Guidance and perspectives on highly processed foods

The CFG has evolved over the past 80 years. It suggests that preparing foods with healthy ingredients and choosing healthier menu options (i.e., fresh or minimally processed foods) on a daily basis are ways to limit HPF consumption (Government of Canada 2019). The 2019 CFG was developed from the Evidence Review for Dietary Guidance 2015 (Health Canada 2016) and the Food, Nutrients and Health: Interim Evidence Update 2018 (Health Canada 2018a). These documents provide evidence that intakes of processed meats, sodium, added sugars, and saturated fats are strongly associated with adverse health outcomes (Health Canada 2018a). In Canada, intakes of saturated fats and added sugars in all age groups exceed recommendations (Kirkpatrick et al. 2019). Primary sources of saturated fats include cheese, red meat, butter, milk, baked products, processed meat, poultry, confectionary and frozen desserts, and margarines and oils. Primary sources of added sugars include sugar beverages, syrups, baked products, desserts, and sweetened yogurt. High sodium intakes result from consumption of bakery products, mixed dishes and processed foods (Kirkpatrick et al. 2019). According to Guideline 2, “processed or prepared foods and beverages that contribute to excess sodium, free sugars, or saturated fat undermine healthy eating and should not be consumed regularly” (Government of Canada 2019). However, Health Canada also recognizes that food processing has benefits. For example, processed foods may be healthy options if they contain little to no added sodium, saturated fat or free sugars. They are also convenient options, especially when fresh food is out of season, costly, or unavailable. Although there is convincing evidence that links excess consumption of sodium, saturated fat, and free sugars to negative health outcomes (Chen et al. 2020), Health Canada recognizes that not all processed foods are created equally and that the focus should be on reducing and limiting HPF in the general population.

Although there are recommendations that HPF should not be consumed regularly (Health Canada 2019), it is also important to consider the unintended consequences of avoiding them. Since there is no clear consensus on the definition of HPF, consumers may not know which foods to avoid. For example, Health Canada suggests including whole grains (e.g., quinoa, whole grain pasta, and bread) as an important component of healthy eating. However, under the NOVA classification 91% of Canadian grain-based foods meet the definition of ultra-processed (Gupta et al. 2019). Avoiding grain products may result in other health challenges such as inadequate intakes of dietary fibre and folic acid. In one study, individuals who consumed no grains had the lowest fibre intakes, whereas those who consumed whole or mixed grains had the highest fibre intakes (Hosseini et al. 2019). The goal of reducing HPF is to reduce risk of chronic disease; however, the question remains whether eliminating them entirely will improve nutrition and health or whether there will be unintended consequences. In the Physicians Health Study (Bazzano et al. 2005), those who consumed ≥ 1 serving/day of ready-to-eat cereals with whole or refined grains had significantly lower body weight than those who rarely consumed these foods. Furthermore, ready-to-eat cereals have been inversely associated with risks of obesity, cardiovascular disease, type 2 diabetes, and certain cancers (Cho et al. 2013; Xu et al. 2016). Total breads, total grains, cereals, refined grains, and white or total rice (both minimally processed foods) (Jones et al. 2020) have been found to be associated with increased risk of cardiovascular disease or all-cause mortality. Another example is sweetened yogurt, which under the NOVA classification is an UPF, but has been associated with a lower risk of several health outcomes such as obesity and type 2 diabetes (Mozaffarian et al. 2011; Mozaffarian 2016). However, although these benefits are only half of that of plain yogurt, sweetened yogurt still contributes to higher calcium intakes and has not been shown to negatively impact body weight (Mozaffarian et al. 2011). In addition, there are HPF that meet a health need such as gluten-free crackers for those with celiac disease and lactose-free milk for those lactose intolerance. Finally, while reducing HPF intake could theoretically be favourable towards preventing obesity and chronic diseases, the reality is more complex. Therefore, it is important to focus on dietary patterns rather than specific foods.

Additionally, HPF serve an important role today as food preparation must fit a consumer's time, skill, budget, and other resources. Historically, in the 1900s, women spent approximately 6 hours/day in food preparation. In the present context, the pressure of time is difficult and a return to minimally processed foods will result in greater food preparation time in the home, which is not currently available in most Canadian households. Certainly, homes with more children have also been shown to use more HPF dinner products (including fast food) than households with fewer children, potentially due to the decreased cost of some processed foods, but also less time for food preparation (Djupegot et al. 2017). There is also evidence that as a parent's cooking skills decrease, intake of processed foods increases (Martins et al. 2020). Over the past several decades, food skills have been on the decline (Government of Canada 2010). Men's cooking skills, specifically, may be limited compared with women, and men tend to consume more HPF and fast food than women (Djupegot et al. 2017). These factors may have an important impact on healthy eating and the health of Canadians. However, with current initiatives in communities and schools to address food literacy and culinary skills, there may be room for improvement (Doustmohammadian et al. 2020).

