food processing: criteria for dietary guidance and public health? · nutrient density: added...

The Nutrition Society Scottish Section Meeting was held at the Royal College of Physicians and Surgeons Glasgow on 26ndash27 March 2018

Conference on lsquoNutrientndashnutrient interactionrsquoPlenary Lecture 1

Food processing criteria for dietary guidance and public health

Julie Miller Jones1Exercise Science and Nutrition St Catherine University 2004 Randolph Ave St Paul MN 55105 USA

The NOVA food categorisation recommends lsquoavoiding processed foods (PF) especiallyultra-processed foods (UPF)rsquo and selecting minimally PF to address obesity and chronic dis-ease However NOVA categories are drawn using non-traditional views of food processingwith additional criteria including a number of ingredients added sugars and additivesComparison of NOVArsquos definition and categorisation of PF with codified and publishedones shows limited congruence with respect to either definition or food placement into cat-egories While NOVA studies associate PF with decreased nutrient density other classifica-tions find nutrient-dense foods at all levels of processing Analyses of food intake data usingNOVA show UPF provide much added sugars Since added sugars are one criterion fordesignation as UPF such a proof demonstrates a tautology Avoidance of foods deemedas UPF such as wholegrainenriched bread and cereals or flavoured milk may not addressobesity but could decrease intakes of folate calcium and dietary fibre Consumer under-standing and implementation of NOVA have not been tested Neither have outcomesbeen compared with vetted patterns such as Dietary Approaches to Stop Hypertensionwhich base food selection on food groups and nutrient contribution NOVA fails to demon-strate the criteria required for dietary guidance understandability affordability workabilityand practicality Consumersrsquo confusion about definitions and food categorisations inad-equate cooking and meal planning skills and scarcity of resources (time money) mayimpede adoption and success of NOVA Research documenting that NOVA can be imple-mented by consumers and has nutrition and health outcomes equal to vetted patterns isneeded

Nutrient density Added sugars Dietary guidance Processed food Ultra-processed food

The rise in the availability and intake of processed foods(PF) and ultra-processed foods (UPF) has been positedby some public health authorities and organisations tobe a prime cause of poor diets and rising rates of obesityand chronic disease(1ndash10) Therefore Montiero and otherspublished the NOVA (not an acronym) categorisationwhich divides foods into four categories minimallyPF-NOVA (MPFn) UPFn processed culinary ingredi-ents (PCI) PFn Designation of NOVA categories inthe present paper will carry the subscript n for exampleUPF-NOVA is UPFn By contrast for generic PF andUPF there is no subscript Those classified by

International Food Information Council (IFIC) will beMPFi and PFi

(1211) NOVA proponents suggest thatshifts from ingestion of the two latter categories toMPFn and PCIn will improve nutrition and health

Category designations in NOVA are controversialbecause they imply their basis on the complexity of foodprocessing however this is not the case For examplefoods with added sugar are deemed as PFn or UPFnregardless of processing methods or technology usedFoods processed by innovative non-traditional techniquessuch as electric or magnetic fields may be deemed as MPFndespite the use of non-traditional complex processes(12ndash14)

Corresponding author Julie Miller Jones email jmjonesstkateedu

Abbreviations DASH Dietary Approaches to Stop Hypertension E energy (in terms of the energy ) IFIC International Food InformationCouncil MPF mimimally processed food PCI processed culinary ingredients PF processed foods RTE ready-to-eat RTEC ready-to-eat cerealsUPF ultra-processed foods

Proceedings of the Nutrition Society (2019) 78 4ndash18 doi101017S0029665118002513copy The Author 2018 First published online 25 September 2018

Proceedings

oftheNutritionSo

ciety

httpswwwcambridgeorgcoreterms httpsdoiorg101017S0029665118002513Downloaded from httpswwwcambridgeorgcore IP address 5439106173 on 09 Jun 2020 at 144208 subject to the Cambridge Core terms of use available at

Studies using NOVA demonstrate that PFnUPFndeliver most of the added sugars and are associatedwith obesity and other health risks(6ndash915) but other cate-gorisations yield different results(16ndash18) Further place-ment of foods into categories among NOVA studies isinconsistent(6ndash919)

The present paper will compare the NOVA definitionwith legal technical popular press and public health defini-tions The NOVA categorisation will be compared withthat of the IFIC Designation of foods with more thanfive ingredients or presence of lsquoadded sugarsrsquo or additivesasUPFnwill be challenged Further analyses documentingthat foods categorised as PFnUPFn provide much of thelsquoadded sugarsrsquo will be shown as tautological logic

Nutrient intakes and health outcomes using theNOVA system will be compared with those recom-mended in dietary guidance such as Dietary Approachesto Stop Hypertension (DASH)(20) or the United StatesDepartment of Agriculture MyPlate(2122) NOVArsquosadherence to requirements for dietary guidance under-standability adaptability applicability and practicalitywill be questioned(2324)

Processed food history and definitions

lsquoCooking which is one part of processing wenthand-in-hand with becoming human Human food is pro-cessed foodrsquo according to food historian RachelLaudan(25) PF enabled world exploration and settling ofterritories and continents PFrsquos ability to extend the foodsupply yielded the highest accolades from Napoleonwho awarded 50 000 francs to Nicholas Appert for devel-oping canned food to feed French troops(26) PF becamevital to a countryrsquos food supplies and as such they becamethe purview of governments to ensure their safety(27)Thus they were regulated and defined(28ndash36)

Definitions of processed foods legal and food science

Regulatory and food science definitions are found inTable 1A(28ndash36) These definitions show strong congru-ence but differ in detail All agree that one or more phys-ical chemical or microbiological steps change rawcommodities into ingredients or foods All allow formu-lations with any number or type of ingredients TheUnited States Department of Agriculture also has alegal definition of MPF(31)

Goals of food processing are also aligned in this groupof definitions These include increasing shelf life main-taining or enhancing safety and nutrient quality addres-sing specific nutritional requirements and adding varietyand convenience

Newer usages and definitions of processed foods andultra-processed foods

Bibliographic citations in PubMed about PF until 10years ago were about the intersection of food scienceand nutrition and presented data on the impacts of

processing techniques on food safety nutrient retentionor availability and microbiological quality In 2009UPF emerged as a term and transmuted (along withthe term PF) from food science to public health Itdefined the degree of processing non-traditionally andadded presence or absence of certain food componentsas a dimension(1ndash4) This prompted studies that documen-ted the penetration of PF and UPF into diets and thattested associations between their intake and nutrientquality obesity and disease(2ndash467937) This spawned pro-motion of the NOVA dietary system that recommendedthe use of MPFn and avoidance of PFnUPFn

Definitions of processed foods dictionary consumerorganisations and popular press

Among this group (Table 1B)(38ndash43) definitions and con-notations vary greatly Only two Wikipedia(38) andIFIC(39) show alignment with legal or food sciencedefinitions Several recognise that most foods are pro-cessed in some way to improve nutrient absorption tomake food safer and to prevent waste and that they arelsquonot all badrsquo(40ndash45)

Many websites and popular press definitions(Table 1B) describe PF as requiring complex processesand having lengthy ingredient lists including chemicalsand additives(46ndash49) Regardless of nutritive value PFare often presented pejoratively with comments such aslsquonot whole or found in naturersquo lsquosold in packets or tinsrsquolsquofast or junk foods with minimal nutrients and fiberrsquolsquoless satisfyingrsquo and lsquouse fewer calories to metabolizethan whole foodsrsquo(50ndash56) Web images most frequentlydepict sugary drinks candy crisps chips (fries) and fro-zen or baked sugary fatty or salty treats However somealso show bread canned fish and fruit baby foods infantformula and ready-to-eat cereals (RTEC)(5758)

The diversity of foods images and descriptions por-trayed demonstrate lack of agreement as to definitionor food categorisation in the popular press Further con-fusing consumers is the suggestion that home-preparedfoods are always nutritionally superior and are not pro-cessed even when techniques and ingredients areidentical(59)

Processed foods continuums and categorisations

Food scientists

PF exist on a continuum that food scientists base on thecomplexity of processes not numbers or kinds of ingredi-ents Additives salts and sugars are regarded as part ofthe recipe not as processes and can add flavour butalso extend shelf life and preserve nutrients(60) Thesecomponents help to fulfill the goal of processing whichis to reduce pre- and post-harvest losses to minimiseresource use to decrease waste to maintain safety andquality and to offer convenience(6162) These may addressfood supply issues and lower costs(6364)

Food scientists recognise processing may alter nutrientcontent and bioavailability either positively or

Processed food categorisation and dietary guidance 5

Proceedings

oftheNutritionSo

ciety


Table 1 Representative definitions and descriptions of food processing (FP) and processed food (PF)

Organisation or entity Definition of FP or PF Descriptions or notes

(A) Legal and food science definitions and descriptionsFood and AgricultureOrganization (FAOWHO)(28)

FP is any change made to a food to alter its eating quality or shelf life FP involves the application of science and technology

(1) to preserve or inhibit decay(2) to maintain or enhance the eating and quality of foods(3) to provide a range of products for consumers of varying ethnicities and

nutritional needs(4) to reduce waste along the food chain

European Food SafetyAuthority (EFSA)(29)

PF is defined with the definition of food Food is any substance or productwhether processed partially processed or unprocessed intended to be orreasonably expected to be ingested by human subjects

FP applies to all stages of food production processing and distribution of foodand feed

UK National Health Service(NHS)(30)

PF is any food that has been altered from its natural state in some wayeither for safety or convenience

US Department of Agriculture(USDA)(31)

PF is any raw agricultural commodity that has been subject to washingcleaning milling cutting chopping heating pasteurising blanchingcooking canning freezing drying dehydrating mixing packaging orother procedures that alter the food from its natural stateMinimally processed foods (MPF) are defined as retaining most of theirinherent physical chemical sensory and nutritional properties

Includes ingredients and additives such as preservatives flavours and nutrientsUSDA comments that processes or additives may reduce increase or leaveunaffected the nutritional characteristics of the raw agricultural commodityMPF are noted to have the nutritional value of their raw counterpartsUSDA notes that some nutrients may be more or less available than in moreprocessed forms

US Food and DrugAdministration (FDA)(32)

Similar to USDA

Food Standards Australia NewZealand (FSANZ)(33)

Similar to USDA FSANZ Standard 3middot1middot1 and 3middot22

The European FoodInformation Council(EUFIC)(34)

FP is any method used to turn fresh foods into food products This caninvolve one or more steps It includes adding components to food eg toextend shelf life or adding vitamins and minerals to improve the nutritionalquality of the food (fortification)

Food Science Textbook(35) FP is the transformation of animal and plant materials into intermediate orfinished value-added food products that are safe to eat

FP requires the application of labour energy machinery and scientificknowledge in one or of stepsFPrsquos goal is (1) to extend the period during which food remains wholesome(microbially and biochemically) (2) to provide nutrients required for health and(3) add variety and convenience

Food Science Journal(36) PF are raw ingredients transformed by physical or chemical means into foodingredients and foods

PF are marketable food products that can be easily prepared by consumers

(B) Popular press andconsumer definitions anddescriptionsWikipedia(38) FP is the transformation or combining of raw ingredients by physical or

chemical means to produce marketable food productsPF can be incorporated into recipes or prepared and served by the consumer

International Food InformationCouncil (IFIC)(39)

FP is any deliberate change in a food FP can be simple eg freezing or drying or complex with many processes andingredients

Organic ConsumersAssociation(46)

PF are convenientrsquo easy-to-eat products PF are altered through the addition of artificial ingredients synthetic flavourings

fillers and chemical or genetically-engineered additives They are more likely tohave longer ingredient lists

SF Gate (for San FranciscoChronicle)(47)

sectPF are foods in boxes cans or bags and often containing additives artificialflavourings and other chemical ingredients

PF often needing numerous complex processing steps and may not be found innature

JMJones

6

Proceedings of the Nutrition Society

httpsww

wcam

bridgeorgcoreterms httpsdoiorg101017S0029665118002513

Dow

nloaded from httpsw

ww

cambridgeorgcore IP address 5439106173 on 09 Jun 2020 at 144208 subject to the Cam

bridge Core terms of use available at

negatively(59) Processes and ingredients are adjusted tominimise losses and maintain nutrients Fortificantsmay be added to address demonstrated deficiencies(6566)Additional ingredients can add variety and palatabilitymaking nutrients more likely to be ingested(67) Whilevariety may induce overeating so can food that is unsat-isfying as people eat more to seek satisfaction Bothaspects need more study(68)

