Food Additive Use in Ultraprocessed Foods: Can Processing Use of Industrial Additives Contribute to Adverse Health Outcomes in Children?

The negative health perception of industrially processed food, which now represents >60% of energy intake of the US population, is reinforced by the ever-growing number of studies linking ultraprocessed food (UPF) intake to adverse health outcomes, including obesity, cardiovascular disease, chronic kidney disease, cancer, type 2 diabetes, hypertension, dementia, and mortality.1Capozzi F. Magkos F. Fava F. et al.A multidisciplinary perspective of ultra-processed foods and associated food processing technologies: A view of the sustainable road ahead.Nutrients. 2021; 13: 3948https://doi.org/10.3390/nu13113948Crossref PubMed Scopus (14) Google Scholar Concern about high UPF consumption is not restricted to adults, given a recent report of increasing trends in UPF consumption among children and adolescents (2 to 19 years) assessed from 2 decades of National Health and Nutrition Examination Survey data.2Wang L. Martínez Steele E. Du M. et al.Trends in consumption of ultraprocessed foods among US youths aged 2-19 years, 1999-2018.JAMA. 2021; 326: 519-530Crossref PubMed Scopus (82) Google Scholar The adverse health reports linked to high UPF intake are only associative and do not indicate that industrially processed food consumption causes these health problems; although, they do alert us to the potential for considerable health problems related to intensive processing of packaged foods. The NOVA system of classification of food based on the degree of processing3Monteiro C.A. Cannon G. Moubarac J.C. Levy R.B. Louzada M.L.C. Jaime P.C. The UN decade of nutrition, the NOVA food classification and the trouble with ultra-processing.Public Health Nutr. 2018; 21: 5-17Crossref PubMed Scopus (856) Google Scholar has been criticized for vague and subjective definitions identifying processed food and UPF, which has been attributed to notable variations in exposure estimates among investigators.4Gibney M.J. Forde C.G. Mullally D. Gibney E.R. Ultra-processed foods in human health: A critical appraisal.Am J Clin Nutr. 2017; 106 ([Erratum in: Am J Clin Nutr. 2018;107(3):482-483]): 717-724Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar, 5Tseng M. Grigsby C.J. Austin A. Amin S. Nazmi A. Sensory-related industrial additives in the US packaged food supply.Front Nutr. 2022; 8762814https://doi.org/10.3389/fnut.2021.762814Crossref PubMed Scopus (3) Google Scholar, 6Visioli F, Marangoni F, Fogliano V, et al. The ultra-processed foods hypothesis: A product processed well beyond the basic ingredients in the package [published online ahead of print June 22, 2022]. Nutr Res Rev. https://doi.org/10.1017/S0954422422000117Google Scholar UPFs are characterized by the use of industrial formulations, usually containing 5 or more ingredients not commonly used in home food preparation (eg, high-fructose corn syrup and soy protein hydrolysates), and reliance on the addition of processing ingredients (additives and substances) with specific technical functions, such as preservatives, sweeteners, color additives, flavors and spices, flavor enhancers, nutrients, emulsifiers, leavening agents, anticaking agents, stabilizers, and thickeners.3Monteiro C.A. Cannon G. Moubarac J.C. Levy R.B. Louzada M.L.C. Jaime P.C. The UN decade of nutrition, the NOVA food classification and the trouble with ultra-processing.Public Health Nutr. 2018; 21: 5-17Crossref PubMed Scopus (856) Google Scholar What is in question is whether certain processing techniques that refine grains, eliminating fiber; use high levels of specific ingredients to improve palatability (sugar, fat and salt); or use additives with specific technical functions, work in unison or individually to contribute to the observed health risks. Of these suspected processing techniques, added sugar, fat, and salt has been the key focus of studies trying to answer this question, especially as it relates to obesity across all ages.7Lane M.M. Davis J.A. Beattie S. et al.Ultraprocessed food and chronic noncommunicable diseases: A systematic review and meta-analysis of 43 observational studies.Obes Rev. 2021; 22e13146https://doi.org/10.1111/obr.13146Crossref PubMed Scopus (189) Google Scholar,8Maldonado-Pereira L. Barnaba C. de Los Campos G. Medina-Meza I.G. Evaluation of the nutritional quality of ultra-processed foods (ready to eat + fast food): Fatty acids, sugar, and sodium.J Food Sci. 2022; 87: 3659-3676Crossref PubMed Scopus (1) Google Scholar The objective of this editorial was to take a closer look at the research needed to determine the potential role that food additive use may play in the association of adverse health risks with high UPF consumption. Food additive use is a characteristic of the NOVA classification of UPF, but it is not clear whether it contributes to the associated health risks of UPF intake. By providing preliminary data on exposure to food additives in UPF found in grocery-purchased foods over time, the authors of “Food Additives in Ultra-Processed Packaged Foods: An Examination of Use of Household