Ultra-processed Food Intake and Obesity: What Really Matters for Health—Processing or Nutrient Content?
Purpose of Review
The aim of this narrative review was to summarize and critique recent evidence evaluating the association between ultra-processed food intake and obesity.
Four of five studies found that higher purchases or consumption of ultra-processed food was associated with overweight/obesity. Additional studies reported relationships between ultra-processed food intake and higher fasting glucose, metabolic syndrome, increases in total and LDL cholesterol, and risk of hypertension. It remains unclear whether associations can be attributed to processing itself or the nutrient content of ultra-processed foods. Only three of nine studies used a prospective design, and the potential for residual confounding was high.
Recent research provides fairly consistent support for the association of ultra-processed food intake with obesity and related cardiometabolic outcomes. There is a clear need for further studies, particularly those using longitudinal designs and with sufficient control for confounding, to potentially confirm these findings in different populations and to determine whether ultra-processed food consumption is associated with obesity independent of nutrient content.
KeywordsFood processing Ultra-processed food Processed food Overweight Obesity
Body mass index
Food frequency questionnaire
This work was supported by the NIH (R01DK098072, DK56350) and the Carolina Population Center and its NIH Center grant (P2C HD050924) at the University of North Carolina at Chapel Hill.
Compliance with Ethical Standards
Conflict of Interest
Jennifer M. Poti, Bianca Braga, and Bo Qin declare they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 3.•• Moubarac JC, Parra DC, Cannon G, Monteiro C. Food classification systems based on food processing: significance and implications for policies and actions—a systematic literature review and assessment. Curr Obes Rep. 2014;3:256–72. This paper was the first systematic review to evaluate existing classification systems that categorize products by degree of food processing. Of the five identified systems, the NOVA food processing classification was rated highest in quality based on criteria for being a specific, coherent, clear, comprehensive, and workable system. CrossRefPubMedGoogle Scholar
- 4.• Monteiro CA, Cannon G, Moubarac JC, Levy RB, Louzada ML, Jaime PC. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutr. 2017:1–13. doi: https://doi.org/10.1017/S1368980017000234. This commentary outlines the NOVA food processing classification and summarizes the use of NOVA in numerous studies to describe ultra-processed food consumption, examine the associations of ultra-processed foods with dietary quality and diet-related health outcomes, and inform dietary guidelines.
- 5.Pan American Health Organization of the World Health Organization. Ultra-processed food and drink products in Latin America: trends, impact on obesity, policy implications. Washington, DC: Pan American Health Organization of the WHO; 2015.Google Scholar
- 9.Slimani N, Deharveng G, Southgate DA, Biessy C, Chajes V, van Bakel MM, et al. Contribution of highly industrially processed foods to the nutrient intakes and patterns of middle-aged populations in the European Prospective Investigation into Cancer and Nutrition study. Eur J Clin Nutr. 2009;63(Suppl 4):S206–25. https://doi.org/10.1038/ejcn.2009.82.CrossRefPubMedGoogle Scholar
- 12.FAO. Guidelines on the collection of information on food processing through food consumption surveys. Rome: Food and Agriculture Organization of the United Nations; 2015.Google Scholar
- 13.• Monteiro CA, Cannon G, Moubarac JC, Martins AP, Martins CA, Garzillo J, et al. Dietary guidelines to nourish humanity and the planet in the twenty-first century. A blueprint from Brazil. Public Health Nutr. 2015;18(13):2311–22. https://doi.org/10.1017/S1368980015002165. This paper discusses the development and aims of the Brazilian dietary guidelines released in 2014, which include recommendations to make minimally processed foods the basis of diet and to avoid consumption of ultra-processed foods. This is the first peer-reviewed paper by Monteiro and colleagues to describe the current NOVA classification for food processing. CrossRefPubMedGoogle Scholar
- 15.Moubarac JC, Claro RM, Baraldi LG, Levy RB, Martins AP, Cannon G, et al. International differences in cost and consumption of ready-to-consume food and drink products: United Kingdom and Brazil, 2008-2009. Glob Public Health. 2013;8(7):845–56. https://doi.org/10.1080/17441692.2013.796401.CrossRefPubMedGoogle Scholar
- 18.Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA. Consumption of ultra-processed foods and likely impact on human health. Evidence from Canada. Public Health Nutr. 2012:1–9. doi: https://doi.org/10.1017/S1368980012005009.
