A new study from researchers at the Global Food Research Program at UNC-Chapel Hill and The George Institute for Global Health highlights how deeply ultra-processed foods (UPFs) dominate grocery purchases in the United States and how these patterns vary by race, income, and education level. 

Using nationally representative data from the NielsenIQ Homescan Consumer Panel, researchers examined more than 33 million packaged food and beverage purchases from 2020 across nearly 60,000 U.S. households. Each purchased item was classified using the Nova food processing system, which identifies foods based on their level of industrial processing. 

“Our findings show that almost half of all packaged food purchases and over one-third of beverage purchases were ultra-processed,” said Barry Popkin, PhD, co-author and W.R. Kenan Jr. Distinguished Professor of Nutrition at UNC-Chapel Hill’s Gillings School of Global Public Health. “This has serious implications for public health, given the strong links between UPF consumption and chronic, nutrition-related diseases like obesity, cancer, and heart disease.” 

The study found that certain food categories were overwhelmingly ultra-processed: 90% of carbonated soft drinks, 81% of mixed dishes and soups, and 71% of sweets and snacks fell into the UPF category. These three categories made up 36% of total purchases. Meanwhile, minimally processed categories like fruits, vegetables, nuts, and oils made up only a small fraction of overall purchases at 12%. 

Importantly, disparities were observed across socioeconomic groups. Households with lower incomes and lower education levels purchased a higher proportion of UPFs compared to higher-income, higher-education households. Race and ethnicity also played a role, with non-Hispanic White households purchasing a significantly higher proportion of UPFs than Black, Hispanic, or other race/ethnic groups. 

“Understanding these purchasing patterns is crucial for shaping effective food policies,” said Elizabeth Dunford, PhD, lead author of the study and researcher at The George Institute and UNC-Chapel Hill’s Gillings School of Global Public Health. “Policies that aim to reduce ultra-processed food consumption must take into account how access, marketing, and affordability impact different communities.” 

The findings underscore the urgent need for policy interventions that address not just high levels of nutrients like sugar, sodium, or saturated fat in the food supply, but also the level of food processing. Current U.S. dietary guidelines focus on nutrient-dense foods but do not make recommendations based on food processing levels, unlike emerging guidelines in some other countries. 

“This research reinforces that we need a shift toward promoting less processed food options and reducing the market dominance of ultra-processed products,” Popkin said. “Without it, diet-related health disparities are likely to persist or even widen.” 

The study, “Exploring disparities in the proportion of ultra-processed foods and beverages purchased in grocery stores by US households in 2020,” is now available in Public Health Nutrition. 

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This study was funded primarily by Bloomberg Philanthropies.

AUTHORS

Barry M. Popkin
Donna R. Miles
Elizabeth K. Dunford

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Read the full study in Public Health Nutrition

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Learn more about ultra-processed foods and the Nova classification system in our fact sheet:

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MORE GFRP RESEARCH ON ULTRA-PROCESSED FOODS

New study charts policy path to identifying ultra-processed foods and beverages high in nutrients of concern
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Ultra-processed products make up nearly half of low-income South African adults’ diets
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A new study that models the combined effects of a sugar-based tax on beverages and targeted subsidies for minimally processed foods and drinks found that under these policies, low-income consumers would purchase less sugar-sweetened beverages and more fruits, vegetables, and healthier drinks, particularly in households without children.  

Researchers from the Global Food Research Program at UNC-Chapel Hill developed a model to simulate what would happen if national-level taxes on less-healthy, ultra-processed foods and beverages were used to fund subsidies for low-income households participating in food assistance programs to spend on minimally processed fruits, vegetables, healthy proteins, and unsweetened drinks. They found that this combined policy scenario would likely lead low-income households to improve the nutritional quality of their grocery purchases without increasing their overall costs or negatively impacting consumer satisfaction.

Targeted taxes are a proven, cost-effective means to reduce purchase and intake of sugary drinks, which could potentially save millions of years of life globally by reducing chronic diseases caused by excess sugar and calories. While over 60 countries and smaller jurisdictions worldwide have implemented health-focused sugary drink taxes, relatively few have earmarked the revenue raised to subsidize healthy food purchases.

