Trajectories of Nutritional Quality, Diet-Related Environmental Impact, and Diet Cost in China: How Much Does Ultra-Processed Food and Drink Consumption Matter?

Background: Rapid socio-economic developments confront China with a rising consumption of ultra-processed foods (UPFs) and ultra-processed drinks (UPDs). This study aims to evaluate their potential impact on diet transformation towards sustainability including nutrition, environmental sustainability, and diet-related cost. Methods: Dietary intake was assessed by 24 h recalls in 27,311 participants (age: 40.5 +/- 19.7; female, 51.1%) in the China Health and Nutrition Survey 1997-2011. The nutrient quality, environmental sustainability (greenhouse gas emission (GHGE), total water use (TWU), land use (LU), and diet cost were assessed as diet-related sustainability indicators. Foods and drinks were classified according to the degree of processing based on NOVA. Two-level mixed effects models were applied to explore the secular trends of the sustainability indicators being nested within random effect (individual level). Results: UPFs and UPDs are less nutrient-dense, containing more energy, sodium, and added sugar compared to unprocessed or minimally processed foods and drinks (MPFs and MPDs). UPFs and UPDs were higher for GHGE and TWU but lower for LU. Costs of UPDs tripled those of MPDs. In the period of 1997-2011, the percentage of UPFs and UPDs per 2000 kcal increased for both sexes. The increase in UPFs and UPDs was associated with a lower nutrient quality but a higher environmental impact and diet cost. Conclusions: From 1997 to 2011, there was a significant increase in the consumption of UPFs and UPDs in China. This trend had negative impacts on both the nutrient quality and environmental impact; meanwhile, it led to increased diet costs. Policies to reduce the production and consumption of UPFs and UPDs should be reinforced by making alternatives for ultra-processed breakfast cereals, snacks, and alcoholic beverages available and acceptable. Additionally, instead of only focusing on high-UPFD consumers, attention is needed on the currently low-UPFD consumers as their consumption has been growing rapidly in the last decades.