How PCPs can address the 'undeniably significant' impact of ultraprocessed foods

Key takeaways:

• Ultraprocessed foods are associated with negative health outcomes such as obesity, CVD and diabetes.
• Reducing one’s intake can be tough for a variety of reasons, like their prevalence and cost.

Ultraprocessed foods are associated with poor health outcomes, but helping patients reduce their intake can be difficult because of their prevalence, broad definition and affordability, according to experts.

In 2009, researchers at the University of Sao Paulo published the first paper on the concept of ultraprocessed foods (UPFs) in Public Health Nutrition. Shortly after, they proposed the NOVA classification, which organizes foods according to their level of processing, and included UPFs as a group.

One of the researchers who spearheaded the concept was Carlos A. Monteiro, MD, PhD, a professor of nutrition and public health and scientific coordinator at the Center for Epidemiological Studies in Nutrition and Health of the University of São Paulo.

Monteiro told Healio that UPFs “are not properly foods,” but “formulations of substances derived from foods, often chemically modified and exclusively for industrial use, containing little or no whole foods and typically enhanced with colorings, flavorings, emulsifiers and other cosmetic additives to make them palatable or hyper-palatable.”

UPFs are tasty, convenient, shelf stable, cheap to produce and difficult to stop eating after just one serving, Kate Nixon, DO, MS, program director and director of Osteopathic Education at MountainView Regional Medical Center, said.

“UPF has a long list of ingredients that can be difficult to pronounce. It can be sweet, salty or both. It is usually high in carbs and fat. It is addictive. It can contain chemical additives, preservatives, dough conditioners, artificial colors and artificial flavors. They often contain hydrogenated oils, which contain trans fats,” Nixon said. “These foods are very prevalent in the standard American diet.”

Montiero offered some examples of UPFs, including cookies, cakes, sodas, breakfast cereals, cereal bars and ready-to-eat meals like frozen lasagnas.

“Alongside the United Kingdom, the United States has the highest consumption globally: on average, about 60% of the calories consumed by Americans come from UPFs,” he said.

The prevalence of UPFs in the average American’s diet is concerning because “the connections between UPFs and poor health outcomes are well documented,” according to Farzaneh Daghigh, PhD, a professor of biochemistry and director of a culinary medicine course at the Philadelphia College of Osteopathic Medicine.

“The impact of UPFs on health is undeniably significant,” she said.

Downstream health effects

Previous research has indicated that UPFs are associated with higher risks for cancer, CVD and premature mortality.

“These foods are often high in added sugars, unhealthy fats and sodium, leading to increased risks of obesity, cardiovascular diseases and metabolic disorders,” Daghigh said. “The excessive consumption of UPFs has been linked to elevated blood pressure, disrupted metabolic function and a higher likelihood of developing chronic conditions such as type 2 diabetes.”

Monteiro said that all UPFs have the potential to cause harm, “both due to their poor nutritional composition or their content of cosmetic additives and by replacing meals based on fresh foods, which are truly nutritious and health protective.”

“The numbers are clear: globally, there are pandemics of chronic diseases such as diabetes and hypertension, along with an increase in the number of people with overweight and obesity,” he said. “This trend coincides with the rise in the consumption of UPFs in various countries.”

Additionally, UPFs seem to have connections to mental health, Kisha Davis, MD, MPH, FAAFP, a member of the American Academy of Family Physicians’ board of directors, said.

“There have been some suggestions that when folks have fewer UPFs in their diet, when they have more whole foods in their diet ... then symptoms like depression and anxiety also improved in terms of emotional well-being,” Davis said. “These foods are high in calories and short on the vitamins and nutrients, especially the vitamins and nutrients that we know contribute to a healthy emotional state. Things like folic acid, vitamin D, magnesium, B vitamins, those are found in a healthy diet, and they are often not found in these UPFs.”

Another negative effect of these foods is the promotion of potentially harmful lifestyle behaviors that often accompany UPF consumption.

“While the foods themselves are not very healthy, they also don’t contribute to a healthy relationship with food,” Davis said.

For example, because UPFs are usually on-the-go foods, many eat quickly rather than take the time to eat mindfully, which “we know is not good for our bodies,” she said.

“UPFs kind of contribute to that behavior of ... not taking time to sit and digest and be mindful of your meal,” Davis said. “I often tell people that UPFs are like disappearing foods. You eat it and then you're like, ‘Oh, what did I eat again? What did it taste like? I don't even know anymore.’”

It follows, then, that patients should strive to cut UPFs from their diet altogether, but that may be easier said than done.

“Certainly, we should focus on avoiding UPFs as much as possible ... with the support of governments through public food and nutrition policies,” Montiero said. “Removing UPFs from the diet is always possible, but it can be more or less challenging depending on factors such as the food culture of the country, local public policies and access to fresh foods. ... In countries like the U.S. and the U.K., where UPF consumption is high, eliminating them may be more challenging.”

‘The key lies in moderation’

One difficulty that patients may face when seeking to reduce their UPF intake is that there is a wide range of products that fall under the UPF umbrella term.

Arne V. Astrup, MD, PhD, the program director of Novo Nordisk Foundation in Copenhagen, has been vocal about the broad definition of UPF under the NOVA classification system. In 2022, he debated Monteiro and pointed out that meals made from similar ingredients by the same processes might be classified differently based on where they are prepared. For example, the ingredients to make a pizza or a burger are the same, but if the preparation is industrial, then it is considered an UPF.

He echoed that sentiment and said that “if you make some additives to the food — and that can be everything from some protein, fat or starch to quite innocent additives such as vitamin C — then it’s automatically classified as an UPF.”

