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Policies that require front-of-package (FoP) nutrient warnings are becoming increasingly common across the globe as a strategy to discourage excess consumption of sugary drinks and ultra-processed food. However, a better understanding of the pathway through which FoP nutrient warnings work, as well as a review of how outcomes being measured in recent studies map onto this pathway, are needed in order to inform policy on the most effective FoP label design for reducing purchases of ultra-processed foods. This scoping review describes a conceptual model for how FoP nutrient warnings affect consumer behavior, examines which of these outcomes are currently being measured, and summarizes evidence from randomized controlled experiments. Twenty-two studies which experimentally tested nutrient warnings against a control label or other labeling systems were included for full-text review. Our conceptual model includes attention; comprehension, cognitive elaboration, and message acceptance; negative affect and risk perception; behavioral intentions, and behavioral response, along with other elements such as external factors and interpersonal communications. We found that many studies focused on outcomes such as attention, comprehension, and behavioral intentions, but considerable gaps in the evidence remain, particularly for intermediary steps on the pathway to behavioral change, such as negative affect and social interactions. FoP nutrient warnings were visually attended to by consumers, easy to understand, helped consumers identify products high in nutrients of concern, and discouraged them from purchasing these products, although other labeling systems were perceived as containing more information and performed better at helping consumers rank the healthfulness of products. More research is needed to understand whether and how nutrient warnings work in the real world to discourage consumer purchases of sugary drinks and ultra-processed food.

Ultra-processed food (UPF) accounts for a majority of calories consumed in the United States, but the impact on human health remains unclear. We aimed to identify poly-metabolite scores in blood and urine that are predictive of UPF intake. Of the 1,082 Interactive Diet and Activity Tracking in AARP (IDATA) Study (clinicaltrials.gov ID NCT03268577) participants, aged 50-74 years, who provided biospecimen consent, n = 718 with serially collected blood and urine and one to six 24-h dietary recalls (ASA-24s), collected over 12-months, met eligibility criteria and were included in the metabolomics analysis. Ultra-high performance liquid chromatography with tandem mass spectrometry was used to measure >1,000 serum and urine metabolites. Average daily UPF intake was estimated as percentage energy according to the Nova system. Partial Spearman correlations and Least Absolute Shrinkage and Selection Operator (LASSO) regression were used to estimate UPF-metabolite correlations and build poly-metabolite scores of UPF intake, respectively. Scores were tested in a post-hoc analysis of a previously conducted randomized, controlled, crossover-feeding trial (clinicaltrials.gov ID NCT03407053) of 20 subjects who were admitted to the NIH Clinical Center and randomized to consume ad libitum diets that were 80% or 0% energy from UPF for 2 weeks immediately followed by the alternate diet for 2 weeks; eligible subjects were between 18-50 years old with a body mass index of >18.5 kg/m2 and weight-stable. IDATA participants were 51% female, and 97% completed ≥4 ASA-24s. Mean intake was 50% energy from UPF. UPF intake was correlated with 191 (of 952) serum and 293 (of 1,044) 24-h urine metabolites (FDR-corrected P-value < 0.01), including lipid (n = 56 serum, n = 22 24-h urine), amino acid (n = 33, 61), carbohydrate (n = 4, 8), xenobiotic (n = 33, 70), cofactor and vitamin (n = 9, 12), peptide (n = 7, 6), and nucleotide (n = 7, 10) metabolites. Using LASSO regression, 28 serum and 33 24-h urine metabolites were selected as predictors of UPF intake; biospecimen-specific scores were calculated as a linear combination of selected metabolites. Overlapping metabolites included (S)C(S)S-S-Methylcysteine sulfoxide (rs = -0.23, -0.19), N2,N5-diacetylornithine (rs = -0.27 for serum, -0.26 for 24-h urine), pentoic acid (rs = -0.30, -0.32), and N6-carboxymethyllysine (rs = 0.15, 0.20). Within the cross-over feeding trial, the poly-metabolite scores differed, within individual, between UPF diet phases (P-value for paired t test < 0.001). IDATA Study participants were older US adults whose diets may not be reflective of other populations. Poly-metabolite scores, developed in IDATA participants with varying diets, are predictive of UPF intake and could advance epidemiological research on UPF and health. Poly-metabolite scores should be evaluated and iteratively improved in populations with a wide range of UPF intake.

