July/August 2021

Eating Out of the Box or Bag
By KC Wright, MS, RDN
Today’s Geriatric Medicine
Vol. 14 No. 4 P. 10

A diet of ultraprocessed foods fuels diabetes.

The projected prevalence of diabetes among US adults in the coming few decades presents a grim image, as the disease is expected to nearly triple from 22.3 million adults (9.1% of the population) in 2014 to 39.7 million (13.9% of the current population) in 2030, and soar to 60.6 million people (17.9% of the current population) by 2060.1 Based on today’s population, that's 1 in 6 adults with diagnosed diabetes.

Consider this burden on society, our health care system, and the national economy. Medical costs for a person with diabetes are more than twice those for a person without diabetes. Yet despite advancements in medication and technological treatments, clinical target goals for diabetes have not been met—or worse, have reversed—since 2005.2

It’s well established that diabetes is a complex and challenging disease and one that relies on numerous daily self-care decisions for effective management and improved outcomes. This requires both attentive clinical care as well as extensive education services. People with diabetes need detailed instructions and demonstrations to monitor blood glucose, manage medications, practice healthy eating, manage weight, be physically active, and practice personal strategies to cope with psychosocial issues every day.

Diet is both a critical and modifiable risk factor for diabetes that has traditionally focused simply on the nutritional merits of certain foods. Yet modern changes in our food supply—in which food undergoes multiple physical, chemical, and/or biological processes before combining with additives—has raised questions beyond the nutritional density of food. In fact, the significance of the health impacts of industrial processing of food has been generally understated.3 Ultraprocessed foods (UPFs) are formulations of industrial sources of dietary energy and nutrients, particularly unhealthy fats, starches, sugars, and salt, plus additives, including those designed to intensify sensory impact.4 The NOVA Food Classification system, designed by the Center for Epidemiological Studies in Health and Nutrition at the University of Sao Paulo in Brazil, categorizes food and beverages according to the extent and purpose of industrial processing. It’s recognized as a valid tool for nutrition and public health research and policy.

Research Links UPFs to Diabetes
The concept of UPF as a descriptor of unhealthy foods within the overall diet is increasingly recognized in the scientific literature and among nutrition experts, while influence of their consumption on risk factors for diet-related disorders is becoming more evident.5 Population-based studies have shown that UPFs are typically high in energy density, sugar, unhealthy fats, and salt, while being low in fiber, protein, vitamins, and minerals. Recent research has shown that as consumption of UPF increases, measures of cardiovascular health decreases.6 A randomized controlled crossover trial observed that participants had higher energy intake and weight gain while consuming a UPF diet, whereas they lost weight when consuming a non-UPF diet.7 Still other research suggests that UPF consumption was associated with increased risk of cancer, mortality, depression, and irritable bowel syndrome.8

A large observational prospective study had more than 100,000 adults keep 24-hour dietary recall records designed to identify more than 3,500 food items categorized according to degree of processing by the NOVA classification system.8 Consumption of UPF was associated with a higher risk of type 2 diabetes (T2D) and remained significant after adjustments for several markers of the nutritional quality of the diet, other metabolic comorbidities, and weight change. Specifically, the absolute amount of UPF consumption in daily grams was consistently associated with T2D risk, even when adjusting for unprocessed or minimally processed food intake. Remarkably, a 10% increase in UPF in the diet was associated with a 15% higher risk of T2D.

UPF Mechanism of Action
Biological mechanisms tying UPF to diabetes and other diseases have yet to be fully defined. However, it’s important to keep in mind that the cellular structure of foods is altered by processing, and that additives likely have some influence. Commonly consumed processed foods and drinks have been implicated by researchers and health professionals in obesity and various chronic noncommunicable diseases.3 Some UPFs that are heated to high temperatures or undergo an extruding process may cause contaminants to form. For example, acrylamide, a chemical produced in some foods during high-heat cooking such as deep-frying, has been associated with insulin resistance. In addition, urinary markers of polycyclic hydrocarbons, produced from industrial food processing, were positively associated with diabetes.8 Certainly, regular and high intake of UPFs, especially those that are energy-dense foods high in sugar, fat, and salt, can gradually displace the consumption of healthy, whole foods, including vegetables and fruits as well as minimally processed home-prepared meals.

