Issue 147 Ultra-processed foods: news headlines and nutrition

PUBLIC HEALTH

Emma Berry Associate Nutritionist (Registered) Emma is working in Research and Development and is enjoying writing freelance nutrition articles.

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ULTRA-PROCESSED FOODS: NEWS HEADLINES AND NUTRITION In May 2019, The British Medical Journal (BMJ) published a research article on ultra-processed foods and the link to all-cause mortality.1 The research article adds to a growing body of evidence that claims processed foods may be bad for health. So, what constitutes an ‘ultraprocessed food’ and how do messages that hit the media impact on the public?

The BMJ article, by Rico-Campa et al (2019) followed a cohort of 19,899 University graduates aged between 2091 years.1 This received media attention across the UK, including from the BBC and in The Guardian.2,3 The participants were followed up every two years, between December 1999 and February 2014, gathering food frequency data from web or postal questionnaires.

The study states that it was a dynamic cohort, so recruitment to the study was ongoing throughout the data collection period. The data collected from the questionnaires was then used to work out the consumption of ultraprocessed foods by participants. Foods in the questionnaire were grouped into four categories1 dependent on their processing (based on NOVA1): 1 Unprocessed/minimally processed, such as fruits, vegetables, fresh and pasteurised milk, herbs, spices.

2 Processed cooking ingredients, such as salt, sugar, oils and butter.

3 Processed foods, such as cheese, fresh bread, salted nuts and canned vegetables.

4 Ultra-processed foods, including sodas, sausages, fruit yoghurts, bottled fruit juices, sweets and alcohol.

The researchers focused specifically on the ultra-processed foods (listed as group 4 above). These foods are defined as ultra-processed as they have a high energy/calorie content, low nutritional

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value and generally contain added sugar, salt and additives.1 When carrying out the data analysis, the researchers did take into consideration influencing factors such as smoking, exercise, age and BMI and adjusted their findings to account for these factors. The research found that an increased consumption of ultra-processed foods was linked to an increased risk of death. However, the actual number of participants who passed away during this study was 335, with the main cause of death being cancer (164 deaths out of the total 335).

Although this study has many strengths, like the high number of participants and a high retention rate (90%), the results should be taken with a healthy dose of caution. Food frequency questionnaires can be at risk of bias (as many people may not be able to accurately record their food intake from a two-year period – understandably so).

However, these food questionnaires were originally developed in the 1990s and would not accurately capture our changing food landscape, which has been changing rapidly, with food manufacturers following the latest food trends when developing new products. The researchers do state that this is a limitation, as the questionnaire did not include information on energy bars, energy drinks, health or slimming products and more. It is also important to say that as the participants were all university graduates, the research

PUBLIC HEALTH

The researchers focused specifically on the ultraprocessed foods. These foods are defined as ultra-processed as they have a high energy/calorie content, low nutritional value and generally contain added sugar, salt and additives.

results may not provide a full example of the relationship across a wider population, as socioeconomic status was not adjusted for.1 Although this study may give important information about a potential relationship between ultra-processed food and death. It does in no way prove that ultra-processed foods can cause a person to have an increased risk of dying. There are numerous reasons as to why people may choose to eat a lot of ultraprocessed foods, eg, a lack of time or knowledge in cooking, being too unwell to cook fresh foods, or because they taste good. There are also many foods which are branded as a healthier option, which would still fall into the ultra-processed category, eg, protein bars, low-calorie cake bars and low fat ‘healthier’ yoghurts. It is incredibly hard to pinpoint a causal relationship in nutrition studies, as people’s diets are extremely varied and can change over time. Individuals often don’t eat the same food every day and food is closely linked to socialising and celebrations, so finding the effects of a specific food, or food group, on health is incredibly challenging.

