Food For Thought: Ultra-Processed Foods in a Healthy Diet?

Ultra-Processed Foods in a Healthy Diet?JULIE M. HESS, PHD

MADELINE E. COMEAU, MS, DEBRA L. FOSSUM, MPH, RDN, LRD, ANGELA J. SCHEETT, MPH, RDN, LRD

img3NOVA divides foods into 4 groups based on their level of processing.“What Are Ultra-Processed Foods? What Should I Eat Instead?,” “New Evidence Links Ultra-Processed Foods With a Range of Health Risks,” and “‘Frankenfoods’: Why Ultra-Processed Foods Make You Crave More Unhealthy Stuff” are just a few of the recent headlines that highlight the growing concerns about ultra-processed foods.Defining Ultra-Processed FoodsThe most commonly used scale to determine whether a food is “ultra-processed” (UPF) or not is referred to as NOVA (not an acronym), as noted by Lichtenstein et al. NOVA divides foods into 4 groups based on their level of processing (Table 1).At first glance, categorizing foods in this way may sound easy. When you think of UPF, like many Americans, you may think of products like chips, sodas and other sugar-sweetened beverages, packaged cookies, and American cheese. A consumer survey on processed food perceptions conducted by the International Food Information Council reported that 75% of Americans claim to be able to easily identify examples of processed foods.Tab1But according to the NOVA classification system, although salty and sugary snack foods and sodas and sweetened drinks are considered Category 4 foods, or UPF, some nutrient-dense foods also fit into Category 4. For example, fruitflavored yogurt, light orange juice, whole wheat bread, canned collard greens, flavored sunflower seeds, peanut butter, and tofu can be considered UPF in the NOVA scale, depending on their ingredients (Table 2).Nutrient-dense foods are a recommended part of healthy dietary patterns in current US dietary guidance, according to the 2020-2025 Dietary Guidelines for Americans. In fact, research from the USDA (Hess et al) indicates that “healthy dietary patterns can include most of their energy from UPF [NOVA category 4 foods] and still receive a high diet quality score and contain adequate amounts of most macro- and micronutrients.”Current Research on UPFThere is a body of research that indicates that eating UPF (as defined by NOVA) leads to negative health outcomes, including cardiovascular disease (Juul et al), weight gain (Juul et al), and even type 2 diabetes (Levy et al). This research is primarily comprised of observational studies, which have important limitations. A key limitation is that these studies are not able to access the level of detail (eg, ingredient list for specific foods) required for accurate NOVA categorizations.Determining a correct NOVA category generally requires an ingredient list for each food product, which is not available from dietary recalls, so research teams must make assumptions about the contents of the foods people report eating.img4Determining a correct NOVA category generally requires an ingredient list for each food product, which is not available from dietary recalls, so research teams must make assumptions about the contents of the foods people report eating. As a result, the articles about these studies tend to describe UPF and unprocessed foods in broad terms that are not consistent with NOVA. For instance, the 2018 study from Juul et al refers to “vegetables” as a “minimally processed food.” Yet, as indicated in Table 2, several vegetables are considered part of NOVA Category 4 (UPF).Table 2 Foods by NOVA Categories That Are Recommended in Eating Patterns From the 2020 Dietary Guidelines for Americans.Tab2img5There is more nuance to the relationship between UPF intake and health—and more research needed—than current headlines convey.NOVA classification of foods by processing level is not a reliable method of determining whether a food is nutrient-dense or not.In addition to the observational studies, there was an intervention study in which Hall et al fed study participants a mostly UPF diet or a mostly unprocessed foods diet and compared the outcomes. Consuming a diet rich in UPF led to more calories eaten and more weight gained compared to eating an unprocessed foods diet, but the study has limitations similar to those in the observational studies. The test diets in this trial were comprised of very different foods, not just different levels of processing applied to the same foods.There is more nuance to the relationship between UPF intake and health—and more research needed—than current headlines convey.Discussing UPF With Clients and PatientsWhere does this leave us in counseling clients and patients on building healthy and nutritious diets with or without UPF? Here are few tips to consider.

All foods can fit: Rather than limiting foods based on an ingredient list, recognize that more information may be needed to help make a decision about foods to include or avoid. A small serving of a UPF may meet needs better than a large serving of an unprocessed food, which can be a key consideration in diabetes eating plans.

Nutrient-density: It is important to read Nutrition Facts labels when deciding on a food item, not just the ingredient list. Nutrient-dense foods, such as nonfat milk, collard greens, and whole wheat bread, are high in essential nutrients, like protein and calcium, but low in calories. Depending on the ingredient list, these items may be considered ultra-processed while also providing crucial nutrients. Use the percentage Daily Value (%DV) on a Nutrition Facts label to make informed choices and compare foods. Remember that 5% or less of DV indicates a “low” source of the nutrient and that 20% or more is a “high” source of a nutrient. Nutrients to get less of include saturated fat, sodium, and added sugars. Nutrients to get more of include dietary fiber, Vitamin D, calcium, iron (for some groups), and potassium.

