Abstracts

INTRODUCTION

In Brazil, according to a report issued by the 2008-2009 Pesquisa de Orçamentos Familiares (POF – Family Budget Survey), the prevalence of obesity has doubled in the last 30 years, reaching 50.0% in men and 48.0% in women.^aa Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2008-2009. Rio de Janeiro (RJ); 2010. Unhealthy diets and physical inactivity were found to be the main risk factors for obesity.¹¹11. Malik VS, Willett WC, Hu FB. Global obesity: trends, risk factors and policy implications. Nat Rev Endocrinol. 2013;9(1):13-27. DOI:10.1038/nrendo.2012.199 With respect to diet, the current recommendations and guidelines while providing guidance on the consumption of foods tend to focus on nutrient intake, with a certain disregard for the factors that favor food choice.¹⁴14. Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr. 2009;12(5):729-31. DOI:10.1017/S1368980009005291 The Global Strategy on Diet, Physical Activity and Health, created by the World Health Organization, emphasizes the need to reduce the consumption of foods containing high amounts of energy, sodium, saturated fats, trans fats, refined carbohydrates, and those that are low in nutrients.^bb World Health Organization, Department of Chronic Diseases and Health Promotions. Global strategy on diet, physical activity and health. Geneva; 2003. The new version of the Guia Alimentar Para a População Brasileira (Food Guide for the Brazilian Population)^cc Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica, Coordenação Geral de Alimentação e Nutrição. Guia alimentar para a população brasileira (versão para consulta pública). Brasília (DF); 2014. gives guidance on meals and aspects related to eating behavior, including cultural, social, economic, and environmental factors.

We should consider that individuals consume food and/or preparations in which the nutrients themselves are not the main factors in determining the choice, a fact that is well-known and exploited by the food industry, which increasingly offers practical, palatable, durable, and more attractive food choices for the population.¹⁴14. Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr. 2009;12(5):729-31. DOI:10.1017/S1368980009005291 Processed foods have become increasingly accessible to all age groups and are sold pre-prepared or ready-to-eat.¹⁵15. Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saude Publica. 2010;26(11):2039-49. DOI:10.1590/S0102-311X2010001100005 The increased consumption of processed food and beverages has been considered as one of the factors contributing to the increased prevalence of obesity and chronic diseases.²⁵25. World Health Organization. Diet, nutrition and the prevention of chronic diseases: Report of a Joint WHO/FAO Expert Consultation. Geneva; 2003. (WHO Technical Report Series, 916).

According to the classification proposed by Monteiro et al,¹⁵15. Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saude Publica. 2010;26(11):2039-49. DOI:10.1590/S0102-311X2010001100005 foods and/or cooking ingredients that acquire and retain some or all of the above characteristics during the production process are designated as ultra-processed foods. A few studies have shown that the domestic acquisition of this food group has increased in recent decades.¹²12. Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Increased contribution of ultra-processed food products in the Brazilian diet (1987-2009). Rev Saude Publica. 2013;47(4):656-65. DOI:10.1590/s0034-8910.2013047004968,¹⁸18. Moubarac JC, Batal M, Martins AP, Claro R, Levy RB, Cannon G, et al. Processed and ultra-processed food products: consumption trends in Canada from 1938 to 2011. Can J Diet Pract Res. 2014;75(1):15-21. DOI:10.3148/75.1.2014.15 To date, studies on the individual consumption of this food group are limited; however, the availability of this food group in homes has been associated with an increased income¹⁶16. Monteiro CA, Levy RB, Claro RM, Castro IR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr. 2011;14(1):5-13. DOI:10.1017/S1368980010003241 and the risk of obesity in the Brazilian population.⁶6. Canella DS, Levy RB, Martins AP, Claro RM, Moubarac JC, Baraldi LG, et al. Ultra-processed food products and obesity in Brazilian households (2008-2009). PLoS One. 2014;9(3):e92752. DOI:10.1371/journal.pone.0092752

The objective of this study was to evaluate the consumption of ultra-processed foods, its associated factors, and its influence on nutrient intake in young adults.