Experimental data suggest that the more food is processed, the higher glycemic response and the lower its satiety potential.9 Factors introduced during the processing of food are associated with promoting inflammation-related processes through diet-microbiome-host interactions.10 As UPFs often lack fiber, these foods might not be as filling as are minimally processed foods and may perpetuate overeating, leading to high glycemic loads.4 High-intensity flavoring (in products such as Flamin’ Hot Cheetos or Doritos) make UPFs extremely palatable, which may override natural satiety signals.7

UPFs often have much longer shelf lives compared with unprocessed or minimally processed foods, mainly due to the use of preservatives. During the many months that UPFs can be held in storage, the potential exists for packaged materials to migrate into the food, such as bisphenol A—a known endocrine disruptor associated with an increased risk for T2D in a recent meta-analysis of observational studies.11 Phthalates also used in food packaging have shown to be associated with adverse health outcomes, including diabetes.6

UPFs Dominate Diets
Food processing itself is not the issue, as almost all foods are processed to some extent—for example, as basic as peeling, chopping, and boiling down whole apples to make applesauce. Adding sugar to the applesauce adds another layer of processing, as would heat treatment and canning for safe preservation. The NOVA system is characterized by four categories that detail the degree to which a food is processed: unprocessed or minimally processed foods, such as those that have been cleaned or fruits or vegetable that have had inedible or unwanted parts removed; processed culinary ingredients such as oils from plants; processed foods with added salt, sugar, and/or fat, such as bread; and foods categorized as ultraprocessed, which have undergone several processing steps using multiple ingredients, such as a frozen dinner entrée.4

Sophisticated marketing strategies with large budgets, mutually beneficial partnerships with retailers to secure prime shelf space, and the establishment of franchise outlets all contribute to the promotion and growth of UPF consumption. When considering the many foods categorized as UPFs, including sodas and energy drinks (as well as other beverages with added sugars, colorings, and flavorings); sweet or savory packaged snacks; candies; commercially baked breads; margarines and condiments; store-bought cookies, pastries, cakes, and cake mixes; breakfast cereals; chicken nuggets; fish sticks; sausage; hot dogs; and instant foods to reconstitute, it’s easy to see how they prevalent they are in our daily diets. In fact, UPFs already comprise more than 50% of the total energy consumed in high-income countries such as the United States, Canada, and the United Kingdom.4 Since last year, research has shown that the high frequency of UPF has become even worse over the course of the worldwide lockdown caused by the coronavirus.12

Most countries do not address how types of processing affect the nature and quality of foods in their national dietary guidelines. In the United State, the 2020–2025 Dietary Guidelines for Americans advise limited intake of sugars, saturated fat, and sodium with mention of affiliated foods, but there’s no focus on the industrial processing of these products. Concerns over food additives are mainly confined to toxicity or other forms of contamination—certainly critical issues—yet little attention is given to the other important issues of adulteration. Additives include the use of cosmetics (flavors, colors, and emulsifiers) that combine with modified oils (eg, hydrogenated vegetable oils), refined sugars and starches, and sodium to make products with both visual appeal and palatability. The food industry is not required to list processes used to manufacture its products on the food label, nor is it required to identify a certain percentage of an ingredient contained. Food ingredients are listed on the label in order of predominance by weight. Yet sometimes it may be difficult to identify UPFs with confidence (see sidebar “What Are Ultraprocessed Foods?”).4

In general, a food is ultraprocessed if the product contains a substance never or rarely used in a home kitchen. To some, UPFs are not considered “real food.”4 There is a plethora of highly processed gluten-free food products on the market, along with other food products marketed to be help regulate blood glucose, reduce weight, add protein to the diet, and more. Many of these products, bearing what appear to be health claims, may actually be more detrimental to health due the amount of industrial processing of the food.

Diabetes Self-Management Education and Support
In the landmark Diabetes Prevention Program, participants ages 60 and older assigned to an intensive lifestyle intervention for diabetes experienced a 71% reduction in incidence of T2D compared with those assigned to follow standard lifestyle interventions for diabetes. This decrease was the highest among any age group, demonstrating that older adults reaped the greatest benefit from lifestyle interventions.13

Similar results may be achieved by adhering to recommendations in the consensus report “Diabetes Self-Management Education and Support in Adults With Type 2 Diabetes,” published last year, which reinforces the value of medical nutrition therapy (MNT). When a person at risk for or diagnosed with diabetes is referred for MNT, a registered dietitian nutritionist can help patients manage food plans and plan meals to enhance their quality of life and reap improved outcomes. In fact, MNT has been shown to reduce A1c by up to 2%, which makes it an essential component at diagnosis and regular follow-up appointments.2

