title: The share of ultra-processed foods and the overall nutritional quality of diets in the US: evidence from a nationally representative cross-sectional study.
abstract: Recent population dietary studies indicate that diets rich in ultra-processed foods, increasingly frequent worldwide, are grossly nutritionally unbalanced, suggesting that the dietary contribution of these foods largely determines the overall nutritional quality of contemporaneous diets. Yet, these studies have focused on individual nutrients (one at a time) rather than the overall nutritional quality of the diets. Here we investigate the relationship between the energy contribution of ultra-processed foods in the US diet and its content of critical nutrients, individually and overall.
  
  
  
  We evaluated dietary intakes of 9,317 participants from 2009 to 2010 NHANES aged 1+ years. Food items were classified into unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods. First, we examined the average dietary content of macronutrients, micronutrients, and fiber across quintiles of the energy contribution of ultra-processed foods. Then, we used Principal Component Analysis (PCA) to identify a nutrient-balanced dietary pattern to enable the assessment of the overall nutritional quality of the diet. Linear regression was used to explore the association between the dietary share of ultra-processed foods and the balanced-pattern PCA factor score. The scores were thereafter categorized into tertiles, and their distribution was examined across ultra-processed food quintiles. All models incorporated survey sample weights and were adjusted for age, sex, race/ethnicity, family income, and educational attainment.
  
  
  
  The average content of protein, fiber, vitamins A, C, D, and E, zinc, potassium, phosphorus, magnesium, and calcium in the US diet decreased significantly across quintiles of the energy contribution of ultra-processed foods, while carbohydrate, added sugar, and saturated fat contents increased. An inverse dose-response association was found between ultra-processed food quintiles and overall dietary quality measured through a nutrient-balanced-pattern PCA-derived factor score characterized by being richer in fiber, potassium, magnesium and vitamin C, and having less saturated fat and added sugars.
  
  
  
  This study suggests that decreasing the dietary share of ultra-processed foods is a rational and effective way to improve the nutritional quality of US diets.
authors.affiliation: Department of Nutrition, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, 01246-907, São Paulo, Brazil.|Center for Epidemiological Studies in Health and Nutrition, University of São Paulo, São Paulo, Brazil.
authors.forename: Euridice
authors.initials: E
authors.lastname: Martínez Steele
authors.affiliation: Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Barry M
authors.initials: BM
authors.lastname: Popkin
authors.affiliation: School of Population Health, University of Auckland, Auckland, New Zealand.
authors.forename: Boyd
authors.initials: B
authors.lastname: Swinburn
authors.affiliation: Department of Nutrition, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, 01246-907, São Paulo, Brazil. carlosam@usp.br.|Center for Epidemiological Studies in Health and Nutrition, University of São Paulo, São Paulo, Brazil. carlosam@usp.br.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Monteiro
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D004032:Diet; D004043:Dietary Fiber; D004044:Dietary Proteins; D002149:Energy Intake; D057140:Fast Foods; D005247:Feeding Behavior; D005260:Female; D005511:Food Handling; D006801:Humans; D007223:Infant; D016014:Linear Models; D008297:Male; D018977:Micronutrients; D008875:Middle Aged; D009749:Nutrition Surveys; D009753:Nutritive Value; D025341:Principal Component Analysis; D055815:Young Adult
chemical_list: D004043:Dietary Fiber; D004044:Dietary Proteins; D018977:Micronutrients
keywords: Diet quality; Dietary nutrient profile; Dietary patterns; Macronutrients; Micronutrients; NHANES; PCA; Ultra-processed