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341ANALESRANFwwwanalesranfcomUltra-processedFoodIntakeandRiskofCardiovascularDiseasea systematicreviewAmeliaMartidelMoral ySofíaAimiArrúeIshiyamaAnRealAcadFarmVol87nº3(2021)·pp339-350nutrientdensity(nutrientcontentinagivenvolumeoffood)islowerinhighlyprocessedfoodthaninunprocessedorminimallyprocessed foodsLowernutrientdensity suggests fewercontentoffiber,vitaminsmineralsprotectivebioactivecompoundstraceelementsandantioxidants(49) All thesecompoundscontainedin foodhavebeen shown tobe significantmultifactorialchronicdiseasespreventionfactorsinanumberofstudies(3)Moreover,UPFhaslowersatietyandahigherglycemicindexleading to theirexcessiveconsumption(1011)InadditionconsumptionofUPFisoftenlinkedtoasedentarylifestylewithunhealthyhabitssuchaslittleexercise smoking…(7) thereforeitisnot surprising that theconsumptionofUPFscanberelatedtoahigherriskofchronicdiseasessuchas type 2diabetesoverweightandobesity;allof whichmayincreasetheriskofcVD(12)However,establishingaclearrelationshipbetweenconsumptionofprocessedfoodsandhealthisagreatlycomplextask(13)thisisduetothewiderangeoffoods(withvastlydifferentnutritionalprofiles) thatmaybeclassifiedin the samenOVAgroupsinceithasa verylargeandgenericclassificationFurthermore fora typeofprocessedproduct(eg yoghurt)eachcompanyhasadifferentformulationwithvaryingconcentrationsofingredientsDespitenOVAclassificationbeingoverallapowerful toolitisalso veryreductionistandusesaqualitativeclassification whichmakesitdifficulttoclassifyfoodsintothecategorieswhenthereislimitedinformationavailable for somegiven foodsMisclassificationmayoccurifafoodfrequencyquestionnairecannotdeterminethedegreeofprocessingorspecificinformationaboutacertainfoodwhichmayaffect theaccuracyof studies this willbe takenintoconsiderationwhendiscussingtheresultstheaimofthispaperistoconductasystematicreviewtoassessthepossibleassociationbetweentheconsumptionofUPFsandtheriskofcVD2SUBJECTS ANDMETHODSFor theelaborationof this systematicreview, the standardinformativemethodscorrespondingtothePrIsMA(14)statementwere followedrelevantarticles wereidentifiedbya targeted searchofthePubMedscientificdatabaseforstudieswhichevaluatedtheintakeofUPFanditseffectontheriskofcVDthesearchstrategywasbasedon theuseofMesH termsrelated toultra-processed foodintake(Ultra-processedfoodOrFastfood)andtheireffectontheriskofcardiovasculardiseases(cardiovasculardiseaseOrcardiovascularrisk factor) Withsuch termsintroducedin thesearch field118results wereobtained 52references wereexcludedafterreadingtheabstractobtaining66articles screened tonarrowdown the searchinclusioncriteriawasappliedbasedonthefollowingconditions Articlesusedhad toa)have freeaccess to the full text;b)bescientificarticlespublishedinEnglishor spanish;c)be studiesdoneinhumans;d)beoriginalarticlesexcludingmeta-analysisandreviewsthetitlesand/orabstractsofthe36articlesobtainedinthe final search werereviewed toidentifyall those that wererelatedtotheobjectiveofthestudyandmettheinclusioncriteriaAtotalof31studieswereexcludedduetobeingstudiesondiseasesotherthancVDsuchasobesity,type2diabetesornotbeingrelatedtothetopicofinterestobtainingafinalselectionof 5articlessubsequently,relevantarticleswereevaluatedindetailtobefurtherincludedinthisarticleFurthermorefiveadditionalarticleswereincludedfromthereferencelistoftheselectedstudiesduringthefull-textreviewFigure1showstheflowdiagramwhichfollowingthePrIsMAstatementshows themethodologyused for thepreparationofthissystematicreview3RESULTSAllarticlesincludedin thisreview wererecentlypublishedissuedinthelastsixyears(2015-2021)regardingthedesignofthe studies four wereprospectivecohort studies(15-18) fourcrosssectional studies(19-22)and twomodel studies(23 24)Outof the10studiesidentifiedmostof them werecarriedoutinhigh-incomecountriesFivewereperformedintheUsA(16-1820-22)oneinspain(21)oneinFrance(15)andonein theUK(23) the twostudiesleftwereconductedinbrazil(1924)twostudieshadasamplesizegreaterthan100000subjects(1516); twostudieshadasamplesizeinbetween10000and99999subjects(1720)andthesmallestsamplesizewas56(19)Participantsin twoof theidentified studies(1617)had tobemiddleagedorelderly subjects(aged 50-71and 55-74) studypopulationsin theother studiesrequired subjects that wereatleast18 yearsoldhowever theaverageageof theparticipants wasshown tobein themiddle-agedrange(427(15)535(18)625(19))thestudiesconductedinspainandbrazilwerecross-sectionalstudieswheresubjectsweremenandpostmenopausalwomendiagnosedwithrheumatoidarthritisrespectively.therearecertainuniformitiesintheparametersusedinthe tenselectedstudies thenOVAsystemclassification wasusedinallstudiestodefinefoodaccordingtoprocessingwhichmakesitconvenienttogrouptheresultsobtainedandallowstosuggestadose-responserelationshipOnestudy(18)includedthecategory