Ultra-processed food consumption and the risk of overweight and obesity in adolescents: A systematic review and meta-analysis

Mekuriaw Nibret Aweke; Habtamu Wagnew Abuhay; Miteku Andualem Limenih; Anas Ali Alhur; Nebebe Demis Baykemagn; Gebrie Getu Alemu; Makda Fekadie Tewelgne; Tirualem Zeleke Yehuala

doi:10.1371/journal.pone.0344873

. 2026 Apr 15;21(4):e0344873. doi: 10.1371/journal.pone.0344873

Ultra-processed food consumption and the risk of overweight and obesity in adolescents: A systematic review and meta-analysis

Mekuriaw Nibret Aweke ^1,^*, Habtamu Wagnew Abuhay ², Miteku Andualem Limenih ², Anas Ali Alhur ³, Nebebe Demis Baykemagn ⁴, Gebrie Getu Alemu ², Makda Fekadie Tewelgne ⁴, Tirualem Zeleke Yehuala ⁴

Editor: Giulia Squillacioti⁵

PMCID: PMC13082653 PMID: 41984760

Abstract

Introduction

Overweight and obesity during early life increase the risk of premature morbidity and mortality. Adolescent obesity raises the likelihood of developing cardiovascular risk factors, including prediabetes, type 2 diabetes, dyslipidemia, hypertension, liver disease, and metabolic syndrome. Sedentary lifestyles and unhealthy diets are major contributors, with one of the fastest-growing unhealthy eating patterns being the consumption of ultra-processed foods (UPFs). No systematic review and meta-analysis has specifically examined the association between UPF consumption and overweight/obesity in adolescents.

Objective

To systematically review and conduct a meta-analysis of available evidence on the association between UPF consumption and overweight or obesity among adolescents.

Methods

We searched PubMed, ScienceDirect, HINARI, Google, and Google Scholar for primary studies reporting UPF consumption and overweight/obesity outcomes in adolescents, without restrictions on language or study period. Study quality was assessed using the Newcastle–Ottawa Scale. Heterogeneity was evaluated using Cochrane’s Q test and the I² statistic. Publication bias and small-study effects were assessed using Egger’s regression test (p < 0.05). A random-effects model estimated pooled associations.

Results

Twenty-three studies involving 155,000 adolescents were included. Adolescents with higher UPF consumption had 63% greater odds of overweight or obesity compared with those with lower intake (OR = 1.63; 95% CI: 1.36–1.95).

Conclusion

High UPF consumption is associated with an increased risk of overweight and obesity among adolescents. Public health strategies targeting reduced UPF intake and promotion of healthier diets should be prioritized to prevent adolescent overweight/obesity and associated health risks.

Introduction

The burden of non-communicable diseases (NCDs) such as heart disease, type 2 diabetes, and several types of cancer has increased worldwide [1]. The rise of these NCDs is closely related to metabolic disorders, which include hypertension, insulin resistance, central obesity, high blood sugar and dyslipidemia [2]. The risk of chronic diseases in early life is a concerning issue, as these conditions were previously believed to affect only adults [3]. Adolescents are now increasingly being diagnosed with these NCDs [4]. This early onset not only increases the lifetime risk of such diseases but also imposes a considerable long-term burden on healthcare systems worldwide.

A major contributor to both metabolic syndrome and the development of NCDs is sedentary life style and unhealthy diet [5]. Among the most increasing unhealthy eating pattern is the growing consumption of ultra-processed foods(UPFs) [6]. Ultra-processed foods are industrial products made largely from extracted, modified, or synthetic ingredients, created through multiple processing steps for industrial use [7]. Process foods are typically energy-dense and nutritionally poor, high in added sugars, salt, unhealthy fats, and chemical additives [8]. High consumption of UPFs displaces nutrient-rich whole foods and promotes excessive caloric intake, contributing directly to weight gain and adiposity [9].

Adolescents are particularly vulnerable to higher consumption of UPF because of their growing independence, higher nutritional needs, heavy marketing, easy access to tasty foods, and often inactive lifestyles [10]. During this developmental stage, unhealthy diatary pattern can significantly influence growth, hormonal balance, and long-term metabolic health [11]. Several studies have found that adolescents with higher intake of UPFs are more likely to be overweight or obese [12,13].

In the last few decades, there has been a significant increase in early stage of life overweight and obesity which has now become epidemics [14]. Over a period of 40 years, the number of girls with obesity increased tenfold from 5 million in 1975–50 million in 2016, while the number of boys with obesity increased twelvefold from 6 million in 1975–74 million in 2016 [15]. According to a 2019 World Obesity Federation estimation, 206 million children and adolescents between the ages of 5 and 19 would be obese in 2025, and 254 million in 2030 [16].

Overweigh and obesity during early life impart significant risks of premature morbidity and mortality, which may be evident before the age of 30 [17]. Adolescent obesity increase the risk of developing cardiovascular risk factors that include prediabetes, type 2 diabetes, high cholesterol levels, Hypertension, liver diseases, and metabolic syndrome [18]. Additionally, adolescents with obesity can suffer from psychological issues such as depression, anxiety, poor self-esteem, body image and peer relationships, and eating disorders [18,19]. Furthermore, adolescent obesity is associated with a heightened risk of early puberty [20], menstrual irregularities in girls [21], and sleep disorders such as obstructive sleep apnea and linked to notable social disadvantages [22,23].