In the United States, studies evaluating programs that provide additional cash benefits for food assistance participants to spend on fruits and vegetables consistently find that they increase consumers’ purchase and intake of targeted products. This new study’s findings support a novel policy approach, combining both policy types to expand low-income households’ access to additional healthier alternatives like minimally processed proteins such as beans, legumes, or unprocessed meats, and no- or low-sugar beverages.

“Our findings show that we can support healthier dietary patterns in the US by directing revenues from national taxes on ultra-processed products high in sugar, sodium and/or saturated fats towards additional benefits to help low-income households purchase more fruits, vegetables and other healthier alternatives,” said senior author Shu Wen Ng, PhD, Distinguished Scholar in Public Health Nutrition at the UNC-Chapel Hill.

“This is an equity-enhancing approach that sends a clear and consistent message to the public and the food industry on the overarching goal of improving dietary patterns and nutritional security,” added first author Pourya Valizadeh, PhD, who completed this research during a post-doctoral fellowship at UNC-Chapel Hill. “The taxes should not be primarily about generating revenue, but rather shifting the relative prices of unhealthy vs healthy foods so that lower-income families in the US can more reliably attain foods and beverages that support health.” This study’s findings could inform recent congressional bills including the “GusNIP Expansion Act” and the “Opt for Health with SNAP (OH SNAP) Close the Fruit and Vegetable Fap Act” that would levy taxes on unhealthy beverages and expand targeted subsidies beyond existing SNAP benefits for minimally processed foods and beverages to low-income households.

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This study was funded by Robert Wood Johnson Foundation Healthy Eating Research and Arnold Ventures.

AUTHORS

Shu Wen Ng
Pourya Valizadeh

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Read the full study in the American Journal of Preventive Medicine

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Learn more about
sugary drink taxes.

A new study from researchers at the Global Food Research Program at UNC-Chapel Hill and The George Institute for Global Health provides guidance for policymakers on how to identify ultra-processed foods and beverages that are also high in salt, sugar, saturated fat, or calorie-dense for regulation.

To date, food policies aimed at improving population nutrition and health have targeted foods and drinks based primarily on their nutritional profile — that is, energy-dense products high in nutrients such as sugar, sodium, or saturated or trans fats have been subject to regulations such as taxes, marketing restrictions, or front-of-package warning labels. With concern mounting over the many health harms associated with high intake of ultra-processed foods, scholars and policymakers have begun exploring how these nutrition-focused policies could target products based on degree of processing.

“Researchers in this area typically use the detailed Nova Classification criteria to identify ultra-processed products in food consumption surveys, but regulatory bodies need a simpler, more objective way to identify ultra-processed food, and ideally one that can be applied globally,” said Barry Popkin, PhD, W.R. Kenan Jr. Distinguished Professor of Nutrition at the UNC Gillings Global School of Public Health, co-director of the Global Food Research Program, and the study’s first author.

For this study, researchers compared different methods for policies to identify products that are ultra-processed and/or high in fat, sugar and/or sodium (HFSS). They used one of the objective dimension of Nova Classification: whether a product’s ingredients list includes one or more additives from 12 Codex classes which are thought to enhance hyper-palatability and are considered markers of ultra-processing. These classes include hundreds of different additives used in food processing and included in product ingredient lists. Researchers tested the ability of four different profiling approaches combining different groups of these additives with the “high in fat, sodium, sugar, or calories” (HFSS) criteria from Chile’s nutrient profiling model to capture products that were both ultra-processed and HFSS. These profiling approaches include:

1. HFSS + contains non-nutritive sweeteners
2. HFSS + contains colors/flavors
3. HFSS + non-nutritive sweeteners + colors/flavors (combination of approaches 1 & 2)
4. HFSS + 12 Codex classes of additives (flavor enhancers, colors, emulsifiers, emulsifying salts, sweeteners, thickeners, anti-foaming, bulking, carbonating, foaming, gelling and glazing agents)

Researchers applied these four approaches on a sample of over 33 million food products purchased by a representative sample of roughly 60,000 US consumers in 2020. They found that scenario 4 was most effective, under which 100% of product purchases considered ultra-processed foods under Nova Classification would be targeted for policy intervention. In addition, their findings demonstrate that policies could achieve comparable results using a more streamlined profiling model that simply combines Codex colors and flavors with HFSS criteria, which missed only 1% of ultra-processed products.

Notably, if a policy intervention such as mandatory front-of-package warning labels or restrictions on marketing used this approach, nearly 75% of products purchased by U.S. households would be subject to regulation. This highlights the predominance of foods and drinks that do not build health in the US food supply.

