超加工食品（ultra-processed foods, UPFs）是经过一系列复杂的加工工序并添加糖、油、盐以及一系列工业配料而制成的即食的、可口美味的食品，通常具有高能量密度和低营养素密度的营养特点。近几十年来，UPFs的消费量在全球范围内急剧增加，研究显示，高UPFs摄入会增加成人超重/肥胖、2型糖尿病、高血压、癌症、心脑血管疾病发生/死亡、全因死亡、抑郁症、孕妇体重过度增加、子痫前期、妊娠期高血压、妊娠期糖尿病及儿童青少年超重/肥胖等健康问题的发生风险。目前我国对UPFs和健康关系的研究较少，基于UPFs已知的健康危害，我国需要进行更多的深入研究，以期更好地了解UPFs与健康之间的关系。
上海中医药大学公共健康学院钟佳倩、复旦大学公共卫生学院余江月等撰文《超加工食品消费及与健康关联的研究进展》。文章回顾了UPFs的定义、营养特点、国内外消费现状，重点探讨了超加工食品对人体多种健康结局的影响，并从加工生产角度探讨造成UPFs对人体健康影响的可能原因，以期更好地了解UPFs与健康之间的关系，为我国开展UPFs的相关研究提供思路。文章刊登于《环境与职业医学》2024年11月刊。本文通信作者为上海市疾病预防控制中心臧嘉捷、孙卓。
编辑部邀请到论文一作钟佳倩、余江月为读者带来研究的精彩解读，请点击观看。
来源：https://www.jeom.org/
阅读目录
UPFs的定义和营养特点
UPFs的历史
UPFs国内外消费现状和趋势
UPFs和多种健康结局
4.1 UPFs和超重/肥胖
4.2 UPFs和2型糖尿病
4.3 UPFs和心血管疾病
4.3.1 UPFs和高血压
4.4 UPFs和癌症
4.5 UPFs和全因死亡
4.6 UPFs和焦虑抑郁
4.7 UPFs对特殊人群健康结局的影响
UPFs影响健康的可能因素和机制
5.1 UPFs的优势引起饮食结构的改变
5.2 UPFs中碳水化合物与脂肪共同暴露增加摄食欲望
5.3 UPFs加工过程产生有害化合物
5.4 UPFs包装材料的外源性食品污染物迁移
5.5 UPFs中食品添加剂的添加
结语
正 文
随着现代科技进步和商业化发展，天然食物加工为高能量密度、高脂肪、高精制碳水的食品成为越来越普遍的现象。超加工食品（ultra-processed foods, UPFs）的普及与多种健康结局的关系也引起了学者和公众的关注，但有关超加工食品对健康影响的研究仍存在一些争议。本文将回顾UPFs的定义、营养特点、国内外消费现状，重点探讨超加工食品对人体多种健康结局的影响，并从加工生产角度探讨造成UPFs对人体健康影响的可能原因，以期更好地了解UPFs与健康之间的关系，为我国开展UPFs的相关研究提供思路。
1. UPFs的定义和营养特点
2. UPFs的历史
3. UPFs国内外消费现状和趋势
向上滑动阅览
UPFs的消费量在发达地区持续处于较高水平，美国[9]、英国[10]和加拿大[11]等高收入国家（high-income countries, HICs）中，UPFs人均供能比分别高达57.9%、56.8%和45.1%；巴西[12]、智利[13]、墨西哥[14]等中等收入国家UPFs人均供能比也分别达到19.7%、28.6%和29.8%。UPFs在中国的消费量于近几十年内急剧增加，1990年至2019年的估计数据表明，中国人群工业加工食品摄入的供能比已从1.5%增长到28.7%[15]。
2019年全球超加工固体食品（ultra-processed solid foods, UPSFs）和超加工饮料（ultra-processed beverages, UPBs）的销售数据显示，UPSFs在HICs的人均消费量（每年109.3 kg）远高于其他国家，分别达到中等偏上收入国家（upper-middle-income countries, UMICs）和中等偏下收入国家（lower-middle-income countries, LMICs）人均销售额的3.4倍（每年32.3 kg）和11.3倍（每年9.7 kg）；UPBs在HICs的人均销售额（每年161.6 L）分别是UMICs和LMICs的2.4倍（每年68.5 L）和8.9倍（每年18.1 L）[16]。