Grocery Store Purchases,”9Dunford E.K. Miles D.R. Popkin B. Food additives in ultra-processed packaged foods: An examination of US household grocery store purchases.J Acad Nutr Diet. 2023; 123 (00-00)Google Scholar in this issue, are leading the way in this much needed research. Early cross-sectional surveys and prospective studies to address possible mechanisms involved with UPF intake and poor health outcomes relied on the tools available to determine what individuals eat—dietary recall and food frequency questionnaires. These tools reveal the categories of foods and proportions consumed by individuals and, using the NOVA system, foods can be classified into 4 groups according to their perceived degree of industrial processing (ie, minimally processed, processed culinary ingredients, processed foods, and UPF). The NOVA system provides an imprecise characterization of additives and processed ingredients not typically used in home cooking, which helps to identify UPF, and added sugar, fat, salt, and fiber content are required on US food labels. There are reliable data in the nutrient databases to determine accurate exposure of added sugar, fat, salt, and fiber, but no such tools are available in the United States to study exposure to the more than 3,975 approved food additives listed in the US Food and Drug Administration’s (FDA) inventory of substances added to food.10International Food Information Council (IFIC) and US Food and Drug Administration (FDA)Overview of Food Ingredients, Additives & Colors. US Food and Drug Administration.http://www.fda.gov/food/food-ingredients-packaging/overview-food-ingredients-additives-colorsDate accessed: November 11, 2022Google Scholar The FDA’s Nutrition Facts label and ingredients list provide limited additive data to inform individual consumers. Therefore, population exposure estimates for food additives in the United States cannot be made from dietary intake surveys, as there is no access to label information on the specific foods consumed in 24-hour dietary recalls. The Branded Food Products Database introduced by the US Department of Agriculture provides information on more than 200,000 brand name foods. Recently, 30,000 of these brand name foods were used to estimate the presence of sensory-related industrial additives,5Tseng M. Grigsby C.J. Austin A. Amin S. Nazmi A. Sensory-related industrial additives in the US packaged food supply.Front Nutr. 2022; 8762814https://doi.org/10.3389/fnut.2021.762814Crossref PubMed Scopus (3) Google Scholar but use of this database cannot support a population exposure estimate without links to intake data. A French study has recently estimated food additive exposure from surveys determining usual dietary intakes in adults made possible by the European Union additives labeling system, which differs from that used in the United States.11Chazelas E. Druesne-Pecollo N. Esseddik Y. et al.Exposure to food additive mixtures in 106,000 French adults from the NutriNet-Santé cohort.Sci Rep. 2021; 1119680https://doi.org/10.1038/s41598-021-98496-6Crossref PubMed Scopus (19) Google Scholar The French investigators estimated the consumption of 90 top food additives from repeated 24-hour dietary records provided by 106,489 adults participating in the French NutriNet-Santé cohort study. They measured qualitative and quantitative exposure using 3 large-scale composition databases, information from brands of commercial products, and a combination of laboratory assays and data from the European Food Safety Authority and the Joint European Committee on Food Additives (JEFCA). The authors found several frequently used food additives among the top 50 consumed that were associated with potential adverse health risks based on evidence from experimental studies.11Chazelas E. Druesne-Pecollo N. Esseddik Y. et al.Exposure to food additive mixtures in 106,000 French adults from the NutriNet-Santé cohort.Sci Rep. 2021; 1119680https://doi.org/10.1038/s41598-021-98496-6Crossref PubMed Scopus (19) Google Scholar In contrast to France, with access to European Food Safety Authority and JEFCA data, no publicly available ingredient databases exist that identify and quantify the top additives in US foods, which presents a formidable barrier to estimating population exposure and safety of food additives in UPFs. Dunford and colleagues9Dunford E.K. Miles D.R. Popkin B. Food additives in ultra-processed packaged foods: An examination of US household grocery store purchases.J Acad Nutr Diet. 2023; 123 (00-00)Google Scholar went around this barrier by using a novel approach to determine food additive exposure changes over time and the food categories with the highest use of food additives approved for 1 or more of the 4 most frequently used technical functions of industrial food processing. Most importantly, the authors’ approach enabled exposure estimates in understudied vulnerable populations of infants and children. There are several noteworthy findings from this novel approach that allow identification of potential additives that may contribute to adverse health mechanisms with high UPF consumption.9Dunford E.K. Miles D.R. Popkin