This study is the first to show how to operationalize healthy food policies aimed at reducing ultra-processed product consumption using the ingredients list on food packages and can help inform policymakers as they design healthy food regulations such as front of package warnings, marketing restrictions, and taxes on ultra-processed products.

These findings are timely given increasing interest in and momentum behind policies targeting ultra-processed foods. A large-scale “umbrella” review published in the British Medical Journal last month highlighted the imperative to act, finding that exposure to ultra-processed food was associated with 32 different health risks related to mortality, cancer, and mental, respiratory, cardiovascular, gastrointestinal, and metabolic health outcomes.

“Countries around the world are currently trying to figure out how to best guide consumers away from ultra-processed foods and towards more whole or minimally processed options, whether that’s via updated dietary guidelines or policies that will incentivize purchase changes and protect consumers from harm,” said Popkin. “Our findings give policymakers one of the tools they need to implement effective policies towards this end.”

In the United States, the Food and Drug Administration is currently considering options for a front-of-package warning label, which under the current proposal would be applied only to products that contain more than 20% of certain nutrients’ recommended daily intake per serving. “Our study suggests that the FDA needs to go beyond looking at nutrients per serving and include profiling for Codex classes of additives, which number in the hundreds,” said Popkin.

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This study was funding primarily by Bloomberg Philanthropies.

AUTHORS

Barry M. Popkin
Donna R. Miles
Lindsey Smith Taillie
Elizabeth K. Dunford

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Read the full study in The Lancet Regional Health – Americas.

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Learn more about ultra-processed foods and the Nova classification system in our fact sheet:

A new study in the Journal of the Academy of Nutrition and Dietetics has found that 60% of foods purchased by Americans contain technical food additives such as coloring or flavoring agents, preservatives, or sweeteners. This represents a 10% increase since 2001. Manufacturers have also increased the average number of additives in purchased food and beverage products from 3.7 in 2001 to 4.5 in 2019. These findings indicate that prevalence of food additives is on the rise.

While food additives can extend shelf life and improve palatability, their health consequences are not fully understood, though mounting evidence points to high intake of ultra-processed foods — which often contain multiple additives — is connected to a multitude of health risks. Assessing food-additive exposure over time is a vital step in understanding its role in nutrition-related diseases, negative changes to the gut microbiome, and other adverse health outcomes associated with ultra-processed foods.

“Our research clearly shows that the proportion of ultra-processed foods with additives in Americans’ shopping carts increased significantly between 2001 and 2019. We observed this trend across all food and additive categories,” noted lead investigator Elizabeth K. Dunford, PhD, Food Policy Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia, and Department of Nutrition, Gillings Global School of Public Health, The University of North Carolina at Chapel Hill, USA.

By 2019, more than half of the overall packaged food and beverage products bought by U.S. households contained three or more additives. Furthermore, and perhaps most concerning, a 22% higher percentage of baby food purchases were ultra-processed and contained additives. “These findings give us reason for concern, given the growing evidence linking high consumption of processed foods with adverse health outcomes,” noted Dr. Dunford, adding that the investigators observed one positive trend, a decrease in the use of added flavors in carbonated soft drinks.

U.S. consumers purchase more than 400,000 different packaged food and beverage products each year at grocery stores, with new products constantly being added to shelves. Increased ultra-processed foods means that Americans are consuming more sugar, sodium, and saturated fats.

“With manufacturers producing foods and beverages with an increasingly higher number of additives, it is more important than ever to understand what is in the foods that Americans are buying and eating,” commented the study’s senior investigator, Barry Popkin, PhD, W.R. Kenan, Jr. Distinguished Professor, Department of Nutrition, Gillings Global School of Public Health, and the Carolina Population Center, The University of North Carolina at Chapel Hill, USA.

“U.S. consumers are demanding a much higher level of transparency from brands and retailers than in previous years. We hope the findings from this study will be used to inform policymakers on where Americans – especially babies – are being exposed to additives, and how the packaged food supply is changing,” Dr. Popkin said.