Overweight and obesity in adolescents are influenced by a range of factors, including sociodemographic and biological determinants, as well as lifestyle behaviors. Studies showed that physical inactivity, frequent consumption of unhealthy or processed foods, prolonged sedentary behavior, and extended periods of screen time are the modifiable risk factors associated with adolescent obesity and overweight [24–26].

Systematic review and meta-analysis on the association of UPFs consumption and the risk of overweight and obesity was done on adult population group. However there is no systematic review and meta-analysis on the link of UPF consumption and overweight/obesity during adolescence. Findings from individual studies on the relationship between UPF consumption and overweight or obesity are inconsistent. For instance multiple studies done in Indonesia, Iraq, Bangladesh and China have reported a positive association suggesting that higher UPF intake increases the risk of overweight and obesity in this age group [27–29]. In contrast, a study conducted in Qatar revealed a strong inverse relationship, indicating that higher consumption of unhealthy foods was linked to a reduced likelihood of being overweight or obese during adolescence [30].

These inconsistency results highlight the need for a systematic review and meta-analysis to comprehensively synthesize the available evidence and clarify the overall strength and direction of the association. This study aims to bring together existing research to better understand how eating ultra-processed foods is linked to overweight and obesity in adolescents. The goal is to provide stronger evidence that can help shape public health recommendations and support efforts to reduce overweight and obesity in young people.

Methods

Study protocol and registration

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [31]. The protocol for this review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) (Registration No: CRD420251121568).

Search strategy

A comprehensive literature search was conducted across major databases including PubMed, HINARI, Science direct, google scholar and google to retrieve primary observational studies reporting on the association between UPF consumption and the risk of overweight or obesity among adolescents. The keywords and MeSH terms used in the search included: (“ultra processed” OR “ultra processed” OR “ultra-processed” OR “processed food” OR “industrialized” OR “fast-food” OR “fast food” OR “fast-food” OR “junk food” OR “carbonated beverage”) AND (“adolescents” OR “teen” OR “teenager” OR “teenagers” OR “youth” OR “young people”) AND (“obesity” OR “overweight” OR “BMI” OR “Body Mass Index”). Database searches were conducted to retrieve articles published up to July 21, 2025.. The full search strategies for each database are provided in S1 File.

Study selection

All retrieved articles were imported into EndNote 21 (Clarivate, Philadelphia, PA, USA) reference manager to remove duplicates. Titles and abstracts were screened for relevance based on predefined eligibility criteria by two investigators (MNA. and NDB.). Full texts of potentially eligible studies were then reviewed in detail. No restrictions were applied on language or year of publication and all relevant studies published up to July, 2025 were included.

Inclusion and exclusion criteria

We included studies that met the following criteria: (1) published or unpublished full-text articles; (2) conducted among adolescents aged 10–19 years; (3) investigated the association between UPF consumption and overweight or obesity, using defined criteria for both exposure and outcome and (3), primary observational studies(cross-sectional, cohort, or case-control studies).

Studies were excluded if they: (1) lacked sufficient data to calculate effect estimates (e.g., odds ratios or risk ratios); (2) employed experimental or qualitative study designs (e.g., clinical trials, case series, case reports); (3) were not conducted exclusively among adolescents or did not provide stratified results for this age group; or (4) included mixed samples of adolescents, children, and/or adults without separate reporting for adolescents.

Overweight and obesity were diagnosed using standardized growth references, including the WHO Growth Reference (BMI-for-age z-score > +1 SD for overweight and> +2 SD for obesity) [32], the CDC Growth Charts (85th–94th percentile for overweight and ≥ 95th percentile for obesity), and the International Obesity Task Force (IOTF) age- and sex-specific BMI cut-offs corresponding to adult BMI thresholds of 25 kg/m² for overweight and 30 kg/m² for obesity [33]. In addition abdominal obesity was assessed using waist circumference, defined as ≥ 90th percentile for age and sex [34] (Table 1).

Table 1. Criteria for Inclusion of Quantitative Studies Based on the Population, Exposure, Comparator, Outcome (PECO) Framework.

Criteria	Details
Population (P)	Adolescents (10–19 years old) from any geographic region; excludes studies involving mixed populations of adolescents, children, and/or adults without stratified results for adolescents
Exposure (E)	Consumption of ultra-processed foods (UPFs)
Comparator (C)	Low or no consumption of UPFs, or consumption of minimally processed/unprocessed foods
Outcome (O)	Risk of overweight and obesity, assessed by body mass index (BMI), BMI-for-age z-scores, BMI percentiles, or waist circumference

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Outcomes of interest

The primary outcome was overweight and/or obesity in adolescents. It is defined by each included study according to internationally recognized criteria. Overweight and obesity were identified based on body mass index (BMI)-for-age z-scores, using cut-off points recommended by the World Health Organization (WHO) (overweight: >+1 SD; obesity: >+2 SD), International Obesity Task Force (IOTF) age- and sex-specific cutoffs, or equivalent national reference standards. Any available categorical (overweight/obese vs. normal weight) were extracted to assess the pooled effect size of the associations.

Assessment of the quality of the individual studies

Three independent reviewers (GGA. MFT. and TZY.) assessed the methodological quality of the included studies using the Newcastle-Ottawa Scale (NOS) modified for cross-sectional and cohort designs. This tool evaluates selection of participants, comparability of study groups, outcome ascertainment, and statistical analysis methods [35]. Studies were evaluated on a 0–10 scale and classified as “Very Good” (9–10), “Good” (7–8), “Satisfactory” (5–6), or “Unsatisfactory” (0–4). Any differences in scoring were resolved through consensus among the reviewers.