Nutrition and the food processing continuum

Traditional dietary guidance is based on optimisingintakes of food groups and nutrients(6970) Nutrient-poor foods are to be chosen infrequently(71) Vetted dietplans with proven health benefits such as DASH use amix of foods from all levels of processing to help consu-mers reach nutrition and health targets(2072ndash77) PF arefeatured in the United States Department of AgricultureMyPlate (ChooseMyPlategov) sample menu planswhich are designed to meet recommendations for consu-mers with limited resources(2178)

International Food Information Council categorisation

Table 2 shows the five categories of the IFIC model Allcategories contain foods to choose frequently and infre-quently Addition of sugar salt or additives or numbersof ingredients had no effect on category placementHome-prepared foods are categorised with the same cri-teria as manufactured ones

NOVA

Public Health Professor Carlos Montiero and colleaguesinitiated the NOVA categorisation of foods found inTable 3(1ndash4) Initially there were three categoriesMPFn PCI PFn

( 79) Subsequently PFn was split intoPFn and UPFn making four categories MPFn aredescribed as undergoing minimal processing such aswashing milling chilling freezing or vacuum-packing(vacuum-packing especially of cooked refrigeratedvegetables is viewed by food scientists as one whichrequires attention to maintain nutrients and safety andhas a degree of complexity) PCI include ingredientsfound in home kitchens such as starch sugar and oil(PCI initially included starch and pasta) PFn aredefined as recognisable versions of original foods thatmay have added PCI (eg sugar or salt) to extend shelflife or modify palatability They are generally consumedas part of meals or dishes UPFn are described as indus-trial formulations with five or more ingredients whichare often packaged branded convenient and highly pal-atable and function as snacks or replace homemadedishes They may include additives sweeteners andadded micronutrients to fortify them

The NOVA categorisation was enfranchised by thePan American Health Organisation(2) While PanAmerican Health Organisation recognises that nearlyall foods are processed and notes their benefitsand essentiality they raise concern about and theirpotential contribution to disease(2) Pan AmericanHealth Organisationrsquos document described UPFn asC

once

ntra

Hea

lthNew

sletter(4

8)

PFreferto

mos

tfood

ssinc

emos

tareproce

ssed

inso

meway

Con

centra

differen

tiatesbetwee

nmec

hanica

l(eg

grindingmea

t)an

dch

emical

proce

ssing(ega

ddition

ofad

ditive

s)w

hich

isdee

med

asno

tlsquonaturalrsquopara

PFareallege

dto

have

lsquobarelyan

ynu

trientsan

dfibrersquoto

beless

satis

fying

and

tous

eless

energy

tometab

olisethan

who

lefood

sWellW

isdom

(49)New

sletter

FPca

npreve

ntwas

tean

dmak

efood

saferbut

canco

ntainch

emicalsthat

shou

ldno

tbeinge

sted

Nea

rlyallleg

alan

dfood

scienc

edefi

nitio

nsof

food

proce

ssingha

vesimilarex

amplesan

dallow

addition

sto

thelistas

new

proce

ssed

emerge

Exa

mple

ofaco

nsum

ered

ucationgrou

pus

ingdietitians

andfood

professiona

lsas

spok

espeo

ple

Exa

mple

ofan

orga

nicag

riculturalp

roduc

tsmarke

tingan

dtrad

ereso

urce

that

isno

tin

favo

urof

biotech

nology

orpes

ticides

sectExa

mple

ofaUSne

wsp

aper

web

site

Exa

mple

ofhe

alth

newsletteras

sociated

with

thelargehe

alth

system

paraNatural

isno

tlega

llydefi

nedin

man

yjuris

dictio

ns

Exa

mple

ofthene

wsletterfrom

ave

ndor

ofsu

pplemen

tsan

dhe

alth

food

s


Proceedings

oftheNutritionSo

ciety


lsquoattractive hyper-palatable cheap ready-to-consumefood products that are characteristically energy-densefatty sugary or salty and generally obesogenicrsquo(2)

Comparison of definitions and categorisations

Legal food science Wikipedia and IFIC usage defini-tions and categorisations of PF show congruence butthose of NOVA public health popular press or websitedefinitions show dissimilarities Among the IFIC andNOVA categories MPF foods that require little process-ing are most similar(1ndash416ndash18) However the addition ofsugar or salt moves foods fromMPFn to PFn despite iden-tical processing Thus pasteurised milk yoghurts androasted nuts are MPF in IFIC and NOVA but onlyremain MPFn in NOVA if no sugar salt or additivesare present In the IFIC classification(816ndash18) canned orfrozen fruit vegetables meat or fish would be classed aslsquofoods processed to help preserve and enhance nutrientsrsquoregardless of the numbers or types of ingredients or addi-tives In NOVA a single food without additives would beMPFn but the addition of sugar or additives make themPFn and more than five ingredients UPFn

Bread and cereals in IFIC classification would be in theready-to-eat (RTE) category In NOVA breads with fiveor fewer ingredients and unpackaged are PFn but becomeUPFn if packaged or contain more than five ingredientsAll cereals containing sugar and salt are UPFn

Studies on nutrient contribution of foods in InternationalFood Information Council and NOVA categorisations

Post hoc analyses using food intake databases have beenconducted with the IFIC categorisation and NOVA Theresults of the analyses differ because criteria for the foodcategories are so different

International Food Information Council

Analyses of US National Health and NutritionExamination Survey (n 25 351 over 2 years old) showedthat MPFi contributed 17 of energy (E) but over 50of the vitamin D (mostly due to fortified dairy) and over30 of the potassium calcium and vitamin B12

(816ndash18)Foods processed for preservation (mostly canned andfrozen) contributed about 5 of E but over 30 vitaminC and over 5 of potassium fibre magnesium folatecalcium vitamin B6 and iron This category contributedlt5 of the salt but 8 of the sugar

RTE PFi contributed 35 of E and higher percen-tages of iron folate and vitamin B6 It also contributed45 of the added sugars (45) with major contributionsfrom sugar-sweetened beverages juice drinks and grain-based snacks and desserts(816ndash18) Sodium contributionswere lower than the percent of E

Mixtures of ingredients provided 17 of E and slightlymore carbohydrate fibre thiamin folate calcium andiron but a lower percentage of added sugars than thepercent of E

Table

2Internationa

lfoo

dinform

ationco

uncil(IFIC)p

roce

ssed

food

catego

risation

IFIC

catego

ryExa

mples

Minim

ally

proce

ssed

Foo

dsthat

require

little

proce

ssingat

theplant

but

oftenrequire

preparationbeforeea

ting

Roa

sted

cho

pped

nutsw

hole

ampcrac

kedce

reals

coffe

ebea

nsw

ashe

dpac

kage

dfruit

vege

tables

bag

gedsa

lads

pas

teurised

milk

Proce

ssed

tohe

lpprese

rvean

den

hanc

enu

trientsan

dfres

hnes

sof

food

sat

theirpea

kFroz

enc

anne

dor

cook

edampva

cuum

-pac

kedamprefrigerated

fish

mea

tfruitamp

vege

tables

and

bab

yfood

sUHTdairy

Food

sthat

combine

ingred

ientsan

dad

ditive

ssu

chas

spices

oilsfl

avou

rsp

rese

rvatives

andnu

trientsto

ensu

resa

fety

andse

nsoryap

pea

l(The

seus

ually

require

furthe

rpreparation

anddono

tinclud

elsquorea

dy-to-eat

food

srsquo(RTE

))listedbelow

Pac

kage

dfood

ssu

chas

riceor

potatosidedishe

sca

kemixjarredtomatosa

uce

spice

mixes

dressings

sau

ces

ampco

ndim

entsg

elatin

RTE

food

sthat

may

have

man

yingred

ientsan

dproce

sses

but

need

little

prepa

ratio

nBread

sampflat

bread

sRTE

ampinstan

tcerea

lsg

rano

lasnu

trition

barsbiscu

itsjam

sampjellies

nut

buttersice

crea

myog

hurtc

ookies

fruitch

ews

rotis

serie

chicke

nlunc

heon

mea

tsc

ooke

dha

ms

chee

ses

spread

sfruitdrin

kss

altedco

ndim

ents

such

asolives

carbon

ated

bev

erag

es

Food

spac

kage

dto

stay

fres

han

dsa

vetim

ePrepared

refrigerated

ampdelifoo

ds

froz

enmea

lse

ntreacutees

sides

pot

pies

andpizza

s

Adap

tedfrom

httpwwwificorg

J M Jones8

Proceedings

oftheNutritionSo

ciety


Table 3 NOVA classification of foods(26)

NOVA category Definition Examples

2010 classificationMinimally processed foods (MPFn) No processing or minimal (mostly physical

processes) used to make single whole plants oranimal foods more durable accessible convenientpalatable or safeContain few if any added components

Fresh frozen vacuum-packed refrigerated amp driedfruit vegetables meats poultry fish nuts seedsgrains 100 juices eggs milk amp fermented milkyoghurt teas coffeeNo added sugar or salt

Processed culinary ingredients(PCIn)

Extracted and purified components of single wholefoodsUsed in the preparation of meals made with MPFn

Fats and oils (not margarine) cream starchesgrits meals starches pastas noodles (madeonly with starch and water) various proteins egsoy casein gums preservatives additives sugarsand sweeteners of all types salt

Ultra-processed foods(In 2016 this category was dividedinto Processed andUltra-processed foods)

Durable accessible convenient palatableready-to-eat or -heat foods to replace homemadefoods or eaten as snacks and desserts

Crisps chips biscuits cookies cakes pastries icecreams amp frozen desserts dessert mixes sodascarbonated energy amp lsquofruitrsquo drinksmixes jamsconfectionery - chocolates candiessweetened milk amp beveragescocoas drinks lsquofruitrsquoyoghurts margarinesspreads saucescondiments rice amp noodles sidesmixes manyready to heat products pre-prepared piespastapizza dishes poultryfish lsquonuggetsrsquolsquosticksrsquosausages burgers hot dogs deli pre-preparedmeats canned or dried soups noodles vegetableother lsquorecipersquo dishes pickled smoked or curedmeatfish brined vegetables fish canned in oilinfant formulas follow-on milk baby foodslsquohealthrsquolsquoslimmingrsquo products meal replacements

2016 classificationMinimally processed foods(MPFn)

Foods of plant or animal origin that are altered inways that do not add anything but may removeparts Minimal processes such as cleaning peelinggrinding pasteurising canning and vacuum- orgas-packing

Fresh frozen vacuum-packedrefrigerated anddried fruit vegetables meats poultry fish nutsseeds starches grains ndash all types of rice 100juices eggs pasteurizeddried fresh milk ampfermented milk yoghurt teas coffee pastas (Noadditives added sugar or salt allowed)


Extracted from food constituents these may containpreservatives and additives

Plant oils animal fats starches sugars and syrupssalt

Processed foods (PFn) Products (up to five ingredients) May contain sugaroil salt or combinations of PCI to MPF May befermented or have additives to enhancepreservation or impede microorganisms

Tinnedbottled vegetables fruit in juice or syruplegumes meat and fish vegetables bottled orcanned in brinesalted or sugared nutsseeds cheesesunpackaged freshly made breads (or breads le5ingredients)

Ultraprocessed foods (UPFn) Industrial formulations (5+ ingredients containingadded sugars or sweeteners oils fats saltadditives and uncommon culinary ingredientsThey are convenient packaged brandedaccessible highly palatable Most are consumed assnacks or replace homemade dishes and mealsbased on MPFn

Chipscrisps mass-produced breads and bunsbreads ge5 ingredientsBreakfast cereals with added sugar nutrition barssavorysweet snack products biscuits cookiescakes pastries packaged desserts and mixesice creams and frozen dessert sweetened milkcocoa drinks sweetened yoghurts margarinesspreads sauces condiments sodas energy andlsquofruitrsquo drinks confectionery jams chocolatescandies vegetable rice amp noodles sides andmixes many ready- to -eat or -heat products andmeals pre-prepared pies pasta pizza dishespoultryfish lsquonuggetsrsquo lsquosticksrsquo sausages burgershot dogs deli meats and foods infant formulasfollow-on milk baby foods lsquohealthrsquolsquoslimmingrsquoproducts as meal replacements fortified meal orentree substitutes

PCIn minus2010 MPFn-2016UPFn minus2010 PFn-2016

(1ndash46)


Proceedings

oftheNutritionSo

ciety


Prepared foods and meals provided about 4 of E and5 of protein and sodium and contributed other nutri-ents equal to or slightly less than the percent of E

