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Distribution of the total energy intake and of the energy intake from added sugars according to food groups, and the mean content of added sugars of each food group

We used Gaussian regression to estimate the association between the dietary contribution of ultra-processed foods and the dietary content of added sugars, each expressed as proportions of total energy. This association was also explored after adjusting for the proportion of added sugars in non-ultra-processed energy intake. The dietary contribution of ultra-processed foods was transformed using restricted cubic spline functions to allow for non-linearity.

The average content of added sugars in the overall diet was compared across quintiles of the dietary contribution of ultra-processed foods. Poisson regression was used to assess whether the percentage of diets with more than 10% or 20% of total energy from added sugars increased across quintiles. This increase was also evaluated across demographic subgroups in stratified analysis. Tests of linear trend were performed in order to evaluate the effect of quintiles as a single continuous variable.

All regression models were adjusted for age (1–5, 6–11, 12–19, 20–39, 40–59, 60+ years), sex, race/ethnicity (Mexican-American, Other Hispanic, Non-Hispanic white, Non-Hispanic black, Other race including Multi-racial), ratio of family income to poverty (categorised on the basis of Supplemental Nutrition Assistance Program (SNAP) eligibility as 0.00–1.30, >1.30–3.50 and >3.50 and above) 14 and educational attainment of respondents, for participants aged 20+ years, and of household reference persons otherwise (<12, 12 and >12 years). Since 908 participants had missing values on family income and/or educational attainment, multivariable-adjusted analysis included 8409 individuals. The analysis which also adjusted for the added sugar content of all non-ultra-processed foods grouped together included 8335 individuals.

The NHANES sample weights were used in all analyses to account for differential probabilities of selection for the individual domains, non-response to survey instruments, and differences between the final sample and the total US population. The Taylor series linearisation variance approximation procedure was used for variance estimation in all analysis in order to account for the complex sample design and the sample weights. 14

To minimise chance findings from multiple comparisons, statistical hypotheses were tested using a two tailed p<0.001 level of significance. Data were analysed using Stata statistical software package V.12.1.

Distribution of total energy intake by food groups

The average US daily energy intake in 2009–2010 was 2069.5 kcal, and nearly three in five calories (57.9%) came from ultra-processed foods ( Prizma Leather dOrsay Pumps 15EKIu0k

Unprocessed or minimally processed foods contributed 29.6% of total calories, processed foods an additional 9.4%, and processed culinary ingredients the remaining 2.9%. The most common ultra-processed foods in terms of energy contribution were breads; soft drinks, fruit drinks and milk-based drinks; cakes, cookies and pies; salty snacks; frozen and shelf-stable plates; pizza and breakfast cereals. Meat, fruit and milk provided the most calories among unprocessed or minimally processed foods; ham and cheese, the most calories among processed foods; and table sugar and plant oils, the most calories among processed culinary ingredients.

Distribution of energy intake from added sugars by food groups

The average US daily intake of added sugars was 292.2 kcal ( Pelle Moda Bex Open Toe Patent Leather SlipOn Dress Sandals wfZMRWzi
). Notably, almost 90% of this (89.7%) came from ultra-processed foods. The main sources of added sugars among ultra-processed foods were: soft drinks (17.1% of US intake of added sugars); fruit drinks (13.9%); milk-based drinks (4.6%); cakes, cookies and pies (11.2%); breads (7.6%); desserts (7.3%); sweet snacks (7.1%); breakfast cereals (6.4%); and ice creams and ice pops (5.9%). In contrast, only 8.7% of the added sugars in the US diet came from processed culinary ingredients (table sugar consumed as part of dishes or drinks prepared from scratch by consumers or a cook), and only 1.6% from processed foods.

The average 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%) ( table 1 ).

In unadjusted restricted cubic splines Gaussian regression analysis, a strong linear association was identified between the dietary contribution (percentage of calories) of ultra-processed foods and the dietary content (percentage of calories) in added sugars (coefficient for linear term=0.20, 95% CI 0.17 to 0.23) ( Miz Mooz Carey qHTFayZghl

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