Data extraction

Data extraction was performed independently by three reviewers (HWA. MAL. and MNA.) using a standardized Excel spreadsheet. The following information was extracted from each study: author, publication year, study design, country, study setting, publication type, sampling method, age group of participants, anthropometric measurements used to assess obesity/overweight, method of obesity/overweight measurement, types of ultra-processed foods consumed, response rate, actual sample size, confounders, and odds ratios (OR) or relative risks (RR) (S2 File). Any disagreements in data extraction were resolved by discussion and consensus.

Statistical analysis

Extracted data were compiled in Microsoft Excel and analyzed using STATA/MP version 17.0 (Stata Corp, College Station, TX, USA). A random-effects meta-analysis using the DerSimonian–Laird method was conducted to calculate pooled effect estimates (odds ratios) for the association between UPF consumption and overweight/obesity in adolescents. Heterogeneity among studies was assessed using the Cochran Q-test and quantified using the I² statistic [36]. Values of <50%, 50–75%, and >75% were interpreted as low, moderate, and high heterogeneity, respectively [37].

For the meta-analysis, we extracted and pooled multivariable-adjusted odds ratios (ORs) whenever reported; in cases where adjusted estimates were unavailable, crude ORs were used. We conducted sensitivity analyses to determine whether any individual study disproportionately influenced the overall findings on ultra-processed food consumption and the risk of overweight and obesity in adolescents. Publication bias was evaluated both visually, using funnel plots, and statistically with Egger’s regression test where a p-value below 0.05 suggested possible bias from smaller studies. We applied the trim-and-fill method to adjust the pooled estimates. All results are presented with 95% confidence intervals.

Results

Selection and identification of studies

An initial total of 2,100 records was identified and 175 duplicates were removed. From the remaing 1925 studies 1,813 were excluded based on title review, and a further 34 were excluded following abstract screening. The remaining 77 articles were assessed for eligibility through full-text review, resulting in the inclusion of 23 studies in the systematic review and meta-analysis. A flow diagram of study selection is shown in Fig 1.

Characteristics of included studies

The current systematic review and meta-analysis included 23 studies [27–30, 38–56] involving a total of 155, 000 adolescents. The meta-analysis included observational research designs cross-sectional, case-control, and cohort conducted between 2008 and 2025. The studies included in this review were conducted in different countries with the largest proportion originating from Indonesia [27,48,54,56] with four studies, followed by Bangladesh [29,44,49] and India [40,46,51] with three studies each. In addition two studies were from Brazil [43,45] while China [53], Ethiopia [52], Greece [50], Iraq [28], Jamaica [47], Mexico [38], Poland [42], Qatar [30], South Korea [41], United States [39] and Vietnam [55] each contributed one study.

The largest sample size was from a study conducted in China with 97,536 adolescents, followed by South Korea with 20,497 adolescents, while the smallest sample size was from Indonesia involved in 76 adolescents. The majority of the studies were cross-sectional in design [27–30,39–43,45–47,49–56], with a smaller number employing case-control methods [44,48] and one study utilizing a combined follow-up and cross-sectional approach [38] (Table 2). All included studies were peer reviewed and high methodological quality, with quality scores ranging from six to eight (S3 File).

Table 2. Characteristics of included studies on ultra-processed food consumption and adolescent obesity.

S.no	Author	Year	Study design	Country	Study setting	Publication type	Sampling method	Age group	sample size	OR(RR)
1	Alam et al.	2018	case-control	Bangladesh	School-based	Peer-reviewed	Purposive sampling	10–16	240	3.05
2	B. Saleh and E. Ma΄ala	2015	Cross-sectional	Iraq	School based	Peer-reviewed	Purposive	10_19	1254	1.27
3	Banik et al.	2020	Cross-sectional	Bangladesh	School Based	Peer-reviewed	Multi-stage random sampling	10_19	518	2.71
4	Borges et al.	2018	Cross-sectional	Brazil	Community-based	Peer-reviewed	Multi-stage cluster sampling	10–18	6784	1.55
5	Chernet Elias et al.	2022	Cross-sectional	Ethiopia	Community-based	Peer-reviewed	multistage	10_19	546	2.98
6	Denova-Gutiérrez E. et al.	2008	Cross-sectional/Follow-up/	Mexico	Community-based	Peer-reviewed	convenience	10_19	1055	1.55
7	Francis DK et al.	2009	Cross-sectional	Jamaica	Community-based	Peer-reviewed	Multi-stage random sampling	15–19	1317	1.52
8	Goyal et al.	2009	Cross-sectional	India	school based	Peer-reviewed	multistage	12_18	5664	1.54
9	Kerkadi et al	2019	Cross-sectional	Qatar	School Based	Peer-reviewed	multistage	14 - 18	1161	0.7
10	Khan et al.	2019	Cross-sectional	Bangladesh	school based	Peer-reviewed	clustered sampling technique	11-17	2980	2.35
11	M. Anitha Rani	2013	Cross-sectional	India	Schools	Peer-reviewed	Random sampling	10_19	1842	1.905
12	Makri et al.	2022	Cross-sectional	Greece	school based	Peer-reviewed	multistage	11, 13, 15	3816	1.2
13	Neri, D. et al.	2022	Cross-sectional	USA	Community-based	Peer-reviewed	Multistage	12–19	3587	1.07
14	Nguyen et al.	2021	Cross-sectional	Vietnam	School Based	Peer-reviewed	Random sampling	11-14	2660	0.996
15	Putra and Santoso	2024	Cross-sectional	Indonesia	School Based	Peer-reviewed	Random sampling	13-18	350	2.87
16	Ra, J. S. & Huyen, D. T. T	2024	Cross-sectional	South Korea	School-based	Peer-reviewed	Stratified two-stage cluster sampling	13–18	20497	1.12
17	Rifqi et al	2025	Cross-sectional	Indonesia	School Based	Peer-reviewed	Random sampling	12–14	261	2.32
18	Souza SF. et al.	2022	Cross-sectional	Brazil	School-based	Peer-reviewed	convenience	10_17	576	1.58
19	Stanislas and Santoso	2024	Cross-sectional	Indonesia	School Based	Peer-reviewed	Random sampling	10_19	350	2.87
20	Vanitha et al.	2019	Cross-sectional	India	School Based	Peer-reviewed	Multi-stage random sampling	13-15	230	2.84
21	Wuenstel, J. W. et al.	2015	Cross-sectional	Poland	School-based	Peer-reviewed	Random sampling	13-19	1700	1.62
22	Yolanda Patrichia et al.	2024	Case-control	Indonesia	School based	Peer-reviewed	Purposive	16-18	76	6.98
23	Zhihao Huang et al.	2024	Cross-sectional	China	School Based	Peer-reviewed	multistage	12-15	97536	1.06

