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ObjectivesTo compare ultra-processed food consumption across sociodemographic groups and over time (2007–2008, 2009–2010, 2011–2012) in the USA.DesignCross-sectional study.SettingNational Health and Nutrition Examination Survey (NHANES) 2007–2012.ParticipantsAll individuals aged ≥2 years with at least one 24-hour dietary recall were included (n=23 847).Main outcome measuresAverage dietary contribution of ultra-processed foods (expressed as a percentage of the total caloric value of the diet), obtained after classifying all food items according to extent and purpose of industrial food processing using NOVA classification.Data analysisLinear regression was used to evaluate the association between sociodemographic characteristics or NHANES cycles and dietary contribution of ultra-processed foods.ResultsAlmost 60% of calories consumed in the period 2007–2012 came from ultra-processed foods. Consumption of ultra-processed foods decreased with age and income level, was higher for non-Hispanic whites or non-Hispanic blacks than for other race/ethnicity groups and lower for people with college than for lower levels of education, all differences being statistically significant. Overall contribution of ultra-processed foods increased significantly between NHANES cycles (nearly 1% point per cycle), the same being observed among males, adolescents and high school education-level individuals.ConclusionsUltra-processed food consumption in the USA in the period 2007–2012 was overall high, greater among non-Hispanic whites or non-Hispanic blacks, less educated, younger, lower-income strata and increased across time.

To explore whether individuals who consume higher amounts of ultra-processed food (UPF) have more adverse mental health symptoms. Using a cross-sectional design, we measured the consumption of UPF as a percentage of total energy intake in kilo-calories using the NOVA food classification system. We explored whether individuals who consume higher amounts of UPF were more likely to report mild depression, more mentally unhealthy days and more anxious days per month using multivariable analyses adjusting for potential confounding variables. Representative sample from the United States National Health and Nutrition Examination Survey between 2007 and 2012. 10 359 adults aged 18+ without a history of cocaine, methamphetamine or heroin use. After adjusting for covariates, individuals with the highest level of UPF consumption were significantly more likely to report at least mild depression (OR: 1·81; 95 % CI1·09, 3·02), more mentally unhealthy (risk ratio (RR): 1·22; 95 % CI 1·18, 1·25) and more anxious days per month (RR: 1·19; 95 % CI 1·16, 1·23). They were also significantly less likely to report zero mentally unhealthy (OR: 0·60; 95 % CI 0·41, 0·88) or anxious days (OR: 0·65; 95 % CI 0·47, 0·90). Individuals reporting higher intakes of UPF were significantly more likely to report mild depression, more mentally unhealthy and more anxious days and less likely to report zero mentally unhealthy or anxious days. These data add important information to a growing body of evidence concerning the potential adverse effects of UPF consumption on mental health.

ObjectivesTo describe dietary sources of free sugars in different age groups of the UK population considering food groups classified according to the NOVA system and to estimate the proportion of excessive free sugars that could potentially be avoided by reducing consumption of their main sources.Design and settingCross-sectional data from the UK National Diet and Nutrition Survey (2008–2014) were analysed. Food items collected using a 4-day food diary were classified according to the NOVA system.Participants9364 individuals aged 1.5 years and above.Main outcome measuresAverage dietary content of free sugars and proportion of individuals consuming more than 10% of total energy from free sugars.Data analysisPoisson regression was used to estimate the associations between each of the NOVA food group and intake of free sugars. We estimated the per cent reduction in prevalence of excessive free sugar intake from eliminating ultra-processed foods and table sugar. Analyses were stratified by age group and adjusted for age, sex, ethnicity, survey year, region and equivalised household income (sterling pounds).ResultsUltra-processed foods account for 56.8% of total energy intake and 64.7% of total free sugars in the UK diet. Free sugars represent 12.4% of total energy intake, and 61.3% of the sample exceeded the recommended limit of 10% energy from free sugars. This percentage was higher among children (74.9%) and adolescents (82.9%). Prevalence of excessive free sugar intake increased linearly across quintiles of ultra-processed food consumption for all age groups, except among the elderly. Eliminating ultra-processed foods could potentially reduce the prevalence of excessive free sugar intake by 47%.ConclusionOur findings suggest that actions to reduce the ultra-processed food consumption generally rich in free sugars could lead to substantial public health benefits.

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

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.