Affordability, convenience, feasibility: A big concern for many people is the cost of food and ease of preparation. UPF may be considered a better option for a limited budget based on the perceived or real cost of such items. To those who have not learned how to cook, the thought of preparing meals from scratch could be overwhelming. Including UPF in the diet may make meal planning and preparation easier.

Culturally appropriate options: Another thing to keep in mind is the effect NOVA classification may have on cultural foods. Patients trying to follow a specific culture’s diet while avoiding UPF may struggle to find unprocessed options. And such a trade-off may not be necessary if UPF versions meet cultural needs.

ConclusionNOVA classification of foods by processing level is not a reliable method of determining whether a food is nutrient-dense or not. Because more research is needed, the jury is out on UPF and whether NOVA can be used as a measure of a food’s healthfulness. But until we have a working definition that aligns with our current understanding of healthy eating patterns, there is no reason to remove nutrient-dense foods from the plate, even if they are ultra-processed.Julie M. Hess, PhD; Madeline E. Comeau, MS; Debra L. Fossum, MPH, RDN, LRD; and Angela J. Scheett, MPH, RDN, LRD, are with USDA-ARS Grand Forks Human Nutrition Research Center in Grand Forks, ND. Ms Fossum and Ms Scheett are also with the University of North Dakota in Grand Forks.AcknowledgmentsThe US Department of Agriculture prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.Duality of InterestThe authors declare having no professional or financial association or interest in an entity, product, or service related to the content or development of this article.FundingUSDA Agricultural Research Service project Grant 3062-51000-057-00D.Julie M. Hess https://orcid.org/0000-0001-9146-6380Angela J. Scheett https://orcid.org/0000-0002-7152-9249ReferencesBMJ. New evidence links ultra-processed foods with a range of health risks. ScienceDaily. Accessed April 23, 2023. https://www.bmj.com/company/newsroom/new-evidence-links-ultra-processed-foods-with-a-range-of-health-risks/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(1):67-77.e3. doi:10.1016/j.cmet.2019.05.008Hess JM, Comeau ME, Casperson S, et al. Dietary guidelines meet NOVA: developing a menu for a healthy dietary pattern using ultra-processed foods. J Nutr. 2023;153(8):2472-2481. doi:10.1016/j.tjnut.2023.06.028International Food Information Council. Perceptions on processed: consumer sentiment and purchasing habits. November 15, 2022. Accessed September 14, 2023. https://foodinsight.org/perceptions-on-processed-2022/Juul F, Deierlein AL, Vaidean G, Quatromoni PA, Parekh N. Ultra-processed foods and cardiometabolic health outcomes: from evidence to practice. Curr Atheroscler Rep. 2022;24(11):849-860. doi:10.1007/s11883-022-01061-3Juul F, Martinez-Steele E, Parekh N, Monteiro CA, Chang VW. Ultra-processed food consumption and excess weight among US adults. Br J Nutr. 2018;120(1):90-100. doi:10.1017/s0007114518001046Levy RB, Rauber F, Chang K, et al. Ultra-processed food consumption and type 2 diabetes incidence: a prospective cohort study. Clin Nutr. 2021;40(5):3608-3614. doi:10.1016/j. clnu.2020.12.018Lichtenstein AH, Appel LJ, Vadiveloo M, et al. 2021 Dietary guidance to improve cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2021;144(23):e472-e487. doi:10.1161/CIR.0000000000001031O’Connor A. What are ultra-processed foods? What should I eat instead? Washington Post. September 27, 2022. Accessed April 23, 2023. https://www.washingtonpost.com/wellness/2022/09/27/ultraprocessed-foods/Monteiro C, Cannon G, Levy R, et al. Food classificationpublic health. NOVA. The star shines bright. World Nutrition. 2016;7(1-3):28-38.Smith P. ‘Frankenfoods’: why ultra-processed foods make you crave more unhealthy stuff. Khou*11 News. September 30, 2022. Accessed April 23, 2023. https://www.khou.com/article/news/news-explainers/the-why/ultra-processed-foods-health-concerns/285-8ebad649-7189-4348-8767-ac51888e5bc1#:~:text=According%20to%20the%20Washington%20Post,system%20and%20trigger%20powerful%20cravingsJournal CoverMedtronic Minimed 780G SystemADCES Certified Diabetes Care and Education Specialist ExamAIP Journal InfoEditorial BoardOwen MumfordADCES The Art and Science of Diabetes Care and EducationFrom the Editor: We Change LivesFrom the President: Celebrating 2023 and ADCESTranslating Guidelines into PracticePharmacist Implementation of Transitions of Care to Adult Endocrinology in a PediatricDiabesity Treatments Today and TomorrowADCES Diabetes Team TrainingFood For Thought: Ultra-Processed Foods in a Healthy Diet?Career To Calling: Stories of TransformationEffects of Glucagon-Like Peptide-1 Receptor Agonists and Sodium Glucose Cotransporter-Test Your KnowledgeCBDCE Propel Your Career to New HeightsReflectionsNews & Events 2023 Diabetes Technology ConferenceTest Your Knowledge AnswersADCES Quick Guide to MedicationsADCES/BC-ADM Get Recognized