METHODS

The individuals belonging to the cohort study conducted in 1982 in Pelotas, RS, Southern Brazil were identified.²³23. Victora CG, Barros FC. Cohort profile: the 1982 Pelotas (Brazil) birth cohort study. Int J Epidemiol. 2006;35(2):237-42. DOI:10.1093/ije/dyi290 The methodology used to evaluate the 1,982 cohort has been detailed elsewhere.⁹9. Halpern R, Barros AJD, Matijasevich A, Santos IS, Victora CG, Barros FC. Estado de desenvolvimento aos 12 meses de idade de acordo com peso ao nascer e renda familiar: uma comparação de duas coortes de nascimentos no Brasil. Cad Saud Publica. 2008;24(Supl 3):S444-50. DOI:10.1590/S0102-311X2008001500010 ^{, 23}23. Victora CG, Barros FC. Cohort profile: the 1982 Pelotas (Brazil) birth cohort study. Int J Epidemiol. 2006;35(2):237-42. DOI:10.1093/ije/dyi290 In 2004-2005, the cohort participants, with a mean age of 22.8 years (21.9-23.7), were interviewed in approximately 98,000 households.

The interviews were conducted in the participants’ homes and were administered by trained examiners using a previously tested and structured questionnaire (pre-pilot and pilot), which addressed several sociodemographic and health-related aspects, including dietary habits. To evaluate food consumption, the food frequency questionnaire (FFQ) was used. The FFQ, adapted from a tool developed and validated by Sichieri,²⁰20. Sichieri R, Everhart JE. Validity of a Brazilian food frequency questionnaire against dietary recalls and estimated energy intake. Nutr Res. 1998;18(10):1649-59. DOI:10.1016/S0271-5317(98)00151-1 contained 85 food items which were divided into two components: quantitative, with evaluation of domestic food portions and consisting of 70 food items and preparations; and qualitative, assessing only the frequency with which foods are consumed. The percentage of daily caloric intake of ultra-processed foods was calculated using the food items listed in the quantitative component of the FFQ. The caloric intake of these foods was estimated by converting the frequency of consumption reported for each item into the annual consumption. The reported daily intake was multiplied by 365.24 days of the year, the weekly intake was multiplied by 52.18 weeks in a year, the monthly consumption was multiplied by 12 months, and a value of one was used for the annual consumption.

The intake of household portions of the food items was converted to grams using the Tabela para Avaliação do Consumo Alimentar em Medidas Caseiras (Table for Evaluation of Food Consumption in Household Measures) – 5^th edition.¹⁹19. Pinheiro ABV, Lacerda EMA, Benzecry EH, Gomes MCS, Costa VM. Tabela de avaliação de consumo alimentar em medidas caseiras. 5.ed. Rio de Janeiro: Atheneu; 2005. The food intake in grams was converted into the amount of macro- and micronutrients using the Tabela Brasileira de Composição de Alimentos (TACO – Brazilian Table of Food Composition)^dd Universidade Estadual de Campinas, Núcleo de Estudos e Pesquisas em Alimentação - NEPA. Tabela brasileira de composição de alimentos - TACO. 2 ed. Campinas (SP): UNICAMP; 2006. or the USDA Nutrient Database for Standard Reference^ee USDA National Nutrient Database for Standard Reference [Internet]. Beltsville: Human Nutrition Research Center, Nutrient Data Laboratory; 2011 [cited 2014 Dec 10]. Available from: http://ndb.nal.usda.gov/ when the TACO was unavailable. The evaluated nutrients included carbohydrates, proteins, fats, cholesterol, fiber, sodium, iron, and calcium. The energy intake of each food item was estimated by multiplying the amount of carbohydrates and proteins by 4 kcal and the amount of lipids by 9 kcal, and the annual caloric intake of each food item was obtained after totaling the calories derived from each macronutrient. To calculate the daily energy intake of each food item, the annual caloric intake was divided by 365.24. The total daily energy intake was evaluated by totaling the calories consumed in each of the 70 food items.