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Footnotes: OR, odds ratio; RR, relative risk.

Among the 23 studies that reported their dietary assessment methods, 19 primarily used food frequency questionnaires (FFQs), while two studies employed 24-hour dietary recalls or food records methods. These studies consistently reported high intake of ultra processed foods such as pizza, burgers, sugary drinks, fried snacks, processed meats, and sweets items typically high in calories, added sugars, unhealthy fats, and low in nutritional quality. The studies assessed overweight and obesity primarily using BMI-for-age indices and Z-scores based on WHO, CDC, or IOTF growth references (Table 3).

Table 3. Characteristics and Key Findings of Studies on Ultra-Processed Foods and Adolescent Obesity.

S.no	Author	Year	Type of UPF	Exposure Assessment	Outcome Assessment	Result	Conclusion
1	Alam et al.	2018	Fast food, cakes/biscuits, chocolates, ice cream, soft drinks	NOVA classification based on FFQ	BMI CDC growth chart	UPF consumption particularly fast foods and cakes/biscuits, was associated with overweight/obesity in adolescents.	Ultra-processed food consumption, contributes to overweight and obesity among adolescents
2	B. Saleh and E. Ma΄ala	2015	Fast foods, sugar-sweetened beverages, sweets, snacks/meals in front of screens	NOVA classification based on FFQ	Overweight and obesity was assessed 85th −94th Percentile =>95th Percentile	There is highly significant association between eat the snacks and fast foods in home with their Body Mass Index	Fast foods increase the odds of overweight and obesity
3	Banik et al.	2020	Fast foods: burgers, pizza, fried chicken, puri, chips, etc.	NOVA classification based on FFQ	Overweight was defined as having a BMI between the 85th and 95th percentile, and obesity was defined as having a BMI in the 95th percentile or higher	Frequent consumers of UPF (OR=2.712, 95% CI = 1.592–4.622, p < 0.05) were the most important factors of obesity.	This study found a positive association between fast food consumption and obesity.
4	Borges et al.	2018	Fast Food and Snacks (e.g., sweetened beverages, sweets, pizzas, processed meats)	NOVA classification based on Food record	BMI standard deviation (SD) 136 scores were used to classify adolescents’ nutritional status, whereas overweight >+1SD, obesity >+2SD	Higher the adherence to the To the Fast-Food Pattern (OR: 1.55 fifth quintile vs first (CI95% = 1.12; 246 2.12) for linear trend <0,001), the greater the chances of becoming overweight	The greater the adherence to the Fast-Food patterns, the greater the adolescents’ chances of becoming overweight.
5	Chernet Elias et al.	2022	Fast foods: pizza, burgers, chocolate, ice cream, chips, soft drinks	NOVA classification based on FFQ	Overweight: BMI-for-age > +1SD; Obesity: BMI-for-age > +2SD (WHO growth reference	Adolescents who are female, come from high-income families, and eat fast-food frequently are more likely to be overweight or obese	Eat fast food frequently are more likely to be overweight or obese.
6	Denova-Gutiérrez E. Et al.	2008	Sweetened beverages (sbs): colas, flavored sodas, sugar-sweetened flavored waters, diet colas	NOVA classification based on Semi QFFQ	WC ≥ 75th percentile and 85th percentile and lower than the 95th percentile	Subjects consuming 3 daily servings of SB face a higher greater risk of proportionally excess body fat than those who consume less than 1 SB a day	The consumption of SB increases the risk of overweight and/or obesity
7	Francis DK et al.	2009	Fast foods and sweetened beverages: sodas, lemonade, Kool Aid, pastries	NOVA classification based on FFQ	Internal BMI Z-scores from LMS method, WC cut-offs at age 18: 93 cm (males) and 81 cm (females). For <18 yrs, equivalent internal Z-score cut-offs were applied.	High WC was associated with the absence of fruit consumption and overweight with high sweetened beverage consumption.	Overweight occurs frequently among Jamaican 15–19-year-olds and is associated with increased consumption of sweetened beverages
8	Goyal et al.	2009	Bakery items, pizza, burgers, cheese, butter, oily items, chocolates	NOVA classification based on FFQ	He BMI of each child was determined and adjusted for expected BMI at age 18	Eating habit like junk food, chocolate remarkable effect on prevalence on overweight and obesity	Overweight and obesity were associated with life style such as higher consumption of UPFs.
9	Kerkadi et al	2019	junk food, chocolate	NOVA classification based on FFQ	BMI, waist–height ratio (WHtH)	The consumption of an unhealthy diet, especially sugary snacks, while watching TV may be considered a contributing factor for obesity	The present study revealed significant associations between low frequency of intake of breakfast, sugar-sweetened beverages, fast food, fries and sweets and obesity,
10	Khan et al.	2019	Fast foods, low fruit/vegetable intake	NOVA classification based on FFQ	Overweight: BMI > +1SD Z-score (≈25 kg/m² at 19 yrs); Obese: BMI > +2SD Z-score (≈30 kg/m² at 19 yrs), per WHO.	High soft drink Consumption and high fast food consumption were vital influencing factors for being overweight or obese among 16 adolescents across both sexes	Higher consumption of soft drink and fast food were associated with overweight and obesity
11	M. Anitha Rani	2013	Fast food items like cakes, burgers, pizza, noodles, puffs, and fried chaat snacks	Not specified	Overweight (≥85th and <95th%), and obese (≥95th%), according to the guidelines from the CDC	Intake of fast-food increase overwieght and obesity	Higher consumption of fast food is associated with overweight and obesity
