Reducing the Children’s Intake of Ultra-Processed Foods: History
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Subjects: Public, Environmental & Occupational Health
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Myriam El Ati-Hellal

Excessive fat and fatty acids intake are associated with significant health hazards such as obesity or chronic diseases. The implementation of a relevant strategy for fat reduction, especially from ultra-processed foods, considered as low nutrient energy-dense products, is needed to promote health among children and prevent diet-related chronic diseases.

  • trans fatty acids
  • saturated fatty acids
  • ultra-processed foods
  • children
  • Tunisia

1. Introduction

Fatty acids are carboxylic acids with either saturated or unsaturated aliphatic chains [1][2][3]. Saturated fatty acids (SFA) have no double bonds, while unsaturated fatty acids have at least one double bond in their cis or trans configuration [4]. The main sources of SFA in the food supply are animal products, including meat and dairy products and processed foods, e.g., biscuits and cakes [2][5][6]. Trans fatty acids (TFA) are produced naturally in ruminants’ stomachs or industrially by partial hydrogenation of vegetable oils. Hydrogenation increases the melting point of fats, making it possible to convert fats from the liquid state to the semi-solid or solid-state [7][8]. The benefits of such a process are the increase of flavor stability and shelf life of unsaturated fatty acids.
The association between high dietary intakes of fat and mortality remains controversial. In this way, the main findings of a meta-analysis carried out on six randomized controlled trials which examined the association between dietary fat, serum cholesterol, and the risk of coronary heart disease (CHD) indicated there was no statistically significant difference in deaths from CHD between the intervention and control groups [9]. By contrast, several studies showed that the consumption of diets high in SFA increased the risk of mortality from all causes, cardiovascular disease (CVD), and cancer, and high dietary intakes of TFA were associated with higher all-cause mortality and CVD [8][10][11]. Because of these deleterious health effects, 2018 WHO draft guidelines on SFA and TFA intake for adults and children recommend reducing the intake of SFA and TFA to less than 10% and 1% of total energy intake, respectively. They suggest using polyunsaturated fatty acids as a replacement energy source, if needed [12].

2. Results

The characteristics of the study population according to gender are presented in Table 1.

