Prioritizing Health | Ultra-Processed Foods: The Enemy in the Food System?

Poor dietary habits are a critical determinant of cardiovascular health and a major modifiable risk factor in the development of cardiovascular disease.1,2 Plant-based, Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets have all demonstrated clear cardioprotective benefits in primary and secondary prevention.3-6
However, the standard American diet remains largely low in fruits, vegetables, whole grains and lean protein, and high in ultra-processed foods (UPF).7,8
The term ultra-processed food was first coined in the 1980s to reference highly-processed, calorically-dense and nutrient-poor convenience foods and snacks.9
They were originally developed to enhance the palatability, durability and affordability of products, and are made with substances extracted from whole foods (starches, dextrins) or synthesized in laboratories (flavor enhancers, colors, preservatives). While their energy density is high, they offer very little nutritional value.10
Today, the topic of UPF has generated significant global health interest,9 as they become increasingly more available, making up to 50% of caloric intake in high-income countries.11
UPF are classically high in fat, sugar, salt and preservatives, which have been associated with adverse health outcomes, including higher rates of hypertension, cancer, type 2 diabetes, metabolic syndrome and all-cause mortality.12-14
Meta-analyses have also revealed that total UPF intake at the highest vs. the lowest level (42.8-49.6% of daily caloric consumption vs. 15.3-20.8%) is associated with a 17% and 23% higher risk of cardiovascular disease and coronary heart disease, respectively.15
Research has also shown eating UPF can increase risk of stroke and cognitive impairment, with a greater effect on stroke risk among Black than White individuals.16
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Consumption of UPF, such as prepackaged meals and snacks, processed meats, fried foods, sweetened drinks and desserts, has been shown to trigger dopaminergic reward pathways and reduce satiety, leading to overeating.17
In fact, diets high in UPF have been linked to higher consumption of simple carbohydrates and fat-rich foods, lower protein intake, and greater weight gain relative to diets composed of unprocessed food.18
Studies also suggest UPFs significantly compromise the integrity of the gut microbiome. Disruption of the gut-brain axis not only leads to gut inflammation and inflammatory diseases,19 but has also been shown to disturb regulation of caloric intake by compromising food reward signals.20
Nearly 18 million American households are experiencing food insecurity – defined as lack of access to sufficient food, or food of adequate quality, to meet basic nutritional needs.21
Several social determinants of health impact dietary choices among vulnerable communities, including stress, income, zip code, access to nutrition and media exposure.
For instance, food insecurity has been associated with higher stress levels which may then predispose individuals to select highly palatable, dopamine-releasing foods that are heavily processed and nutrient poor.22
Individuals from lower income brackets may also not be able to afford fresher, notoriously more expensive foods, and thus purchase low-cost UPF more often.23
In fact, consumption of UPF is notably higher among those experiencing food insecurity and participating in the Supplemental Nutrition Assistance Program.24
Those who live in food deserts, or geographic areas that lack access to grocery stores within convenient traveling distances, may also heavily rely on smaller convenience stores and restaurants, which offer fewer fresh, and far more processed, options.25
Food companies have also been found to disproportionately advertise their least nutritious foods, such as sugary drinks, candy and chips to Black and Hispanic consumers from low-income neighborhoods.26,27
As a result, underresourced communities are more prone to diets composed of UPF,28,29 because of their affordability30,31 and accessibility, and are consequently disproportionately predisposed to the negative health effects of these highly processed options.
Countries have begun to target UPF in their national dietary guidelines and school food programs. For instance, some have placed black box warnings on foods or placed higher taxes on their production.32
However, there are multiple pitfalls in regulating these food products in the U.S., including even standardizing the definition of these unhealthy foods.
The NOVA classification system is the most widely used method to identify UPF, which characterizes foods as either unprocessed, minimally processed, processed or ultra-processed.
However, it's not used by national agencies that regulate food production and labeling.33 Instead agencies place greater regulations on foods considered to be high in fat, salt and sugar (HFSS), but this does not necessarily include all UPFs.33
By adding elements of UPF to the definition of HFSS foods, we could streamline the approach for targeting the production and distribution of the most unhealthy products.
The Way Ahead
As a medical community involved in the treatment of diet-driven chronic diseases, we can encourage replacing UPF across hospital systems, whose menus contain up to 25% UPF, with nutrient-dense meals and snacks.34
In addition, clinicians, health care providers and medical organizations need to support standardized, nutritionist-led sessions that educate patients and their families on how to prepare and access healthier, affordable alternatives within their communities.
Beyond hospitals, as a society, we must educate policy makers on the severe detrimental health effects of UPF and the financial burden they inflict on our health care system.
This could then inform efforts to restructure and improve access to healthier nutrition across at-risk communities. Such initiatives could be the first of many steps to help mitigate adverse health outcomes of UPF and to promote health equity.
This article was authored by Lauren Belak, MD, MPH, Department of Medicine, Massachusetts General Hospital; Brooke Zlotshewer, MD, Department of Medicine, Temple University Hospital; Lily Nedda Dastmalchi, DO, MA, Associate Fellow of ACC, Inova Schar Heart and Vascular, Inova Health Systems; Elizabeth Klodas, MD, FACC, Step One Foods; Penny M. Kris-Etherton, PhD, RD, Department of Nutritional Sciences, Pennsylvania State University; and Monica Aggarwal, MD, FACC, Division of Cardiology, University of Florida.
All are members of ACC's Prevention of Cardiovascular Disease Section. Click here to learn more and join.
References
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- Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010;121:586-613.