The consumption of ultra-processed foods was evaluated according to the classification proposed by Monteiro,¹⁵15. Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saude Publica. 2010;26(11):2039-49. DOI:10.1590/S0102-311X2010001100005 i.e., according to the degree of processing, as follows: unprocessed or minimally processed foods (group 1), processed foods used as ingredients in cooking preparations by the food industry (group 2), and ultra-processed foods or food products (group 3). In this classification, ultra-processed foods were considered as products that originate from the processing of a mixture of foods from groups 1 and 2, which were developed with the aim of creating pre-prepared or ready-to-eat meals that are long-lasting, accessible, convenient, and palatable. The production processes generally characterize these foods as salted, cured, sweetened, baked, fried, smoked, or pickled, and they can also insert preservative or cosmetic additives, synthetic vitamins and minerals, and use sophisticated types of packaging.¹⁵15. Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saude Publica. 2010;26(11):2039-49. DOI:10.1590/S0102-311X2010001100005 ^{, 16}16. Monteiro CA, Levy RB, Claro RM, Castro IR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr. 2011;14(1):5-13. DOI:10.1017/S1368980010003241 Alcoholic beverages were not included in this study.

In the quantitative FFQ, 21 food items were classified as ultra-processed and were placed into the following groups: breads; cookies; sweets; soft drinks; salted, cured, and smoked meats and sausages; sauces; snacks; pizzas; salted and fried foods; and sweetened dairy beverages. Based on this classification, the percentage of daily caloric intake was calculated from each group of ultra-processed foods.

The independent variables studied were as follows: gender, marital status, current education (years of schooling), change of income from birth to 23 years of age, and nutritional status. For the construction of changes in income, the variable family income, which was collected in a categorical form, in minimum wages in 1982 (< 1; 1.1-3.0; 3.1-6.0; 6.1-10.0, and > 10.0, with frequencies of 21.9%, 47.4%, 18.5%, 6.5%, and 5.7%, respectively) was estimated based on household and family characteristics, with a principal component analysis of four variables (health security in childbirth delivery care, education, height, and the mother’s ethnicity). Because of the unequal frequencies between categories, subjects were classified into tertiles to allow the evaluation of changes in income levels since childhood. Therefore, the score generated by the first variable of the principal component analysis helped to identify cutoff points that allowed the differentiation of individuals of the second category of family income (47.4%) to a lower or intermediate tertile. The cohort participants answered questions about the income of each family member obtained through work, pension, social benefits, retirement, and rented properties, among others. Based on the tertiles of family income in 1982 and 2004-2005, the following classification was used: always poor (those in the lowest tertile of family income in 1982 and 2004-2005), poor → not poor (those in the lowest tertile in 1982 who climbed to the middle or upper tertile in 2004-2005), not poor → poor (those in the middle or upper tertile in 1982 who moved down to the lowest tertile in 2004-2005), and never poor (those in the middle or upper tertile in 1982 and 2004-2005).

The nutritional status of the cohort was classified as recommended by WHO for the body mass index (BMI) categories.^ff World Health Organization. Obesity: preventing and managing the global epidemic: report of a WHO Consultation; Geneva; 1997 June 3-5. Geneva; 2000. (WHO Technical Report Series, 894). To obtain the BMI, the subject’s weight was measured using an electronic scale by subtracting the weight of the clothes. The weight of the clothes is based on a table created by the research team, which shows the weights of various items of clothing. Height was measured using a stadiometer, with the participants barefoot and the head positioned in the Frankfurt plane.

Analysis of variance and linear regression were used in the crude and adjusted associations between the consumption of ultra-processed foods (percentage of caloric intake) and sociodemographic variables. The percentage of caloric intake from carbohydrates, proteins, and fats and the average consumption of fiber (g), cholesterol (mg), sodium (mg), iron (mg), and calcium (mg) were evaluated according to the quintiles of the consumption of ultra-processed foods using the Student’s t-test, analysis of variance, or a corresponding non-parametric test when non-compliance with any of the premises was found. The association between the percentages of cohort participants who met the current recommendations for nutrient intake established by the Guia Alimentar para a População Brasileira ^gg Ministério da Saúde, Secretaria de Atenção à Saúde, Coordenação Geral da Política de Alimentação e Nutrição. Guia alimentar para a população brasileira. Brasília (DF); 2005. (Série A. Normas e Manuais Técnicos). and Dietary Reference Intakes (DRI)^hh Institute of Medicine, Food and Nutrition Board. Dietary reference Intakes: a risk assessment model for establishing upper intake levels for nutrients. Washington (DC): National Academy of Sciences; 1998. and the quintiles of the consumption of ultra-processed foods was evaluated using Pearson’s Chi-square test. In all analyses, a 5% significance level was considered.

