European Journal of Clinical Nutrition (2009) 63, S206–S225 & 2009 Macmillan Publishers Limited All rights reserved 0954-3007/09 $32.00 www.nature.com/ejcn ORIGINAL ARTICLE Contribution of highly industrially processed foods to the nutrient intakes and patterns of middle-aged populations in the European Prospective Investigation into Cancer and Nutrition study { N Slimani1, G Deharveng1, DAT Southgate2, , C Biessy1, V Chaje`s1,3, MME van Bakel1, MC Boutron-Ruault4, A McTaggart5, S Grioni6, J Verkaik-Kloosterman7, I Huybrechts1, P Amiano8, M Jenab9, J Vignat1, K Bouckaert1, C Casagrande1, P Ferrari1,28, P Zourna10, A Trichopoulou10, E Wirfa¨lt11, G Johansson12, S Rohrmann13, A-K Illner14, A Barricarte15, L Rodrı´guez16, M Touvier4,17, M Niravong4, A Mulligan5, F Crowe18, MC Ocke´7, YT van der Schouw19, B Bendinelli20, C Lauria21, M Brustad22, A Hjarta˚ker23, A Tjønneland24, { AM Jensen25, E Riboli26 and S Bingham5,27, 1Dietary Exposure Assessment Group, International Agency for Research on Cancer, Lyon, France; 28 Penryn Close, Norwich, Norfolk, UK; 3Institut Gustave Roussy, CNRS FRE 2939, Villejuif, France; 4Inserm, ERI 20, Institut Gustave Roussy, Villejuif, France; 5Department of Public Health and Primary Care, MRC Centre for Nutritional Epidemiology in Cancer Prevention and Survival, University of Cambridge, Cambridge, UK; 6Department of Preventive & Predictive Medicine, Nutritional Epidemiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; 7National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; 8Public Health Department of Gipuzkoa, Basque Government, San Sebastian and CIBER Epidemiologı´ay Salud Pu´blica (CIBERESP), Spain; 9Lifestyle and Cancer Group, International Agency for Research on Cancer, Lyon, France; 10Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece; 11Department of Clinical Sciences, Lund University, Malmo¨, Sweden; 12Department of Nutritional Research, University of Umea˚, Umea˚, Sweden; 13Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany; 14Department of Epidemiology, German Institute of Human Nutrition, Potsdam-Rehbru¨cke, Germany; 15Institute of Public Health of Navarra, Pamplona and CIBER Epidemiologı´a y Salud Pu´blica (CIBERESP), Spain; 16Public Health and Participation Directorate, Health and Health Care Services Council, Asturias, Spain; 17AFSSA (French Food Safety Agency), DERNS/PASER, Maisons-Alfort, France; 18Cancer Epidemiology Unit, University of Oxford, Oxford, UK; 19Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; 20Molecular and Nutritional Epidemiology Unit, ISPO, Florence, Italy; 21Cancer Registry, Azienda Ospedaliera ‘Civile-M.P.Arezzo’, Ragusa, Italy; 22Institute of Community Medicine, University of Tromsø, Tromsø, Norway; 23Cancer Registry of Norway, Oslo, Norway; 24Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark; 25Institute of Preventive Medicine, Copenhagen, Denmark; 26Department of Epidemiology, Public Health and Primary Care, Imperial College, London, UK and 27Diet and Cancer Group, MRC Mitochondrial Biology Unit, Cambridge, UK Correspondence: Dr N Slimani, Dietary Exposure Assessment Group, International Agency for Research on Cancer (IARC), WHO, Lyon, France. E-mail: [email protected] { The authors are deceased. 28Current address: Data Collection and Exposure Unit (DATEX), European Food Safety Authority, Parma, Italy. Guarantor: N Slimani. Contributors: NS initiated and wrote this paper, taking into account comments from all co-authors, and was the overall coordinator of this project and of the EPIC Nutrient DataBase (ENDB) project. CB carried out the statistical analysis and preparation of tables and figures. GD was in charge of recoding dietary data according to the project-specific food reclassification, under the supervision of NS and DATS. DATS acted as an external expert on food chemistry and helped withthe reclassification according to food processing methods. NS, GD, DATS, CB, VC, MMEvB, MCBR, AMcT, SG, JVK, IH, PA and MJ were members of the writing group and gave input on statistical analysis, drafting of the article and interpretation of results. MCBR, AMcT, SG, JVK, PA, PZ, AT, EW, GJ, SR, AKI, AB, LR, MT, MN, AM, FC, MCO, YTvdS, BB, CL, MB, AH, AT, AMJ and SB were local EPIC collaborators involved in collecting data, checking the project-specific food reclassification and documenting, compiling and evaluating the subset of their national nutrient databases used in the ENDB. ER is the overall coordinator of the EPIC study. All co- authors provided comments and suggestions on the article and approved the final version. Highly industrially processed foods in EPIC N Slimani et al S207 Objectives: