Consumption of ultra-processed foods predicts diet quality in Canada
Introduction
The current pandemic of obesity and other diet-related non-communicable diseases (NCDs) constitutes a serious threat to the future well-being and economic prosperity of all nations (N.C.D. Risk Factor Collaboration, 2016a, N.C.D. Risk Factor Collaboration, 2016b). In Canada, one quarter of the population is now obese and each year up to 66,000 Canadians die due to health complications associated with obesity (Ogilvie & Eggleton, 2016). More so, the annual economic burden of obesity is estimated at 7.1 billion Canadian dollars (Ogilvie & Eggleton, 2016). However, most obesity and NCDs can be prevented by changes in diet.
To improve the Canadian's diet and address the obesity crisis, the Standing Senate Committee on Social Affairs, Science and Technology of Canada called for a national awareness campaign on the risks associated with excessive consumption of “processed foods” and an overhaul of the Canadian food guide that currently overlooks food processing (Ogilvie & Eggleton, 2016). Such recommendations stem from a growing body of knowledge suggesting a close relationship between food processing and the nutritional quality of foods and diets (Adams and White, 2015, Fardet, 2016, Louzada et al., 2015, Martinez Steele et al., 2016, Poti et al., 2015, Vandevijvere et al., 2013, Wahlqvist, 2016).
Food processing per se is not a problem for human nutrition. To the contrary, it played a key role in the evolution of humanity and of civilizations by making diets more safe, secure, and diverse (Wrangham, 2009). However, food processing has profoundly and rapidly evolved in the past decades following industrialization and globalization of food systems with potential negative consequences on the nutritional value of food, and in turn diet quality (Armelagos, 2014). Today, a rigorous distinction of foods by type of processing and an examination of their impacts on diet and health can help address the obesity and NCDs crisis (Moubarac, Parra, Cannon, & Monteiro, 2014). So far, a few countries have incorporated food processing considerations into their official dietary guidelines, including Brazil (Brazilian Ministry of Health, 2014).
The most frequently used method to examine diets according to food processing is the Nova food classification (Monteiro et al., 2013, Moodie et al., 2013), which has been employed in many studies conducted in several countries (Monteiro et al., 2016). It is also recognized and used by international bodies including PAHO, WHO and FAO (PAHO, 2015, FAO, 2015). Food processing, as understood by Nova, involves physical, biological, and chemical processes applied to foods after their separation from nature and before they are submitted to culinary preparation (cleaning, peeling, seasoning, cooking, etc.) or prior to their consumption in the case of items which do not require culinary preparation (Monteiro et al., 2016).
Nova classifies all foods according to the nature, extent and purpose of the processing they undergo into four groups: unprocessed or minimally processed foods, processed culinary ingredients, processed foods and ultra-processed foods (see Box 1 for a definition and example list of each food groups). Particularly important for this study, ultra-processed foods are industrial food and drink formulations made mostly from refined substances extracted or derived from foods and additives. They include soft drinks and other packaged juices and drinks, sweet or savory packaged snacks, confectionery and industrialized desserts, mass-produced packaged breads and buns, poultry and fish nuggets and other reconstituted meat products, instant noodles, instant soups as well as several sauces and dressings (Monteiro et al. 2016).
Using Nova, we have previously shown that between 1938 and 2001 Canadian food purchases were marked by the replacement of unprocessed or minimally processed foods and processed culinary ingredients by ultra-processed foods (Moubarac, Batal, et al., 2014). Similar trends have been documented elsewhere (Juul and Hemmingsson, 2015, Monteiro et al., 2011) and are confirmed by global time trends in the sales of ultra-processed foods (Monteiro et al., 2013, PAHO, 2015). After the United States population, Canadians were the second largest buyers of ultra-processed foods and drinks in the world with an average of 230 kilos per person in 2013 (PAHO, 2015).
Analyses of nationally representative dietary surveys conducted in the United States (Martinez Steele et al., 2016), the UK (Adams & White, 2015), Brazil (Costa Louzada et al., 2015; Louzada, Martins et al., 2015) and Chile (Crovetto, Uauy, Martins, Moubarac, & Monteiro, 2014) have consistently shown that ultra-processed foods are nutritionally imbalanced and that their consumption negatively impacts the nutritional quality of diets. These products are also less satiating and more hyperglycemic compared to minimally processed foods (Fardet, 2016). They are aggressively marketed, are often commercialized in big portion sizes and tend to favor snacking over regular meals and, in general, mindless eating, all factors that induce passive energy overconsumption (Monteiro et al., 2013).