- 19.Martinez Steele E, Baraldi LG, Louzada ML, Moubarac JC, Mozaffarian D, Monteiro CA. Ultra-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study. BMJ Open. 2016;6(3):e009892. https://doi.org/10.1136/bmjopen-2015-009892.CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Fardet A, Rock E, Bassama J, Bohuon P, Prabhasankar P, Monteiro C, et al. Current food classifications in epidemiological studies do not enable solid nutritional recommendations for preventing diet-related chronic diseases: the impact of food processing. Adv Nutr. 2015;6(6):629–38. https://doi.org/10.3945/an.115.008789.CrossRefPubMedPubMedCentralGoogle Scholar
- 28.Bertoia ML, Mukamal KJ, Cahill LE, Hou T, Ludwig DS, Mozaffarian D, et al. Changes in intake of fruits and vegetables and weight change in United States men and women followed for up to 24 years: analysis from three prospective cohort studies. PLoS Med. 2015;12(9):e1001878. https://doi.org/10.1371/journal.pmed.1001878.CrossRefPubMedPubMedCentralGoogle Scholar
- 31.Summerbell CD, Douthwaite W, Whittaker V, Ells LJ, Hillier F, Smith S, et al. The association between diet and physical activity and subsequent excess weight gain and obesity assessed at 5 years of age or older: a systematic review of the epidemiological evidence. Int J Obes. 2009;33(Suppl 3):S1–92. https://doi.org/10.1038/ijo.2009.80.Google Scholar
- 37.Cornwell B, Villamor E, Mora-Plazas M, Marin C, Monteiro CA, Baylin A. Processed and ultra-processed foods are associated with lower-quality nutrient profiles in children from Colombia. Public Health Nutr. 2017:1–6. https://doi.org/10.1017/S1368980017000891.
- 40.Monteiro CA, Moubarac JC, Levy RB, Canella DS, Louzada M, Cannon G. Household availability of ultra-processed foods and obesity in nineteen European countries. Public Health Nutr. 2017:1–9. https://doi.org/10.1017/S1368980017001379.
- 41.Julia C, Martinez L, Alles B, Touvier M, Hercberg S, Mejean C, et al. Contribution of ultra-processed foods in the diet of adults from the French NutriNet-Sante study. Public Health Nutr. 2017:1–11. https://doi.org/10.1017/S1368980017001367.
- 43.Djupegot IL, Nenseth CB, Bere E, Bjornara HBT, Helland SH, Overby NC, et al. The association between time scarcity, sociodemographic correlates and consumption of ultra-processed foods among parents in Norway: a cross-sectional study. BMC Public Health. 2017;17(1):447. https://doi.org/10.1186/s12889-017-4408-3.CrossRefPubMedPubMedCentralGoogle Scholar
- 45.O'Halloran SA, Lacy KE, Grimes CA, Woods J, Campbell KJ, Nowson CA. A novel processed food classification system applied to Australian food composition databases. J Hum Nutr Diet. 2017; https://doi.org/10.1111/jhn.12445.
- 46.Venn D, Banwell C, Dixon J. Australia’s evolving food practices: a risky mix of continuity and change. Public Health Nutr. 2016:1–10. https://doi.org/10.1017/S136898001600255X.
- 47.Luiten CM, Steenhuis IH, Eyles H, Ni Mhurchu C, Waterlander WE. Ultra-processed foods have the worst nutrient profile, yet they are the most available packaged products in a sample of New Zealand supermarkets. Public Health Nutr. 2015:1–9. https://doi.org/10.1017/S1368980015002177.