12	Makri et al.	2022	Fast foods, sugar-sweetened beverages, sweets, snacks/meals in front of screens	NOVA classification based on FFQ	BMI Z-scores from 2007 WHO growth charts: Underweight <−2SD; Overweight > +1SD to ≤ + 2SD; Obesity > +2SD (age- and sex-specific).	Daily consumption of sweets compared to eating sweets less than once per week was associated with being overweight in the total sample	Consumptions of sweet beverages are associated with increasing overweight and obesity.
13	Neri, D. Et al.	2022	Ultra processed food(not specified)	NOVA classification based on 24 dietary recall	BMI, WC	The highest consumption of ultra-processed food was associated with higher odds of total, abdominal, and visceral overweight/obesity.	Study findings showed the associations between ultra-processed foods and increased adiposity and also with metabolically unhealthy phenotypes of obesity in adolescence.
14	Nguyen et al.	2021	Sugar-sweetened beverages (ssbs): soft drinks, tonic drinks, fruit juices, sweetened milk drinks, iced tea, etc.	NOVA classification based on FFQ	He status of overweight or obesity were defined using International Obesity Taskforce 120 (IOTF) sex and age specific BMI cut-offs.	Energy intake from 265 all other sugar-sweetened beverages combined showed slightly higher odds for overweight/obesity 266 but not significant.	No significant association was observed with total energy intake from SSB and overweight and obesity
15	Putra and Santoso	2024	Sugary drinks, packaged snacks, fast food, sweet breakfast cereals, processed meats	NOVA classification based on FFQ	The BMI cut-off recommended by WHO for adolescents	The results showed that high UPF consumption (above the median 4.2 servings/day) significantly increased the risk of obesity in adolescents in Jambi City	High UPF consumption is an independent risk factor for the incidence of obesity in adolescents.
16	Ra, J. S. & Huyen, D. T. T	2024	Sugar-sweetened beverages (ssbs): sodas, sports drinks, other sweetened drinks	NOVA classification based on 7days FFQ	Overweight (≥85th and <95th percentile), and obese (≥95th percentile) according to the screening criteria for growth abnormalities in the 2017 Korean national growth charts	Low and medium consumption of SSBs were associated with increased likelihood of obesity	SSBs consumptions were positively associated with obesity among adolescents.
17	Rifqi et al	2025	Sugar-sweetened beverages (ssbs): sweet drinks, fruit juices, fatty fried foods	NOVA classification based on FFQ & 24-hour dietary recall	Nutritional status assessed by BMI-for-age Z-scores.	Key risk factors for overweight status included sugary drink consumption (OR 2.32), high-fat food intake (OR 1.61).	Sugary drink consumption was associated with obesity among urban residents.
18	Souza SF. Et al.	2022	Sugar-sweetened beverages: Soft/energy drinks, artificial juices Industrialized sweets: Candies, chocolates, cookies, cakes Flours: Industrialized cereal flours Dairy products: Cream cheese, flavored dairy drinks Snacks & fast foods: Chips, pizza, pasta, hot-dogs, fries Sauces & fats: Ketchup, mayonnaise, margarine Processed meats: Sausages, processed meat dishes Instant foods: Instant noodles, ready-made soups	NOVA classification based on monthly FFQ	(BMI/A) was assessed using the curves by sex recommended by the World Health Organization (WHO), The waist circumference was used as an indicator of abdominal obesity, considering the 80th percentile, waist-to-height ratio (WHTR)	ultra processed(prevalence ratio of 1.58; 95%CI: 1.07–2.34) was associated with a higher prevalence of overweight	A higher consumption of processed foods associated with culinary ingredients was related to being overweight, and ultra processed foods with overweight and abdominal obesity.
19	Stanislas and Santoso	2024	High-calorie junk foods: fast food, sugary drinks, packaged snacks, fried foods	NOVA classification based on FFQ	Obesity was defined as BMI ≥ 95th percentile for age and sex based on WHO standards.	Adolescents who frequently consume junk food have a 2.87 times higher risk of becoming obese than those who rarely consume it	Consumption of high-calorie foods (junk food) has a significant role in increasing the risk of obesity in high school adolescents
20	Vanitha et al.	2019	Junk foods: foods made of white flour, fried/salty snacks, carbonated drinks	NOVA classification based on FFQ	Overweight is defined as Body Mass Index (BMI) at or above the 85th percentile or>+1SD and below the 95th percentile	There was significant association with frequency of junk food consumption and BMI variation.	here was significant association with frequency of junk food consumption and BMI variation.
21	Wuenstel, J. W. Et al.	2015	Fruit juices and sweetened beverages (carbonated and non-carbonated)	NOVA classification based on 7days FFQ	BMI cut of point	Daily consumption of sweetened beverages among young people increased the risk of being overweight by more than 60% compared to young people consuming them once a week.	The prevalence of overweight among adolescents was associated with the frequency of sweetened beverage consumption.
22	Yolanda Patrichia et al.	2024	Fast foods: pizza, burgers, chocolate, ice cream, chips, soft drinks	NOVA classification based on FFQ	Obesity was measured using BMI-for-age index (BMI/A)	There is a relationship between junk food consumption patterns and the incidence of adolescent obesity	The prevalence of overweight among adolescents was associated with the frequency of sweetened beverage consumption, but not with the frequency of fruit juice consumption.
23	Zhihao Huang et al.	2024	Fast foods	NOVA classification based on FFQ	BMI = weight(kg)/height(m)²; overweight/obesity defined by IOTF age- and sex-specific cut-offs	Frequent fast-food consumption was associated with overweight/obesity	This study reported that consumption of SSBs, screen-based sedentary behaviors, and sleep duration might be important targets to prevent adolescent obesity

