Ultra-processing of food. Definition, consequences for health and emerging critic.

1. Ultra-processing of food.
Definition, consequences for
health and emerging critic.
Dietician, PhD
Reijo Laatikainen
Aava Medical Centre
Docrates Cancer Hospital
www.pronutritionist.net
https://twitter.com/Reijo_RD_FIN
www.facebook.com/pronutritionist
www.slideshare.net/pronutritionist

3. Definition
NOVA-classification, contains 4
sub-classes

4. Definition and classification 1/3
Monteiro, C.A., Cannon, G., Lawrence, M., Costa Louzada, M.L. and Pereira Machado, P. 2019. Ultra-processed
foods, diet quality, and health using the NOVA classification system. Rome, FAO.
Carlos Monteiro is Professor of Nutrition and Public
Health at the University of Sao Paulo, Brazil and Head
of the University’s Centre for Epidemiological Studies
in Health and Nutrition.

5. All foods prepared by
industry containing
salt, sugar, honey or
fermented
Foods containing
additives (may be
reformulated too)
1. Unprocessed and
minimally processed
food
2 & 3. Processed
culinary ingredients
and processed food
4. Ultra-processed food
Four different classes 2/3

6. Ultra-processed food according to NOVA:
1. A Is reformulated
fractioning (of whole foods into substances)
assembly (of unmodified and modified food substances
by using high technology)
OR
1. B Contains additives* (other than salt, natural species or
natural fat)
 Gluten, lactose, fructose, fructose-corn syrup
2. Sophistically packaged
3. Very profitable, convenient, hyper-palatable
* It does not play any role if additives are healthy, natural, or
industrial, probably unhealthy, i.e. ascorbic acid is
considered equally bad as added nitrites or phosphates
Definition and classification 3/3

7. A bread brand as an example.
It does not take much to convert a processed food item
into ultra-processed
Wholemeal rye flour, water,
wheat flour, rye malt meal,
wheat gluten, barley and rye
malt extract, yeast, iodized salt,
When you add: ”… wheat
gluten, barley and rye malt
extract” → ultra-processed
bread
Wholemeal rye flour (85%),
water, yeast, iodized sea salt
CLASS 3
CLASS 4,
ultra-
processed

8. A hamburger as an example
When you add: ”industrial
cheddar cheese (sulatejuusto),
industrial mayo, bacon” →
ultra-processed hamburger
CLASS 3 CLASS 4,
ultra-
processed
Home made hamburger with
home made mayo, Emmental
cheese

9. Human studies
Relatively much (weak)
epidemiological studies but
extremely limited number of high-
quality clinical studies

10. Systematic review and meta-analysis of 7 cohort studies
(totaling 207,291 adults): All cause mortality increased
15 % per each 10% of daily calories
…each 10% increase in UPF consumption in daily calorie intake was
associated with a 15% higher risk of all-cause mortality
Suksatan W, et al. Ultra-Processed Food Consumption and Adult Mortality Risk: A Systematic
Review and Dose-Response Meta-Analysis of 207,291 Participants. Nutrients. 2021 Dec
30;14(1):174.

11. High consumption of UP foods is associated with the
increased risk of many chronic diseases (but data is still
limited)
• Obesity
• Metabolic syndrome (abdominal obesity, hypertension,
hypercholesterolia, diabetes/prediabetes)
• Type 2 diabetes
• Astma
• Cancer
• Frailty of elderly people
• Depression
• Irritable bowel syndrome
• Inflammatory bowel disease
Chen X, Zhang Z, Yang H, Qiu P, Wang H, Wang F, Zhao Q, Fang J, Nie J. Consumption of ultra-processed foods and health
outcomes: a systematic review of epidemiological studies. Nutr J. 2020 Aug 20;19(1):86. | Moradi S, et al. Ultra-Processed
Food Consumption and Adult Diabetes Risk: A Systematic Review and Dose-Response Meta-Analysis. Nutrients. 2021 Dec

12. When a diet is considered as ultra-processed –this
is what it looks like
Machado PP, Steele EM, Levy RB, Sui Z, Rangan A, Woods J, Gill T, Scrinis G, Monteiro CA. Ultra-processed foods and
recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from a nationally
representative cross-sectional study. BMJ Open. 2019 Aug 28;9(8):e029544.
Ultra-processed foods consumed most by those people whose dietary
pattern is classified as ultra-processed (Q5, as calories)
1 Mass-produced packaged breads [often bread low in fiber in US, UK, AUS,…
]
2 Frozen and shelf stable ready meals
3 Fast foods dishes
4 Pastries, buns and cakes
5 Breakfast cereals
6 Biscuits
7 Fruit drinks and iced teas
8 Confectionery
9 Sausage and other reconstituted meat products
10 Carbonated soft drinks

13. In epidemiological and clinical studies UP
concepts graps the western dietary pattern
Machado PP, Steele EM, Levy RB, Sui Z, Rangan A, Woods J, Gill T, Scrinis G, Monteiro CA. Ultra-processed foods and
recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from a nationally
representative cross-sectional study. BMJ Open. 2019 Aug 28;9(8):e029544. doi: 10.1136/bmjopen-2019-029544. PMID:
31462476; PMCID: PMC6720475.