All International Food Information Council processedfood categories combined

When IFIC categories containing PFi (omitting MPFi)were combined they contributed 57 of E but theydelivered nutrients of concern (designated by the 2010US Dietary Guidelines Advisory Committee)(16ndash1880)Specifically PFi contributed 45ndash55 of dietary fibreand nearly all the cereal fibre 48 of the calcium 43of the potassium 34 of the vitamin D 64 of theiron 65 of the folate and 46 of the vitamin B12For constituents to limit total PFi contributed equivalentor slightly lower percent of E for saturated fat (52) andsodium (57) All five IFIC categories provided about2300 mg sodium with most coming from mixtures ofcombined ingredients (approximately 700 mg) and RTEfoods (approximately 1000 mg) Foods eaten outsidethe home provided about 1200 mg(16ndash18)

While MPFi contributed 5 of the added sugars thefour PFi combined contributed 75 and restaurantfoods the remainder The RTE category provided themost added sugars(16ndash18) but most were from foods diet-ary guidance recommends limiting such as sugary bev-erages However some added sugars were from foodsto encourage such as fibre-rich enriched and fortifiedbread and cereals fruit and dairy

Diet selection and categorisation

Authors of the IFIC studies(16ndash18) concluded that dietswere more likely lsquoto meet recommendations if nutri-ent-dense foods either processed or not are selectedrsquoPoti et al(81) also concluded that while PF had moreadded sugars there was a wide variation in nutrient con-tent within categories and that choice within a categorymattered Similar examples are gleaned from healthydietary patterns such as DASH and the US Healthy-Style Eating Pattern (as symbolised by MyPlate) thatshow nutritious diets can be constructed with the rightmix of PF and MPF(666972ndash78)

NOVA and nutrients

Several studies correlated the increased availability ofUPFn over the last 30+ years with a decline in overallnutrient quality(4103782) Analyses of food intake datafrom several countries documented that those whochose the most UPFn had lower nutrient quality thanthose who chose the least In the 2004 CanadianCommunity Health Survey2 (n 33 694 gt2 years)those in the highest quintile of intake of UPFn ate onaverage 1046 kJ (250 kcals) more but compared withthose in the lowest quintile ingested lower levels ofriboflavin niacin and vitamins A B12 C D and B6

(6)Sodium and energy density were higher for the consu-mers of UPFn

Similar results came from 2008 to 2009 Pesquisa deOrccedilamentos Familiares (Brazilian Family Budgets

Survey of 32 898 individuals over 10 years) UPFn con-tributed 21middot5 of E(7) Those in the highest quintile ofUPFn intake consumed more energy but less fibre andpotassium However the analysis showed that certainPFn and UPFn specifically bread cheese processedmeats and canned fruit and vegetables contributedimportant nutrients This latter statement agrees withfindings from other studies that emphasise choice offoods within a category not the category itself(16ndash1881)

Added sugars and the NOVA and International FoodInformation Council classifications

Since NOVA categorises all commercially preparedfoods with added sugars as PFn or UPFn it is self-evident that analysis of food intake data would iden-tify them as significant contributors of added sugarsAccording to the US National Health and NutritionExamination Survey 2009ndash2010 (n 9317) UPFn deliverednearly 60 of E but 90 of the added sugars for childrenand adults(8) Canadian data showed UPFn contributing49 of E and a significant amount of free sugars(6)Analysis of Chilersquos 2010 Encuesta Nacional de ConsumoAlimentario (n 4920 2+ years) showed that UPFn con-tributed 29 of E and 59 of added sugars(9) In the22 116 households participating in the 2010 SpanishHousehold Budget Surveys (food disappearance notintake data) UPFn provided 31middot7 of daily E and80middot4 of added sugars(83) In the Brazilian Pesquisa deOrccedilamentos Familiares UPFn provided 21middot5 of E and29 of added sugars(7)

Ultra-processed foods-NOVA and obesity

Proponents of NOVA have noted that the rise in obesityover the last 30+ years has paralleled the increased avail-ability of UPFn

( 67) Specifically in nineteen Europeancountries their increased availability between 1991 and2008 was associated with increased obesity(84) Theauthors concluded that lsquoA significant positive associationwas found between national household availability ofultra-processed foods and national prevalence of obesityamong adults rsquo However further analyses of their datashowing UPFn availability by country does not showstrong concordance with obesity data from theOrganisation for Economic Co-operation andDevelopment(8586) Table 4 compares a few countrieswith the high and low availability of UPFn and obesitypercentages Simple associational data(84) fail to considerFood and Agriculture Organization data documentingincreased energy consumed over that same time period(87)

Studies associating UPFn with obesity had differingoutcomes if they were adjusted for other contributorsto obesity Findings from the 2008 to 2009 BrazilianDietary Survey showed that those in the quintile eatingthe most UPFn compared those eating the least hadhigher risks of overweight (OR = 1middot26) or obesity (OR= 1middot98)(88) However it also showed that energy intakesfor the higher quintile were 1255 kJ (300 kcal) morethan for the lowest quintile(7) This begs the questionabout adjusting for energy and whether the cause ismore energy consumed or UPFn Findings were similar

J M Jones10

Proceedings

oftheNutritionSo

ciety


from Spanish University of Navarra cohort where thosein the highest v lowest quartile of UPFn consumption(three NOVA categories not four) had a hazard riskfor obesity of 1middot26(8990) However there was no relation-ship between UPFn and weight in the UKrsquos NationalDiet and Nutrition Survey (2008ndash12 n 2174) afteradjusting for other causes of obesity This study didshow that diets high in PCIn were associated with bodyweight indicating that food prepared at home may notstem the rise in obesity(84)

Processed foods nutrient intake food choice and addednutrients

MPFn were shown to contain the greatest share of vita-mins and minerals and UK diets high in PFnUPFnwere lower in nutrients(79) However the study affirmedprevious findings that not all PFnUPFn were of lowernutritional quality The studyrsquos authors emphasised theneed for attention to nutrient density not processingwhen constructing diets(16ndash187981)

Consumption of ultra-processed foods-NOVA mayimpact consumption of minimally processed

foods-NOVA

Many MPF are processed or combined with other ingre-dients before eating This not only may improve safetyand acceptability it may help with nutrient availabilityFor example fat-soluble components in raw vegetablesare better absorbed with fat from dressings and sauces(UPFn) and are more likely to be chosen by chil-dren(9192) Furthermore homemade oil-based condi-ments are not inherently healthier than commercial ones

Consumption of certain UPFn appears to encourageconsumption of important MPFn For example childrenand adolescents who consume RTEC breakfast also con-sumed more milk yoghurt and fruit than those who con-sumed other breakfasts(9394)

Questions about foods categorised as ultra-processedfoods-NOVA

UPFn as a group contributed smaller amounts of fibrevitamins and minerals than other groups(67) Howeverplacement of foods in various groupings is puzzlingCategorising discretionary foods (candies sugary bev-erages and grain-based desserts) with core (staple)

foods such as whole grain bread and cereals not onlyfails to make logical sense it can foster erroneous conclu-sions about the nutrient contribution of core foods Forexample categorising corn or wheat starch as a PCInbut whole grain bread and cereals as UPFn does notmake sense in terms of many nutrients Whole grainenrichedfortified breads are the leading sources ofwhole grain and fibre and are components that are under-consumed(95ndash101) Consumption of enrichedfortifiedRTEC was in a meta-analysis of sixty-four studies asso-ciated with healthier dietary patterns and more fibre andwhole grains intake despite higher intakes of totalsugars(94) Persons consuming RTEC frequently (ge5timesweek) were more likely to have adequate intakesof vitamins A and B6 folate calcium magnesium andzinc(66)

Similarly labelling of some forms of oily fish espe-cially shelf stable affordable sources as PFnUPFnmight decrease intakes of n-3 fatty acids(102)

Fortified foods

All foods with added nutrients are UPFn However datasupport the positive impact of enrichment and fortifica-tion In the USA their use means that fewer than 12of the US population fall below the estimated averagerequirement for thiamin riboflavin folate iron and vita-min B6

( 1766) For thiamin 49 meet the estimated aver-age requirement without fortificants but 96 withthem for folate 12 without and 89 with them(66)Avoidance of folate-fortified grains in women the yearprior to conception (as part of low carbohydrate or glu-tengrain-free diets) was associated with a 30 increasedrisk of spina bifida and anencephaly in the infants(103)Thus questionable placement of some foods into variouscategories and recommending the avoidance of all foodsdesignated as UPFn may not be sound dietary advice andmay carry risks

Ultra-processed foods grain foods and body weight

Most grain-based foods are listed as UPFn Many eattoo many grain servings especially grain-based dessertsor snacks and most fail to ingest recommended levels ofwholegrain and fibre(80104ndash106) Excess consumption ofgrain-based desserts and snacks may be associatedwith weight However avoidance of wholegrain andhigh-fibre bread and cereals because they are deemedUPFn may not address weight concerns In thePhysicians Health Study those who ate one or moreservings of whole and refined grain cereals daily com-pared with those who ate less were associated withlower risk of increasing BMI over time(107)Adolescents in the European HELENA cohort whowere daily RTEC consumers either whole grain orrefined had an OR of being overweight 0middot43 comparedwith non-consumers(108) Similar findings have beenshown in Australian children and adults(109110)Designation of RTEC and bread as PFnUPFn maydecrease wholegrain fibre and nutrient intakes andmay not address the obesity problem(111)

Table 4 UPFn Availability and obesity in selected countries (2008)

UPFn availability Obesity rate

Portugal 10middot2 15middot4Italy 13middot4 10middot3Germany 46middot2 14middot7UK 50middot4 26middot1

UPFn Ultraprocessed foods NOVA(84)

OECD Organisation for Economic Co-operation and Development(8586)


Proceedings

oftheNutritionSo

ciety


Added sugars flavoured milk nutrients and obesity

Flavoured milk and yoghurts are categorised as UPFnHowever children consuming flavoured v unflavouredmilk have higher calcium and nutrient intakes and lowerobesity risks(112113) Initiatives to eliminate flavouredmilk in schools made no difference in added sugars con-sumption However there was a significant drop in overallmilk and calcium consumption(114115) because flavouredmilk drinkers consumed more milk Avoidance offlavoured milk may do little to address obesity and mayreduce nutrient intake(112113)

Ultra-processed foods and other foods

Designating foods eg infant formulas supplementalfoods lactose- and gluten-free foods as UPFn mightcause avoidance by those who need these(116ndash118)Avoidance of any of those foods might do little toaddress rising rates of obesity and may not improvehealth

Does the NOVA categorisation meet standards fordietary guidance

Nutrition recommendations should follow the Hippocraticoath primum non nocere lsquofirst do no harmrsquo Ideally theyshould improve food choices and health outcomes andnot create a possibility of less healthy choices(119)

Standards for dietary recommendations state thatthey (1) are based on valid assumptions and sound sci-ence (2) improve nutrient intakes and public health (3)have been successfully β-tested with consumers andhave outcomes equivalent to vetted recommendations(4) address the four principles for successful dietaryrecommendations (Table 5)(1819)

Does the placement of foods in the NOVA categories usevalid assumptions and sound science

Placement of foods in NOVA categories may not bebased on valid assumptions as noted in the previous dis-cussion Analyses of food intake data showing thatPFnUPFn provide a large proportion of added sugarsdemonstrates a tautology(120) (A tautology exists whena conclusion involves circular reasoning and cannot betested with empirical data) Since foods with addedsugars were designated as PFnUPFn most added sugarswould come from these categories(121)

Recommendations to avoid foods containing morethan five ingredients has an equivocal theoretical basisProof that foods with fewer than five ingredients arehealthier than those with more is not possible becausea foodrsquos nutritional quality depends on the ingredientsand their treatment More ingredients might complete aprotein contribute needed nutrients or act synergisticallyto improve nutrient absorption(122) Ingredients (includingadditives) can make food safer prevent nutrient lossenable foods for special needs (eg gluten-free products)or enhance acceptability of needed dietary components

eg bran(123ndash125) They also can do the opposite especiallyif the ingredients are lsquocomponents to limitrsquo such assugar(103) Judging food quality on the number of ingre-dients rather on their nutritional contribution isquestionable(119120)

Are NOVA categories understandable and actionable

Dietary guidance works when recommendations giveconsumers clarity about foods to choose The many dis-parate definitions and categories (Tables 1ndash3) are a testa-ment to the lack of agreement Even within NOVAstudies foods are not uniformly categorised among stud-ies and their placement in categories is not consistentamong studies(1ndash157982ndash8488ndash90)

