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. 2016 Mar 9;6(3):e009892.
doi: 10.1136/bmjopen-2015-009892.

Ultra-processed Foods and Added Sugars in the US Diet: Evidence From a Nationally Representative Cross-Sectional Study

Free PMC article

Ultra-processed Foods and Added Sugars in the US Diet: Evidence From a Nationally Representative Cross-Sectional Study

Eurídice Martínez Steele et al. BMJ Open. .
Free PMC article


Objectives: To investigate the contribution of ultra-processed foods to the intake of added sugars in the USA. Ultra-processed foods were defined as industrial formulations which, besides salt, sugar, oils and fats, include substances not used in culinary preparations, in particular additives used to imitate sensorial qualities of minimally processed foods and their culinary preparations.

Design: Cross-sectional study.

Setting: National Health and Nutrition Examination Survey 2009-2010.

Participants: We evaluated 9317 participants aged 1+ years with at least one 24 h dietary recall.

Main outcome measures: Average dietary content of added sugars and proportion of individuals consuming more than 10% of total energy from added sugars.

Data analysis: Gaussian and Poisson regressions estimated the association between consumption of ultra-processed foods and intake of added sugars. All models incorporated survey sample weights and adjusted for age, sex, race/ethnicity, family income and educational attainment.

Results: Ultra-processed foods comprised 57.9% of energy intake, and contributed 89.7% of the energy intake from added sugars. The content of added sugars in ultra-processed foods (21.1% of calories) was eightfold higher than in processed foods (2.4%) and fivefold higher than in unprocessed or minimally processed foods and processed culinary ingredients grouped together (3.7%). Both in unadjusted and adjusted models, each increase of 5 percentage points in proportional energy intake from ultra-processed foods increased the proportional energy intake from added sugars by 1 percentage point. Consumption of added sugars increased linearly across quintiles of ultra-processed food consumption: from 7.5% of total energy in the lowest quintile to 19.5% in the highest. A total of 82.1% of Americans in the highest quintile exceeded the recommended limit of 10% energy from added sugars, compared with 26.4% in the lowest.

Conclusions: Decreasing the consumption of ultra-processed foods could be an effective way of reducing the excessive intake of added sugars in the USA.

Keywords: NHANES; US; added sugars; dietary intake; ultra-processed.


Figure 1
Figure 1
The dietary content in added sugars regressed on the dietary contribution of ultra-processed foods evaluated by restricted cubic splines. US population aged 1+ years (National Health and Nutrition Examination Survey 2009–2010) (N=9317). The values shown on the x-axis correspond to the 5th, 27.5th, 50th, 72.5th, and 95th centiles for percentage of total energy from ultra-processed foods (knots). Coefficient for linear term=0.20 (95% CI 0.17 to 0.23). There was little evidence of non-linearity in the restricted cubic spline model (Wald test for linear term p<0.0001; Wald test for all non-linear terms p=0.27).

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