This first paper in a three-part Lancet Series combines narrative and systematic reviews with original analyses and meta-analyses to assess three hypotheses concerning a dietary pattern based on ultra-processed foods. The first hypothesis—that this pattern is globally displacing long-established diets centred on whole foods and their culinary preparation as dishes and meals—is supported by decades of national food intake and purchase surveys, and recent global sales data. The second—that this pattern results in deterioration of diet quality, especially in relation to chronic disease prevention—is confirmed by national food intake surveys, large cohorts, and interventional studies showing gross nutrient imbalances; overeating driven by high energy density, hyper-palatability, soft texture, and disrupted food matrices; reduced intake of health-protective phytochemicals; and increased intake of toxic compounds, endocrine disruptors, and potentially harmful classes and mixtures of food additives. The third and final hypothesis—that this pattern increases the risk of multiple diet-related chronic diseases through various mechanisms—is substantiated by more than 100 prospective studies, meta-analyses, randomised controlled trials, and mechanistic studies, covering adverse outcomes across nearly all organ systems. The totality of the evidence supports the thesis that displacement of long-established dietary patterns by ultra-processed foods is a key driver of the escalating global burden of multiple diet-related chronic diseases. Two companion papers in this Series specify policy actions and wider public health strategies to promote, protect, and support diets based on fresh and minimally processed foods and prevent their displacement by ultra-processed foods.

Ultra-processed foods damage health and shorten life

PurposeThis study evaluated the association between ultra-processed food (UPF) consumption and cognitive performance among older US adults.MethodsThis cross-sectional study assessed 3632 participants aged 60+ years from the National Health and Nutrition Examination Survey (NHANES) 2011–14. Cognitive performance was assessed using the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD), Word Learning test, Animal Fluency test, and the Digit Symbol Substitution test (DSST). Dietary intake was assessed using two 24-h diet recalls. Food items were classified according to the NOVA system, a classification based on the nature, extent, and purpose of industrial food processing. Linear regression models were used to evaluate the association of dietary share of UPF (% of daily energy intake) (categorized as tertiles) and cognitive test scores, adjusting for socio-demographic variables, physical activity, smoking status, and chronic diseases (cardiovascular diseases, diabetes, and depression). Models excluding participants with pre-existing diseases were carried out to address potential reverse causality.ResultsOn average, UPF accounted for 53% of total energy intake, ranging from 33 to 70% across extreme tertiles. Inverted U-shape association between UPF consumption and Animal fluency and DSST was observed. No significant associations were observed between the UPF intake tertiles and the cognitive test results. Nonetheless, UPF consumption was significantly associated with worse performance in Animal Fluency in older adults without pre-existing diseases (P < 0.05).ConclusionUPF consumption was associated with worse performance in Animal Fluency among older people without pre-existing diseases. Decreasing UPF consumption may be a way to improve impaired cognition among older adults.

AbstractObjectiveTo examine the association between consumption of ultra-processed foods and risk of colorectal cancer among men and women from three large prospective cohorts.DesignProspective cohort study with dietary intake assessed every four years using food frequency questionnaires.SettingThree large US cohorts.ParticipantsMen (n= 46 341) from the Health Professionals Follow-up Study (1986-2014) and women (n=159 907) from the Nurses’ Health Study (1986-2014; n=67 425) and the Nurses’ Health Study II (1991-2015; n=92 482) with valid dietary intake measurement and no cancer diagnosis at baseline.Main outcome measureAssociation between ultra-processed food consumption and risk of colorectal cancer, estimated using time varying Cox proportional hazards regression models adjusted for potential confounding factors.Results3216 cases of colorectal cancer (men, n=1294; women, n=1922) were documented during the 24-28 years of follow-up. Compared with those in the lowest fifth of ultra-processed food consumption, men in the highest fifth of consumption had a 29% higher risk of developing colorectal cancer (hazard ratio for highest versus lowest fifth 1.29, 95% confidence interval 1.08 to 1.53; P for trend=0.01), and the positive association was limited to distal colon cancer (72% increased risk; hazard ratio 1.72, 1.24 to 2.37; P for trend<0.001). These associations remained significant after further adjustment for body mass index or indicators of nutritional quality of the diet (that is, western dietary pattern or dietary quality score). No association was observed between overall ultra-processed food consumption and risk of colorectal cancer among women. Among subgroups of ultra-processed foods, higher consumption of meat/poultry/seafood based ready-to-eat products (hazard ratio for highest versus lowest fifth 1.44, 1.20 to 1.73; P for trend<0.001) and sugar sweetened beverages (1.21, 1.01 to 1.44; P for trend=0.013) among men and ready-to-eat/heat mixed dishes among women (1.17, 1.01 to 1.36; P for trend=0.02) was associated with increased risk of colorectal cancer; yogurt and dairy based desserts were negatively associated with the risk of colorectal cancer among women (hazard ratio 0.83, 0.71 to 0.97; P for trend=0.002).ConclusionsIn the three large prospective cohorts, high consumption of total ultra-processed foods in men and certain subgroups of ultra-processed foods in men and women was associated with an increased risk of colorectal cancer. Further studies are needed to better understand the potential attributes of ultra-processed foods that contribute to colorectal carcinogenesis.

BackgroundRapid 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.MethodsA 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.ResultsSignificant (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.ConclusionThe 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.