在不同收入状况的国家中，UPSFs和UPBs的销售额都在增长，其中在HICs中总体增长较为缓慢，甚至有所停滞。从2009年至2019年，HICs、UMICs和LMICs的UPSFs人均销售额的复合年增长率分别为0.4%、2.8%和4.4%，UPBs人均销售额的复合年增长率分别为0.1%、2.2%和6.6%。中国作为UMICs之一，其UPSFs和UPBs人均销售额的复合年增长率分别为3.8%和3.5%[16]。Baker等[16]预计未来HICs的UPBs总销售额增长将停滞不前，UMICs和LMICs仍将保持强劲增长。2006、2012、2019和Baker等[16]预计的2024年UPSFs及UPBs人均销售额见图1A和图1B。由于目前UPFs的人均销售额在HICs中停滞不前，大型跨国食品公司将业务拓展至中低收入国家，积极寻求新的发展机会[17]。
▲图1 2006—2019年及预计至2024年按国家收入水平划分UPSFs、UPBs每年人均销售额
图A和图B分别为UPSF（kg）和UPBs（L）。
2019年，UPSFs在不同收入国家的人均消费量依次为：HICs、UMICs、LMICs（图2A）；UPBs与UPSFs呈现同样的趋势（图2B）。UPSFs消费种类在不同收入水平国家的差别十分明显，烘焙食品在HICs消费量最高，UMIC、LMICs则分别为固体调味料、咸味零食。UPBs消费量最高的种类在不同收入水平国家中没有差别，均为碳酸软饮料，次高为果汁饮料。以国家划分，UPSFs人均消费量最高的国家依次为：德国、美国、日本（图3A）；UPBs人均消费量最高的国家依次为：美国、德国、日本（图3B）。从类型上看，以美国、德国为代表的欧美国家，烘焙食品消费占比最高，而在以中国、日本为代表的东亚地区，固体调味料消费量占比最高。UPBs高消费种类在不同地区差别也十分明显，欧美国家更偏好碳酸软饮料、果汁饮料、功能饮料；而中国、日本等东亚地区国家更偏好即饮（ready-to-drink, RTD）的茶和咖啡。不同地区的UPFs消费种类存在较大差异与当地居民特有的传统饮食偏好、文化和经济息息相关，并对各地的饮食摄入的加工程度产生巨大冲击[18–19]。
▲图2 2019年按国家收入水平划分UPSFs、UPBs人均销售额
图A和图B分别为UPSF和UPBs。
▲图3 2019年部分国家UPSFs、UPBs人均销售额
图A和图B分别为UPSF和UPBs。
4. UPFs和多种健康结局
向上滑动阅览
近年来，越来越多的证据表明，UPFs的高消费会对人类的健康产生负面影响[20–25]。在UPFs摄入与健康结局的剂量-反应关系的研究中，UPFs供能比通常被分成不同的分位数组别（多为3~5组），比较最高分位数组（Q3/Q4/Q5）与最低分位数组（Q1）健康结局的发病风险。
4.1 UPFs和超重/肥胖
超重/肥胖是过量摄入UPFs最常见的研究结局，多项系统评价显示，UPFs的消费与超重/肥胖的风险高度相关[22–24，26]。Moradi等[26]回顾了UPFs摄入与普通人群超重、肥胖和腹型肥胖风险之间的关系并进行荟萃分析（Meta），结果显示，与最低UPFs消费组相比，高UPFs消费与肥胖（OR=1.55，95%CI：1.36~1.77）、超重（RR=1.36，95%CI：1.14~1.63）、超重/肥胖（OR=1.29，95%CI：1.05~1.28）、腹型肥胖（OR=1.41，95%CI：1.18~1.68）的发生风险增加有关，并进一步揭示了两者间的剂量-反应关系呈线性：在成年人中，UPFs供能比每增加10%，发生肥胖、超重、超重/肥胖和腹型肥胖的风险分别增加7%、6%、3%。
4.2 UPFs和2型糖尿病
2型糖尿病发病率在全球不断攀升，是多种因素共同作用的结果，其中不健康饮食如UPFs会增加患2型糖尿病的风险。研究表明，高UPFs消费与2型糖尿病风险增加之间存在显著关联[27–28]。一项纳入18项纵向研究、涉及近110万名参与者的Meta分析研究显示，与不摄入UPFs相比，高UPFs摄入会增加31%的2型糖尿病发病风险（RR=1.31，95%CI：1.21~1.42）[27]。另一项分别纳入1项横断面研究和4项队列研究、涉及近23万名来自四个不同国家成年人的Meta研究结果进一步揭示了剂量-反应关系为线性关系，UPFs供能比每增加10%，成年人发生2型糖尿病的风险增加15%（RR=1.15，95%CI：1.06~1.26）[28]。
4.3 UPFs和心血管疾病
多项队列研究显示，UPFs的消费量与心血管疾病的发病率有关[29–31]。一项随访24.6年、纳入26369人的队列研究显示，UPFs摄入最高组与最低组相比（Q4：Q1），心血管疾病（RR=1.18，95%CI：1.08~1.29）和缺血性脑卒中（RR=1.17，95%CI：1.03~1.32）的发生风险分别增加了18%和17%，其中冠心病（RR=1.20，95%CI：1.07~1.35）的发生风险增加20%[31]。