HPF have application in the clinical setting. There are several challenges to food provision in both hospital and long-term care and meeting the nutritional needs of individuals in these settings. Food is not prioritized in many hospitals and patients have experienced organizational mealtime and eating environment barriers (Keller et al. 2015). In a study of 16 hospitals, the most important attributes to patients were found to be taste, freshness, if the food meets dietary needs, right temperature, sufficient amount, and easy to eat (Trinca et al. 2022). Patients who eat less than 50% of offered food in their first week in hospital are more likely to deteriorate and stay in the hospital longer due to the dislike of foods or reduced intake due to illness (Allard et al. 2015). There is also a potential disconnect between clinical care and food service, resulting in dietitians not being as involved in the planning of menus. This can result in disparities between patient needs and food offered, further negatively affecting dietary intake. Due to these challenges, there is a place for caloric and nutrient dense foods, some of which are HPF to prevent malnutrition and support recovery.

With respect to food intake, in long-term care, one-third of nutrients are inadequately consumed with high proportions of residents consuming below the Estimated Average Requirement for the nutrient (Keller et al. 2018). As malnutrition is common at 44% (Keller et al. 2020, identifying ways to improve intake is important. Although there is variety and the food may be appealing in terms of visual acceptability, many long-term care residents have reported not recognizing the food or disliking the taste (Pizzola et al. 2013). The CFG is traditionally used for menu planning in long-term care (Duizer and Keller 2020); however, there is provincial variation in nutritional quality of menus due to funding for food and food services (Vucea et al. 2017). Drivers of menu planning in long-term care include ministry standards (Duizer and Keller 2020; Lagace et al. 2020), funding, time, and labour capacity. Ready prepared foods are labour-saving, but the average sodium content may be as high as 3000–3500 mg/serving in some dishes. This creates a public health challenge wherein, nutrient and caloric dense products are needed by those with poor appetite, chewing, and swallowing problems—but these same foods may have excess sodium that impact other health conditions of residents. To limit sodium intake for the day to <3000 mg may lead to significant malnutrition in these residents. Commercially-sourced food, which would be defined as HFP, are often needed to mitigate malnutrition in clinical settings, and careful selection of products to consider sodium content is needed.

In long-term care, food is as much about quality of life as it is about nutrition. In 2020, the Dietitians of Canada, Canadian Malnutrition Task Force, Canadian Nutrition Society, and Ordre professionnel des diététistes du Québec developed a document for menu planning in long-term care including policy recommendations on commercial and prepared foods (Armstrong et al. 2020). As these foods may promote quality of life and satisfaction, their inclusion on the menu is based on resident consultation. Although select items are high in sodium, these preferred foods are commonly offered in Canadian long-term care homes. These prepared foods may also be useful in this setting to support malnourished residents, those with dysphagia, poor appetite, and dementia.

Innovative and nutrient-dense enhanced products are needed for some clinical populations and food producers are responding. For example, there are high protein milk powders, plant-based protein powders and products, protein-enhanced cereals and soups, and protein-enhanced eggs and egg products. Food in healthcare settings requires improvement in nutritional content and sensory quality and the food industry is responding with what would be considered by NOVA as UPF and by CFG as HPF.

Dietary recommendations must be clear, affordable and actionable, and applicable to all lifestyles and consumer segments to support public health goals. It is important to be mindful of how consumers interpret the information and guidance from the CFG and how behaviour change is promoted using food labels in terms of what consumers are selecting and eating. Although CFG recommendations are to reduce consumption of HPF and replace them with healthier options (e.g., nuts, fruits and vegetables, protein foods), providing clear directives and understandable ways to decrease consumption of added sugars, sodium, and saturated fat must be provided to consumers so that they do not appear overly restrictive. Food label literacy is an important way to support consumers in choosing processed foods with lower levels of these nutrients to limit. Furthermore, clear definitions of HPF should be considered by Health Canada as we move forward. New nutrition labeling regulations for packaged foods that require a symbol on the front of packages indicating that a food is high in saturated fat, sugars and/or sodium have recently come into effect (Government of Canada 2022). Front-of-pack symbols coupled with the Nutrition Facts Table would also help consumers choose healthier options and focusing more on dietary patterns rather than specific foods is key. Therefore, examining dietary advice with a focus on reducing HPF has merit and environmental impact from a holistic standpoint.