This is the first study to examine what U.S. consumers are purchasing – rather than relying on reported food and beverage intake – to evaluate exposure to food additives in ultra-processed foods, which is essential for assessing their role in the associated adverse health risks. The investigators used Nielsen Homescan Consumer Panel data from 2001 and 2019 to examine the proportion of products purchased by U.S. households containing four common technical food additives (colors, flavors, preservatives, and nonnutritive sweeteners) and to ascertain whether purchases have changed over time through the products’ scanned Nutrition Facts Panels. Previous research had been hampered by the lack of publicly available ingredient databases identifying and quantifying top additives in U.S. foods.

“The findings from this study could be used to inform policymakers on where American consumers are getting an increasing number of additives and how the packaged food supply is changing. The results can also set the foundation for future work in this area and provide direction for future researchers,” added Dr. Dunford. “At a minimum, I hope this work leads to further investigation into the types and amounts of ingredients being used in the manufacturing of baby food products.”

An accompanying editorial by Mona S. Calvo, PhD, and Jaime Uribarri, MD, of The Icahn School of Medicine at Mount Sinai, NY, New York, USA, cites the study’s contributions, “By providing data on exposure to food additives in ultra-processed foods found in grocery-purchased foods over time, Dr. Dunford’s team is leading the way with much-needed research. Their novel method enabled them to document food additive-exposure changes over time and by food and additive category,” said Dr. Calvo.

Dr. Uribarri added, “Most importantly, the authors’ unique approach enabled exposure estimates in the understudied, vulnerable populations of infants and children.”

Please refer to the detailed media release from the Journal of the Academy of Nutrition and Dietetics for more information about this study and additional resources.

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Funding for this study came primarily from Arnold Ventures, with additional support from the National Institutes of Health.

Read the full article in the Journal of the Academy of Nutrition and Dietetics (full text available free for 30 days).

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RESOURCES

Learn more about ultra-processed foods, their health risks, and policy approaches to curb consumption.

Low-income North Carolinians who received a monthly fruit and vegetable benefit during the COVID-19 pandemic enjoyed the flexibility to choose more and a greater variety of nutritious foods during a time of profound food insecurity, according to a new study in the Journal of Hunger & Environmental Nutrition.

Researchers from UNC-Chapel Hill interviewed participants in the Healthy Helping Fruit and Vegetable Program, which provided beneficiaries $40 per month to purchase fresh, frozen, or canned fruits and vegetables at a chain supermarket retailer. Funded by state allocations from the federal CARES Act and operated by Durham-based nonprofit Reinvestment Partners, the Healthy Helping program ran from June–December 2020 and was offered to adults enrolled in the Supplemental Nutrition Assistance Program (SNAP) who were experiencing additional food insecurity during COVID-19 pandemic.

“We know that targeted fruit and vegetable benefit programs work to increase access and improve dietary quality, but we wanted to learn more about the program experience from participants’ points of view,” said Molly De Marco, leader of the Food, Fitness + Opportunity Research Collaborative at the UNC Center for Health Promotion and Disease Prevention and the study’s lead author.

De Marco and colleagues conducted phone interviews with 10 participants from rural and urban locations and ranging in age from 34 to 72 years. Key themes that emerged included:

• Participants were thankful for the benefit. They purchased more and a greater variety of fruits and vegetables that would normally be outside their budget.
• Using Healthy Helping benefits freed up money to use on other expenses.
• Participants enjoyed being able to choose what foods to buy with the benefit. Several interviewees who were also enrolled in other food assistance programs (e.g., School Meals, USDA’s Farmers to Families Food Boxes, or Meals on Wheels) noted that a lack of choice in how, when, and what foods they received deterred them from continuing to use other programs.

The research team also surveyed a larger group of 200 participants to examine overall dietary quality and found that despite high levels of food insecurity, the foods and drinks consumed in Healthy Helping households were similar to those in the typical American diet.

“Based on previous research, we might expect these lower-income households with food insecurity to be eating fewer fruits, vegetables, and whole grains than higher-income households. Our finding that their diet quality was similar suggests some improvement among Healthy Helping households after enrolling in the program,” said Shu Wen Ng, co-author and Associate Professor of Nutrition and Co-Director of the Global Food Research Program. “We can’t be sure, though, since we had no dietary measures from before respondents enrolled in the program.”

This study supports previous research showing that targeted fruit and vegetable benefit programs are effective and well-liked. “Healthy Helping is a model that offers flexibility for families to make their own decisions about what and how much healthy food to purchase,” said first author Isabel Lu, Healthy Helping project coordinator. “With rising food costs due to inflation and ongoing supply-chain issues, low-income households continue to need greater financial access to healthier diets. Incentive programs like Healthy Helping can help fill this gap.”