B. Food additives in ultra-processed packaged foods: An examination of US household grocery store purchases.J Acad Nutr Diet. 2023; 123 (00-00)Google Scholar First, the authors did not base UPF consumption on food intake surveys over time, rather they examined the proportion of UPF grocery store foods purchased by US households in 2001 and 2019 using the Nielsen IQ Homescan Consumer Panel purchase data that enabled identification of additive use in the scanned products. Second, purchased products were linked to their nutrient content and ingredients information in the products’ scanned Nutrition Facts label and ingredients list using commercial food product databases that reflected this information from the year of product purchase. Registered dietitian nutritionists then assigned all of the purchased food products to major and minor food categories and, with this information, more objectively assigned the foods to the NOVA groups. The authors’ third novel action was to identify foods as containing food additives with specific approved technical functions perceived by the authors as the 4 most common functional classes of food additives used across most categories of foods in the United States. They determined the presence of only those additives with FDA-approved functions as preservatives, flavors, color additives, and non-nutritive sweeteners. Consequently, only a portion of the more than 3,975 approved additives were searched for and the food categories with the greatest total increase in additive use were identified. The authors revealed a sobering finding that purchases of baby food products containing additives had the greatest and most significant increase over the last 2 decades, providing yet another potential concern for industrially processed baby foods.12Grammatikaki E. Wollgast J. Caldeira S. High levels of nutrients of concern in baby foods available in Europe that contain sugar-contributing ingredients or are ultra-processed.Nutrients. 2021; 13: 3105https://doi.org/10.3390/nu13093105Crossref PubMed Scopus (12) Google Scholar, 13da Rocha K.F. de Araújo C.R. de Morais I.L. Padrão P. Moreira P. Ribeiro K.D.D.S. Commercial foods for infants under the age of 36 months: An assessment of the availability and nutrient profile of ultra-processed foods.Public Health Nutr. 2021; 24: 3179-3186Crossref PubMed Scopus (12) Google Scholar, 14Santos M. Matias F. Loureiro I. et al.Commercial baby foods aimed at children up to 36 months: Are they a matter of concern?.Foods. 2022; 11: 1424https://doi.org/10.3390/foods11101424Crossref PubMed Scopus (3) Google Scholar With smaller body weight than adults, food additives may have a higher potential for toxicity in children compared with adults.15Kraemer M.V.D.S. Fernandes A.C. Chaddad M.C.C. et al.Food additives in childhood: A review on consumption and health consequences.Rev Saude Publica. 2022; 56: 32https://doi.org/10.11606/s1518-8787.2022056004060Crossref PubMed Google Scholar By presenting a new path to determining food additive exposure in specific foods through the use of purchased products and commercial brand label information, these authors facilitate research into the exposure and safety of food additive use in vulnerable populations. Given the demographic information, which is also collected with Nielsen IQ Homescan purchased foods data, Tseng and colleagues5Tseng M. Grigsby C.J. Austin A. Amin S. Nazmi A. Sensory-related industrial additives in the US packaged food supply.Front Nutr. 2022; 8762814https://doi.org/10.3389/fnut.2021.762814Crossref PubMed Scopus (3) Google Scholar pointed out the huge potential of using this approach to address questions that specifically target various population groups with greater disease risks or vulnerabilities. Determination of additive exposure in baby foods could examine links to additives used in each of the 32 FDA-approved technical function classes using the Nielsen IQ Homescan purchase product data and commercial databases. When examining additive exposure by technical class, consideration must be given to the fact that many food additives are approved for more than 1 technical function, and some have been approved for as many as 9 or 10.10International Food Information Council (IFIC) and US Food and Drug Administration (FDA)Overview of Food Ingredients, Additives & Colors. US Food and Drug Administration.http://www.fda.gov/food/food-ingredients-packaging/overview-food-ingredients-additives-colorsDate accessed: November 11, 2022Google Scholar For this reason, future studies should narrow their focus to functional classes where there is evidence of questionable additive safety in children or other at-risk populations. Only 1 functional class of additives, colors, has been systematically reviewed, analyzing the effects of additive consumption on the health of children.15Kraemer M.V.D.S. Fernandes A.C. Chaddad M.C.C. et al.Food additives in childhood: A review on consumption and health consequences.Rev Saude Publica. 