Ultra-processed food intake among South Asians in the United States: Specific vulnerabilities of a growing immigrant population group

Abstract

South Asians are among the fastest growing immigrant population groups in the United States. Their traditional diets are rich in minimally processed fruits, vegetables, grains, herbs, and spices. However, the proliferation of ultra-processed foods (highly processed, industrially manufactured formulations) around the globe may compromise the nutrition profile of South Asians, threatening to increase their risk of noncommunicable diseases. This commentary discusses the rise in ultra-processed food consumption among South Asians in the United States and hypothesizes that South Asians may be especially vulnerable to the effects of ultra-processed foods due to their unique cardiovascular disease risk profiles. Using these emerging data, we propose several strategies for preventing the overconsumption of ultra-processed foods among South Asian Americans. These include the implementation of policies to encourage the consumption of whole foods over ultra-processed foods and the development of culturally tailored interventions, which include promoting consumption of traditional diets, improving affordability of healthful, culturally appropriate foods, and cultivating healthier food environments for South Asians living in the United States.

INTRODUCTION

The traditional diets of South Asians (people with family origins from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka¹) are rich in dishes made from fresh ingredients, including chapattis, rice, daal, vegetables, and yogurt.² However, the rapid growth of the food industry has resulted in increased consumption of ultra-processed foods that displace traditional whole-food items.³ Ultra-processed foods are defined by the Nova framework as formulations manufactured using a series of intense physical or chemical processes and generally containing ingredients and additives of exclusive industrial use (eg, artificial flavors, emulsifiers, food dyes). The shift in dietary pattern is not well studied among South Asians in the United States. This is due to the lack of culturally appropriate dietary assessment tools (such as food-frequency questionnaires) and corresponding nutrient databases that are able to adequately assess diet among this growing population subgroup⁴ and the mis-aggregation of a diverse “Asian” racial group in the collection and reporting of data.⁵ Furthermore, food intake is rarely assessed by processing level.

The American Heart Association has identified that South Asians are at a disproportionately higher risk of cardiovascular disease (CVD) when compared with East Asians and non-Hispanic Whites,¹ even before accounting for dietary intake. This risk of CVD is due to earlier development of symptoms, including hypertension and coronary artery calcification.¹ Adding to this, the South Asian body composition is characterized by the “Asian paradox,”⁶ whereby there is a greater fat distribution in the abdominal area (ie, central adiposity), independent of total body weight.⁶ As a result, South Asians may be particularly vulnerable to adverse health outcomes associated with ultra-processed food intake. Ultra-processed foods tend to be high in calories, total fat, saturated fat, trans fat, added/free sugars, and sodium and low in protein, fiber, and several essential vitamins and minerals.⁷ Accumulating epidemiological evidence supports that high intakes of ultra-processed foods are associated with increased risk of CVD as well as several cardiometabolic risk factors, including obesity, diabetes, hypertension, and dyslipidemia.⁷ With the shift away from nutrient-rich traditional diets towards the energy-, fat-, sugar-, and salt-dense ultra-processed foods diet, South Asians are dangerously susceptible to CVD and related outcomes. This commentary (1) describes the increased consumption of ultra-processed foods among South Asians based on cursory, available data; (2) elucidates the health risks associated with high ultra-processed food intake; and (3) provides recommendations for future research and policy guidelines that empower individual decision making about diet intake. As ultra-processed foods are being consumed at higher rates among South Asians, it is essential to quantify the amount of ultra-processed foods being consumed and disease risk associated with this shift in daily dietary intake.