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Overall association of ultra-processed foods consumption and obesity/overweight

The meta-analysis revealed a significant positive association between consumption of UPFs and the likelihood of overweight or obesity with a pooled effect size of 1.63 (95% CI: 1.36, 1.95). Adolescents with higher consumption of UPFs have 63% greater odds of being overweight or obese compared to those with lower UPF intake. However, there was considerable heterogeneity across the included studies (I² = 97.58%, p < 0.001) suggesting notable variability in effect estimates. The pooled effect size was visually represented using a forest plot (Fig 2).

The subgroup analysis by study design showed a pooled effect size of 1.55 (95% CI: 1.29, 1.86) for cross-sectional studies 1.55 (95% CI: 1.33–1.81) for cross-sectional follow-up studies, and a markedly higher effect size of 4.71 (95% CI: 2.09–10.58) for case–control studies (Fig 3).

Subgroup analyses by geographic region indicated that the positive association between UPF consumption and overweight/obesity was observed across all regions, though the magnitude and heterogeneity varied. In Africa, evidence from a single study demonstrated a strong association (OR = 2.98, 95% CI 1.88, 4.73). In Asia, the pooled odds ratio demonstrated a significant positive association between UPF consumption and overweight/obesity (OR = 1.73, 95% CI 1.34, 2.23). Similarly, in Europe, the pooled estimate indicated a modest but statistically significant association (OR = 1.31, 95% CI 1.00–,.70). In North America, the pooled analysis also revealed a significant association (OR = 1.33, 95% CI 1.02–1.73). Likewise, evidence from South America showed a significant positive relationship (OR = 1.58, 95% CI 1.07, 2.34) (Fig 4).

Subgroup analyses by sampling approach revealed that studies using non-random sampling showed a statistically significant association between UPF consumption and overweight/obesity (OR = 1.91, 95% CI 1.20–3.04). Similarly, studies employing random sampling also demonstrated a significant association (OR = 1.58, 95% CI 1.29, 1.93). Heterogeneity was present in both subgroups due to the variability in effect sizes across individual studies (Fig 5).

The subgroup analysis based on year of publication showed that the most recent studies (2024–2025) reported the highest pooled odds ratio, with an OR of 2.09 (95% CI: 1.24, 3.51). The findings revealed that the recent rise in ultra-processed food (UPF) consumption is closely linked to the increasing risk of overweight and obesity (Fig 6).

Publication Bias.

Studies were assessed for potential publication bias using funnel plots and Egger’s regression test. The Egger’s test result (p < 0.05) suggested the presence of small-study effects, consistent with possible publication bias (Table 4). Visual inspection of the funnel plot indicated that unpublished or smaller studies may have had smaller effect sizes compared to published studies (Fig 7) The Trim and Fill method was applied to assess and correct for potential publication bias. This approach estimated the number of studies likely missing to achieve funnel plot symmetry and calculated the effect sizes of these potentially missing studies, providing a bias-adjusted pooled effect size that offers a more conservative and robust estimate of the true effect (Fig 8).

Table 4. Egger’s for publication bias in the systematic review and meta-analysis of the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Std_Eff	Coefficient	Std. err.	T	P > \|t	[95% conf. interval]
slope	−.0099752	.0034286	1.38	0.008	−.0171052	−.0028451
bias	2.882687	.3510949	8.21	0.000	2.152545	3.612829

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Sensitivity analysis.