The 2020 consensus report is directed at the entire health care team to provide and modify diabetes self-management education and support (DSMES) at four critical times of patient contact: at diagnosis, annually and/or when the client isn’t meeting treatment targets, when complicating factors develop, and when transitions in life and care occur. When DSMES is provided using best practices, strong evidence suggests optimal outcomes. Yet, despite its proven benefits, the number of people referred to DSMES and who receive it is significantly low.2 Barriers created both by providers and patients need to be addressed with intentional interventions by the health care team. DSMES services can connect directly with primary care for effective cost-saving, high-impact resource to enhance a person’s ability to manage diabetes.

Eating for Healthy Aging
A narrative review that systematically identified and appraised findings of studies on healthy subjects investigated associations between levels of UPF consumption and health outcomes.5 Diets higher in both unprocessed and minimally processed foods were associated with beneficial health outcomes. A whole-foods, plant-based eating pattern generally includes legumes, whole grains, vegetables, fruits, and nuts, and is high in dietary fiber. All these foods have been found to be protective against diabetes. Cohort studies strongly support the role of plant-based diets in reducing the risk of T2D, while evidence from observational and interventional studies demonstrates the benefits of plant-based diets in treating T2D.14

Although the macronutrient profile to help prevent and treat T2D remains somewhat controversial, this research suggest that the focus should instead be on eating patterns and actual foods. Evidence further notes that unrefined carbohydrates are better than refined for managing blood glucose. Plant-based diets may help moderate insulin resistance, manage body weight, and increase food-microbiome interactions. Improved outcomes for both cardiovascular disease and certain cancers have also been achieved when following a mostly plant-based diet.14 To that end, Kaiser Permanente and other large health care systems promote plant-based diets for all of their patients as a cost-effective, low-risk intervention that simultaneously addresses numerous chronic diseases (which also influences the rising cost of health care).

With MNT, a registered dietitian nutritionist can assess and counsel patients and solve problems to define a healthy food and menu plan to meet individual needs (see sidebar “Dietary Advice for Older Adults”). The National Institutes of Health’s National Institute on Aging provides extensive complimentary resources for older adults that are practical and engaging, from online meal plan and sample menus (nia.nih.gov/health/sample-menus-healthy-eating-older-adults) to a colorful, easy-to-read book on healthy eating for older adults that’s available online or to order as reprints for clinic use (order.nia.nih.gov/publication/whats-on-your-plate).

Address UPFs in Practice
The increasing prevalence of diabetes requires accountability by all stakeholders, from every member of the health care team to individual patients and their families. As more research has begun to tie UPF to diabetes and other noncommunicable diseases, with significant and graded associations, both health care providers and public policy advocates need to advise people to reduce and eliminate the volume of these products in the diet. Primary care providers and geriatricians alike need to acknowledge the overreliance on UPF that has displaced vegetables, fruits, and home-prepared meals as part of a typical diet.

UPFs are increasingly associated with poor nutrition and health, yet are modifiable risk factors that play a role in the etiology of diabetes. Although more research is needed on the effects of UPF and diabetes, available data already provide evidence to support the need for public health policy that would recommend limiting purchase and consumption of UPF.8 This may help close the gap in effectively modifying diets to reduce disease risk, to work toward improved health of both individuals and populations, and to reduce the prevalence of diabetes.

— KC Wright, MS, RDN, is a research dietitian and nutrition writer. She can be found at wildberrycommunications.com.

WHAT ARE ULTRAPROCESSED FOODS?4
UPFs are defined within the NOVA classification system, which groups foods according to the extent and purpose of industrial production. During processing, manufacturers are able to fraction whole foods into substances and chemically modify and reassemble them and to incorporate additives and package the foods distinctively. Processes and ingredients used to manufacture UPFs are designed to create highly profitable, convenient, hyperpalatable food products that most often displace whole unprocessed or minimally processed foods.

UPFs can be identified when at least one of the ingredients listed is an unfamiliar food substance—one that’s never or rarely used in a home kitchen, such as high-fructose corn syrup, hydrogenated or interesterified oils, or hydrolyzed proteins, or classes of additives to increase appeal—such as flavors, colors, emulsifiers, salts, sweeteners, thickeners, and antifoaming, bulking, carbonating, foaming, gelling, and glazing agents.