NOVA guidance requires consumers to have theknowledge of menu planning and skills and abilitytime and resources to utilise PCI and MPFn to planmenus and prepare meals However consumers inmany regions have limited skills in these areas(126ndash129)Elderly and those with mobility or cognitive limitationsmay find PFn and UPFn not only helpful butnecessary(130131)

Time cost and affordability for most consumers arelimited especially for those with children employed out-side the home Processed foods and labour-saving equip-ment have decreased the 6+ hours spent daily in 1900 bywomen on food-related activities(132133) Almost half ofthe respondents in a Euromonitor survey said that theydo not cook from scratch because of lack of time(134)A 2018 survey of US households showed that only 28of meals are prepared from scratch(135) These data sug-gest that the operationalising NOVA would be difficultfor many

Cost of home-prepared foods from MPFn may not belower especially when time is considered(136) Forexample the price of US packaged bread is about $2(600 g ten servings) and lasts up to 5ndash10 days classicFrench baguette about $5middot00 (360 g fivendashsix servings)and lasts 1ndash2 days and ingredients homemade breadabout $1ndash1middot50 (450 g and at $17hour the loaf costsover $8middot00) and lasts 2ndash5 days depending on the ingredi-ents If most foods were prepared using PCI and MPFnthe time (and cost of time) dedicated to food procure-ment preparation and cleaning would be significant

Dietary recommendations must be affordable for allsocioeconomic levels Calls to avoid PFnUPFn mayadversely impact food selection especially for lower-income consumers(137) Studies show that the cost offresh produce can inhibit the selection of fruit and vege-tables(138ndash143) The United States Department ofAgriculture has designed nutritionally-balanced menus

Table 5 Principles for successful dietary recommendations(56)

UnderstandableActionableAffordable and safe

Adaptable to many lifestyles and cultures for the long term

J M Jones12

Proceedings

oftheNutritionSo

ciety


made primarily with PF UPF for consumers with limitedrefrigeration cooking facilities time and money(77144)

Safety

Techniques and equipment for safe food handling arerequired to use MPFn especially as many outbreaks arelinked to these foods(145ndash149) PFn and MPFn (withoutadditives and preservatives) may not only have shortershelf lives but also may pose a greater risk because lsquohur-dlersquo technologies and additives that inhibit microbialgrowth and maintain safety are not used(150)

Infant formulas are designated as UPFn While breast-feeding is optimal safe options are needed where this isnot possible Home-prepared formulas not only carryrisks of nutritional imbalances they have documentedfood safety risks(151152)

Is NOVA adaptable for the long term

Long-term food availability must address many issuesincluding food waste Food processing in developingcountries has reduced losses by nearly 50Commercial processors have channels for waste notavailable to consumers(153154) Studies in Europe docu-ment lower food waste with frozen foods than fresh orambient equivalents(6263)

Additives and ingredients such as fat or sugar extendshelf life and potentially decrease food cost and wasteThus diets constructed primarily of PCI and MPFnmay not be the best ways to address food supply issues

Will use of NOVA result in better diet quality

No studies show that consumers can use NOVA to matchenergy intake with energy needs and can replace foodswith added sugar and fat with those that arerecommended Modelling studies replacing current pro-ducts with those reformulated to meet lowered sugarand other values showed the only meaningful reductionin added sugars occurred if sugar-sweetened beverageconsumption decreased(155) Advice to decrease con-sumption of nutrient-poor foods(156) rather than foodslabelled as PFnUPFn may be clearer and have fewerunintended consequences

Studies are needed demonstrating that home-preparedfoods from MPFn and PCI will improve diets and lowerenergy intake Recipes from popular UK cooking pro-grammes were shown to be neither lower in sugar andenergy contributed nor higher in nutrients than RTE ver-sions from the supermarket(157) The nutrient contribu-tion of the ingredients mattered not where and bywhom the food is prepared

Conclusion

Consumers fail to meet recommended intakes for nutri-ents and food groups(158159) Unhealthy diet patternswith excess energy intake meat salt sugar saturated

fat and nutrient- poor foods are common and contributeto obesity and chronic disease(119160ndash164)

NOVA proponents suggest that replacement of PFnUPFn with MPFn will improve diets and decrease diseaserisks(165)

NOVA definitions are non-traditional and lack con-gruence with legal or food science ones Further manydivergent definitions on the web and popular presscould muddle consumer understanding about whichfoods to avoid as PFnUPFn Further the NOVA cat-egories are different from the IFIC ones With IFICall categories had foods lsquoto limitrsquo and lsquoto encouragersquo InNOVA foods designated as PFnUPFn are to be limiteddespite their nutrient contribution

Analyses of food intake databases using NOVA doshow that diets high in UPFn have lower nutrient densityand more added sugars but studies also show that not allfoods in these categories are poor nutritional choicesStudies with the IFIC categorisation suggest that thereare nutritious choices from all levels of processing Dietssuch as DASH and MyPlate constructed with the rightmix of foods from all categories can be nutritious

No studies or β-testing show that consumers can oper-ationalise NOVArsquos definitions and categories to choosenutrient-rich foods to eschew foods of low nutritional qual-ity and improve diets and health outcomes Further thereare significant concerns about NOVArsquos actionability andpracticality for various lifestyles skill sets and resource avail-ability Studies comparing NOVA implementation with vet-ted plans such as DASH or MyPLATE are needed to showthat nutrient intakes and health outcomes are at leastequivalent to those from plans that promote the right bal-ance of foods from all levels of processing(272ndash76166ndash169)

Acknowledgements

The concept and much background for the present paperresulted from work of the Ad Hoc Joint Food andNutrition Science Solutions Task Force (Task Force)[2006ndash2016] representing the Academy of Nutritionand Dietetics American Society for Nutrition (ASN)Institute of Food Technologists (IFT) andInternational Food Information Council (IFIC) Theauthor would like to take this opportunity to thank2015ndash2016 members of the Task Force who helpedwith the manuscript Mildred M Cody RogerClemens Janet Collins Silvia Dumitrescu JohannaT Dwyer Mary Christ-Erwin Guy Johnson GilLeveille Barbara Ivens Catherine Metzgar Lo FaridaMohamedshah Sarah Ohlhorst Robert C Post andKatherine Wilkes While the Task Force was made upof members of the Academy IFT ASN or IFIC the pre-sent paper may not reflect the positions of thoseorganisations

Financial Support

The staff from the Academy of Nutrition and DieteticsASN IFT and IFIC assisted with the planning and


Proceedings

oftheNutritionSo

ciety


facilitation of the conference calls and with the reviewand editing of the manuscript No specific grant fromany funding agency commercial or not-for-profit sectorswas received for the development of this manuscript

Conflicts of Interest

Julie Miller Jones is a scientific advisor to the Grains FoodFoundation The Healthy Grains Institute (Canada)Quaker Oats Advisory Board and the Campbell SoupCompany Plant and Health Advisory Board She has writ-ten papers of given speeches for Centro Internacional deMejoramiento de Maiacutez y Trigo CIMMYT (InternationalMaize and Wheat Improvement Center Mexico)Cranberry Institute and Tate and Lyle

Authorship

The author had sole responsibility for all aspects of prep-aration of this paper

References

1 Monteiro CA (2009) Nutrition and health Public HealthNutr 12 729ndash731

2 Pan American Health Org PAHOWHO NoncommunicableDiseases and Mental Health (2015) Ultra-processed food anddrink products in Latin America Trends impact on obesitypolicy implications httpirispahoorgxmluibitstreamhandle12345678976999789275118641_engpdf (accessed September2016)

3 Monteiro C Cannon G Moubarac JC et al (2018) TheUN Decade of Nutrition the NOVA food classificationand the trouble with ultra-processing Public Health Nutr21 5ndash17

4 Montiero CA Moubarac JC Cannon G et al (2013)Ultra-processed products are becoming dominant in theglobal food system Obes Rev 14(Suppl 2) 21ndash28

5 Aguayo-Patroacuten SV amp Calderoacuten de la Barca AM (2017)Old fashioned vs ultra-processed-based current diets pos-sible implication in the increased susceptibility to type 1diabetes and celiac disease in childhood Foods 6

6 Moubarac JC Batal M Louzada ML et al (2017)Consumption of ultra-processed foods predicts diet qualityin Canada Appetite 108 512ndash520

7 Costa Louzada ML Martins AP Canella DS et al (2015)Ultra-processed foods and the nutritional dietary profile inBrazil Rev Saude Publica 49 38

8 Martiacutenez Steele E Baraldi LG Louzada ML et al (2016)Ultra-processed foods and added sugars in the US diet evi-dence from a nationally representative cross-sectionalstudy BMJ Open 6 e009892

9 Cediel G Reyes M da Costa Louzada ML et al (2018)Ultra-processed foods and added sugars in the Chileandiet [2010] Public Health Nutr 21 125ndash133

10 Popkin BM amp Reardon T (2018) Obesity and the foodsystem transformation in Latin America Obes Rev 191028ndash1064

11 Monteiro CA Levy RB Claro RM et al (2010) A newclassification of foods based on the extent and purpose oftheir processing Cad Saude Publica 26 2039ndash2049

12 Heinrich V Zunabovic M Varzakas T et al (2016) Pulsedlight treatment of different food types with a specialfocus on meat a critical review Crit Rev Food Sci Nutr56 591ndash613

13 Peacuterez-Andreacutes JM Charoux CMG Cullen PJ et al (2018)Chemical modifications of lipids and proteins by nonther-mal food processing technologies J Agric Food Chem 665041ndash5054

14 Misra NN Koubaa M Roohinejad S et al (2017)Landmarks in the historical development of twenty first cen-tury food processing technologies Food Res Int 97 318ndash339

15 Juul F Martinez-Steele E Parekh N et al (2018) Ultra-pro-cessed food consumption and excess weight among USadults Br J Nutr 120 90ndash100

16 Eicher-Miller HA Fulgoni VL 3rd amp Keast DR (2012)Contributions of processed foods to dietary intake in theUS from 2003-2008 a report of the Food and NutritionScience Solutions Joint Task Force of the Academy ofNutrition and Dietetics American Society for NutritionInstitute of Food Technologists and International FoodInformation Council J Nutr 142 2065Sndash2072S

17 Weaver CM Dwyer J Fulgoni VL 3rd et al (2014)Processed foods contributions to nutrition Am J ClinNutr 99 1525ndash1542

18 Eicher-Miller HA Fulgoni VL Keast DR et al (2015)Processed food contributions to energy and nutrient intakediffer among US children by raceethnicity Nutrients 710076ndash10088

19 Dwyer JT Fulgoni VL 3rd Clemens RA et al (2012) Islsquoprocessedrsquo a four-letter word The role of processedfoods in achieving dietary guidelines and nutrient recom-mendations Adv Nutr 3 536ndash548

20 Challa HJ amp Uppaluri KR (2018) DASH Diet (DietaryApproaches to Stop Hypertension) StatPearls [Internet]Treasure Island FL StatPearls Publishing

21 US Department of Agriculture Center for NutritionPolicy and Promotion USDA Food Patterns September2011 available at httpwwwcnppusdagovUSDAFoodPatternshtm (accessed September 2017)

22 Britten P Marcoe K Yamini S et al (2006) Developmentof food intake patterns for the MyPyramid Food GuidanceSystem J Nutr Educ Behav 38(Suppl 6) S78ndashS92

23 Evert AB Boucher JL Cypress M et al (2013) Nutritiontherapy recommendations for the management of adultswith diabetes Diabetes Care 36 3821ndash3842

24 Rowe S Alexander N Almeida NG et al (2011) Translatingthe dietary guidelines for Americans 2010 to bring about realbehavior change J Amer Dietetic Assn 111 28ndash39

25 Laudan R (2015) Cuisine and Empire A World History ofCooking Berkeley CA University of California Press

26 Nicholas A (1811) The Art of Preserving All Kinds ofAnimal and Vegetable Substances for Several Years AWork Published by Order of the French Ministry ofHealth 2nd ed (Translated from the French) LondonBlack Parry and Kingsbury London Digital editionOxford Library httpsarchiveorgdetailsartpreservinga-l00appegoog (accessed January 2018)

27 US Food and Drug Administration (2006) Harvey WileyFDA Consumer httpswwwfdagovAboutFDAWhatWeDoHistoryFOrgsHistoryLeadersucm2016811htm (accessedJanuary 2018)