MIXED MESSAGES

The link between processed foods and health is not necessarily new. The International Agency for Research on Cancer (IARC) announced the

link between processed meats and cancer back in 2015.4 There have been many headlines written about sugary beverages and the UK’s sugar tax since it was announced in 2016.5,6 However, these articles often discuss obesity, health risks and what a healthy diet should look like, but is this actually helping? The current UK guidelines on a healthy diet for the public are provided by the Eatwell Guide, but is it fair to promote the Guide as a ‘healthy diet’ when some people can’t afford the fresh food that is recommended?

Often people can’t access this food, or are unable to cook it for various reasons.7,8 Some people say that they do not even feel they know what ‘healthy’ food or a ‘healthy’ diet actually is, due to so many mixed nutrition messages.8 People may categorise foods into ‘good’ and ‘bad’, ‘healthy’ and ‘unhealthy’, which doesn’t necessarily stop people from eating certain things, but can result in feelings of guilt.9 Food guilt is the feeling of guilt after eating, normally linked to eating a food which is perceived to be unhealthy (characterised by a high fat, salt or sugar content and likely to fall into the ultra-processed food category). It is likely that these foods have been given the label of being bad for you through public health messages, or have the perceived risk of making us gain weight by eating them.9 However, this www.NHDmag.com August/September 2019 - Issue 147

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PUBLIC HEALTH food guilt and pressure to eat only ‘healthy’ foods can have negative effects on overall health and nutritional status.10 One example of a negative effect on health is that individuals could have disordered eating leading to the development of orthorexia.* Orthorexia is a relatively new eating disorder, initially discovered in 1998 and is not a formally recognised condition.11 The condition generally involves restricting food intake to foods deemed healthy or safe – often cutting out entire food groups from the diet, such as sugar, dairy, meat or carbohydrates.12 Eliminating food groups can impact on nutrition and so result in malnourishment.11 Conversely, food guilt and trying to eat healthy foods can result in weight gain.10 For individuals trying to ‘eat healthier’, or lose weight, eating a food they perceive as unhealthy, such as cake, may then result in negative emotions. Restraint with foods perceived as unhealthy has been linked to weight gain and disordered eating.10 Therefore, choosing to avoid these foods may result in individuals having poorer physical and mental health.10 *For more on orthorexia, please see Alice Fletcher’s article: Orthorexia: an eating disorder of the modern age? NHD Feb 2019, issue 141, pp 22-26, available in the Subscriber zone at www.NHDmag.com INTUITIVE EATING

It has been suggested that an intuitive eating** approach may be a better way of promoting healthier diets. This may be an alternative to the current culture of promoting unprocessed foods and dietary restraint as being superior for health.10,13,14 Our current health messages on reducing obesity and following a healthy diet may be causing more problems than they are solving.

Suggesting that some foods are unhealthy or less healthy than others, can create a complex

emotional relationship to the foods we eat. Often having foods that we, or our friends and family, may deem as unhealthy will result in people feeling they have to “make up for it later,” or they will be “extra good tomorrow”, rather than just enjoying the food they are eating. This stems from a fear of becoming obese, which also then means that individuals who perceive themselves as at risk of this, could have resulting negative mental health symptoms.10 This may be disproportionately affecting certain groups of society, as often the foods deemed unhealthy are cheaper and available in areas with limited access to fresh food. We are setting nutritional messages and guidelines that not everyone is supported to achieve. **For more on intuitive eating, please see Jess English’s article in NHD May 2019, issue 144, pp 35-38 available in the Subscriber zone at www.NHDmag.com.

CONCLUSION

If we remove the message of certain foods being labelled healthy or unhealthy and, instead, promote a diet of diversity, then this could be a positive step in helping achieve better nutrition for the population as a whole. By changing the message, we could remove the fear of weight gain that we now have as a society, reduce the risk of disordered eating and support more of our population in having better nutrition.

Although there is a fear that ultra-processed foods are bad for health, eating any food or food group to a high frequency will not be ideal for human health, but fearmongering from the media can often cause more harm by reinforcing the idea that all ultra-processed foods are bad all of the time. This may lead to confusion as to what a healthy diet actually is and what it consists of.

Ultimately, messages on how we can promote health through a varied diet need to be clear and consistent. Avoiding certain food groups is not the answer.

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