- 49.Martinez Steele E, Popkin BM, Swinburn B, Monteiro CA. The share of ultra-processed foods and the overall nutritional quality of diets in the US: evidence from a nationally representative cross-sectional study. Popul Health Metrics. 2017;15(1):6. https://doi.org/10.1186/s12963-017-0119-3.CrossRefGoogle Scholar
- 52.• Adams J, White M. Characterisation of UK diets according to degree of food processing and associations with socio-demographics and obesity: cross-sectional analysis of UK National Diet and Nutrition Survey (2008–12). Int J Behav Nutr Phys Act. 2015;12:160. https://doi.org/10.1186/s12966-015-0317-y. This cross-sectional study found that higher consumption of processed/ultra-processed food among adults in the UK was not associated with BMI or the likelihood of being overweight/obese or being obese. CrossRefPubMedPubMedCentralGoogle Scholar
- 54.• Canella DS, Levy RB, Martins AP, Claro RM, Moubarac JC, Baraldi LG, et al. Ultra-processed food products and obesity in Brazilian households (2008–2009). PLoS One. 2014;9(3):e92752. https://doi.org/10.1371/journal.pone.0092752. This cross-sectional study found that, in a nationally representative sample of Brazilians, the prevalence of obesity was 3.7 percentage points higher among children and adults living in household strata in the highest compared with lowest quartile of ultra-processed food purchases. CrossRefPubMedPubMedCentralGoogle Scholar
- 55.•• Louzada ML, Baraldi LG, Steele EM, Martins AP, Canella DS, Moubarac JC, et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9–15. https://doi.org/10.1016/j.ypmed.2015.07.018. This cross-sectional study was the first to assess the relationship between ultra-processed food consumption and obesity using dietary intake rather than food purchases. In a nationally representative sample, Brazilians in the highest quintile of ultra-processed food consumption had 0.94 kg/m 2 higher BMI and were 26% more likely to be obese compared with those in the lowest quintile. CrossRefPubMedGoogle Scholar
- 56.•• Mendonca RD, Pimenta AM, Gea A, de la Fuente-Arrillaga C, Martinez-Gonzalez MA, Lopes AC, et al. Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra Follow-Up (SUN) cohort study. Am J Clin Nutr. 2016;104(5):1433–40. https://doi.org/10.3945/ajcn.116.135004. This investigation is the first prospective cohort to examine the association between ultra-processed food consumption and incident overweight/obesity. Highly educated middle-aged Spanish adults in the highest quartile of ultra-processed food intake at baseline had a 26% higher risk of developing overweight/obesity over a mean of 9 years of follow-up than those in the lowest quartile. CrossRefPubMedGoogle Scholar
- 58.•• Rauber F, Campagnolo PD, Hoffman DJ, Vitolo MR. Consumption of ultra-processed food products and its effects on children’s lipid profiles: a longitudinal study. Nutr Metab Cardiovasc Dis. 2015;25(1):116–22. https://doi.org/10.1016/j.numecd.2014.08.001. This study is the first prospective investigation to examine the association between ultra-processed food intake and changes in lipid profiles. Higher ultra-processed food intake among Brazilian preschoolers was associated with greater increases in total and LDL cholesterol between ages 3–4 and 7–8 years. CrossRefPubMedGoogle Scholar
- 59.• Rinaldi AE, Gabriel GF, Moreto F, Corrente JE, KC ML, Burini RC. Dietary factors associated with metabolic syndrome and its components in overweight and obese Brazilian schoolchildren: a cross-sectional study. Diabetol Metab Syndr. 2016;8(1):58. https://doi.org/10.1186/s13098-016-0178-9. This cross-sectional examination found that higher processed industrialized food intake was associated with higher fasting glucose, but was not associated with waist circumference, blood pressure, HDL cholesterol, triglycerides, or metabolic syndrome among school-aged children with overweight/obesity in Brazil. CrossRefPubMedPubMedCentralGoogle Scholar
- 60.• Lavigne-Robichaud M, Moubarac JC, Lantagne-Lopez S, Johnson-Down L, Batal M, Laouan Sidi EA et al. Diet quality indices in relation to metabolic syndrome in an Indigenous Cree (Eeyouch) population in northern Quebec, Canada. Public Health Nutr. 2017:1–9. doi: https://doi.org/10.1017/S136898001700115X. This cross-sectional study found that higher consumption of ultra-processed food was associated with increased likelihood of having metabolic syndrome among Eeyouch adults in Quebec, Canada.