28 Food and Agriculture Organization (2004) Processed foodsfor improved livelihoods FAO Diversification booklet 5httpwwwfaoorgdocrep007y5113ey5113e04htm(accessed September 2016)

29 European Food Safety Authority Regulation (EC) No1782002 of the European Parliament and of the Council

J M Jones14

Proceedings

oftheNutritionSo

ciety


(28 January 2002) Article 2 Food Safety Official Journal ofthe European Communities httpeur-lexeuropaeuLexUriServLexUriServdouri=OJL200203100010024ENPDF (accessed September 2016)

30 US Government Printing Office 21 Code of FederalRegulations Chapter I - Food and Drug AdministrationDepartment of Health and Human Services Subchapter A- General (Parts 1ndash 99) Subchapter B - Food for HumanConsumption (Parts 100ndash191ndash199) (2010) Code Of FederalRegulations Processed Fruits And Vegetables Processed(accessed March 2017)

31 National Health Service UK (2017) Eating ProcessedFoods httpswwwnhsukLivewellGoodfoodPageswhat-are-processed-foodsaspx (accessed March 2017)

32 Michigan State University Extension (2014) What isProcessed Food US Department of Agriculture httpmsueanrmsuedunewswhat_is_a_processed_food (accessedSeptember 2016)

33 Australia New Zealand Food Authority Safe FoodAustralia (2001) Glossary of definitions httpswwwfoodstandardsgovaupublicationsdocumentsGlossarypdf p 209(Accessed March 2017)

34 EUFIC Food processing httpswwweuficorgenfood-productioncategoryfood-processing (accessed January2018)

35 Park SH Lamsal BP amp Balasubramaniam VM (2014)Principles of food processing In Food ProcessingPrinciples and Applications 2nd ed pp 1ndash15 [S ClarkS Jung and B Lamsal editors] Chichester UK JohnWiley amp Sons Ltd

36 Omics Journals (2107) Journal of Food Processing ampTechnology httpswwwomicsonlineorgfood-processing-technologyphp (accessed November 2017)

37 Moubarac JC Batal M Martins AP et al (2014) Processedand ultra-processed food products consumption trendsin Canada from 1938 to 2011 Can J Diet Pract Res 7515ndash21

38 Food Processing httpsenwikipediaorgwikiFood_processing (accessed January 2018)

39 International Food Information Council (2010) Whatrsquos aprocessed food Food Insight httpwwwfoodinsightorgarticlesunderstanding-our-food-communications-tool-kit2010(accessed September 2016)

40 Collins K (2013) HealthTalk American Institute for CancerResearch httpwwwaicrorgpresshealth-featureshealth-talk201308aug2013minimally-processed-foodhtml (accessedFebruary 2017)

41 Collins K (2013) What does it mean when AICR says weshould choose ldquominimally processed foodrdquo more oftenAmerican Institute for Cancer Research httpwwwaicrorgpresshealth-featureshealth-talk201308aug2013minimally-processed-foodhtml (accessed March 2017)

42 Brooking K amp Upton J (2016) Are ultraprocessed foodsruining your health httpappforhealthcom201603ultra-processed-foodsMarch (accessed September 2016)

43 Peitrangelo A (2016) If you cut one thing from your dietmake it ultra-processed foods Care2 httpswwwcare2comgreenlivingif-you-cut-one-thing-from-your-diet-make-it-ultra-processed-foodshtmland (accessed January 2018)

44 Welch A (2016) Huge chunk of the American diet isldquoUltra-processedrdquo foods CBS News httpswwwsottnetarticle314099-Huge-chunk-of-the-American-diet-is-Ultra-processed-foods (accessed January 2016)

45 Sunley N (2107) Ultra-processedrsquo food ndash myth or a viableclassification parameter FoodStuff South Africa httpswwwfoodstuffsacozaultra-processed-food-myth-viable-classification-parameter (accessed January 2018)

46 Ferrer ECR (2017) How processed foods wreak havoc onyour health httpswwworganicconsumersorgessayshow-processed-foods-wreak-havoc-your-health (accessedMarch 2017)

47 Decker F (2016) Processed food definition SF Gate httphealthyeatingsfgatecomprocessed-food-definition-2074html(accessed February 2017)

48 Bass H (2016) What are processed foods and why are theybad for me Concentra Newsletter httpwwwconcentracomnewsroomarticleswhat-are-processed-foods-and-why-are-they-bad-for-me (accessed September 2017)

49 The dangers of ultra processed foods (2015) httpwwwwellwisdomcomthe-dangers-of-ultra-processed-foods (accessedJanuary 2018)

50 UK NHS Eating processed food (2017) httpswwwnhsuklive-welleat-wellwhat-are-processed-foods (accessedMarch 2018)

51 Body Nutrition (2017) 17 processed foods to avoid (httpsbodynutritionorgprocessed-foods)

52 Gunnar MS (2017) Nine ways that processed foods areharming people Medical News Today (accessed March2018)

53 Gallagher J (2018) Ultra-processed foods lsquolinked to cancerrsquohttpswwwbbccomnewshealth-43064290 (accessed March2018)

54 Diabetes UK httpswwwdiabetescoukfoodprocessed-foodshtml (accessed March 2018)

55 Ansel K (2017) The beginnerrsquos guide to ditching processedfoods httpswwwpreventioncomfood-nutritiong20454808the-beginner-s-guide-to-ditching-processed-foods(accessed March 2018)

56 Gif MK (2018) Processed food isnrsquot killing youhttpsmediumcomgidmkprocessed-food-isnt-killing-you-43556b943bd6

57 Eating clean rebel dietitian (2018) Ultra-processed food is achemical shit storm httpswwwpinterestcoukpin531565562251681372 (accessed March 2018)

58 Safari (2018) Processed food images (accessed March 2018)59 Wahlqvist M amp Briggs D Food Facts Asia Pacific Journal

of Clinical Nutrition Eating Club (online book) httpapjcnnhriorgtwserverinfobooks-phdsbooksfoodfactshtmlmaintextmain10ahtml (accessed October 2017)

60 Sandulachi E amp Tatarov P (2012) Water activity conceptand its role in strawberries food Chem J Mold 7 103ndash115

61 van Boekel M Fogliano V Pellegrini N et al (2010) Areview on the beneficial aspects of food processing MolNutr Food Res 54 1215ndash1247

62 Xu Z Sun DW Zeng XA et al (2015) Research dev-elopments in methods to reduce the carbon footprint ofthe food system a review Crit Rev Food Sci Nutr 551270ndash1286

63 Martindale W (2017) The potential of food preservation toreduce food waste Proc Nutr Soc 76 28ndash33

64 Janssen AM Nijenhuis-de Vries MA amp Boer EPJ (2017)Fresh frozen or ambient food equivalents and their impacton food waste generation in Dutch households WasteManag 67 298ndash307

65 Food amp Agriculture Organization (1995) Annex 4 -Micronutrient Fortification Of Food Technology AndQuality Control January httpwwwfaoorgdocrepW2840Ew2840e0bhtm (accessed 2018)

66 Fulgoni VL 3rd Keast DR Bailey RL et al (2011) Foodsfortificants and supplements where do Americans get theirnutrients J Nutr 141 1847ndash1854

67 Bernstein MA Tucker KL Ryan ND et al (2002) Higherdietary variety is associated with better nutritional status infrail elderly people J Am Diet Assoc 102 1096ndash1010


Proceedings

oftheNutritionSo

ciety


68 Johnson F amp Wardle J (2014) Variety palatability andobesity Adv Nutr 5 851ndash859

69 Food amp Agriculture Organization (2018) Food-based diet-ary guidelines httpwwwfaoorgnutritionnutrition-edu-cationfood-dietary-guidelinesen (accessed January 2018)

70 European Food Information Council (2009) Food-baseddietary guidelines in Europe httpwwweuficorgenhealthy-livingarticlefood-based-dietary-guidelines-in-eur-ope (accessed January 2018)

71 US Department of Agriculture (2008) Glossary of termsused in the MyPyramid Food Guidance System httpswwwcnppusdagovsitesdefaultfilesmyplate_miplatoJNEBGlossarypdf (accessed February 2018)

72 Panagiotakos DB Notara V Kouvari M et al (2016) TheMediterranean and other dietary patterns in secondarycardiovascular disease prevention a review Curr VascPharmacol 14 442ndash451

73 Steyn NP amp Temple NJ (2012) Dietary Patterns and Type 2Evidence to support a food-based dietary guideline onsugar consumption in South Africa BMC Public Health12 502

74 Jannasch F Kroumlger J amp Schulze MB (2017) Diabetes asystematic literature review and meta-analysis of prospect-ive studies J Nutr 147 1174ndash1182

75 Soltani S Shirani F Chitsazi MJ et al (2016) The effect ofdietary approaches to stop hypertension (DASH) diet onweight and body composition in adults a systematic reviewand meta-analysis of randomized controlled clinical trialsObes Rev 17 442ndash454

76 Gay HC Rao SG Vaccarino V et al (2016) Effects of dif-ferent dietary interventions on blood pressure systematicreview and meta-analysis of randomized controlled trialsHypertension 67 733ndash739

77 Duyff R (for the Canned Food Alliance (2014) Menu mod-eling tool kit httpwwwmealtimeorgresourcesmenu-modeling-tool-kitaspx (accessed February 2018)

78 US Department of Agriculture Center for Nutrition Policyamp Promotion (2000) Recipes and Tips for Healthy ThriftyMeals httpswwwcnppusdagovsitesdefaultfilesusda_food_plans_cost_of_foodFoodPlansRecipeBookpdf (accessedFebruary 2018)

79 Adams J amp White M (2015) Characterisation of UK dietsaccording to degree of food processing and associationswith socio-demographics and obesity cross-sectional ana-lysis of UK National Diet and Nutrition Survey (2008-12) Int J Behav Nutr Phys Act 12 160

80 US Department of Agriculture amp US Department ofHealth and Human Services (2010) Dietary Guidelinesfor Americans 7the ed Washington DC GovernmentPrinting Office

81 Poti JM Mendez MA Ng SW et al (2015) Is the degree offood processing and convenience linked with the nutritionalquality of foods purchased by US households Am J ClinNutr 101 1251ndash1262

82 Martins AP Levy RB Claro RM et al (2013) Increasedcontribution of ultra-processed food products in theBrazilian diet (1987-2009) Rev Saude Publica 47 656ndash665

83 Latasa P Louzada MLDC Martinez Steele E et al (2017)Added sugars and ultra-processed foods in Spanish house-holds (1990-2010) Eur J Clin Nutr 71 1ndash9

84 Monteiro CA Moubarac JC Levy RB et al (2018)Household availability of ultra-processed foods and obesityinnineteenEuropean countriesPublicHealthNutr 21 18ndash26

85 Anon (2013) Rising EU obesity rings alarm bells in Brusselshttpwwwdwcomenrising-eu-obesity-rings-alarm-bells-in-brusselsa-16821112

86 Organisation for Economic Co-operation and Develop-ment (2012) Obesity Update wwwoecdorghealth49716427pdf

87 Roser M amp Ritchie H (2017) Food per person httpsour-worldindataorgfood-per-person (accessed May 2018)

88 Louzada ML Baraldi LG Steele EM et al (2015)Consumption of ultra-processed foods and obesity inBrazilian adolescents and adults Prev Med 81 9ndash15

89 Mendonccedila RD Pimenta AM Gea A et al (2016)Ultraprocessed food consumption and risk of overweightand obesity the University of Navarra Follow-Up (SUN)cohort study Am J Clin Nutr 104 1433ndash1440

90 Mendonccedila RD Lopes AC Gea A et al (2017)Ultraprocessed food consumption and risk of overweightand obesity the University of Navarra Follow-Up (SUN)cohort study Am J Hypertens 30 358ndash366

91 Zeinstra GG Vrijhof M amp Kremer S (2018) Is repeatedexposure the holy grail for increasing childrenrsquos vegetableintake Lessons learned from a Dutch childcare interven-tion using various vegetable preparations Appetite 121316ndash325

92 Fisher JO Mennella JA Hughes SO et al (2012) Offeringldquodiprdquo promotes intake of a moderately-liked raw vegetableamong preschoolers with genetic sensitivity to bitterness JAcad Nutr Diet 112 235ndash245

93 Affenito SG Thompson D Dorazio A et al (2013) Ready-to-eat cereal consumption and the School BreakfastProgram relationship to nutrient intake and weight JSch Health 83 28ndash35