- Satija A, Bhupathiraju SN, Spiegelman D, et al. Healthful and unhealthful plant-based diets and the risk of coronary heart disease in U.S. adults. J Am Coll Cardiol 2017;70:411-22.
- Ahmad S, Moorthy MV, Lee IM, et al. Mediterranean diet adherence and risk of all-cause mortality in women. JAMA Netw Open 2024;7(5):e2414322.
- Fung TT, Chiuve SE, McCullough ML, et al. Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women. Arch Intern Med 2008;168:713-20.
- Sotos-Prieto M, Bhupathiraju SN, Mattei J, et al. Association of changes in diet quality with total and cause-specific mortality. N Engl J Med 2017;377:143-53.
- Di Cesare M, Perel P, Taylor S, et al. The Heart of the World. Glob Heart 2024;19:11.
- Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics-2021 update: A report from the American Heart Association. Circulation 2021;143:e254-e743.
- Logan AC, D'Adamo CR, Pizzorno JE, Prescott SL. "Food faddists and pseudoscientists!": Reflections on the history of resistance to ultra-processed foods. Explore (NY) 2024;20:470-76.
- Monteiro CA, Cannon G, Levy R, et al. Nova. The Star Shines Bright. J World Public Health Nutr Assoc 2016;7:1-3.
- Baker P, Machado P, Santos T, et al. Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers. Obes Rev 2020;21:e13126.
- Small DM, DiFeliceantonio AG. Processed foods and food reward. Science 2019;363:346-47.
- Chen X, Zhang Z, Yang H, et al. Consumption of ultra-processed foods and health outcomes: a systematic review of epidemiological studies. Nutr J 2020;19:86.
- Pagliai G, Dinu M, Madarena MP, et al. Consumption of ultra-processed foods and health status: a systematic review and meta-analysis. Br J Nutr 2021;125:308-18.
- Dicken SJ, Batterham RL. The role of diet quality in mediating the association between ultra-processed food intake, obesity and health-related outcomes: A review of prospective cohort studies. Nutrients 2022; 14:23.
- Mendoza K, Smith-Warner SA, Rossato SL, et al. Ultra-processed foods and cardiovascular disease: analysis of three large US prospective cohorts and a systematic review and meta-analysis of prospective cohort studies. Lancet Reg Health Am 2024;37:100859.
- Gearhardt AN, Bueno NB, DiFeliceantonio AG, et al. (2023). Social, clinical, and policy implications of ultra-processed food addiction. BMJ 383: e075354.
- Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause excess calorie intake and weight gain: An inpatient randomized controlled trial of ad libitum food intake. Cell Metab 2019;30:67-77.e3.
- Shi Z. Gut microbiota: An important link between western diet and chronic diseases. Nutrients 2019;11:2287.
- Bhave VM, Oladele CR, Ament Z, et al. Associations between ultra-processed food consumption and adverse brain health outcomes. Neurology 2024;102:e209432.
- Rabbitt MP, Reed-Jones M, Hales LJ, Burke MP. Household Food Security in the United States in 2023. U.S. Department of Agriculture. September 2024. Available here.
- Laraia BA, Leak TM, Tester JM, Leung CW. Biobehavioral factors that shape nutrition in low-income populations: A narrative review. Am J Prev Med 2017;52(2S2):S118-S126.
- Darmon N, Drewnowski A. Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: A systematic review and analysis. Nutr Rev 2015;73:643-60.
- Leung CW, Fulay AP, Parnarouskis L, et al. Food insecurity and ultra-processed food consumption: The modifying role of participation in the Supplemental Nutrition Assistance Program (SNAP). Am J Clin Nutr 2022;116:197-205.
- Page E, Kantor L. Food APS National Household Food Acquisition and Purchase Survey. USDA. Published online August 20, 2019. Available here.
- Harris JL. Targeted food marketing to Black and Hispanic consumers: The tobacco playbook. Am J Public Health 2020;110:271-2.
- Zenk SN, Tabak LA, Pérez-Stable EJ. Research opportunities to address nutrition insecurity and disparities. JAMA 2022;327:1953-4.
- Leung CW, Fulay AP, Parnarouskis L. Food insecurity and ultra-processed food consumption: The modifying role of participation in the Supplemental Nutrition Assistance Program (SNAP). Am J Clin Nutr 2022;116:197-205.
- Khoury N, Martínez MÁ, Garcidueñas-Fimbres TE, et al. Ultraprocessed food consumption and cardiometabolic risk factors in children. JAMA Netw Open 2024;7:e2411852.
- Pomeranz JL, Mande JR, Mozaffarian D. U.S. policies addressing ultraprocessed foods, 1980-2022. Am J Prev Med 2023;65:1134-41.
- Popkin BM, Barquera S, Corvalan C, et al. Towards unified and impactful policies to reduce ultra-processed food consumption and promote healthier eating. Lancet Diabetes Endocrinol 2021;9:462-70.
- Popkin BM, Miles DR, Taillie LS, Dunford EK. A policy approach to identifying food and beverage products that are ultra-processed and high in added salt, sugar and saturated fat in the United States: A cross-sectional analysis of packaged foods. Lancet Reg Health Am 2024;32:100713.
- Detopoulou P, Panoutsopoulos GI. How processed is the hospital menu? An analysis based on NOVA food scoring system. Clin Nutr ESPEN 2023;53:277-81.
Keywords: Cardiology Magazine, ACC Publications, Food, Food Quality, Food Industry, Diet, Food, and Nutrition, Nutrition Assessment, Risk Factors