一项纳入7项队列、207291名成年人的Meta研究合并结果显示，与UPFs最低消费组相比，高UPFs消费增加了心血管疾病的死亡风险（HR=1.50，95%CI：1.37~1.63），其中心脏病的死亡风险增加最为显著，达66%[32]。
4.3.1 UPFs和高血压
由于UPFs在加工过程中往往添加大量食盐、饱和脂肪和糖，且损失了膳食纤维和维生素等营养素，许多学者探究了UPFs与高血压的关系，认为UPFs消费与高血压风险呈正相关。Mendonça等[33]进行了一项UPFs摄入量与高血压风险关系的前瞻性队列研究，共纳入14790名基线时无高血压的大学生并随访9.1年。研究发现，随访中共发生1702例高血压，最高UPFs消费组（Q3）比最低UPFs消费组（Q1）患高血压的风险更大（多变量校正HR=1.21，95%CI：1.06~1.37）。对美国3个队列的分析[34]结果显示，长期食用水果与降低成年人患高血压的风险有关，并据此推测高UPFs摄入的热量可能取代了健康水果和蔬菜的热量。一项纳入9项观察性研究（4项队列、5项横断面研究，111594名参与者）的Meta分析结果显示，与最低UPFs消费组（Q1）相比，UPFs高消费组（Q3、Q4、Q5）显著增加了高血压的发病风险（总体OR=1.23，95%CI：1.11~1.37）[35]。
4.4 UPFs和癌症
一项纳入了8项病例对照、3项前瞻性队列研究的Meta研究[36]结果显示，在校正了肥胖和总能量摄入等混杂因素后，UPFs供能比每增加10%，可能会增加13%的总体癌症发生风险（HR=1.13，95%CI：1.07~1.18）和11%的乳腺癌的发生风险（HR=1.11，95%CI：1.01~1.21）。此外，和最低UPFs消费组相比，高UPFs消费可能与直肠癌（OR=1.30，95%CI：1.11~1.51）和胰腺癌（HR=1.49，95%CI：1.07~2.07）的发生风险增加有关[36]。
英国的一项纳入了近20万名40~69岁参与者的前瞻性队列研究显示，UPFs消费每增加10%，可能会增加6%总体癌症死亡风险、30%卵巢癌相关死亡风险和16%乳腺癌相关死亡风险[37]。一项合并了2项队列研究的Meta研究却显示了不同的结果[38–39]：与UPFs最低消费组相比，高UPFs消费与癌症死亡风险无关（HR=1.00，95%CI：0.81~1.24，P=0.976）[32]。未来需要进一步开展高质量的前瞻性队列以验证UPFs和癌症死亡之间的关联。
4.5 UPFs和全因死亡
四项Meta研究的结果均显示，和最低的UPFs消费量相比，最高的UPFs消费与全因死亡呈正相关（RR=1.21~1.29）[22–23，32，40]，其中Suksatan等[32]发表的Meta研究进一步揭示了线性的剂量-反应关系：在成年人中，UPFs供能比每增加10%，全因死亡风险增加15%（OR=1.15，95%CI：1.09~1.21）。
4.6 UPFs和焦虑抑郁
全球UPFs消费量的迅速增长与抑郁症的发展相关，和焦虑症的发展及预后之间的关系尚有争议。多项系统评价研究结果显示，与低UPFs消费相比，高UPFs消费与抑郁症相关[22–23，41–42]。一项纳入了2项队列研究、涉及41627人的Meta研究结果表明，在成人中，相比较低的UPFs消费量（热量范围为13.0%~35.2%），抑郁与较高的UPFs消费量（热量范围为29.0%~76.2%）显著相关（HR=1.22，95%CI：1.16~1.28）[23]；另一项纳入了34项观察性研究的Meta研究显示，与不消费UPFs相比，消费UPFs能增加抑郁症风险（RR=1.28，95%CI：1.19~1.38），两者存在的剂量-反应关系呈线性：UPFs供能比每增加10%，成年人发生抑郁的风险增加11%（RR=1.11，95%CI：1.01~1.17）[42]。
在UPFs消费量和焦虑关系的研究中，两项Meta研究显示出不同的结果。一项纳入1项队列和4项横断面研究的Meta研究结果显示，与不消费UPFs相比，UPFs消费与焦虑之间没有统计学关联（RR=1.35，95%CI：0.86~2.11）[42]。另一项纳入3个横断面研究的Meta研究结果却显示，更多的UPFs消费与焦虑症状（OR=1.48，95%CI：1.37~1.59）的发生风险增加有关[41]。未来需要进一步开展高质量的前瞻性队列以验证UPFs和焦虑之间的关联。
4.7 UPFs对特殊人群健康结局的影响