Table 1. Characteristics of Tunisian children aged 3–9 years old.
Physiological Characteristics All Boys Girls
n % a n % n % a
Boys 582 50        
Girls 582 50        
Age (years)            
 3–4 350 33.8 191 36.5 159 31.0
 5–6 334 29.9 162 28.7 172 31.0
 7–8 307 23.2 149 22.6 158 23.9
 9–10 173 13.1 80 12.2 93 14.1
Socio-economic factors            
Economic level of the household            
 Upper tertile 383 32.2 187 31.5 196 32.9
 Medium tertile 392 34.1 197 34.0 195 34.1
 Lower tertile 389 33.7 198 34.5 191 33.0
Profession of household head            
 Upper/medium 507 44.4 247 42.9 260 45.8
 Employee/worker 637 54.0 324 55.3 313 52.8
 Not working/retired 20 1.6 11 1.8 9 1.4
Education of household head            
 University/Secondary 882 76.4 440 75.9 442 76.9
 Primary school or none 282 23.6 142 24.1 140 23.1
Profession of mother            
 Upper/medium 332 29.5 160 28.8 172 30.2
 Employee/worker 253 22.0 123 21.4 130 22.7
 Not working/retired 579 48.5 299 49.8 280 47.1
Education of mother            
 University/Secondary 878 76.5 433 75.4 445 77.6
 Primary school or none 286 23.5 149 24.6 137 22.4
Anthropometric characteristics            
 Stunting 16 1.4 10 1.7 6 1.0
 Underweight 37 3.0 19 3.1 18 2.9
 Overweight 311 26.0 151 25.2 160 26.7
 Obesity 122 9.9 65 10.7 57 09.1
a Weighted percentage.
The mean daily total fat, SFA and TFA intakes of boys and girls of all age groups are reported in Table 2. 
Table 2. Intake of total fat, SFA and TFA according to gender and age by Tunisian children aged 3–9 years old.
Nutrient Unit   Total Gender Age Groups
  Boys Girls p Value 3–4
Years Old		 5–6
Years Old		 7–8
Years Old		 9–10 Years Old p Value a
Fat total (g/d) Mean (s.e.) b 49.8 (0.5) 50.5 (0.7) 48.9 (0.6) 0.084 46.3 (0.8) 51.0 (1.0) 52.3 (0.9) 50.9 (1.2) 0.000
95% CI 48.7–49.7 49.1–51.9 47.6–50.1   44.7–47.8 49.0–52.9 50.6–54.1 48.5–53.3  
(% E) c Mean (s.e.) 29.6 (0.3) 29.6 (0.6) 29.6 (0.3) 0.931 29.2 (0.3) 30.4 (1.0) 29.3 (0.4) 29.2 (0.5) 0.968
95% CI 28.9–30.2 28.5–30.8 29.0–30.1   28.5–29.9 28.5–32.3 28.6–30.1 28.3–30.2  
SFA d (g/d) Mean (s.e.) 19.2 (0.2) 19.6 (0.3) 18.8 (0.3) 0.070 18.5 (0.4) 19.7 (0.4) 19.6 (0.4) 19.4 (0.6) 0.110
95% CI 18.8–19.7 19.0–20.2 18.2–19.4   17.8–19.2 18.9–20.5 18.7–20.4 18.1–20.7  
(% E) Mean (s.e.) 11.4 (0.1) 11.3 (0.1) 11.4 (0.2) 0.887 11.7 (0.2) 11.5 (0.2) 10.9 (0.2) 11.0 (0.3) 0.008
95% CI 11.2–11.6 11.1–11.6 11.1–11.7   11.3–12.0 11.2–11.9 10.5–11.3 10.5–11.5  
TFA e (g/d) Mean (s.e.) 0.24 (0.01) 0.26 (0.02) 0.23 (0.02) 0.158 0.29 (0.03) 0.25 (0.03) 0.24 (0.03) 0.13 (0.02) 0.000
95% CI 0.22–0.27 0.22–0.30 0.19–0.26   0.23–0.34 0.20–0.30 0.18–0.29 0.08–0.18  
(% E) Mean (s.e.) 0.15 (0.01) 0.16 (0.01) 0.14 (0.01) 0.219 0.18 (0.02) 0.15 (0.02) 0.14 (0.02) 0.08 (0.01) 0.000
95% CI 0.13–0.16 0.13–0.18 0.11–0.16   0.15–0.22 0.12–0.18 0.10–0.17 0.05–0.10  
a—Comparison between sexes adjusted for age. b—Weighted mean value (standard error). c—Energy percent. d—Saturated fatty acids. e—Trans fatty acids.
The percentage contributions of the major food groups to the fat and fatty acids intake in the total study population can be found in Table 3. Ultra-processed foods (mainly cheese, package cakes, pies and biscuits) were the major food sources of total fat, SFA and TFA intakes in Tunisian children with respective percentage contributions of 32.5%, 28.9% and 48.4%. Breakfast cereals were the second and the third main contributors to the total fat and SFA consumption, respectively. Dairy products were classified at the second and the fourth rank respectively for fatty acids and total fat intakes. Beverages and industrial juices did not contribute to the fat and fatty acids intake.
Table 3. Percentage contributions of the major food groups to the total fat, SFA and TFA intakes in Tunisian children.
Total Fat SFA a TFA b
Rank Food Group % c Rank Food Group % Rank Food Group %
1 Ultra-processed foods 32.5 1 Ultra-processed foods 29.0 1 Ultra-processed foods 48.4
2 Breakfast cereals 20.5 2 Dairy products 22.7 2 Dairy products 47.1
3 Vegetables, legumes and fruits 16.1 3 Breakfast cereals 17.3 3 Fat and oils 4.4
4 Dairy products 11.7 4 Vegetables, legumes and fruits 12.9 4 Breakfast cereals 0.1
5 Meat, fish and eggs 10.7 5 Meat, fish and eggs 10.8 5 Beverages and industrial juices 0.0
6 Fat and oils 5.8 6 Fat and oils 5.2 6 Meat, fish and eggs 0.0
7 Potatoes and grains 2.0 7 Potatoes and grains 1.6 7 Potatoes and grains 0.0
8 Beverages and industrial juices 0.2 8 Beverages and industrial juices 0.2 8 Vegetables, legumes and fruits 0.0
a Saturated fatty acids. b Trans fatty acids. c Percentage contributions of food groups.