The study was approved by the Research Ethics Committee of the Faculdade de Medicina of the Universidade Federal de Pelotas (Protocol 020/2003). All participants signed a free informed consent form.

RESULTS

A total of 4,297 individuals belonging to the 1982 cohort were interviewed, corresponding to a follow-up rate of 77.4% after considering the identification of 282 deaths.

Ninety-five individuals were excluded from the study: 52 because of implausible answers to the FFQ, including the reporting of high daily intake of all foods or the excessive daily intake of foods from the same food group (consumption of beans and lentils five times a day); and 43 because they reported a daily caloric intake above three standard deviations of the mean. Thus, the final study sample included 4,202 young adults, representing 97.8% of respondents in 2004-2005. Table 1 shows that most of the participants were men (51.4%), 61.4% participants reported not living with a partner, 64.0% had finished high school education, and 52.0% had never been poor.

The average daily caloric intake was 3,758 calories, of which > 50.0% was attributed to the consumption of ultra-processed foods (Table 2). The analysis of consumption by food group indicates that bread represented 15.1% of the daily calorie intake among men, followed by sweets with 13.0%. For women, sweets were the main contributors to the daily caloric intake (16.8%), followed by bread (13.0%). Snacks were the third group of ultra-processed foods consumed by both genders (men: 10.8%; women: 10.4%). The percentage of caloric intake attributed to the consumption of sweets, cookies, and yoghurts was higher among women, whereas the intake of bread, soft drinks, and processed meats was higher among men. The consumption of ultra-processed foods was more frequent among women living without a partner, individuals with higher education, those who had never been poor, and those who were not overweight (Table 3). After adjusting for other sociodemographic variables, education remained positively associated with the percentage of caloric intake attributed to the consumption of ultra-processed foods. Therefore, cohort participants with ≥ 12 years of education reported an additional 4.8% caloric intake attributed to the consumption of these foods compared with participants with ≤ 4 years of education (95%CI 2.9;6.7). Individuals who had never been poor reported a higher consumption of ultra-processed foods compared with those who had always been poor (regression coefficient [β] = 5.3, 95%CI 4.0;6.6). Overweight individuals reported a lower consumption of ultra-processed foods (β = -1.0, 95%CI -1.9;0.0), whereas obese individuals presented a lower caloric intake derived from these foods (β = -2.0, 95%CI -3.4;0.5).

Table 4 shows the tendency for daily protein intake to decrease with the increase in the consumption of ultra-processed foods p < 0.001). The same tendency was observed in relation to carbohydrate intake (p < 0.001), and cohort participants in the lower and upper quintile of the consumption of ultra-processed foods presented an average carbohydrate consumption of 65.6% and 54.7% of their total caloric intake, respectively. In contrast, the percentage of total caloric intake attributed to the consumption of fats ranged from 19.5% in the upper quintile to 33.6% in the lower quintile (p < 0.001). Moreover, individuals from the upper quintile of the consumption of ultra-processed foods had an average of 8.2% and 0.4% of total calories intake assigned to saturated and trans fats, respectively, whereas those in the lower quintile had an average of 6.0% and 0.2%, respectively.

With respect to cholesterol intake (Table 4), individuals in the lower three quintiles of the consumption of ultra-processed foods showed a similar consumption of cholesterol, whereas those in the upper two quintiles had a higher intake (p < 0.001). A progressive decrease in the consumption of dietary fiber occurred with an increasing consumption of ultra-processed foods (p < 0.001); therefore, the individuals in the lower quintile reported an additional average intake of 15 g of fiber compared with those in the upper quintile. In addition, individuals in the upper quintile reported an additional average daily sodium intake of 1,400 mg compared with those in the lower quintile (p < 0.001). The daily intake of iron and calcium was also positively correlated with the consumption of ultra-processed foods (p < 0.001). Individuals with a higher consumption of ultra-processed foods reported a higher daily caloric intake; this value was 1,000 kcal/day higher among those in the upper quintile compared with those in the lower quintile (p < 0.001).