94 Michels N De Henauw S Beghin L et al (2016) Ready-to-eat cereals improve nutrient milk and fruit intakeat breakfast in European adolescents Eur J Nutr 55771ndash779

95 Priebe MG amp McMonagle JR (2016) Effects of ready-to-eat-cereals on key nutritional and health outcomes a sys-tematic review PLoS ONE 11 e0164931

96 Marriott BP Olsho L Hadden L et al (2010) Intake ofadded sugars and selected nutrients in the United StatesNational Health and Nutrition Examination Survey(NHANES) 2003-2006 Crit Rev Food Sci Nutr 50228ndash258

97 Albertson AM Reicks M Joshi N et al (2016) Wholegrain consumption trends and associations with bodyweight measures in the United States results fromthe cross sectional National Health and NutritionExamination Survey 2001ndash2012 Nutrition J 15 8

98 Reicks M Jonnalagadda S Albertson AM et al (2014)Total dietary fiber intakes in the US population are relatedto whole grain consumption results from the NationalHealth and Nutrition Examination Survey 2009 to 2010Nutr Res 34 226ndash234

99 Mann KD Pearce MS McKevith B et al (2015) Wholegrain intake and its association with intakes of otherfoods nutrients and markers of health in the NationalDiet and Nutrition Survey rolling programme 2008-11Br J Nutr 113 1595ndash1602

100 Stephen AM Champ MM Cloran SJ et al (2017)Dietary fibre in Europe current state of knowledge ondefinitions sources recommendations intakes and rela-tionships to health Nutr Res Rev 30 149ndash190

101 Fayet-Moore F Cassettari T Tuck K et al (2018) Dietaryfibre intake in Australia Paper I associations with demo-graphic socio-economic and anthropometric factorsNutrients 10 599

102 Fayet-Moore F Baghurst K amp Meyer BJ (2015) Fourmodels including fish seafood red meat and enriched

J M Jones16

Proceedings

oftheNutritionSo

ciety


foods to achieve Australian Dietary Recommendations forn-3 LCPUFA for all life-stages Nutrients 7 8602ndash8614

103 Desrosiers TA Siega-Riz AM amp Mosley BS (2018)National Birth Defects Prevention Study Low carbohy-drate diets may increase risk of neural tube defectsBirth Defects Res 110 901ndash909

104 US Department of Agriculture amp US Department ofHealth and Human Services (2015) Dietary Guidelinesfor Americans 8th ed Washington DC GovernmentPrinting Office

105 Bachman JL Reedy J Subar AF et al (2008) Sources offood group intakes among the US population 2001-2002J Am Diet Assoc 108 804ndash814

106 Cohen DA Sturm R Lara M et al (2010) Discretionarycalorie intake a priority for obesity prevention results ofrapid participatory approaches in low-income US com-munities J Public Health (Oxf) 32 379ndash386

107 Bazzano LA Song Y Bubes V et al (2005) Dietary intakeof whole and refined grain breakfast cereals and weightgain in men Obes Res 13 1952ndash1960

108 Michels N De Henauw S Breidenassel C et al (2015)Europeanadolescent ready-to-eat-cereal (RTEC) consumershave a healthier dietary intake and body composition com-pared with non-RTEC consumers Eur J Nutr 54 653ndash664

109 Fayet-Moore F Petocz P McConnell A et al (2017) Thecross-sectional association between consumption of therecommended five food group ldquograin (cereal)rdquo dietaryfibre and anthropometric measures among Australianadults Nutrients 9 E157

110 Fayet-Moore F Kim J Sritharan N et al (2016) Impactof breakfast skipping and breakfast choice on the nutrientintake and body mass index of Australian childrenNutrients 8 E487

111 Ludwig DS Hu FB Tappy L et al (2018) Dietary carbo-hydrates role of quality and quantity in chronic diseaseThe BMJ 361 k2340

112 Fayet-Moore F (2016) Effect of flavored milk vs plainmilk on total milk intake and nutrient provision in chil-dren Nutr Rev 74 1ndash17

113 Murphy MM Douglass JS Johnson RK et al (2008)Drinking flavored or plain milk is positively associatedwith nutrient intake and is not associated with adverseeffects on weight status in US children and adolescentsJ Am Diet Assoc 108 631ndash639

114 Nicklas TA OrsquoNeil C amp Fulgoni V 3rd (2017) Flavoredmilk consumers drank more milk and had a higher preva-lence of meeting calcium recommendation than nonconsu-mers J Sch Health 87 650ndash657

115 Hanks AS Just DR amp Wansink B (2014) Chocolate milkconsequences a pilot study evaluating the consequencesof banning chocolate milk in school cafeterias PLoSONE 9 e91022

116 Ortega RM Jimeacutenez Ortega AI amp Perea Saacutenchez JM(2017) Oral feeding and nutritional improvement in hospi-tals and residential care homes Industry innovationsNutr Hosp 34(Suppl 4) 13ndash18

117 Kim JM amp Sung MK (2016) The efficacy of oral nutri-tional intervention in malnourished cancer patients a sys-temic review Clin Nutr Res 5 219ndash236

118 Schultz TJ Roupas P Wiechula R et al (2016)Nutritional interventions for optimizing healthy bodycomposition in older adults in the community anumbrella review of systematic reviews JBI DatabaseSyst Rev Implement Rep 14 257ndash308

119 Tapsell LC Neale EP Satija A et al (2016) Foods nutri-ents and dietary patterns interconnections and implica-tions for dietary guidelines Adv Nutr 7 445ndash454

120 Vogt WP (Editor) (2005) Dictionary of Statistics ampMethodology 3rd ed httpdxdoiorg1041359781412983907n1956 (accessed October 2017)

121 Gibney MJ Forde CG Mullally D et al (2017) Ultra-processed foods in human health a critical appraisalAm J Clin Nutr 106 717ndash724

122 Cheatham CL (2018) Whole foods and nutrient synergyUNC Nutrition Research Institute httpswwwuncnriorgindexphpwhy-we-eat-applesauce-with-pork-whole-foods-and-nutrient-synergy (accessed June 2018)

123 Hossain MI Sadekuzzaman M amp Ha SD (2017)Probiotics as potential alternative biocontrol agents inthe agriculture and food industries a review Food ResInt 100 63ndash73

124 Case S (2016) Gluten-Free The Definitive Resource GuideRegina CA Case Nutrition Consulting

125 Goldfein KR amp Slavin JL (2015) Why sugar is added tofood Food Science 101 Comprehensive Rev Food SciFood Safety 14 644ndash656

126 Burton M Reid M Worsley A et al (2017) Food skillsconfidence and household gatekeepersrsquo dietary practicesAppetite 108 183ndash190

127 McGowan L Pot GK Stephen AM et al (2016) Theinfluence of socio-demographic psychological and knowl-edge-related variables alongside perceived cooking andfood skills abilities in the prediction of diet quality inadults a nationally representative cross-sectional studyInt J Behav Nutr Phys Act 13 111

128 McGowan L Caraher M Raats M et al (2017) Domesticcooking and food skills a review Crit Rev Food Sci Nutr57 2412ndash2431

129 Murray DW Mahadevan M Gatto K et al (2016)Culinary efficacy an exploratory study of skills confi-dence and healthy cooking competencies among univer-sity students Perspect Public Health 136 143ndash151

130 Goverover Y Strober L Chiaravalloti N et al (2015)Factors that moderate activity limitation and participa-tion restriction in people with multiple sclerosis Am JOccup Ther 69 6902260020p1ndash6902260020p9

131 Van Gameren-Oosterom HB Fekkes M Reijneveld SAet al (2013) Practical and social skills of 16-19-year-oldswith Down syndrome independence still far away ResDev Disabil 34 4599ndash4607

132 Arnquist IF amp Roberts EH (1929) The Present Use ofWork Time of Farm Homemakers Bulletin No 234State College of Washington Agricultural ExperimentStation Pullman Washington

133 Leeds JB (1917) The Household Budget With a SpecialInquiry into the Amount and Value of Household WorkPhD diss Columbia University Available at httphearthlibrarycornelleducgittexttext-idxc=hearthidno=4217462 (accessed March 2018)

134 Euromonitor (2011) Home cooking and eating habitsGlobal survey strategic analysis httpsblogeuromonitorcom201204home-cooking-and-eating-habits-global-sur-vey-strategic-analysishtml (accessed March 2018)

135 Watrous M (2018) The decline of breakfast lunch anddinner Food Bus News httpswwwfoodbusinessnewsnetarticles11701-the-decline-of-breakfast-lunch-and-din-ner (accessed 27 April 2018)

136 Yang Y Davis GC amp Muth MK (2015) Beyond thesticker price including and excluding time in comparingfood prices Am J Clin Nutr 102 165ndash171

137 Mendoza Velaacutezquez A (2012) Index of NutritionalPurchasing Power Parity comparison of caloric costs ofa healthy versus an unhealthy diet Rev Panam SaludPublica 31 17ndash24


Proceedings

oftheNutritionSo

ciety


138 Mulik K amp Haynes-Maslow L (2017) The affordability ofMyPlate an analysis of SNAP benefits and the actual costof eating according to the dietary guidelines J Nutr EducBehav 49 623ndash631

139 Darmon N Lacroix A Muller L et al (2016) Food pricepolicies may improve diet but increase socioeconomicinequalities in nutrition World Rev Nutr Diet 115 36ndash45

140 Chapman K Goldsbury D Watson W et al (2017)Exploring perceptions and beliefs about the cost of fruitand vegetables and whether they are barriers to higherconsumption Appetite 113 310ndash319

141 Plessz M amp Gojard S (2013) Do processed vegetablesreduce the socio-economic differences in vegetable pur-chases A study in France Eur J Public Health 23 747ndash752

142 Mackenbach JD Brage S Forouhi NG et al (2015) Doesthe importance of dietary costs for fruit and vegetable intakevary by socioeconomic position Br J Nutr 114 1464ndash1470

143 Mackenbach JD Burgoine T Lakerveld J et al (2017)Accessibility and affordability of supermarkets Associa-tions with the DASH Diet Am J Prev Med 53 55ndash62

144 US Department of Agriculture (2006) Center for NutritionPolicy and Promotion Thrifty Food Plan 2006 WashingtonDC httpwwwcnppusdagovPublicationsFoodPlansMiscPubsTFP2006Reportpdf (accessed March 2018)

145 Evans EW amp Redmond EC (2015) Analysis of olderadultsrsquo domestic kitchen storage practices in the UnitedKingdom identification of risk factors associated with lis-teriosis J Food Prot 78 738ndash745

146 Kosa KM Cates SC Bradley S et al (2015) Consumer-reported handling of raw poultry products at homeresults from a national survey J Food Prot 78 180ndash186

147 Wills WJ Meah A Dickinson AM et al (2015) lsquoI donrsquotthink I ever had food poisoningrsquo A practice-basedapproach to understanding foodborne disease that origi-nates in the home Appetite 85 118ndash125

148 Young I Thaivalappil A Reimer D et al (2017) Foodsafety at farmersrsquo markets a knowledge synthesis of pub-lished research J Food Prot 80 2033ndash2047

149 US Dept Health Human Services (2018) Centers forDisease Control and Prevention List of selected multi-state foodborne outbreak investigations httpswwwcdcgovfoodsafetyoutbreaksmultistate-outbreaksoutbreaks-listhtml (accessed March 2018)

150 Singh S amp Shalini R (2016) Effect of hurdle technology infood preservation a review Crit Rev Food Sci Nutr 56641ndash649

151 Reece T (2018) Homemade baby formula Is that safeParents httpswwwparentscombabyfeedingformulahomemade-baby-formula-safe-or-not (accessed March 2018)

152 Montastic (2012) Why you should never try homemadebaby formula recipes wholesomebabyfoodmomtasticcomhomemade babyinfantformulahtm (accessed March2018)

153 Segovia Goacutemez F amp Almajano Pablos MP (2016)Pineapple waste extract for preventing oxidation inmodel food systems J Food Sci 81 C1622ndash8

154 Mattos GN Tonon RV Furtado AA et al (2017) Grapeby-product extracts against microbial proliferation andlipid oxidation a review J Sci Food Agric 97 1055ndash1064

155 Mendoza R Tolentino-Mayo L Hernaacutendez-Barrera Let al (2018) Modifications in the consumption of energysugar and saturated fat among the Mexican adult popu-lation Simulation of the effect when replacing processedfoods that comply with a Front of Package LabelingSystem Nutrients 10 101