Such evidence has led the INFORMAS research network (Vandevijvere et al., 2013) to propose the use of the dietary share of ultra-processed foods as a predictive indicator of population diet quality. This use was further endorsed by FAO and PAHO (FAO, 2015, PAHO, 2015). Avoiding the replacement of minimally processed foods and their culinary preparations by ultra-processed foods was the main recommendation of the 2014 Brazilian Dietary Guidelines (Brazilian Ministry of Health, 2014). Consumption of ultra-processed foods was associated with higher risk of overweight and obesity in a prospective cohort of Spanish middle-aged adult university graduates (Mendonça et al., 2016). A cross-sectional time-series analysis revealed a strong correlation between changes in sales of ultra-processed foods and changes in body mass between 2000 and 2013 in 12 countries (PAHO, 2015). Cross-sectional studies undertaken in Brazil also linked ultra-processed food consumption to obesity (Canella et al., 2014; Louzada, Baraldi et al., 2015), and other diet-related NCD outcomes (Rauber et al., 2015, Tavares et al., 2012).
In Canada, there exists little evidence linking food processing to the overall diet quality because foods and diets are not usually examined according to food processing (Garriguet, 2009). For example, the Health Canada's Surveillance Tool Tier System which assesses the adherence of dietary intakes with Eating Well from Canada's Food Guide is a system based on nutrient profiling where all foods are classified into one of four Tiers based on thresholds for contents in key nutrients (total fat, saturated fat, sodium, and sugar) (Health Canada, 2014). This system does not account for food processing and was shown to have several limitations, including lack of specificity (Jessri, Nishi, & L'Abbe, 2016).
One previous study provided a first estimate of food consumption in Canada according to types of food processing and reported that ultra-processed foods were more energy dense, higher in free sugars and sodium and lower in protein and fiber, compared to non-ultra-processed foods (Moubarac, Martins, Claro, Levy, Cannon, & Monteiro, 2013). However, this study was based on household food expenditure which does not include food consumed outside the home nor accounts for food wastage, and was limited to key macronutrients.
The present paper provides a more accurate estimate of food consumption in Canada according to the types of food processing based on the distribution of total daily intake across the four Nova food groups. It also investigates the association between consumption of ultra-processed foods and the nutritional quality of the overall diet using a comprehensive set of nutrients. Such evidence represents the building blocks of a novel approach to food and nutrition in Canada to inform the future development of dietary guidelines and consumer awareness campaigns that would take the type of food processing into account.
Section snippets
Data source and collection
The data analyzed in this study come from the Canadian Community Health Survey (CCHS, cycle 2.2, Nutrition focus) conducted by Statistics Canada between January 2004 and January 2005. The dataset provides the most recent and nationally representative estimate of individual food intake in Canada.
The CCHS covers 98% of the Canadian population and was carried out in all ten provinces. It is based on a multi-level stratified sample where dwellings are the base units within geographic areas. One
Consumption of foods according to food processing in Canada
In 2004, Canadians aged 2 years and above consumed on average 2064 kcal per day, 39.2% of which were from unprocessed or minimally processed foods, 6.1% from processed culinary ingredients, 7.0% from processed foods, and 47.7% from ultra-processed foods (Fig. 1).
Within unprocessed or minimally processed foods, most calories came from meat and poultry (9.0% of total daily intake), followed by grains and flours (7.4%), milk and plain yoghurt (5.8%), fruits (4.5%), pasta (3.3%), roots and tubers
Discussion
This study described food intake patterns of Canadians according to food processing, using the Nova food classification system. In 2004, almost half of daily calories (48%) consumed by Canadians aged 2 years or older came from ultra-processed foods, including soft drinks and packaged juices, chocolate, cookies and cake, mass-produced packaged breads and pastries, as well as fast-food dishes.
Consumption of ultra-processed foods in Canada was significantly higher amongst men, less educated
Conclusion
This study showed that diets in Canada based on ultra-processed foods were grossly nutritionally inferior to diets based on unprocessed or minimally processed foods and freshly prepared dishes and meals made from these foods plus culinary ingredients and processed foods. Half of the daily consumed calories in 2004 were from ultra-processed foods and this may explain most of the nutrient imbalances identified in the Canadian diet.
Based on these findings, Canadians who wish to substantially
Authorship responsibilities
The empirical study was planned by CAM, JCM and ML, and undertaken by JCM. The initial draft of the paper was prepared by JCM following extensive discussions with CAM, MB, ML and E. Successive drafts were developed by JCM, ML and E, with inputs from the other co-authors. All authors have reviewed and approved the final version.
Acknowledgements
This study was supported by one postdoctoral fellowship from Fundação de Amparo à Pesquisa do Estado de São Paulo (2011/08425-5 and 2015/14900-9). It also received funding from the National Council for Scientific and Technological Development (CNPq) in Brazil (No. 443477/2014-0). The authors wish to thank Louis Rochette from the Institut national de santé publique du Québec for statistical analyses.
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