Background Longitudinal cohort studies across the lifespan suggest an association between ultra-processed food (UPF) and depression. However, the effect of UPF on depression and mental health in older adults has not been determined. Therefore, this study investigated the effect of UPF on depressive symptoms and mental health in community-dwelling older adults. Methods A pragmatic target trial was designed and emulated using the ASPirin in Reducing Events in the Elderly longitudinal data. Participants were community-dwelling older adults (≥ 70 years) in Australia. We specified and emulated the protocol of a two-arm randomised pragmatic clinical trial using the level of UPF consumption as the intervention. Greater than or equal to 4 servings of UPF per day was considered the intervention, with less than 4 servings per day the control. Dietary consumption was assessed using a mail-based diet screening questionnaire, and the level of food processing was classified based on the NOVA classification. The study outcomes were depressive symptoms, defined as a score of ≥ 8 on the Center for Epidemiological Studies Depression 10-item scale, and general mental health, defined by the mental component summary score of the Short Form-12. We applied inverse probability treatment weighting to balance confounders. Marginal structural models were employed to estimate the population-level average effect of intervention using generalised estimated equations. Results A total of 11,192 participants (3415 intervention and 7777 control) were eligible for the emulation. High UPF consumption at time zero was associated with an increased risk of depressive symptoms at follow-ups (RR: 1.10; CI: 1.04–1.18). The finding was consistent with sensitivity analyses; after excluding participants on antidepressants at time zero, the risk of depressive symptoms in the intervention group was increased by 11% compared to the control (RR: 1.11; 95% CI: (1.04–1.20)). Consumption of UPF adversely affected the mental component quality of life ( β : − 0.40; CI: − 0.65 to − 0.15). Conclusions A higher level of UPF consumption was associated with a higher risk of depressive symptoms and adversely affected mental health among older adults.

Background/Objectives: It is unknown whether the negative health effects associated with ultra-processed foods (UPFs) are due to their nutritional composition or to the extent of food processing itself. We evaluated the impact of a test meal composed only of UPF, according to the NOVA classification, compared to a similar meal without UPF in adults with obesity. Methods: This is a parallel, randomized trial. Adult individuals with obesity, according to BMI, % body fat, and/or waist circumference were included. Individuals ate one out of two test meals, matched for energy density, macronutrients, sodium, and fiber, differing in NOVA classification, as a breakfast after a 12-h fast. The rate of intake, appetite, satiety hormones, energy expenditure, and autonomic function were measured. Data were analyzed using mixed analysis of variance. Results: Forty-two individuals were included. We found a significantly faster intake rate (07:52 ± 3:00 vs. 11:07 ± 03:16 min), with less chewing and bites, and greater capacity to eat (39.68 ± 22.69 vs. 23.95 ± 18.92 mm) after the UPF meal, without observed differences in the metabolic outcomes. In an exploratory analysis, after adjusting by sex, leptin levels showed a greater decrease after the test meal in the control group. Conclusions: Although we found a faster intake rate in the UPF meal, only marginal effects were found on the participants’ capacity to eat after the UPF meal. The high similarity between meals, despite differences according to the NOVA classification, may explain these results. As our study was small, these findings require further investigation.