“Even some olive oils that are assumed to be very healthy are classified as UPFs,” Astrup said. “I know there’s a need for some kind of definition, so I have the plan to try to join forces with some people working in this field to make a NOVA 2 classification, where it should be more based on scientific evidence.”

Another concern is food addiction. Davis said that a major reason eating UPFs can be “a habit that’s hard to break” for many patients is the cravings that follow.

“I don't think that everybody who's obese is addicted to food, but certainly these foods create cravings that can be hard to break,” she said. “Because of the high salt content, the high sugar content, they become something that your brain really craves.”

Davis said it can also be “pretty challenging to eliminate [UPFs] completely” because of how common these foods are in the U.S.

“They're so prevalent, and it's not that any one UPF in and of itself is bad or wrong; it's really in the collective and looking at the balance of how much of your diet is UPFs and how much of it is ... whole foods,” Davis said. “Is one hamburger, one hot dog, one bag of chips going to set anybody over the edge? No, probably not. But when you look at the collective balance of their diet and how much of the calories are coming from those foods over others, that's where we really get concerned.”

Daghigh agreed that “not all UPFs are inherently bad,” and “the key lies in moderation and mindful consumption.”

Montiero added the importance of recognizing that people do not “consume foods in isolation, but rather as part of meals.”

“Therefore, more than analyzing UPFs individually, it is crucial to have a dietary pattern based on whole or minimally processed foods and with the least possible intake of UPFs,” he said.

Recommendations for PCPs

Davis said the overall goal is to help patients adapt to a healthier lifestyle and relationship with food, so when working with patients to reduce UPF intake, primary care physicians should help their patients to identify whole, nutrient-dense foods.

“I really refer people back to MyPlate — I think that that is just a really good way to think about how you should be eating,” Davis said. “The MyPlate recommendation is half of your plate should be fruits and vegetables, a quarter of it protein, a quarter of it whole grains, maybe with, somewhere during the day, a glass of dairy to go along with it. ... Fresh fruits and vegetables, a little bit of protein, a little bit of whole grains is really how we should be thinking about comprising our meals and our snacks.”

Nixon said she has “many patients who cut out UPFs” successfully and saw improvements in their health. She said they lost weight and she has “even seen type 2 diabetes reversal, specific to the ketogenic diet, which is very low in UPFs.”

When it comes to advising patients on healthy dietary practices, Daghigh said that PCPs “play a pivotal role.”

“PCPs should emphasize the importance of a balanced diet rich in vegetables, whole grains, and lean proteins while minimizing the intake of UPFs,” she said. “They should also discuss the potential health risks associated with excessive UPF consumption and work collaboratively with patients to develop sustainable dietary changes.”

Equity considerations

Some patients may have a more difficult time consistently eating nutritious meals. Monteiro, Nixon, Davis and Daghigh pointed to the fact that those with lower socioeconomic status may face challenges when it comes to affording and accessing whole, fresh foods.

“When you're trying to eat on a budget, at the end of the day, you want to make sure your kids are fed, and so that might mean getting the thing that's cheaper,” Davis said. “Our low-income families are often living in food deserts. There's a town in my own community where they don't have a grocery store. It does have a Dollar General, but Dollar General doesn't have fresh fruits and vegetables. ... So, what you're relying on are UPFs.”

Being forced to turn to the default option of the cheaper and more convenient UPFs then contributes to health disparities, Daghigh said.

“Addressing this issue requires a comprehensive approach involving community initiatives, education programs and policy changes to make healthier food options more accessible to all,” she said.

Nixon, who said she does not support any policy to limit UPFs in the U.S., offered a few options for families struggling to eliminate UPFs from their diets because of money. She said, “healthy meals do not have to be expensive or difficult.”

“Ground beef is less expensive than specific cuts of beef,” Nixon said. “Frozen chicken and ground turkey are wonderful nutrient-dense foods that are less expensive options. Frozen veggies are often cheaper than fresh veggies and are easy to prepare. Hard-boiled eggs are a convenient snack, and meals made with eggs are delicious and versatile. Think huevos rancheros, omelets, or a burger with a fried egg on top.”

Monteiro said that “access to fresh food is a complex issue that varies from country to country.”

“In Brazil, for example, non-UPFs are still cheaper than UPFs. This is not the case, for example, in the U.S.,” he said. “Public policies are crucial, as we already have enough scientific evidence to assert that the consumption of UPFs is associated with a higher risk of developing many chronic diseases — from hypertension to depression. Lower income population groups should have easy access to fresh foods, allowing them to consume grains, vegetables, greens, fruits and quality meats in sufficient quantity. This is within reach for the U.S., one of the wealthiest countries globally.”

To reduce UPF intake on a larger scale, a multifaceted approach is required, Daghigh said, noting that “the most effective strategies for promoting public health and addressing health disparities lie in prioritizing education and advocating for changes in the food industry.”

“Policy changes are essential to reshape the landscape of the food industry,” she said. “Implementing measures such as transparent food labeling, restrictions on advertising unhealthy products and incentives for companies to reformulate their products for better nutritional profiles can contribute substantially to reducing UPF intake. By combining educational initiatives with industry-level changes, we can foster a culture of informed consumer choices and encourage the food industry to prioritize health over profit, ultimately promoting a healthier society and addressing health disparities.”

References:

• Monteiro CA. Public Health Nutr. 2009;doi:10.1017/S1368980009005291.
• Monteiro CA, et al. Cad Saude Publica. 2010;doi: 10.1590/s0102-311x2010001100005.