Sensitivity analysis was performed to assess the effect of each study on the pooled estimated association by excluding each study step-by-step from the analysis process and the result showed that excluded studies led to no significant changes in the shared estimation of the association. The results demonstrated that omission of any single study did not materially alter the statistical significance of the association, indicating that the overall finding was robust and not driven by a single influential study. However, as shown in the sensitivity plot, the pooled odds ratios obtained after excluding individual studies were generally lower than the overall estimate, decreasing from 1.62 to approximately 1.46 when each study was omitted in turn (Fig 9).

Discussion

Overweight and obesity among adolescents are increasing alarmingly and exposing them to various health problems including non-communicable diseases [57]. Unhealthy dietary patterns are the most common cause that increasing the risk of overweight and obesity along with the risk of non-communicable diseases [58]. The aim of this study is to investigate the association between UPF consumption and overweight/obesity among adolescents.

The current systematic review and meta-analysis revealed that there is an association between UPF consumption and the odds of being overweight or obese. According to the findings, higher consumption of UPFs was associated with a 63% increase in the odds of overweight/obesity among adolescents (AOR = 1.63; 95% CI: 1.36–1.95). This finding aligns with previous research demonstrating that higher consumption of UPFs is associated with an increased risk of overweight and obesity. A systematic review and meta-analysis conducted in 2020 reported a positive association between ultra-processed food intake and excess body weight or obesity with a 2% increase in the odds of overweight and obesity among 10–64 years of the population [59]. Similarly, another systematic review and meta-analysis conducted in 2021 found a significant positive relationship between UPF consumption and the risk of overweight and obesity, reporting a 55% increase in the odds of overweight and a 36% increase in the odds of obesity in the general population [60]. In addition, a systematic review and meta-analysis published in 2024, which assessed the relationship between ultra-processed foods and human health, concluded that UPF consumption is associated with a 32% increase in the odds of obesity [61]. This finding is further supported by umbrella review conducted in 2024 indicated that greater exposure to ultra-processed foods was directly associated with obesity [62]. Although these studies focused on the general population rather than adolescents specifically, their findings are consistent with the patterns observed in our review. While the magnitude of effect differs between adolescents and the general population, the direction of the association remains consistent, strengthening the evidence that higher UPF intake contributes to increased odds of overweight and obesity.

The association between UPF consumption and the increased risk of overweight and obesity can be explained by multidimensional factors. Ultra-processed food are typically energy-dense, nutrient-poor, and high in added sugars, unhealthy fats, and salt, which can promote excessive caloric intake and weight gain [63–65]. Moreover, the high palatability and convenience of UPFs often lead to overconsumption and poor dietary quality, further contributing to obesity development [66]. In addition, the high content of rapidly digestible starches and added sugars in UPFs produces large glycemic loads, triggering sharp postprandial insulin surges [67]. This often results in rebound hypoglycemia, which stimulates hunger and promotes fat storage, further sustaining positive energy balance which increase the risk of overweight and obesity [68,69]. Current evidences showed that UPFs often contain additives such as emulsifiers and artificial sweeteners that can disrupt gut microbiota and promote low-grade inflammation [70,71]. Processing also dismantles the natural food matrix, altering digestion dynamics and appetite regulation by dysregulating endocrine function, insulin signaling, and/or adipocyte function all of these are contributed to overweight and obesity [70,71].

The subgroup analysis indicated that case–control studies reported higher odds of association between UPF consumption and overweight/obesity among adolescents. The finding could be due to the fact that case–control studies, being retrospective and collect exposure data after overweight/obesity onset making adolescents prone to recall bias (overreporting of unhealthy exposures) and selection bias if controls are not truly representative [72]. In contrast, cross-sectional studies measure exposure and outcome simultaneously, which limits causal inference and may underestimate associations due to reverse causation, such as dietary changes following obesity [73]. In addition this may be partly explained by the small number of case–control studies included in this review and meta-analysis, which makes the pooled estimate more susceptible to influenced by to a single outlier with a large odds ratio and affect the overall effect size.

This systematic review and meta-analysis revealed that the most recent studies (2024–2025) showed higher odds of association between UPF consumption and overweight/obesity during adolecent. This is likely related to the increased consumption of ultra-processed foods accompanied by more sedentary lifestyles in recent years [74]. All these together contribute to greater energy imbalance and weight gain. Additionally, improvements in dietary assessment methods and study designs and increase exposure to UPFs in today’s food environment may have further contribution the observed associations in these recent studies [75].

Strengths and limitations of the review

To our knowledge, this is the first systematic review and meta-analysis focusing on the adolescent population, based on a comprehensive literature search across multiple databases with no restrictions on publication year or language. However, limitations include the use of observational studies, restricting causal inference; heterogeneity in dietary assessment methods and BMI reference; and limited representation from low-income settings. The absence of age- and sex-specific reporting in the included studies limited subgroup analyses by age and sex. In addition, publication bias cannot be excluded, potentially inflating observed associations.

Conclusions and recommendations

The evidence from this study suggests that higher consumption of ultra-processed foods is associated with overweight and obesity among adolescents. This relationship appears consistent across multiple populations and study settings.