To describe the contribution of highly processed foods to total diet, nutrient intakes and patterns among 27 redefined centres in the 10 countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). Methods: Single 24-hour dietary recalls were collected from 36 034 individuals (aged 35–74 years) using a standardized computerized interview programme (EPIC-SOFT). Centre-specific mean food intakes (g/day) were computed according to their degree of food processing (that is, highly, moderately and non-processed foods) using a specifically designed classification system. The contribution (%) of highly processed foods to the centre mean intakes of diet and 26 nutrients (including energy) was estimated using a standardized nutrient database (ENDB). The effect of different possible confounders was also investigated. Results: Highly processed foods were an important source of the nutrients considered, contributing between 61% (Spain) and 78–79% (the Netherlands and Germany) of mean energy intakes. Only two nutrients, b-carotene (34–46%) and vitamin C (28–36%), had a contribution from highly processed foods below 50% in Nordic countries, in Germany, the Netherlands and the United Kingdom, whereas for the other nutrients, the contribution varied from 50 to 91% (excluding alcohol). In southern countries (Greece, Spain, Italy and France), the overall contribution of highly processed foods to nutrient intakes was lower and consisted largely of staple or basic foods (for example, bread, pasta/rice, milk, vegetable oils), whereas highly processed foods such as crisp bread, breakfast cereals, margarine and other commercial foods contributed more in Nordic and central European centres. Conclusions: Highly industrially processed foods dominate diets and nutrient patterns in Nordic and central European countries. The greater variations observed within southern countries may reflect both a larger contribution of non/moderately processed staple foods along with a move from traditional to more industrialized dietary patterns. European Journal of Clinical Nutrition (2009) 63, S206–S225; doi:10.1038/ejcn.2009.82 Keywords: 24-h dietary recall; standardisation; processed foods; industrial foods; nutrient patterns; EPIC-SOFT Introduction sophisticated preservation and processing techniques that changed food structure, nutritional content, texture and Two major historical periods have introduced profound taste. These processing technologies varied according to food changes in human diet and other lifestyle factors. The types, and involved packaging, moisture removal, heat introduction of agriculture and animal husbandry in the treatments, chilling and freezing, acidity control, chemical neolithic period (B10 000 years ago) and more recently additives and irradiation (Karmas and Harris, 1988). New and the industrial revolution (B200 years ago) have led to an complex food products that combined natural and artificial increased consumption of certain foods (for example, dairy ingredients, including additives, thus became widely avail- products, cereals and cereal products, refined sugars, vege- able. Sugars, salt and fats, available at a relatively low table oils, salt) and of a myriad of processed foods that were cost, were also extensively used for preservation purposes, virtually absent from pre-agricultural hunter-gatherer diets to make foods more palatable or as convenient ingredients (Eaton et al., 1997; Cordain et al., 2005; Eaton, 2006). The to prevent rancidity and improve texture (for example, substitution of unprocessed or modestly processed foods by hydrogenated fats and margarine in cakes, biscuits and more complex, refined (highly processed) foodstuffs may bakery products) (van Erp-Baart et al., 1998). In the first have affected several metabolic and nutritional character- instance, these urban-industrialized food systems helped to istics of ancestral human diets that had remained unchanged improve life conditions and life expectancy and, with the over millions of years (for example, glycaemic load, fatty increasing availability of elaborate ready-to-eat foods and acid composition, macronutrient composition, micronutri- dishes, responded to time scarcity in food preparation and ent density, acid–base balance, sodium–potassium ratio and cooking (Jabs and Devine, 2006). Since the mid twentieth fibre content) (Cordain et al., 2005). The inability to adapt century, however, a growing body of scientific evidence genetically to these recent changes is hypothesized to be one suggests that increased consumption of industrialized foods of the possible explanations for the increased incidence of increases the risk