The consumption of ultra-processed foods and the adequacy of nutrient intake were correlated (Table 5). The cohort participants in the lower quintile had the lowest percentage of adequate protein intake (p < 0.001). Although no trend was observed, a smaller percentage of individuals in the upper two quintiles showed an intake of carbohydrates and fats within the recommended ranges, and only 47.4% and 33.8% of the cohort in the upper quintile reported an adequate consumption of carbohydrates (p < 0.001) and fats (p < 0.001), respectively. Most of the cohort met the recommendations for the intake of trans fats. However, the percentage of individuals with an adequate intake of trans fats varied between 92.3% and 99.2% from the upper to the lower quintile of the consumption of ultra-processed foods. More than 90.0% of the cohort participants in the lower quintile reached the recommendation intake of < 10.0% daily calories from saturated fats, whereas this percentage decreased to 78.3% among those in the upper quintile.

With respect to the intake of cholesterol, dietary fiber, and sodium, the percentage of individuals with an adequate intake of these nutrients in the lower quintile was 15, 12, and 49 percentage points higher than the percentage of subjects in the upper quintile. The opposite was observed in relation to the adequacy of intake of iron and calcium, with a gradual increase in the percentage of participants with an adequate intake of these nutrients as the intake of ultra-processed foods increased (p < 0.001) (Table 5).

DISCUSSION

In this study, approximately 50.0% of the daily caloric intake among the cohort participants at 23 years of age was attributed to the consumption of ultra-processed foods, and there was a significant influence of socioeconomic characteristics in this consumption. The positive association between the consumption of ultra-processed foods and intake of total and saturated fats, cholesterol, sodium, iron, calcium, and the total caloric intake indicates the negative effect of the consumption of processed foods on health and the need for implementing intervention strategies in this population.

Previous studies following the same classification for ultra-processed foods, using data from FBS in Brazil and from the Food Expenditure Survey in Canada, found that the percentage of the total household availability of foods attributed to ultra-processed foods was 28.0% and 61.7%, respectively.¹⁶16. Monteiro CA, Levy RB, Claro RM, Castro IR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr. 2011;14(1):5-13. DOI:10.1017/S1368980010003241 ^{, 17}17. Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA. Consumption of ultra-processed foods and likely impact on human health. Evidence from Canada. Public Health Nutr. 2013;16(12):2240-8. DOI:10.1017/S1368980012005009 Furthermore, the same Brazilian study showed a 9.0% increase in the availability of ultra-processed foods in a 15-year period. Considering that approximately 28.0% of food expenditure was spent on food for consumption outside the home, most of the household consumption by family members can probably be attributed to ultra-processed foods.¹⁶16. Monteiro CA, Levy RB, Claro RM, Castro IR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr. 2011;14(1):5-13. DOI:10.1017/S1368980010003241

In Brazil, public policies on the transmission of information through the media and the packaging of food products remain limited. However, a major advancement, whose impact on food intake by the population could be assessed in future, is that food processing is now discussed in the new version of the Guia Alimentar para a População Brasileira (Food Guide for the Brazilian Population).^cc Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica, Coordenação Geral de Alimentação e Nutrição. Guia alimentar para a população brasileira (versão para consulta pública). Brasília (DF); 2014. This version introduces the concept of ultra-processed foods, thereby enabling them to be identified by the population. The guide also covers important issues that interfere in the consumption of these foods, including supply, cost, time, and advertising.

The abovementioned guide addresses the role of advertising in food choices because of the high levels of media exposure promoting the use of ultra-processed foods¹⁴14. Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr. 2009;12(5):729-31. DOI:10.1017/S1368980009005291 and the benefits of fortified foods, thereby leading consumers to believe that processed fortified foods must be healthier.¹⁵15. Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saude Publica. 2010;26(11):2039-49. DOI:10.1590/S0102-311X2010001100005 This may be one explanation for the association between higher education and higher consumption of ultra-processed foods in the cohort, considering that education and access to information are interrelated factors. Another factor may be the increased purchasing power of this population group.