2022; 56: 32https://doi.org/10.11606/s1518-8787.2022056004060Crossref PubMed Google Scholar The health effects included attention deficit/hyperactivity disorder, rhinitis, urticaria, and angioedema. Colors were among the functional classes explored in this issue; but mechanistic attributes that can be associated with some color additives could not be definitively associated with the health effects observed in the reviews on color additives. In the current study, several additives are approved for all 4 of the functional classes studied, suggesting that all additives in functional classes may not be associated with mechanisms involved in adverse health outcomes and not all additives within a functional class have the same chemical properties or physiological effects. Limiting study to specific additives within a functional class, such as emulsifiers,16Cox S. Sandall A. Smith L. Rossi M. Whelan K. Food additive emulsifiers: A review of their role in foods, legislation and classifications, presence in food supply, dietary exposure, and safety assessment.Nutr Rev. 2021; 79: 726-741Crossref PubMed Scopus (32) Google Scholar with previous evidence of adverse health outcome in adults17Roberts C.L. Rushworth S.L. Richman E. Rhodes J.M. Hypothesis: Increased consumption of emulsifers as an explanation for the rising incidence of Crohn’s disease.J Crohns Colitis. 2013; 7: 338-341Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 18Laster J. Bonnes S.L. Rocha J. Increased use of emulsifiers in processed foods and the links to obesity.Curr Gastroenterol Rep. 2019; 21: 61https://doi.org/10.1007/s11894-019-0723-4Crossref PubMed Scopus (15) Google Scholar, 19Miclotte L. De Paepe K. 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Emulsifiers and intestinal health: An introduction.J Pediatr Gastroenterol Nutr. 2022; 74: 314-319Crossref PubMed Scopus (3) Google Scholar and a plausible mechanism of action23Bancil A.S. Sandall A.M. Rossi M. Chassaing B. Lindsay J.O. Whelan K. Food additive emulsifiers and their impact on gut microbiome, permeability, and inflammation: Mechanistic insights in inflammatory bowel disease.J Crohns Colitis. 2021; 15: 1068-1079Crossref PubMed Scopus (26) Google Scholar would be a better approach to begin to identify the role of specific food additives in adverse health outcomes using the Nielsen IQ Homescan purchased food strategy described in this issue.9Dunford E.K. Miles D.R. Popkin B. Food additives in ultra-processed packaged foods: An examination of US household grocery store purchases.J Acad Nutr Diet. 2023; 123 (00-00)Google Scholar Earlier concern about the role of 2 emulsifiers, carrageenan and carboxymethylcellulose, in the development of inflammation in children,24Martino J.V. Van Limbergen J. Cahill L.E. The role of carrageenan and carboxymethylcellulose in the development of intestinal infammation.Front Pediatr. 2017; 5: 96Crossref PubMed Scopus (71) Google Scholar as well as other emulsifiers associated with health risk reports, including a randomized controlled trial confirming the detrimental impact of carboxymethylcellulose on the intestinal microbiome and metabolome,25Chassaing B. Compher C. Bonhomme B. et al.Randomized controlled-feeding study of dietary emulsifier carboxymethylcellulose reveals detrimental impacts on the gut microbiota and metabolome.Gastroenterology. 2022; 162: 743-756Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar underscore the need for accurate exposure estimates in the use of these food additives in the US food supply. In response to public health concern, the FDA conducted an exposure assessment of 7 commonly used emulsifiers (carboxymethylcellulose, polysorbate 80, lecithin, mono-and diglycerides, stearoyl lactylates, sucrose esters, and polyglycerol polyricinoleate) added to foods in the United States.26Shah R. Kolanos R. DiNovi M.J. Mattia A. Kaneko K.J. Dietary exposures for the safety assessment of seven emulsifiers commonly added to foods in the United States and implications for safety.Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2017; 34: 905-917Crossref PubMed Scopus (39) Google Scholar Although the exposure estimates raised no safety concerns at the specified levels of use at the time of assessment, it is important to note that the FDA’s exposure estimates were based on dietary intake data (two 24-hour dietary recalls) from 2 nationally representative surveys (National Health and Nutrition Examination Survey 1999-2002 and 2003-2010) without access to brand label ingredients lists with food additive content information. Given the growing rate of obesity and other chronic disease risks that parallel high UPF intake, there is merit in taking a closer, more accurate look at the safety of how food is processed, the degree of exposure to food additives, and identifying which frequently consumed UPFs contain questionable additives. The authors’ use of the US household grocery store food purchase data clearly forges a new path to methods for better estimation of the level of use and safety of food additives in industrially processed foods. M. S. Calvo is an adjunct research professor, The Icahn School of Medicine at Mount Sinai, New York, NY. J. Uribarri is a professor of medicine, The Icahn School of Medicine at Mount Sinai, New York, NY.