156 Bailey RL Fulgoni VL Cowan AE et al (2018) Sourcesof added sugars in young children adolescents and adultswith low and high intakes of added sugars Nutrients 10106

157 Howard S Adams J amp White M (2012) Nutritional con-tent of supermarket ready meals and recipes by televisionchefs in the United Kingdom cross sectional study BrMed J 345 e7607

158 Akseer N Al-Gashm S Mehta S et al (2017) Global andregional trends in the nutritional status of youngpeople a crit-ical and neglected age group Ann N Y Acad Sci 1393 3ndash20

159 Pursey KM Collins CE Stanwell P et al (2015) Foodsand dietary profiles associated with lsquofood addictionrsquo inyoung adults Addict Behav Rep 2 41ndash48

160 Ronto R Wu JH amp Singh GM (2018) The global nutri-tion transition trends disease burdens and policy inter-ventions Public Health Nutr 6 1ndash4

161 World Health Organization (2015) Fact Sheet No 394Healthy diets httpwwwwhointmediacentrefactsheetsfs394en

162 Grech A Rangan A amp Allman-Farinelli M (2017)Social determinants and poor diet quality of energy-densediets of Australian young adults Healthcare (Basel) 5 E70

163 Grech AL Rangan A amp Allman-Farinelli M (2017)Dietary energy density in the Australian adult populationfrom national nutrition surveys 1995 to 2012 J Acad NutrDiet 117 1887ndash1899e2

164 Fransen HP Beulens JW May AM et al (2015) Dietarypatterns in relation to quality-adjusted life years in theEPIC-NL cohort Prev Med 77 119ndash124

165 Fardet A Rock E Bassama J et al (2015) Current foodclassifications in epidemiological studies do not enablesolid nutritional recommendations for preventing diet-related chronic diseases the Impact of Food ProcessingAdv Nutr 6 629ndash638

166 Maddock J Ziauddeen N Ambrosini GL et al (2018)Adherence to a Dietary Approaches to Stop Hypertension(DASH)-type diet over the life course and associated vascu-lar function a study based on the MRC 1946 British birthcohort Br J Nutr 119 581ndash589

167 Bettermann EL Hartman TJ Easley KA et al (2018) HigherMediterranean diet quality scores and lower body mass indexare associated with a less-oxidized plasma glutathione andcysteine redox status in adults J Nutr 148 245ndash253

168 Fanelli Kuczmarski M Bodt BA Stave Shupe E et al(2018) Dietary patterns associated with lower 10-year ath-erosclerotic cardiovascular disease risk among urbanAfrican-American and White adults consuming Westerndiets Nutrients 10 158

169 Wang T Heianza Y Sun D et al (2018) Improving adher-ence to healthy dietary patterns genetic risk and longterm weight gain gene-diet interaction analysis in twoprospective cohort studies BMJ 360 j5644

J M Jones18

Proceedings

oftheNutritionSo

ciety


Studies using NOVA demonstrate that PFnUPFndeliver most of the added sugars and are associatedwith obesity and other health risks(6ndash915) but other cate-gorisations yield different results(16ndash18) Further place-ment of foods into categories among NOVA studies isinconsistent(6ndash919)

The present paper will compare the NOVA definitionwith legal technical popular press and public health defini-tions The NOVA categorisation will be compared withthat of the IFIC Designation of foods with more thanfive ingredients or presence of lsquoadded sugarsrsquo or additivesasUPFnwill be challenged Further analyses documentingthat foods categorised as PFnUPFn provide much of thelsquoadded sugarsrsquo will be shown as tautological logic

Nutrient intakes and health outcomes using theNOVA system will be compared with those recom-mended in dietary guidance such as Dietary Approachesto Stop Hypertension (DASH)(20) or the United StatesDepartment of Agriculture MyPlate(2122) NOVArsquosadherence to requirements for dietary guidance under-standability adaptability applicability and practicalitywill be questioned(2324)

Processed food history and definitions

lsquoCooking which is one part of processing wenthand-in-hand with becoming human Human food is pro-cessed foodrsquo according to food historian RachelLaudan(25) PF enabled world exploration and settling ofterritories and continents PFrsquos ability to extend the foodsupply yielded the highest accolades from Napoleonwho awarded 50 000 francs to Nicholas Appert for devel-oping canned food to feed French troops(26) PF becamevital to a countryrsquos food supplies and as such they becamethe purview of governments to ensure their safety(27)Thus they were regulated and defined(28ndash36)

Definitions of processed foods legal and food science

Regulatory and food science definitions are found inTable 1A(28ndash36) These definitions show strong congru-ence but differ in detail All agree that one or more phys-ical chemical or microbiological steps change rawcommodities into ingredients or foods All allow formu-lations with any number or type of ingredients TheUnited States Department of Agriculture also has alegal definition of MPF(31)

Goals of food processing are also aligned in this groupof definitions These include increasing shelf life main-taining or enhancing safety and nutrient quality addres-sing specific nutritional requirements and adding varietyand convenience

Newer usages and definitions of processed foods andultra-processed foods

Bibliographic citations in PubMed about PF until 10years ago were about the intersection of food scienceand nutrition and presented data on the impacts of

processing techniques on food safety nutrient retentionor availability and microbiological quality In 2009UPF emerged as a term and transmuted (along withthe term PF) from food science to public health Itdefined the degree of processing non-traditionally andadded presence or absence of certain food componentsas a dimension(1ndash4) This prompted studies that documen-ted the penetration of PF and UPF into diets and thattested associations between their intake and nutrientquality obesity and disease(2ndash467937) This spawned pro-motion of the NOVA dietary system that recommendedthe use of MPFn and avoidance of PFnUPFn

Definitions of processed foods dictionary consumerorganisations and popular press

Among this group (Table 1B)(38ndash43) definitions and con-notations vary greatly Only two Wikipedia(38) andIFIC(39) show alignment with legal or food sciencedefinitions Several recognise that most foods are pro-cessed in some way to improve nutrient absorption tomake food safer and to prevent waste and that they arelsquonot all badrsquo(40ndash45)

Many websites and popular press definitions(Table 1B) describe PF as requiring complex processesand having lengthy ingredient lists including chemicalsand additives(46ndash49) Regardless of nutritive value PFare often presented pejoratively with comments such aslsquonot whole or found in naturersquo lsquosold in packets or tinsrsquolsquofast or junk foods with minimal nutrients and fiberrsquolsquoless satisfyingrsquo and lsquouse fewer calories to metabolizethan whole foodsrsquo(50ndash56) Web images most frequentlydepict sugary drinks candy crisps chips (fries) and fro-zen or baked sugary fatty or salty treats However somealso show bread canned fish and fruit baby foods infantformula and ready-to-eat cereals (RTEC)(5758)

The diversity of foods images and descriptions por-trayed demonstrate lack of agreement as to definitionor food categorisation in the popular press Further con-fusing consumers is the suggestion that home-preparedfoods are always nutritionally superior and are not pro-cessed even when techniques and ingredients areidentical(59)

Processed foods continuums and categorisations

Food scientists

PF exist on a continuum that food scientists base on thecomplexity of processes not numbers or kinds of ingredi-ents Additives salts and sugars are regarded as part ofthe recipe not as processes and can add flavour butalso extend shelf life and preserve nutrients(60) Thesecomponents help to fulfill the goal of processing whichis to reduce pre- and post-harvest losses to minimiseresource use to decrease waste to maintain safety andquality and to offer convenience(6162) These may addressfood supply issues and lower costs(6364)

Food scientists recognise processing may alter nutrientcontent and bioavailability either positively or


Proceedings

oftheNutritionSo

ciety

















Similar to USDA



















JMJones

6


httpsww

wcam


Dow

nloaded from httpsw

ww








NOVA




once

ntra

Hea

lthNew

sletter(4

8)

PFreferto

mos

tfood

ssinc

emos

tareproce

ssed

inso

meway

Con

centra

differen

tiatesbetwee

nmec

hanica

l(eg

grindingmea

t)an

dch

emical

proce

ssing(ega

ddition

ofad

ditive

s)w

hich

isdee

med

asno


PFareallege

dto

have

lsquobarelyan

ynu

trientsan

dfibrersquoto

beless

satis

fying

and

tous

eless

energy

tometab

olisethan

who

lefood

sWellW

isdom

(49)New

sletter

FPca

npreve

ntwas

tean

dmak

efood

saferbut

canco

ntainch

emicalsthat

shou

ldno

tbeinge

sted

Nea

rlyallleg

alan

dfood

scienc

edefi

nitio

nsof

food

proce

ssingha

vesimilarex

amplesan

dallow

addition

sto

thelistas

new

proce

ssed

emerge

Exa

mple

ofaco

nsum

ered

ucationgrou

pus

ingdietitians

andfood

professiona

lsas

spok

espeo

ple

Exa

mple

ofan

orga

nicag

riculturalp

roduc

tsmarke

tingan

dtrad

ereso

urce

that

isno

tin

favo

urof

biotech

nology

orpes

ticides

sectExa

mple

ofaUSne

wsp

aper

web

site

Exa

mple

ofhe

alth

newsletteras

sociated

with

thelargehe

alth

system

paraNatural

isno

tlega

llydefi

nedin

man

yjuris

dictio

ns

Exa

mple

ofthene

wsletterfrom

ave

ndor

ofsu

pplemen

tsan

dhe

alth

food

s


Proceedings

oftheNutritionSo

ciety













Table

2Internationa

lfoo

dinform

ationco

uncil(IFIC)p

roce

ssed

food

catego

risation

IFIC

catego

ryExa

mples

Minim

ally

proce

ssed

Foo

dsthat

require

little

proce

ssingat

theplant

but

oftenrequire

preparationbeforeea

ting

Roa

sted

cho

pped

nutsw

hole

ampcrac

kedce

reals

coffe

ebea

nsw

ashe

dpac

kage

dfruit

vege

tables

bag

gedsa

lads

pas

teurised

milk

Proce

ssed

tohe

lpprese

rvean

den

hanc

enu

trientsan

dfres

hnes

sof

food

sat

theirpea

kFroz

enc

anne

dor

cook

edampva

cuum

-pac

kedamprefrigerated

fish

mea

tfruitamp

vege

tables

and

bab

yfood

sUHTdairy

Food

sthat

combine

ingred

ientsan

dad

ditive

ssu

chas

spices

oilsfl

avou

rsp

rese

rvatives

andnu

trientsto

ensu

resa

fety

andse

nsoryap

pea

l(The

seus

ually

require

furthe

rpreparation

anddono

tinclud

elsquorea

dy-to-eat

food

srsquo(RTE

))listedbelow

Pac

kage

dfood

ssu

chas

riceor

potatosidedishe

sca

kemixjarredtomatosa

uce

spice

mixes

dressings

sau

ces

ampco

ndim

entsg

elatin

RTE

food

sthat

may

have

man

yingred

ientsan

dproce

sses

but

need

little

prepa

ratio

nBread

sampflat

bread

sRTE

ampinstan

tcerea

lsg

rano

lasnu

trition

barsbiscu

itsjam

sampjellies

nut

buttersice

crea

myog

hurtc

ookies

fruitch

ews

rotis

serie

chicke

nlunc

heon

mea

tsc

ooke

dha

ms

chee

ses

spread

sfruitdrin

kss

altedco

ndim

ents

such

asolives

carbon

ated

bev

erag

es

Food

spac

kage

dto

stay

fres

han

dsa

vetim

ePrepared

refrigerated

ampdelifoo

ds

froz

enmea

lse

ntreacutees

sides

pot

pies

andpizza

s

Adap

tedfrom

httpwwwificorg

J M Jones8

Proceedings

oftheNutritionSo

ciety
























(1ndash46)


Proceedings

oftheNutritionSo

ciety








NOVA and nutrients











J M Jones10

Proceedings

oftheNutritionSo

ciety






foods-NOVA







Fortified foods











Proceedings

oftheNutritionSo

ciety






















J M Jones12

Proceedings

oftheNutritionSo

ciety



Safety









Conclusion







Acknowledgements


Financial Support



Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety

















Similar to USDA



















JMJones

6


httpsww

wcam


Dow

nloaded from httpsw

ww








NOVA




once

ntra

Hea

lthNew

sletter(4

8)

