Ultra-processed foods and cardiometabolic health: public health policies to reduce consumption cannot wait

Abstract:

The effect of diet on health has historically been considered from a nutrient based perspective—for example, excess total fat, saturated fat, dietary cholesterol, calories, sugar, or salt and lack of dietary fibre, vitamins, and minerals.1 

More recently, this approach has been complemented by extensive evidence supporting health effects of dietary patterns (eg, the Mediterranean diet), characterised by various dietary scores such as the Alternative Healthy Eating Index (AHEI), or DASH (Dietary Approaches to Stop Hypertension) diet.2 

However, the degree of processing and formulation of foods was not taken into account. For instance, all vegetable soups were considered similar, regardless of whether they were homemade, industrial canned, or industrial dehydrated and contained food additives and flavours.

The potential health effect of food processing and food formulation, beyond their food ingredients, nutrient composition, and energy content, is now being widely researched. An important milestone was the 2009 publication of the NOVA classification,3 which categorises foods according to the type, intensity, and purpose of food processing (box 1).

The ultra-processed group includes all foods and drinks made using intense physical or chemical processes or containing cosmetic food additives and other industrial ingredients (eg, artificial flavours, hydrogenated oils, glucose/fructose corn syrup).4 These foods are generally convenient, affordable, highly palatable, and often intensively advertised.

Prospective studies since 2015 have found associations between consumption of ultra-processed food and altered lipoprotein profiles in children5 and increased risks of obesity,6 type 2 diabetes,7 and cardiovascular diseases8 in adults.

Over 70 long term prospective epidemiological studies (some of them reviewed elsewhere9) and a handful of short term interventional studies1011 have also consistently observed that consuming ultra-processed foods is linked with weight gain and increased risk of various diseases, particularly cardiometabolic conditions.

It has also been suggested that these foods meet the criteria to be labelled as addictive substances using the standards set for tobacco products.12

Today, the question is: do we have enough evidence to take concrete action from a government policy and public health standpoint? The ultra-processed food category is broad and heterogeneous, encompassing a wide variety of products and ingredients that may have different effects on health. Although evidence is emerging about the mechanisms whereby ultra-processed foods and their components affect human health, much remains to be unravelled.

Given the economic interest in the ultra-processed foods market, some big food companies are advocating for no public action in the meantime, including attempts to conflate the benefits of food processing (such as greater shelf stability, microbiological safety, affordability, and attractive functional and taste properties of foods) with ultra-processing, and promoting a view that there is no or only limited consensus about the relation between food processing and human health.13,14,15

However, we believe that the available evidence justifies certain public health measures to reduce population level exposure. These should be implemented in synergy with measures promoting foods and diets that are minimally processed and have favourable food ingredients and nutritional profiles.