CONSUMPTION OF ULTRA-PROCESSED FOODS AMONG SOUTH ASIANS LIVING IN THE UNITED STATES

With the increasing industrialization of low- and middle-income countries, South Asians have become vulnerable to overconsumption of ultra-processed foods due, in part, to increased exposure. This increased intake among South Asians is due to 3 converging factors: (1) a growing prevalence of ultra-processed food availability and consumption in a person’s home South Asian country, (2) migration to high-income countries with ubiquitous availability and consumption of ultra-processed foods,⁸ and (3) dietary acculturation among South Asian immigrants.⁹

In South Asian countries, urbanization and economic growth have motivated the strategic placement of marketing efforts by the food industry, which, in turn, has increased the demand and availability of processed-food items and decreased reliance on traditional, minimally processed diets.³ This has resulted in an increase in ultra-processed food sales and the distribution of convenience foods across South Asian countries.¹⁰ Based on country-level sales data collected by EuroMonitor International, ultra-processed food sales grew by 144.7% from 2005 to 2018 in South Asian countries.¹¹ The proliferation of ultra-processed food items, which tend to be more financially accessible to a broad population than locally sourced, whole foods, is replacing the routine consumption of traditional food items.

As South Asians immigrate to the United States they tend to incorporate more “American” foods into their daily diet, due in large part to availability and convenience.¹² As a result, immigration to the United States has been associated with increased consumption of added sugars, saturated fat, and animal proteins, with concurrent decreases in the consumption of fruits and vegetables along with overall dietary quality.¹² Coupled with existing changes to dietary patterns in South Asian countries and established increased risk for poor health outcomes,¹ South Asian immigrants may have a particularly heightened vulnerability to disproportionate ultra-processed food consumption. Data from a recent qualitative study conducted at New York University provide a snapshot of how ultra-processed foods are pernicious to a person’s daily intake.¹³ Interview respondents included 31 South Asian adults, aged 20–65 years (90% female). Approximately half of participants reported living in the United States for their whole life (n = 15; 48%) and those who reported immigrating to the United States reported living in the United States for 3 to 56 years. Participants were interviewed regarding their dietary intake, illustrated by a 24-hour dietary recall and home food inventory. Most participants reported a mix of traditional South Asian food items and ultra-processed food items. Figure S1 (see the Supporting Information online) provides 2 examples of dietary recalls from participants from the study. This information points towards dietary trends that are practiced by South Asian adults living in the United States, which should be studied further.

To our knowledge, no data quantify ultra-processed food intake among South Asians in the United States. In analyses of the National Health and Nutrition Examination Surveys (NHANES 2011–2018) ultra-processed foods provided approximately 39% of total daily energy in the diets of Asian Americans (inclusive of South Asians).¹⁴ Ultra-processed food intake was significantly higher among Asian Americans who were born in the United States and those who were younger (44.5% of daily intake among those aged 18–24 years compared to 33.4% daily intake among those aged ≥65 years), more educated (39.7% daily intake among college-educated vs 32.1% daily intake among those with less than a high school education), or had higher household incomes (40.8% of daily intake in the highest family income ratio [≥350%] compared to 35.0% of daily intake in the lowest income ratio [<130%]).¹⁴ Compared with other ethnic subgroups, South Asians tend to be younger⁸ and have higher educational attainment and income,⁸ characteristics associated with higher consumption of ultra-processed foods among Asian Americans.

CARDIOVASCULAR DISEASE ASSOCIATED WITH ULTRA-PROCESSED FOOD CONSUMPTION

There is mounting evidence that links ultra-processed food intake to CVD and related cardiovascular health risk factors. A recent meta-analysis found that the highest intake of ultra-processed foods (>4 servings/d or >22% of total energy) was associated with a 29% increased risk of CVD incidence (risk ratio, 1.29; 95% confidence interval [CI], 1.12–1.48) and 34% increased risk of cerebrovascular disease incidence (risk ratio, 1.34; 95% CI, 1.07–1.68) compared with the lowest intake (<2 servings/d or <11% of total energy).¹⁵ An additional meta-analysis also supports that ultra-processed food intake is significantly associated with the risk of CVD mortality (hazard ratio, 1.50; 95% CI, 1.37–1.63) and cardiovascular-related mortality (hazard ratio, 1.66; 95% CI, 1.50–1.85).¹⁶