有多项研究表明，孕期过量摄入UPFs可能是增加不良母婴健康结局的一个危险因素。一项针对美国孕期饮食的纵向研究显示，怀孕期间从UPFs摄入的能量百分比每增加一个标准差，可使妊娠期体重过度增加的风险上升31%，且与孕期C反应蛋白和产后体重等指标均存在正相关关系（P<0.05）[43]。一项纳入61项（总人群包括698803名来自所有妊娠阶段的妇女）队列研究的Meta分析结果显示，孕妇高UPFs膳食与子痫前期发生风险增加28%相关、与妊娠期糖尿病的发生风险增加48%相关、与妊娠期高血压发生风险的增加无统计学关联[44]。
一项荷兰鹿特丹围产期的前瞻性队列研究显示，孕妇从UPFs摄入的能量百分比每增加10%，胎儿的顶臀径（b=-0.041，95%CI：-0.074~-0.008），胚胎体积（b=-0.016，95%CI：-0.030~-0.001）的生长轨迹显著减小[45]。此外，基于三项前瞻性队列研究（19958对母子，中位随访时间4年，直至18岁或出现超重或肥胖）的合并结果显示，和母亲UPFs摄入量最低组相比，母亲UPFs摄入量最高组增加了后代26%超重/肥胖的发生风险（RR=1.26，95%CI：1.08~1.47）[46]。一项西班牙的出生队列研究显示，与孕妇妊娠期UPFs摄入量的最低三分位数（占总膳食能量的7.2%及以下）相比，孕妇妊娠期UPFs摄入量的最高三分位数（占总膳食能量的28.9%及以上）会让后代的语言发育维度得分更低（b=−2.29，95%CI：-4.13~-0.46）[47]。
儿童和青少年是UPFs的主要消费人群[10，48–50]，既往研究显示，在多个国家儿童青少年平均每天的总能量摄入中，从UPFs摄入的能量百分比达55%以上[48，51–53]。一项发表在《美国医学会杂志·儿科学》（JAMA Pediatrics）的前瞻性队列研究发现，儿童时期UPFs高摄入量与青春期和成年早期的肥胖率增加有关[54]，与UPFs消费量最低的五分位数儿童相比，最高五分位数儿童的肥胖相关指标均有升高：BMI每年增加6%，体脂指数增加3%，体重增加2%，腰围增加0.17cm。童年是形成食物偏好和饮食习惯的关键时期，减少儿童接触和摄入UPFs，有助于改善儿童的肥胖问题。除了超重肥胖，UPFs还会对儿童青少年的骨骼生长[55]、龋齿发生[56]、睡眠质量和时间[57]等方面产生负面影响。
综上，未来还需要在充分控制混杂因素的情况下，开展良好的系统评价和高质量的前瞻性队列在不同人群中以进一步验证UPFs和多种健康结局之间的关联。
5. UPFs影响健康的可能因素和机制
6. 结语
向上滑动阅览
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作者简介
臧嘉捷
本文通信作者。医学博士，主任医师。上海市委组织部青年拔尖人才、市公共卫生优秀学科带头人，上海卫生系统青年人才银蛇奖获得者。长期从事疾病预防控制工作，研究方向为营养与健康，为多项国家标准、指南等政策的制定提供数据支撑。主持国家及省部级项目十余项。兼任《环境与职业医学》青年编委、中国学生营养与健康促进会营养监测分会理事、上海市预防医学会流行病学专委会副主任委员、上海市食品学会儿童营养与食品专委会副主任委员等。
钟佳倩
本文第一作者。上海中医药大学公共健康学院在读研究生。主要研究方向：临床营养与代谢。
余江月
本文共同第一作者。复旦大学公共卫生学院在读硕士研究生，主要研究方向为营养流行病学。
本文内容来自《环境与职业医学》2024年11月刊，原文题目《超加工食品消费及与健康关联的研究进展》
引用格式：钟佳倩，余江月，汪正园，等.超加工食品消费及与健康关联的研究进展[J].环境与职业医学，2024，41（11）：1309-1318，1324.
原文链接：
https://www.jeom.org/article/doi/10.11836/JEOM24141
编辑 | 赵芸稼
审阅 | 张晨晨
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创刊于1984
报道内容
环境因素（自然环境、社会环境）、职业因素与人群健康关系研究成果
主办
上海市疾病预防控制中心
收录数据库
● 中国科学引文数据库（CSCD-C）源期刊
● 中文核心期刊（预防医学、卫生学类核心期刊）
● 中国科技论文统计源期刊（中国科技核心期刊）
● Scopus数据库
● EBSCO数据库
● DOAJ数据库
● Embase数据库
● WHO西太平洋地区医学索引（WPRIM）
● 日本JST数据库
● 美国化学文摘
● 乌利希国际期刊指南
● 英国国际农业与生物科学研究中心
● 美国剑桥科学文摘（自然科学）
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