In the present study, it was observed that ultra-processed foods were consumed, regardless of social mobility. However, in other studies that evaluated the association between social mobility and lifestyle, the prevalence of the behavior investigated (in this case smoking and physical inactivity) was in line with the new socioeconomic status of the groups that presented changes in family income.²2. Azevedo MR, Horta BL, Gigante DP, Victora CG, Barros FC. Fatores associados ao sedentarismo no lazer de adultos na coorte de nascimentos de 1982, Pelotas, RS. Rev Saude Publica. 2008;42(Supl 2):70-7. DOI:10.1590/S0034-89102008000900010 ^{, 13}13. Menezes AM, Minten GC, Hallal PC, Victora CG, Horta BL, Gigante DP, et al. Smoking prevalence in the 1982 birth cohort: from adolescence to adult life, Pelotas, Southern Brazil. Rev Saude Publica. 2008;42(Supl 2):78-85. DOI:10.1590/S0034-89102008000900011 In contrast, the positive association between the consumption of ultra-processed foods and income found in this study was in keeping with the positive correlation between consumption and the household availability of this food group in Brazil.¹⁵15. Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saude Publica. 2010;26(11):2039-49. DOI:10.1590/S0102-311X2010001100005

With respect to the influence of the consumption of ultra-processed foods on the intake of certain nutrients, a study conducted in Canada¹⁷17. Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA. Consumption of ultra-processed foods and likely impact on human health. Evidence from Canada. Public Health Nutr. 2013;16(12):2240-8. DOI:10.1017/S1368980012005009 showed that the percentage of protein in the diet was inversely correlated with the household availability of ultra-processed foods and that the increased intake of ultra-processed foods resulted in an increased consumption of fat and sodium and a lower intake of dietary fiber. However, this study found no association with the percentage of carbohydrates in the total diet.¹⁷17. Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA. Consumption of ultra-processed foods and likely impact on human health. Evidence from Canada. Public Health Nutr. 2013;16(12):2240-8. DOI:10.1017/S1368980012005009

The amount of energy consumed is a cause for concern because of the possibility of positive energy balance in these individuals, which could lead to weight gain, although this hypothesis has not been addressed because of the transverse nature of the analysis. With respect to the nutrients mentioned in the previous paragraph, although a controversy exists,²¹21. Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr. 2010;91(3):535-46. DOI:10.3945/ajcn.2009.27725 the association between fat and sodium intake and the risk of cardiovascular is a cause for concern.⁸8. Clarke R, Frost C, Collins R, Appleby P, Peto R. Dietary lipids and blood cholesterol: quantitative meta-analysis of metabolic ward studies. BMJ. 1997;314(7074):112-7. DOI:10.1136/bmj.314.7074.112 It is speculated that some studies may not find any association between the intake of saturated fats and the risk of cardiovascular disease when these are replaced with carbohydrates, whereas their replacement with polyunsaturated fats could be beneficial to cardiovascular health.¹⁰10. Kuipers RS, Graaf DJ, Luxwolda MF, Muskiet MH, Dijck-Brower DA, Muskiet FA. Saturated fat, carbohydrates and cardiovascular disease. Neth J Med. 2011;69(9):372-8. ^{, 22}22. Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. Saturated fatty acids and risk of coronary heart disease: modulation by replacement nutrients. Curr Atheroscler Rep. 2010;12(6):384-90. DOI:10.1007/s11883-010-0131-6 ^{, 24}24. Willett WC. Dietary fats and coronary heart disease. J Intern Med. 2012;272(1):13-24. DOI:10.1111/j.1365-2796.2012.02553.x Monitoring the consumption of ultra-processed foods and the health condition of these individuals may help elucidate this association, considering that the consumption of carbohydrates was inversely correlated with the consumption of saturated fats in this study population (r = -0.52). With respect to trans fats, current reviews found an association between this type of fat, unfavorable changes in lipid profile and risk for cardiovascular disease.³3. Booker CS, Mann JI. Trans fatty acids and cardiovascular health: translation of the evidence base. Nutr Metab Cardiovasc Dis. 2008;18(6):448-56. DOI:10.1016/j.numecd.2008.02 ^{, 4}4. Brouwer IA, Wanders AJ, Katan MB. Effect of animal and industrial trans fatty acids on HDL and LDL cholesterol levels in humans: a quantitative review. PLoS One. 2010;5(3):e9434. DOI:10.1371/journal.pone.0009434 ^{, 24}24. Willett WC. Dietary fats and coronary heart disease. J Intern Med. 2012;272(1):13-24. DOI:10.1111/j.1365-2796.2012.02553.x The consumption of trans fats was low in the study population. However, the adequacy to the tolerated limit of the consumption of trans fats of ≤ 1.0% of the total caloric intake decreased with the increased consumption of ultra-processed foods.