14. How an ultra-processed dietary pattern could like
in practice (in Finland)?

15. General conclusion
• [High consumption of ultra-processed food] …is
an indicator of poor food quality due to the
generally high amounts of free or added sugars,
fats, low levels of fiber, and high energy
density.”
Marino M, Puppo F, Del Bo' C, et al. A Systematic Review of Worldwide Consumption
of Ultra-Processed Foods: Findings and Criticisms. Nutrients. 2021;13(8):2778.

16. Ultra-processed dietary pattern –Also called as SAD* diet.
*) Standard American Diet

17. Only one well-controlled randomized controlled
trial: Hall Kevin study (2019)
Hall KD, 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 Jul 2;30(1):67-77.e3..

18. Hall Kevin study (2019): Pay attention to the
difference in food volume and the structure of the
food.
Ultra-proccessed Minimally processed

19. Why ultra-processed food might be hazardous to
health and weight management
• Easy to chew, fast to consume
• Often higher energy density
• Sometimes lower in protein (as protein is expensive for
manufacturers)
• Lower in phytochemicals (polyphenols, sulforaphane,
lignan etc. )
• Sometimes lower in vitamins and minerals
• Often higher in salt, more palatable, makes you thirsty
for soda/beer, etc.
• Often refined carbohydrates, low in fiber
• Often higher in saturated fat and lower for omega-3
fatty acids (not true for plant alternatives)
• Bad for gut microbiota and immune function

20. What kind of clinical data is missing?
(Examples only, not exhaustive list)
• No randomized controlled trials
– Ultra-processed healthy vs minimally processed
unhealthy dietary patterns
• For example, margarine, rye bread, smoothie with protein powder and Willja
nuggets vs. butter, artisan wheat bread, banana and beef
– Any randomized hard point studies
• Cardiovascular disease (heart attack, stroke)
• Type 2 diabetes
• Cancer
• Inflammatory bowel disease (Crohn’s
disease/Ulcerative colitis)

21. Ultra-processed dietary pattern is
practically same as Western
dietary pattern –well known
unhealthy dietary pattern
Western dietary pattern: low in fiber, low in
veggies/fruit/berries, low in fish. High in
refined carbohydrates/processed meat, high
in added sugar and salt.

22. 0
500
1000
1500
2000
2500
1970 1980 1990 2000 2010 2020
Pubmed: "Western dietary pattern", 24 394
hits
Ultra-processed food vs. Western dietary pattern.
Scientific publications, Pubmed hits as proxy→
Western dietary pattern query produced
>100x more publications
0
5
10
15
20
25
1972 1982 1992 2002 2012 2022
Pubmed: "Ultra-processed food"

23. Western dietary pattern is a ”reverse dietary
pattern” to the recommended diets
Merra G, Noce A, Marrone G, Cintoni M, Tarsitano MG, Capacci A, De Lorenzo A. Influence of Mediterranean
Diet on Human Gut Microbiota. Nutrients. 2020 Dec 22;13(1):7

24. Practical benefits and
problems with the NOVA
classification

25. SWOT for NOVA classification
Strengths
- Is novel, resonates with many→
gets attention
- Can lead, in theory, to new insights
on health effects additives and
processing
- Highlights the problems in the
global food system (fast, cheap,
hyper -palatable, lucrative
marketing)
Weaknesses
- Some healthy foods will be doomed
unhealthy without true
rationale/evidence
- Some unhealthy foods are not
categorised as ultra-processed
(“bad”)
- ”Just an old concept in new a
package”, i.e. Western dietary
pattern
Opportunities
- Food industry is forced to pay
more attention to the healthiness of
its product lines
- Some new “culprits” can be found,
i.e. specific additives/processing
technologies which may have a very
specific hazardous effect on some
bodily functions
- New studies scrutinizing the effects
of ultra-processed plant-protein
Threats
- Confuses more than clarifies
- All food additives perceived as
dangerous
- Further strengthens the mistrust to
food industry, increases tension
btw some consumer groups and
industry
- Further strengthens the acceptance
of poorly grounded movements
such as “clean eating”, “paleo diet”