Options for expanding programs like Healthy Helping could occur through SNAP, as an additional benefit, or through healthcare settings. Healthcare payers who share an interest in improving patients’ dietary intake and overall health are pilot testing such benefits as a reimbursable, “produce prescriptions.”

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This research was supported by the North Carolina Department of Health and Human Services from their Coronavirus Aid, Relief, and Economic Security (CARES) Act allocation via a grant to Reinvestment Partners.

AUTHORS

Isabel Lu
Brett Sheppard
Shu Wen Ng
Sarah Burstein
Emile Charles
Taylor Williams
Molly De Marco

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READ MORE ABOUT FOOD ASSISTANCE DURING THE COVID-19 PANDEMIC:

Changes to nutrition assistance programs during COVID-19

Increased WIC cash vouchers for fruits & vegetables

The typical American diet is high in red and processed meat, contributing to health risks and raising concerns for environmental sustainability. A study published this week in Public Health Nutrition used data from national diet surveys to look at which specific types of foods make up the bulk of U.S. red and processed meat intake among adolescents and adults.

The authors found that consumption is not dominated by any single food type. Americans most commonly consume unprocessed red meat in the form of burgers, steaks, and mixed dishes such as meatloaf, lasagna, or shepherd’s pie. For processed meats, the most widely eaten forms were deli cold cuts, sausages and frankfurters, pizza, and bacon.

The authors view this variety of food sources as an opportunity, in terms of efforts to reduce average intake or red and processed meats — currently around 450g per adult each week — towards the recommended limit of 100g per week.

“The ways in which Americans eat meat are quite diverse,” said Sarah Frank, PhD student at UNC-Chapel Hill and the study’s lead author. “While meat-centric foods like burgers are popular, we found that a lot of meat is actually consumed in mixed dishes like casseroles. This is exciting for behavior and policy work because it means there are a lot of opportunities to promote healthier, more sustainable, plant-based options into the diet beyond, for example, substitutes for a large cut of meat.”

Dr. Lindsay Jaacks, UKRI Future Leaders Fellow and Chancellor’s Fellow at the Global Academy of Agriculture and Food Security, adds: “Unlike dairy, for which more than 50% of intake comes from just one food group (milk), red meat is highly variable. This means there are a lot more opportunities to promote alternatives to red meat. But we need to be careful and closely monitor these alternatives to make sure environmental gains are not traded at the cost of public health.”

The authors note that for adolescents, concern about climate change might provide more inspiration to eat less meat. Adolescents were found to consume most of their meat from burgers and pizzas purchased at fast-food outlets.

This study was funded by the Wellcome Trust’s Our Planet, Our Health program.

AUTHORS

The Duke Endowment has awarded a $765,000 grant to Dr. Shu Wen Ng and colleagues Dr. Thomas Keyserling (UNC School of Medicine), Dr. Ashley Price (Duke University Department of Family Medicine and Community Health), and Neal Curran and Sam Hoeffler (Reinvestment Partners) to expand their research on the benefits of the food prescription programs.

Administered by the Durham-based nonprofit Reinvestment Partners in communities across North Carolina, the RPRx food prescription program provides $40 per month — distributed electronically through Food Lion’s customer loyalty program — for participants to buy fruits and vegetables.

Previous research has already found that this model is effective at increasing fruit and vegetable purchases, and higher use of the program is associated with fewer hospitalizations. With the new grant, Ng and colleagues will further investigate whether the RPRx program is associated with improved health outcomes and lower health care costs for communities. Their findings will provide valuable information about the program’s cost effectiveness and contribute to the evidence base for efforts to incorporate the food prescription program model into standard health care practice.

Read more about this grant and the researchers’ aims in Gillings School of Global Public Health’s school news.

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Based in Charlotte and established in 1924 by industrialist and philanthropist James B. Duke, The Duke Endowment is a private foundation that strengthens communities in North Carolina and South Carolina by nurturing children, promoting health, educating minds and enriching spirits. Since its founding, it has distributed more than $4 billion in grants. The Endowment shares a name with Duke University and Duke Energy, but all are separate organizations.

See also:
SuperSNAP helps food-insecure households afford healthy foods