Objectives. We examined the effect on food purchases of adding recommended calorie intake per day or per meal to the mandated calorie information posted on chain restaurant menus. Methods. Before and after New York City implemented calorie posting on chain restaurant menus in 2008, we provided daily, per-meal, or no calorie recommendations to randomized subsets of adult lunchtime customers (n = 1121) entering 2 McDonald’s restaurants, in Manhattan and Brooklyn, and collected receipts and survey responses as they exited. In linear and logistic regressions, with adjustment for gender, race, age, and day, we tested for simple differences in calories consumed and interactions between variables. Results. Posting calorie benchmarks had no direct impact, nor did it moderate the impact of calorie labels on food purchases. The recommendation appeared to promote a slight increase in calorie intake, attributable to increased purchases of higher-calorie entrées. Conclusions. These results do not support the introduction of calorie recommendations as a means of enhancing the impact of posted calorie information or reducing the contribution of restaurant dining to the obesity epidemic.

Due to regulatory changes, fast food companies often depict healthy foods in their television advertisements to children. The present study examined how exposure to advertising for ‘healthy’ meal bundles to children influenced the selection of food in children. A total of fifty-nine children (thirty-seven males) aged 7–10 years (8·8 (sd 0·9) years) took part in the present study. The within-participant, counterbalanced design had two conditions: control (exposure to ten toy adverts across two breaks of five adverts each) and experimental (the middle advert in each break replaced with one for a McDonald's Happy Meal® depicting the meal bundle as consisting of fish fingers, a fruit bag and a bottle of mineral water). Following viewing of the adverts embedded in a cartoon, children completed a hypothetical menu task that reported liking for McDonald's food and fast food, in general. Nutritional knowledge, height and weight of the children were measured. There was no significant difference between the two advert conditions for the nutritional content of the meal bundles selected. However, children's liking for fast food, in general, increased after exposure to the food adverts relative to control (P= 0·004). Compared to children with high nutritional knowledge, those with low scores selected meals of greater energy content (305 kJ) after viewing the food adverts (P= 0·016). Exposure to adverts for ‘healthy’ meal bundles did not drive healthier choices in children, but did promote liking for fast food. These findings contribute to debates about food advertising to children and the effectiveness of related policies.

Background: Understanding how food processing impacts type 2 diabetes (T2DM) control is essential for disease management. This study aimed to assess the association between ultra-processed food (UPF) consumption, as defined by the NOVA classification, and metabolic parameters in T2DM patients. Methods: This was a cross-sectional analysis using baseline data from the NUGLIC study, a multicenter randomized clinical trial. Multiple linear and Poisson regressions were used to evaluate associations between quintiles of processed and ultra-processed food consumption and glycated hemoglobin (HbA1c) as the primary outcome. Secondary outcomes included fasting glucose, lipid profile, body mass index (BMI), and waist circumference. Results: This study included 326 participants. UPF consumption accounted for approximately 16.4% of total daily energy intake. No significant linear associations were observed between higher consumption of industrialized foods and anthropometric or glycemic markers. However, intermediate and high consumption levels were associated with an increased total cholesterol (Q3: β = 26.6; Q4: β = 26.7) and LDL-cholesterol (Q4: β = 19.8; Q5: β = 17.5). Conclusion: In T2DM patients, a higher intake of processed and ultra-processed foods was linked to elevated cholesterol and LDL levels. These findings highlight potential cardiovascular risks but do not support causality due to the study’s cross-sectional design.