The biological pathways through which ultra-processed foods may influence CVD risk are not yet fully understood, but the current evidence suggests several hypothesized mechanisms.¹⁷ Ultra-processed foods may promote atherosclerosis through their poor nutritional quality and by replacing health-promoting, minimally processed foods, such as fruits, vegetables, whole grains, lean meat, and fish in the diet.^7,17 In addition to altering the nutrient profile of foods, processing induces significant changes to the food matrix. The highly degraded physical structure of ultra-processed foods may alter nutrient-absorption kinetics and disrupt the gut microbiome,¹⁸ with potential implications for CVD risk. Food additives and neo-formed contaminants produced during processing may also promote disease. For example, rodent studies indicate that artificial sweeteners¹⁹ and emulsifiers²⁰ may alter the gut microbiota, inducing a proinflammatory state and metabolic dysregulation. Phosphate salts, which are commonly used in industrial food processing, may disrupt the hormonal regulation of extracellular phosphate when consumed in excess and promote arterial calcification, oxidative stress of endothelial cells, and impaired endothelial function.²¹

CONCLUSION

At present, there is limited guidance regarding ultra-processed food intake. While the 2025–2030 Dietary Guidelines for Americans will evaluate the health risks associated with ultra-processed foods, the 2020–2025 Dietary Guidelines do not mention ultra-processed foods.²² The American Heart Association dietary guidelines encourage people to choose minimally processed foods instead of ultra-processed foods²³ but do not provide specific recommendations to consumers regarding how to navigate and determine processing levels. Given the accumulating evidence linking ultra-processed foods to poor cardiometabolic health and other disease outcomes, it is crucial to educate consumers regarding how to identify ultra-processed foods and their associated health risks. Importantly, future educational efforts and policy development should prioritize translational components that are culturally appropriate and inclusive of ethnic minority groups with established CVD risk factors. As South Asians in the United States are especially vulnerable to cardiometabolic diseases and may consume other types of ultra-processed foods compared with other racial/ethnic groups in the United States, targeted outreach using materials specifically developed for this population are recommended. Another concern is that South Asians may be excluded from health policies that focus predominantly on obesity that is only defined using body mass index (BMI), even ethnicity-specific BMI cutoff values, rather than including body-composition measurements that assess high central adiposity independently of BMI. Future policies should therefore specifically focus on the reduction in consumption, marketing, and availability of ultra-processed foods to reduce disease risk, independently of body weight or BMI.

US-born Asians living in the United States are substantially younger than all US-born individuals, with a median age of 19 years versus 36 years, respectively.⁸ This indicates a considerable opportunity to intervene on the behaviors of this population group, helping to reduce habitual intake of ultra-processed foods and reduce the incidence of noncommunicable diseases in the future. South Asians in the United States remain susceptible to ultra-processed food consumption and may be specifically vulnerable to the adverse health effects associated with ultra-processed foods due to their existing heightened risk of CVD. The solution to this problem can be addressed through several strategies. First, more research that more specifically defines the patterns and magnitude of ultra-processed food consumption and its association with noncommunicable disease, particularly among racial and ethnic minority groups, is paramount. Second, based on the generated evidence, culturally tailored interventions designed to raise awareness about ultra-processed foods and promote the consumption of traditional whole-food–based diets should be developed. For example, public health professionals can partner with South Asian community groups and centers to spread information and raise awareness about ultra-processed foods and healthy dietary patterns. Faith-based organizations and schools in areas with a high proportion South Asians may be key partners in these aspects. Educating consumers by increasing nutrition literacy and advertising awareness will enhance the individual’s ability to make informed food-purchasing and dietary decisions, guiding their own health promotion efforts. It is also essential to develop policies that promote a healthier food environment and increased access to healthful and culturally appropriate foods. Examples of relevant policies include restrictions on marketing and advertising efforts; front-of-package warning labels; taxation of unhealthy products; as well as regulations to make healthful, minimally processed foods more affordable, available, and accessible, especially in low-resource settings. There is a considerable opportunity to expand the scope of research, policy recommendations, and consumer education to include an increasingly diverse population in the United States, and it is the responsibility of public health researchers, practitioners, and policy makers to prioritize these changes.

Supporting Information

The following Supporting Information is available through the online version of this article at the publisher’s website.

Figure S1  Examples of 24-hour dietary recall provided in qualitative study of South Asians living in the United States