The percentage of individuals with an adequate intake of iron and calcium was higher among the cohort participants who consumed more ultra-processed foods. This fact may indicate some benefits of consuming these products. The consumption of cheese, yogurt, and some sweets containing milk in its composition must have contributed to the higher calcium intake in participants with a higher consumption of ultra-processed foods, although the intake of cheese and yogurt contributed to only 2.0% of the total daily calories consumed. In addition, the proportion of subjects who achieved the recommended daily intake of calcium was very low, even in the upper quintile of the consumption of ultra-processed foods (16.4%).

In Brazil, DRC 344 of December 13, 2002 made the fortification of wheat and maize flour with iron mandatory. This could explain the higher iron intake in individuals with a higher consumption of ultra-processed foods. However, a recent study using data from four population-based surveys conducted with children < 6 years of age from Pelotas found that mandatory fortification of flour and corn did not show any improvement in the prevalence of anemia. The same study indicates that although an adequate intake of iron was observed in > 80.0% of the study group, the bioavailability of iron added to flour was low (5.0%) because of the reduced use of iron by at least 50.0% of the mills in Brazil.¹1. Assunção MC, Santos IS, Barros AJ, Gigante DP, Victora CG. Flour fortification with iron has no impact on anaemia in urban Brazilian children. Public Health Nutr. 2012;15(10):1796-801. DOI:10.1017/S1368980012003047 Therefore, the increased iron intake through the consumption of ultra-processed foods may not add any health benefits, which corroborates with the result of a recent study in which approximately 70.0% of the adult population of Pelotas reported the consumption of food products with voluntary fortification of food items with vitamins and minerals.⁷7. Cirino AC, Vargas Zanini R, Gigante DP. Consumption of foods with voluntary fortification of micronutrients in southern Brazil: prevalence and associated factors. Public Health Nutr. 2014;17(7):1555-64. DOI:10.1017/S1368980013001857

The use of a new classification system that discriminates food items based on industrial processing is considered positive.¹⁵15. Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saude Publica. 2010;26(11):2039-49. DOI:10.1590/S0102-311X2010001100005 Previous studies using this recent classification were conducted based on household food availability.¹⁶16. Monteiro CA, Levy RB, Claro RM, Castro IR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr. 2011;14(1):5-13. DOI:10.1017/S1368980010003241 ^{, 18}18. Moubarac JC, Batal M, Martins AP, Claro R, Levy RB, Cannon G, et al. Processed and ultra-processed food products: consumption trends in Canada from 1938 to 2011. Can J Diet Pract Res. 2014;75(1):15-21. DOI:10.3148/75.1.2014.15 Other advantages of the present study relate to the methodological approach used to exclude outliers in the reporting of the FFQ, thereby decreasing the possibility of information bias. In addition, conducing the FFQ in a representative cohort with a high follow-up rate enables the the consequences of the consumption of ultra-processed foods in the short and long terms to be investigated.

The possibility of overestimating food consumption using the FFQ has been recognized.⁵5. Cade J, Thompson R, Burley V, Warm D. Development, validation and utilisation of food-frequency questionnaires: a review. Public Health Nutr. 2002;5(4):567-87. DOI:10.1079/PHN2001318 Furthermore, the FFQ used in the 1982 cohort was not validated with an internal population. However, the questionnaire was derived from an instrument previously submitted to validation²⁰20. Sichieri R, Everhart JE. Validity of a Brazilian food frequency questionnaire against dietary recalls and estimated energy intake. Nutr Res. 1998;18(10):1649-59. DOI:10.1016/S0271-5317(98)00151-1 and modified only to meet regional food habits (e.g., by including the consumption of herbal mate tea). Another limitation relates to the analysis of the association between the consumption of ultra-processed foods and nutritional status, which may have been affected by reverse causality.

A large proportion of the daily food intake in the 1982 cohort was attributed to the consumption of ultra-processed foods. The consumption of this food group was higher among individuals with higher education and income throughout life, possibly indicating a greater outreach for this food group, and is associated with an improved economic condition and the increased search for ready-to-eat meals by this group. The effect of the consumption of ultra-processed foods on the increased intake of certain nutrients including fat, sodium, and cholesterol was also observed.

Therefore, the results of this study underscore the importance of monitoring the consumption of ultra-processed foods and the influence these products may have on consumers’ health and nutritional status, whether by current or future observation.

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