DIETARY ADVICE FOR OLDER ADULTS
• Eat mostly whole foods.

• Most meals and snacks should comprise a variety of vegetables and fruits, including legumes and lentils. Fresh, frozen, and canned produce (especially reduced/low sodium or no salt added) are all healthful options.

• Choose breads, cereals, crackers, rice, and pastas that are made with 100% whole grains most often.

• Enjoy dairy products that are low in fat.

• Vary protein foods, including lentils, legumes, seafood, lean meat, poultry, eggs, and nuts, throughout the week.

• Limit sodium by comparing labels of similar foods that include added sodium. Use table salt sparingly.

• Limit foods high in saturated fats, including desserts, fried foods, pizza, processed meats (eg, sausage, hot dogs). Use liquid oils instead of butter and margarine.

• Limit foods containing added sugars (consider added sugar contents of yogurt, energy bars, and ready-to-eat cereals, especially).

• Drink plenty of unsweetened beverages throughout the day.

• Enjoy the taste, texture, and satiety that food brings you by being mindful while you eat. Avoid oversized portions.

• Be physically active daily.

— Source: Academy of Nutrition and Dietetics. Eating Right for Older Adults. https://www.eatrightpro.
org/-/MEDIA/FEATURE/EATRIGHT/CAMPAIGN/NNM2021/TIP_SHEETS/EATING-RIGHT-TIPS-FOR-OLDER-ADULTS-2021_ENGLISH_FINAL.PDF?LA=EN&HASH=F0C8C75856ADEB7E3B3E615262
BDD25B1D8799C1. Published 2021. Accessed April 12, 2021.

References
1. Lin J, Thompson TJ, Cheng YJ, et al. Projection of the future diabetes burden in the United States through 2060. Popul Health Metrics. 2018;16(1):9.

2. Powers MA, Bardsley JK, Cypress M, et al. Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the American Diabetes Association, the Association of Diabetes Care and Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Care. 2020;43(7):1636-1649.

3. Monteiro CA, Cannon G, Lawrence M, da Costa Louzada ML, Machado PP; Food and Agriculture Organization of the United Nations. Ultra-processed foods, diet quality, and health using the NOVA classification system. http://www.fao.org/3/ca5644en/ca5644en.pdf. Published 2019. Accessed April 3, 2021.

4. Monteiro CA, Cannon G, Levy RB, et al. Ultra-processed foods: what they are and how to identify them. Public Health Nutr. 2019;22(5):936-941.

5. Elizabeth L, Machado P, Zinöcker M, Baker P, Lawrence M. Ultra-processed foods and health outcomes: a narrative review. Nutrients. 2020;12(7):1955.

6. Zhang Z, Jackson SL, Martinez E, Gillespie C, Yang Q. Association between ultraprocessed food intake and cardiovascular health in US adults: a cross-sectional analysis of the NHANES 2011-2016. Am J Clin Nutr. 2021;113(2):428-436.

7. Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause excess calorie intake and weight gain: an inpatient randomized controlled trial of ad libitum food intake. Cell Metab. 2019;30(1):67-77.e3.

8. Srour B, Fezeu LK, Kesse-Guyot E, et al. Ultraprocessed food consumption and risk of type 2 diabetes among participants of the NutriNet-Santé Prospective Cohort. JAMA Intern Med. 2020;180(2):283-291.

9. Fardet A. Minimally processed foods are more satiating and less hyperglycemic than ultra-processed foods: a preliminary study with 98 ready-to-eat foods. Food Funct. 2016;7(5):2338-2346.

10. Zinöcker MK, Lindseth IA. The Western diet-microbiome-host interaction and its role in metabolic disease. Nutrients. 2018;10(3):365.

11. Hwang S, Lim JE, Choi Y, Jee SH. Bisphenol A exposure and type 2 diabetes mellitus risk: a meta-analysis. BMC Endocr Disord. 2018;18(1):81.

12. Ruíz-Roso MB, de Carvalho Padilha P, Matilla-Escalante DC, et al. Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study. Nutrients. 2020;12(8):2289.

13. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.

14. McMaken M, Shah S. A plant-based diet for the prevention and treatment of type 2 diabetes. J Geriatr Cardiol. 2017;14(5):342-354.