PFreferto

mos

tfood

ssinc

emos

tareproce

ssed

inso

meway

Con

centra

differen

tiatesbetwee

nmec

hanica

l(eg

grindingmea

t)an

dch

emical

proce

ssing(ega

ddition

ofad

ditive

s)w

hich

isdee

med

asno


PFareallege

dto

have

lsquobarelyan

ynu

trientsan

dfibrersquoto

beless

satis

fying

and

tous

eless

energy

tometab

olisethan

who

lefood

sWellW

isdom

(49)New

sletter

FPca

npreve

ntwas

tean

dmak

efood

saferbut

canco

ntainch

emicalsthat

shou

ldno

tbeinge

sted

Nea

rlyallleg

alan

dfood

scienc

edefi

nitio

nsof

food

proce

ssingha

vesimilarex

amplesan

dallow

addition

sto

thelistas

new

proce

ssed

emerge

Exa

mple

ofaco

nsum

ered

ucationgrou

pus

ingdietitians

andfood

professiona

lsas

spok

espeo

ple

Exa

mple

ofan

orga

nicag

riculturalp

roduc

tsmarke

tingan

dtrad

ereso

urce

that

isno

tin

favo

urof

biotech

nology

orpes

ticides

sectExa

mple

ofaUSne

wsp

aper

web

site

Exa

mple

ofhe

alth

newsletteras

sociated

with

thelargehe

alth

system

paraNatural

isno

tlega

llydefi

nedin

man

yjuris

dictio

ns

Exa

mple

ofthene

wsletterfrom

ave

ndor

ofsu

pplemen

tsan

dhe

alth

food

s


Proceedings

oftheNutritionSo

ciety













Table

2Internationa

lfoo

dinform

ationco

uncil(IFIC)p

roce

ssed

food

catego

risation

IFIC

catego

ryExa

mples

Minim

ally

proce

ssed

Foo

dsthat

require

little

proce

ssingat

theplant

but

oftenrequire

preparationbeforeea

ting

Roa

sted

cho

pped

nutsw

hole

ampcrac

kedce

reals

coffe

ebea

nsw

ashe

dpac

kage

dfruit

vege

tables

bag

gedsa

lads

pas

teurised

milk

Proce

ssed

tohe

lpprese

rvean

den

hanc

enu

trientsan

dfres

hnes

sof

food

sat

theirpea

kFroz

enc

anne

dor

cook

edampva

cuum

-pac

kedamprefrigerated

fish

mea

tfruitamp

vege

tables

and

bab

yfood

sUHTdairy

Food

sthat

combine

ingred

ientsan

dad

ditive

ssu

chas

spices

oilsfl

avou

rsp

rese

rvatives

andnu

trientsto

ensu

resa

fety

andse

nsoryap

pea

l(The

seus

ually

require

furthe

rpreparation

anddono

tinclud

elsquorea

dy-to-eat

food

srsquo(RTE

))listedbelow

Pac

kage

dfood

ssu

chas

riceor

potatosidedishe

sca

kemixjarredtomatosa

uce

spice

mixes

dressings

sau

ces

ampco

ndim

entsg

elatin

RTE

food

sthat

may

have

man

yingred

ientsan

dproce

sses

but

need

little

prepa

ratio

nBread

sampflat

bread

sRTE

ampinstan

tcerea

lsg

rano

lasnu

trition

barsbiscu

itsjam

sampjellies

nut

buttersice

crea

myog

hurtc

ookies

fruitch

ews

rotis

serie

chicke

nlunc

heon

mea

tsc

ooke

dha

ms

chee

ses

spread

sfruitdrin

kss

altedco

ndim

ents

such

asolives

carbon

ated

bev

erag

es

Food

spac

kage

dto

stay

fres

han

dsa

vetim

ePrepared

refrigerated

ampdelifoo

ds

froz

enmea

lse

ntreacutees

sides

pot

pies

andpizza

s

Adap

tedfrom

httpwwwificorg

J M Jones8

Proceedings

oftheNutritionSo

ciety
























(1ndash46)


Proceedings

oftheNutritionSo

ciety








NOVA and nutrients











J M Jones10

Proceedings

oftheNutritionSo

ciety






foods-NOVA







Fortified foods











Proceedings

oftheNutritionSo

ciety






















J M Jones12

Proceedings

oftheNutritionSo

ciety



Safety









Conclusion







Acknowledgements


Financial Support



Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety







NOVA




once

ntra

Hea

lthNew

sletter(4

8)

PFreferto

mos

tfood

ssinc

emos

tareproce

ssed

inso

meway

Con

centra

differen

tiatesbetwee

nmec

hanica

l(eg

grindingmea

t)an

dch

emical

proce

ssing(ega

ddition

ofad

ditive

s)w

hich

isdee

med

asno


PFareallege

dto

have

lsquobarelyan

ynu

trientsan

dfibrersquoto

beless

satis

fying

and

tous

eless

energy

tometab

olisethan

who

lefood

sWellW

isdom

(49)New

sletter

FPca

npreve

ntwas

tean

dmak

efood

saferbut

canco

ntainch

emicalsthat

shou

ldno

tbeinge

sted

Nea

rlyallleg

alan

dfood

scienc

edefi

nitio

nsof

food

proce

ssingha

vesimilarex

amplesan

dallow

addition

sto

thelistas

new

proce

ssed

emerge

Exa

mple

ofaco

nsum

ered

ucationgrou

pus

ingdietitians

andfood

professiona

lsas

spok

espeo

ple

Exa

mple

ofan

orga

nicag

riculturalp

roduc

tsmarke

tingan

dtrad

ereso

urce

that

isno

tin

favo

urof

biotech

nology

orpes

ticides

sectExa

mple

ofaUSne

wsp

aper

web

site

Exa

mple

ofhe

alth

newsletteras

sociated

with

thelargehe

alth

system

paraNatural

isno

tlega

llydefi

nedin

man

yjuris

dictio

ns

Exa

mple

ofthene

wsletterfrom

ave

ndor

ofsu

pplemen

tsan

dhe

alth

food

s


Proceedings

oftheNutritionSo

ciety













Table

2Internationa

lfoo

dinform

ationco

uncil(IFIC)p

roce

ssed

food

catego

risation

IFIC

catego

ryExa

mples

Minim

ally

proce

ssed

Foo

dsthat

require

little

proce

ssingat

theplant

but

oftenrequire

preparationbeforeea

ting

Roa

sted

cho

pped

nutsw

hole

ampcrac

kedce

reals

coffe

ebea

nsw

ashe

dpac

kage

dfruit

vege

tables

bag

gedsa

lads

pas

teurised

milk

Proce

ssed

tohe

lpprese

rvean

den

hanc

enu

trientsan

dfres

hnes

sof

food

sat

theirpea

kFroz

enc

anne

dor

cook

edampva

cuum

-pac

kedamprefrigerated

fish

mea

tfruitamp

vege

tables

and

bab

yfood

sUHTdairy

Food

sthat

combine

ingred

ientsan

dad

ditive

ssu

chas

spices

oilsfl

avou

rsp

rese

rvatives

andnu

trientsto

ensu

resa

fety

andse

nsoryap

pea

l(The

seus

ually

require

furthe

rpreparation

anddono

tinclud

elsquorea

dy-to-eat

food

srsquo(RTE

))listedbelow

Pac

kage

dfood

ssu

chas

riceor

potatosidedishe

sca

kemixjarredtomatosa

uce

spice

mixes

dressings

sau

ces

ampco

ndim

entsg

elatin

RTE

food

sthat

may

have

man

yingred

ientsan

dproce

sses

but

need

little

prepa

ratio

nBread

sampflat

bread

sRTE

ampinstan

tcerea

lsg

rano

lasnu

trition

barsbiscu

itsjam

sampjellies

nut

buttersice

crea

myog

hurtc

ookies

fruitch

ews

rotis

serie

chicke

nlunc

heon

mea

tsc

ooke

dha

ms

chee

ses

spread

sfruitdrin

kss

altedco

ndim

ents

such

asolives

carbon

ated

bev

erag

es

Food

spac

kage

dto

stay

fres

han

dsa

vetim

ePrepared

refrigerated

ampdelifoo

ds

froz

enmea

lse

ntreacutees

sides

pot

pies

andpizza

s

Adap

tedfrom

httpwwwificorg

J M Jones8

Proceedings

oftheNutritionSo

ciety
























(1ndash46)


Proceedings

oftheNutritionSo

ciety








NOVA and nutrients











J M Jones10

Proceedings

oftheNutritionSo

ciety






foods-NOVA







Fortified foods











Proceedings

oftheNutritionSo

ciety






















J M Jones12

Proceedings

oftheNutritionSo

ciety



Safety









Conclusion







Acknowledgements


Financial Support



Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety













Table

2Internationa

lfoo

dinform

ationco

uncil(IFIC)p

roce

ssed

food

catego

risation

IFIC

catego

ryExa

mples

Minim

ally

proce

ssed

Foo

dsthat

require

little

proce

ssingat

theplant

but

oftenrequire

preparationbeforeea

ting

Roa

sted

cho

pped

nutsw

hole

ampcrac

kedce

reals

coffe

ebea

nsw

ashe

dpac

kage

dfruit

vege

tables

bag

gedsa

lads

pas

teurised

milk

Proce

ssed

tohe

lpprese

rvean

den

hanc

enu

trientsan

dfres

hnes

sof

food

sat

theirpea

kFroz

enc

anne

dor

cook

edampva

cuum

-pac

kedamprefrigerated

fish

mea

tfruitamp

vege

tables

and

bab

yfood

sUHTdairy

Food

sthat

combine

ingred

ientsan

dad

ditive

ssu

chas

spices

oilsfl

avou

rsp

rese

rvatives

andnu

trientsto

ensu

resa

fety

andse

nsoryap

pea

l(The

seus

ually

require

furthe

rpreparation

anddono

tinclud

elsquorea

dy-to-eat

food

srsquo(RTE

))listedbelow

Pac

kage

dfood

ssu

chas

riceor

potatosidedishe

sca

kemixjarredtomatosa

uce

spice

mixes

dressings

sau

ces

ampco

ndim

entsg

elatin

RTE

food

sthat

may

have

man

yingred

ientsan

dproce

sses

but

need

little

prepa

ratio

nBread

sampflat

bread

sRTE

ampinstan

tcerea

lsg

rano

lasnu

trition

barsbiscu

itsjam

sampjellies

nut

buttersice

crea

myog

hurtc

ookies

fruitch

ews

rotis

serie

chicke

nlunc

heon

mea

tsc

ooke

dha

ms

chee

ses

spread

sfruitdrin

kss

altedco

ndim

ents

such

asolives

carbon

ated

bev

erag

es

Food

spac

kage

dto

stay

fres

han

dsa

vetim

ePrepared

refrigerated

ampdelifoo

ds

froz

enmea

lse

ntreacutees

sides

pot

pies

andpizza

s

Adap

tedfrom

httpwwwificorg

J M Jones8

Proceedings

oftheNutritionSo

ciety
























(1ndash46)


Proceedings

oftheNutritionSo

ciety








NOVA and nutrients











J M Jones10

Proceedings

oftheNutritionSo

ciety






foods-NOVA







Fortified foods











Proceedings

oftheNutritionSo

ciety






















J M Jones12

Proceedings

oftheNutritionSo

ciety



Safety









Conclusion







Acknowledgements


Financial Support



Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety
























(1ndash46)


Proceedings

oftheNutritionSo

ciety








NOVA and nutrients











J M Jones10

Proceedings

oftheNutritionSo

ciety






foods-NOVA







Fortified foods











Proceedings

oftheNutritionSo

ciety






















J M Jones12

Proceedings

oftheNutritionSo

ciety



Safety









Conclusion







Acknowledgements


Financial Support



Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety








NOVA and nutrients











J M Jones10

Proceedings

oftheNutritionSo

ciety






foods-NOVA







Fortified foods











Proceedings

oftheNutritionSo

ciety






















J M Jones12

Proceedings

oftheNutritionSo

ciety



Safety









Conclusion







Acknowledgements


Financial Support



Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety






foods-NOVA







Fortified foods











Proceedings

oftheNutritionSo

ciety






















J M Jones12

Proceedings

oftheNutritionSo

ciety



Safety









Conclusion







Acknowledgements


Financial Support



Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety






















J M Jones12

Proceedings

oftheNutritionSo

ciety



Safety









Conclusion







Acknowledgements


Financial Support



Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety



Safety









Conclusion







Acknowledgements


Financial Support



Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety





Authorship


References






























J M Jones14

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety










































Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety





































J M Jones16

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety







































Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety


































J M Jones18

Proceedings

oftheNutritionSo

ciety


food processing: criteria for dietary guidance and public health? · nutrient density: added...

Documents