3. Research Findings

The results revealed that ultra-processed foods (mainly cheese and cakes, pies and biscuits) were the greatest source of fat and fatty acids in Tunisian children, followed by breakfast cereals for total fat and dairy products for fatty acids. Ultra-processed foods are food products formulated mainly or entirely from processed ingredients, including little or no whole foods [13]. The early consumption of these products could lead to adverse health effects such as obesity or chronic diseases [14][15]. Therefore, it is important to understand the role of food processing and to formulate public health strategies to reduce the consumption of ultra-processed products early in life. Comparing food sources of fat and fatty acids is not easy because food groupings differ between the research studies. The definition of the food groups in the present study was based on the Tunisian food composition table and the USDA table [11][16]. The important contributions of ultra-processed foods, breakfast cereals, and dairy products in children and adolescents’ fat and fatty acids intake were also found elsewhere. 

Asakura and Sasaki (2017) reported that meat, dairy products, and confectionery were the three major sources of SFA in Japanese schoolchildren (26.4%, 25.7% and 11.3% of total SFA intake) [17]. According to Wang et al. (2018), meat, poultry and fish, milk and mixtures consisting mainly of grain were the leading food sources of saturated fats in US children [18]. The Korean study revealed that milk was the major food source of total fat and SFA in 3–5 years old children, with respective percentages contributions of 15.6% and 29.5%, followed by pork and eggs [19]. In Costa Rica, bakery products, red meat and dairy products were the main contributors to SFA and TFA intakes in adolescents [20], while fried eggs, whole milk, breakfast cereals and fresh cheese were among the major food sources of total fat and SFA in diets of Guatemalan schoolchildren [21]. The principal food groups contributing to the total TFA intake in Spanish children were milk (21%), processed baked goods (16%), sweets (12%), fast food (12%) and white bread (10%) [22]. These were comparable to those reported in the Canadian study [23]. Generally, the top three food groups contributing to the total fat and SFA intakes in European adolescents were meat, fish, eggs and meat alternatives (mainly meat), low-nutrient, energy-dense foods (mainly cakes, pies and biscuits) and dairy and soy products (mainly cheese) [24]. In the entry, the meat, fish, eggs and fish alternatives were the fifth main contributors to the total fat and SFA intakes in Tunisian children, with respective percentages of 10.7% and 10.8%. This result is probably due to differences in dietary habits between the Tunisian and other world populations. In Tunisia, the average annual meat consumption per capita was around 32.5 kg in 2015, close to the global average of 34.3 kg, but far from 69 kg in the European Union and 98.3 kg in the United States [25][26]. On the other hand, the mean annual consumption of lean meat in 2015 (19.4 kg for poultry and white meat) is much more important than the consumption of fatty meat (7.1 kg for sheep meat and 3.1 kg for bovine meat) [25]. The general food price index, which makes sheep and bovine meat proportionately more expensive than the other food products, could explain this trend of meat consumption among Tunisian people [27].

Given that a large proportion of Tunisian children exceeded the recommended levels of total fat and SFA intake, the implementation of several policy actions is necessary to prevent diseases and promote health in Tunisia. In this context, the WHO regional office has developed policy guidance with recommended actions for countries in the Eastern Mediterranean Region to reduce national fat intake. These recommendations include establishing mandatory labelling schemes for SFA content that are easily understandable for most consumers and replacing industrially-produced TFA with healthier oils and fats [28]. Future health policies should focus primarily on reducing the children’s intake of ultra-processed foods and increasing access to high nutritive quality foods such as vegetables, fruits, whole-grain products and animal source foods with health-promoting fats (e.g., fish) [29].

This entry is adapted from the peer-reviewed paper 10.3390/children9020126

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