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The Intersection of Diet Quality and Ultraprocessed Food Intake: Using Evidence-Based Categories to Characterize

Elise Sheinberg1, Laura A Schmidt1, Jerold R Mande1

  • 1Elise Sheinberg, Cindy W. Leung, and Deirdre K. Tobias are with the Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA. Laura A. Schmidt is with the Philip R. Lee Institute for Health Policy Studies and the Department of Humanities and Social Sciences, University of California San Francisco. Jerold R. Mande is with Nourish Science, Boston. Euridice Martinez-Steele is with the Department of Nutrition and Center for Epidemiological Studies in Health and Nutrition, University of São Paulo, Brazil.

American Journal of Public Health
|June 3, 2026
PubMed
Summary

Diet quality, not ultraprocessed food (UPF) intake alone, is key for cardiometabolic health. High UPF consumption combined with poor diet quality showed the worst health outcomes in US adults.

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Area of Science:

  • Public Health Nutrition
  • Cardiovascular Health
  • Dietary Assessment

Background:

  • Ultraprocessed food (UPF) consumption is a growing public health concern.
  • Understanding the interplay between UPF intake and overall diet quality is crucial for cardiometabolic health.
  • Previous research has not fully elucidated the combined impact of UPF and diet quality on health outcomes.

Purpose of the Study:

  • To investigate the combined effects of ultraprocessed food (UPF) consumption and diet quality on cardiometabolic health in US adults.
  • To determine whether diet quality or UPF intake is a stronger predictor of cardiometabolic biomarkers.

Main Methods:

  • Serial cross-sectional study utilizing data from 15,760 US adults (aged ≥20 years) from the 2009-2018 National Health and Nutrition Examination Surveys.
  • Diet quality assessed using Healthy Eating Index-2020 (HEI) scores (high, moderate, low, very low).
  • UPF consumption categorized as high (≥40% energy intake) or low (<40% energy intake) based on Nova classification; joint HEI-UPF categories analyzed for associations with anthropometric and cardiometabolic biomarkers.

Main Results:

  • A significant majority of US adults (45.3%) exhibited very low diet quality with high UPF consumption.
  • Individuals with very low HEI-high UPF intake displayed the least favorable metabolic profiles, including highest mean body mass index (29.6 kg/m²) and fasting glucose (106.2 mg/dL).
  • Only 0.3% of participants met criteria for high diet quality with low UPF consumption.

Conclusions:

  • Overall diet quality demonstrated a more consistent association with cardiometabolic health markers than ultraprocessed food intake alone.
  • Public health strategies should emphasize improving overall diet quality as a primary approach to enhance cardiometabolic health, irrespective of UPF consumption levels.
  • The findings highlight the critical role of dietary patterns beyond just the degree of food processing.