010. SUBJECTS: Participants (n 9042) aged ≥2 years with at least one day of 24 h dietary recall data. RESULTS: We found a strong inverse relationship between consumption of UPF and dietary protein density, with mean protein content dropping from 18·2 to 13·3 % between the lowest and highest quintiles of dietary contribution of UPF. Consistent with the PLH, increase in the dietary contribution of UPF (previously shown to be inversely associated with protein density) was also associated with a rise in total energy intake, while absolute protein intake remained relatively constant. CONCLUSIONS: The protein-diluting effect of UPF might be one mechanism accounting for their association with excess energy intake. Reducing UPF contribution in the US diet may be an effective way to increase its dietary protein concentration and prevent excessive energy intake.

Processed and ultra-processed foods are associated with lower-quality nutrient profiles in children from Colombia.

OBJECTIVE: To determine if processed and ultra-processed foods consumed by children in Colombia are associated with lower-quality nutrition profiles than less processed foods. DESIGN: We obtained information on sociodemographic and anthropometric variables and dietary information through dietary records and 24 h recalls from a convenience sample of the Bogotá School Children Cohort. Foods were classified into three categories: (i) unprocessed and minimally processed foods, (ii) processed culinary ingredients and (iii) processed and ultra-processed foods. We also examined the combination of unprocessed foods and processed culinary ingredients. SETTING: Representative sample of children from low- to middle-income families in Bogotá, Colombia. SUBJECTS: Children aged 5-12 years in 2011 Bogotá School Children Cohort. RESULTS: We found that processed and ultra-processed foods are of lower dietary quality in general. Nutrients that were lower in processed and ultra-processed foods following adjustment for total energy intake included: n-3 PUFA, vitamins A, B12, C and E, Ca and Zn. Nutrients that were higher in energy-adjusted processed and ultra-processed foods compared with unprocessed foods included: Na, sugar and trans-fatty acids, although we also found that some healthy nutrients, including folate and Fe, were higher in processed and ultra-processed foods compared with unprocessed and minimally processed foods. CONCLUSIONS: Processed and ultra-processed foods generally have unhealthy nutrition profiles. Our findings suggest the categorization of foods based on processing characteristics is promising for understanding the influence of food processing on children's dietary quality. More studies accounting for the type and degree of food processing are needed.

Ultra-processing. An odd 'appraisal'.

It is now generally agreed that the impact of the current nature, purpose and extent of food processing on human well-being, health and disease needs to be better understood and explained, in order to improve public health. The special issue of Public Health Nutrition devoted to the concept of ultra-processing of food, and the NOVA classification of which ultra-processed foods are one category, is a great step forward in this work. Coincidentally, a polemical 'critical appraisal' of ultra-processing was recently published in another journal. Debate and discussion are an essential part of the scientific endeavour. In this commentary, we correct inaccurate statements made about NOVA in the 'appraisal,' rebut points raised, and discuss the larger issue of scientific responsibility for publishing opposing views on controversial topics.

Ultra-processed foods and added sugars in the Chilean diet (2010).

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.

Automobile, construction and entertainment business sector influences on sedentary lifestyles.

Sedentary lifestyles contribute to premature death and health inequalities. Researchers have studied personal and community-level determinants of inactivity but few have analyzed corporate influences. To reframe the public health debate on inactivity and open new doors for public sector intervention, we conducted a scoping review of evidence from several disciplines to describe how the business and political practices of the automobile, construction, and entertainment sectors have encouraged sedentary lifestyles. In the last 50 years, these industries have found it profitable to produce motor vehicles, housing, and entertainment, which intentionally or unintentionally discourage physical activity. Ceding primary authority for policy decisions in these sectors to the market-based economy has enabled the growth of powerful lobbies that encourage and maintain sedentary lifestyles. To counteract these influences, public health and civil society need to confront more upstream economic and social determinants of sedentary lifestyles. Building on evidence from efforts to change harmful tobacco, alcohol and food industry practices, we propose the creation of research and policy agendas that contribute to public health practice that can modify corporate practices that contribute to physical, social and political environments that discourage physical activity.

The share of ultra-processed foods and the overall nutritional quality of diets in the US: evidence from a nationally representative cross-sectional study.

BACKGROUND: Recent population dietary studies indicate that diets rich in ultra-processed foods, increasingly frequent worldwide, are grossly nutritionally unbalanced, suggesting that the dietary contribution of these foods largely determines the overall nutritional quality of contemporaneous diets. Yet, these studies have focused on individual nutrients (one at a time) rather than the overall nutritional quality of the diets. Here we investigate the relationship between the energy contribution of ultra-processed foods in the US diet and its content of critical nutrients, individually and overall. METHODS: We evaluated dietary intakes of 9,317 participants from 2009 to 2010 NHANES aged 1+ years. Food items were classified into unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods. First, we examined the average dietary content of macronutrients, micronutrients, and fiber across quintiles of the energy contribution of ultra-processed foods. Then, we used Principal Component Analysis (PCA) to identify a nutrient-balanced dietary pattern to enable the assessment of the overall nutritional quality of the diet. Linear regression was used to explore the association between the dietary share of ultra-processed foods and the balanced-pattern PCA factor score. The scores were thereafter categorized into tertiles, and their distribution was examined across ultra-processed food quintiles. All models incorporated survey sample weights and were adjusted for age, sex, race/ethnicity, family income, and educational attainment. RESULTS: The average content of protein, fiber, vitamins A, C, D, and E, zinc, potassium, phosphorus, magnesium, and calcium in the US diet decreased significantly across quintiles of the energy contribution of ultra-processed foods, while carbohydrate, added sugar, and saturated fat contents increased. An inverse dose-response association was found between ultra-processed food quintiles and overall dietary quality measured through a nutrient-balanced-pattern PCA-derived factor score characterized by being richer in fiber, potassium, magnesium and vitamin C, and having less saturated fat and added sugars. CONCLUSIONS: This study suggests that decreasing the dietary share of ultra-processed foods is a rational and effective way to improve the nutritional quality of US diets.