The objective of the present study was to determine the glycaemic index (GI) and glycaemic load (GL) values of standard portion sizes of Southeast Asian traditional foods. A total of fifteen popular Southeast Asian foods were evaluated. Of these foods, three were soft drinks, while the other twelve were solid foods commonly consumed in this region. In total, forty-seven healthy participants (eighteen males and twenty-nine females) volunteered to consume either glucose at least twice or one of the fifteen test foods after a 10–12 h overnight fast. Blood glucose concentrations were analysed before consumption of the test food, and 15, 30, 45, 60, 90 and 120 min after food consumption, using capillary blood samples. The GI value of each test food was calculated by expressing the incremental area under the blood glucose response curve (IAUC) value of the test food as a percentage of each participant's average IAUC value, with glucose as the reference food. Among the fifteen foods tested, six belonged to low-GI foods (Ice Green Tea, Beehoon, Pandan Waffle, Curry Puff, Youtiao and Kaya Butter Toast), three belonged to medium-GI foods (Barley Drink, Char Siew Pau and Nasi Lemak), and the other six belonged to high-GI foods (Ice Lemon Tea, Chinese Carrot Cake, Chinese Yam Cake, Chee Cheong Fun, Lo Mai Gai and Pink Rice Cake). The GI and GL values of these traditional foods provide valuable information to consumers, researchers and dietitians on the optimal food choice for glycaemic control. Moreover, our dataset provides GI values of fifteen foods that were not previously tested extensively, and it presents values of foods commonly consumed in Southeast Asia.

Background/Objectives: Evidence about the relation between dietary patterns and cardiovascular disease (CVD) is scarce in Middle Eastern countries. This study was performed to examine the association between major dietary patterns and CVD mortality in Iranian adults. Subjects/Methods: This population-based prospective cohort study was conducted among 4834 randomly selected participants aged ⩾35 years from urban and rural areas of central Iran (2001–2009) (the Isfahan Cohort Study). Dietary intakes were assessed using a food frequency questionnaire, and major dietary patterns were identified by means of exploratory factor analysis. Subjects or their next of kin were interviewed biannually looking for possible occurrence of events. Cardiovascular mortality was defined as fatal myocardial infarction, fatal stroke and sudden cardiac death. Results: During the median follow-up of 9.0 years and 50 282 person-years, we found a total of 118 CVD mortalities. Four major dietary patterns were identified: 'Western', 'Mediterranean', 'Animal fat' and 'Fast food'. Adherence to the Mediterranean dietary pattern was protectively associated with CVD mortality, such that those in the highest quartile were 46% (hazard ratio (HR): 0.54; 95% confidence interval (CI): 0.32–0.91; P -value for trend=0.03) less likely to have incident CVD mortality than those in the lowest quartile. Further adjustment for potential confounders strengthened this association (HR: 0.42; 95% CI: 0.19–0.96; P -value for trend=0.02). We found no significant association between adherence to the Western, animal fat and fast food dietary patterns and CVD mortality. Conclusions: Adherence to a Mediterranean dietary pattern was associated with reduced risk for cardiovascular mortality even in a developing country setting.

Background/Objectives: A faster eating rate is associated with increased energy intake and risk of obesity. High consumption of ultra-processed foods (UPFs) is associated with a faster eating rate. Psychobehavioral aspects, such as body image self-perception, eating disorders, and anxiety, may modulate this eating behavior. Therefore, this study examined the moderating role of psychobehavioral factors in the association between meal type (UPF vs non-UPF) and eating rate among individuals with obesity. Methods: It is a secondary analysis of a randomized, parallel clinical trial conducted with 39 adults who have obesity. Participants were assigned to consume either a UPF-only composed meal or a UPF-free meal, both of which were isoenergetic (~550 kcal). Psychobehavioral variables (food addiction—mYFAS 2.0, body image perception and satisfaction—Silhouette Rating Scale, eating disorders—EAT-26, and anxiety—GAD-7) were assessed. Eating rate was measured in kcal/min. Results: Body image perception and satisfaction significantly interacted with the type of meal. In the UPF group, lower body image dissatisfaction was associated with a higher eating rate (β = 4.79 kcal/min; 95% CI: 1.40; 8.19; p = 0.007), while a higher body image perception score was associated with a lower eating rate (β = −4.61 kcal/min; 95% CI: −8.57; −0.65; p = 0.024). No significant associations were observed for food addiction scores, eating disorders or anxiety. Conclusions: Body image modulates the eating rate in the context of UPF consumption. These findings suggest that interventions against obesity should consider individual psychobehavioral characteristics.