- 61.•• Mendonca RD, Lopes AC, Pimenta AM, Gea A, Martinez-Gonzalez MA, Bes-Rastrollo M. Ultra-processed food consumption and the incidence of hypertension in a Mediterranean cohort: the Seguimiento Universidad de Navarra Project. Am J Hypertens. 2017;30(4):358–66. https://doi.org/10.1093/ajh/hpw137. This paper presents the first prospective cohort study to evaluate the association between ultra-processed food consumption and risk of hypertension. Highly educated middle-aged Spanish adults in the highest tertile of ultra-processed food consumption had a 21% higher risk of developing hypertension over a mean of 9 years of follow-up compared with those in the lowest tertile. PubMedGoogle Scholar
- 66.Carter A, Hendrikse J, Lee N, Yucel M, Verdejo-Garcia A, Andrews Z, et al. The neurobiology of “food addiction” and its implications for obesity treatment and policy. Annu Rev Nutr. 2016;36:105–28. https://doi.org/10.1146/annurev-nutr-071715-050909.CrossRefPubMedGoogle Scholar
- 69.Sadeghirad B, Duhaney T, Motaghipisheh S, Campbell NR, Johnston BC. Influence of unhealthy food and beverage marketing on children’s dietary intake and preference: a systematic review and meta-analysis of randomized trials. Obes Rev. 2016;17(10):945–59. https://doi.org/10.1111/obr.12445.CrossRefPubMedGoogle Scholar
- 70.Boyland EJ, Nolan S, Kelly B, Tudur-Smith C, Jones A, Halford JC, et al. Advertising as a cue to consume: a systematic review and meta-analysis of the effects of acute exposure to unhealthy food and nonalcoholic beverage advertising on intake in children and adults. Am J Clin Nutr. 2016;103(2):519–33. https://doi.org/10.3945/ajcn.115.120022.CrossRefPubMedGoogle Scholar
- 75.Robinson E, Aveyard P, Daley A, Jolly K, Lewis A, Lycett D, et al. Eating attentively: a systematic review and meta-analysis of the effect of food intake memory and awareness on eating. Am J Clin Nutr. 2013;97(4):728–42. https://doi.org/10.3945/ajcn.112.045245.CrossRefPubMedPubMedCentralGoogle Scholar
- 76.Monteiro C, Cannon G, Levy R, Moubarac J-C, Jaime P, Martins A, et al. NOVA the star shines bright. World Nutr. 2016;7(1–3):28–38.Google Scholar
- 77.Mattei J, Malik V, Wedick NM, Hu FB, Spiegelman D, Willett WC, et al. Reducing the global burden of type 2 diabetes by improving the quality of staple foods: the Global Nutrition and Epidemiologic Transition Initiative. Glob Health. 2015;11:23. https://doi.org/10.1186/s12992-015-0109-9.CrossRefGoogle Scholar
- 79.Eicher-Miller HA, Fulgoni VL 3rd, Keast DR. Contributions of processed foods to dietary intake in the US from 2003–2008: a report of the Food and Nutrition Science Solutions Joint Task Force of the Academy of Nutrition and Dietetics, American Society for Nutrition, Institute of Food Technologists, and International Food Information Council. J Nutr. 2012;142(11):2065S–72S. https://doi.org/10.3945/jn.112.164442.CrossRefPubMedPubMedCentralGoogle Scholar
- 81.Botelho R, Araujo W, Pineli L. Food formulation and not processing level: conceptual divergences between public health and food science and technology sectors. Crit Rev Food Sci Nutr. 2016:1–12. https://doi.org/10.1080/10408398.2016.1209159.
- 82.Wolfson JA, Bleich SN, Smith KC, Frattaroli S. What does cooking mean to you? Perceptions of cooking and factors related to cooking behavior. Appetite. 2016;97:146-54. https://doi.org/10.1016/j.appet.2015.11.030.