26. These food items are examples of unhealthy ultra-
processed foods (if consumed regularly/much)

27. Contains… lecithin (as additive)
Contains… Acidity Regulator
(Dipotassium Phosphate),
Mineral (Calcium
Carbonate), Salt, Vitamin D2,
Vitamin B12).
Contains… added vitamin D and
reformulated by splitting lactose
into glucose and galactose
Contains…added
wheat gluten, rye
malt.
These food items are examples of healthy despite
being classified as ultra-processed foods
Contains… glucose syrup
and E401 (emulgator)

28. Healthy dietary pattern?
Chickpea/wholewheat pasta

29. These is an example of healthy dietary pattern
containing 9 ultra-processed food items

30. Are we creating an
unnecessary dictomy?
Vegan/vegetarian products as
example

31. Plant protein sources are consistently associated with the
best health outcomes in epidemiological studies. CHD as
an example
Bernstein AM, Sun Q, Hu FB, Stampfer MJ, Manson JE, Willett WC. Major dietary protein sources and risk
of coronary heart disease in women. Circulation. 2010;122(9):876-83.

32. Rapeseed oil (43%), Oat
drink 38% (water, oats,
sunflower oil), vegetable
fats (coconut, Shea), water,
salt (0.8%), emulsifier
(Mono- and diglycerides of
fatty acids), flavorings,
vitamins A and D2, color (
beta-carotene). Contains
Margarin ultra-processed but definitely has better
health effects than butter. Margarine outperforms
butter in cholesterol/low-grade inflammation/liver fat
studies
Pasteurized CREAM and salt

33. Ingredients: Water,
cornmeal, pea protein 11%,
(non-EU), sunflower oil,
carrot, OATmeal, OATflour,
WHEAT flour, onion,
rapeseed oil, white beans
<2% (non-EU), beef bean
<2% (Finland), OATbran,
natural flavor, thickener
(methylcellulose), salt,
garlic, spices, barley extract.
Finnish meat (pork, beef),
water, rind, stabilizers
(modified tapioca starch,
E450), iodized salt,
dextrose, meat protein,
potato fiber, spices (e.g.
coriander, cumin, paprika),
antioxidant (ascorbic acid),
aromas (e.g. , black
pepper), preservative
(E250). Sheep casing as
Both are ultra-processed but very likely very
different effects on health favoring plant protein

34. Ultra-processed, plant based protein sources vs.
animal based protein sources →lower cholesterol
levels
Päivärinta E, Itkonen ST, Pellinen T, Lehtovirta M, Erkkola M, Pajari AM. Replacing Animal-Based Proteins with Plant-Based Proteins
Changes the Composition of a Whole Nordic Diet-A Randomised Clinical Trial in Healthy Finnish Adults. Nutrients. 2020 Mar 28;12(4):943.

35. Bergeron N, Chiu S, Williams PT, M King S, Krauss RM. Effects of red meat, white meat, and nonmeat protein sources on
atherogenic lipoprotein measures in the context of low compared with high saturated fat intake: a randomized controlled
trial. Am J Clin Nutr. 2019 Jul 1;110(1):24-33. doi: 10.1093/ajcn/nqz035. Erratum in: Am J Clin Nutr. 2019 Sep
Ultra-processed vegan protein sources vs. animal
based protein sources → lower cholesterol levels
”The results of the present study support current dietary recommendations to
adopt dietary patterns with high vegetable content, but do not provide evidence
for choosing white over red meat for reducing CVD risk on the basis of plasma
lipid and lipoprotein effects.”

36. “Classifying soy-based meat and dairy alternatives as UPFs may hinder their
public acceptance, which could detrimentally affect personal and planetary
health. In conclusion, the NOVA classification system is simplistic and does
not adequately evaluate the nutritional attributes of meat and dairy
alternatives based on soy.”

37. There are no studies available which showed
vegan/vegetarian ultra-processed plant protein
sources would increase health risks vs animal
based protein sources.
• Head to head clinical studies are needed
– Type: fava bean products vs. chicken
– Type: fava bean products vs. dairy protein
– Type: fava bean products vs. red meat
– Type: fava bean products vs. processed meat
• Plant based proteins could contribute to
– Lower risk of type 2 diabetes (fiber, less SFA, & due to replacement
of red/processed meat)
– Cardiovascular disease (lower cholesterol)
– Lower risk of colorectal cancer (fiber, polyphenols & due to
replacement of red/processed meat)

38. Ultra-processing of food.
Definition, consequences for
health and emerging critic.
Dietician, PhD
Reijo Laatikainen
Aava Medical Centre
Docrates Cancer Hospital
www.pronutritionist.net
https://twitter.com/Reijo_RD_FIN
www.facebook.com/pronutritionist
www.slideshare.net/pronutritionist