Public health strategies should prioritize reducing UPF consumption among adolescents through education, policy interventions, and promotion of minimally processed, nutrient-dense foods. Future research should focus on longitudinal and interventional studies to clarify causal relationships and assess effective strategies for obesity prevention.

Supporting information

S1 File. Key words and searching UPF SRMA.

(DOCX)

pone.0344873.s001.docx^{(19KB, docx)}

S2 File. Data extraction table.

(XLSX)

pone.0344873.s002.xlsx^{(24.2KB, xlsx)}

S3 File. Quality assessment of the included studies.

(DOCX)

pone.0344873.s003.docx^{(18.4KB, docx)}

S4 File. PRISMA checklist.

(DOCX)

pone.0344873.s004.docx^{(28.9KB, docx)}

Acknowledgments

The authors would like to thank all authors of studies included in this systematic review and meta-analysis

Abbreviations

BMI: Body Mass Index
CI: Confidence Interval
FFQ: Food Frequency Questionnaire
IOTF: International Obesity Task Force
OR: Odds Ratio
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
RR: Relative Risk
SD: Standard Deviation
UPF: Ultra-Processed Food
WHO: World Health Organization

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0344873.r001

Decision Letter 0

Giulia Squillacioti

23 Dec 2025

Dear Dr. Aweke,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: No

**********

Reviewer #1: General comments

I have read the manuscript with interest, and I appreciated the author’s work in addressing such an important topic through a systematic review. This systematic review investigates the presence of evidence on the association between the ultra-processed food consumption and risk of overweight and obesity in adolescents. The use of appropriate methodology and adherence to PRISMA guidelines enhances the credibility of the work and ensures methodological transparency. That said, I think that some revisions can improve the quality and the robustness of the work. Overall, the statistical and methodological parts are very well explained, but some improvements are required. The plots are clear, but a more precise description of the tables and figures could help the readers understand the data. Finally, while the overall structure and content of the manuscript are solid, there are a few areas where the English could be improved for clarity (for instance, there are a few typos that could benefit from a careful reading).

Specific comments

1. Line 65 – missing a “to” in “are particularly vulnerable higher consumption”?

2. Line 91 – typo “there is”

3. Line 92 – typo “during adolescence”, check the entire manuscript.

4. Line 120 – The meaning of this sentence is somewhat unclear; rephrasing it might help improve clarity.

5. Line 123 – when Endnote is cited, the software version and licence should be added.

6. Line 217 – “overall”

7. Line 246 – please, remove the double dot.

8. Line 279-282 – The paragraph currently lacks references, and including some would help situate the discussion within the broader literature.

9. Line 286 – the phrase “increases the likelihood of overweight/obesity in adolescents by 63%” may be misleading, as it could be interpreted as an increase in absolute risk or probability. To improve clarity and avoid potential misinterpretation by non-technical readers, the authors may consider explicitly stating that this figure refers to an increase in odds.

10. Line 289-296 – It would be helpful to expand on the findings from these publications by specifying the populations they investigated and whether the included studies are comparable to those in your review. Additionally, clarifying how these works support your findings—and, where applicable, how your review addresses any limitations they may have—could strengthen your argument. Are their data directly comparable to the percentages reported in your review? Adding a few lines of explanation could enrich the paragraph and help the reader better appreciate the robustness of your work.

11. Please ensure that all acronyms used in the text are clearly defined and explained.

12. Tables: all Tables lack footnotes with abbreviations, which would help the readers to understand the information included.

13. Figures 1-3-4-6 quality needs to be improved.

14. Figure 8 needs a proper description and legend.

15. Figure 4 represents the stratification by year of publication, not by region. Figure 4 needs to be updated.

16. Line 272 – The sensitivity analysis paragraph could be clarified or expanded. While it is correct that excluding individual studies does not alter the statistical significance of the association, the graph shows that most of the pooled estimates obtained after omitting one study are lower than the overall OR (from 1.62 to approximately 1.46). This suggests that some studies contribute to strengthening the overall association. By clarifying this point, methodological transparency would be improved, helping readers better understand the robustness and dynamics of the overall effect.

17. Line 334-335 – I recommend rephrasing this sentence for improved clarity.

Overall, the statistical and methodological parts are very well explained, but some improvements are required. The plots are clear, but a more precise description of the tables and figures could help the readers understand the data.

Reviewer #2: Comments to the authors

The present article aims at filling a void in scientific literature due to the absence of a systematic review and meta-analysis of the evidence regarding the association between the consumption of UPFs and the overweight/obesity in adolescent. The data showed are relevant, especially the pooled estimation derived from the observational studies that represented the majority of the studies. However, the quality of the language, both from a grammatical and syntactical point of view, employed in this paper needs to be inspected and improved to be fully comprehensible and, then, considered for publication.

Methods

Comment 1. The use of Nova classification system to categorise food on the base of level of processing is defined as strength of this study. For the same reason, why was Nova system not considered among the inclusion criteria for the selection of the studies?

Comment 2. Please, add a reference for each criteria used to define overweigh and obesity.

Comment 3. From a methodological point of view this work is solid, but have some limitations. Firstly, the authors should implement sub-group analysis for age, since the age range considered put together adolescents in a different stage of their maturity with likely different eating habits, and for sex, because in this phase energy expenditure and intake starts to diverge between boys and girls. In case it is not possible to conform with this request, it would be appropriate to report the lack of sub-group analysis for age and sex in the limitation of the paper.

Comment 4. I suggest to specify the nature of the pooled measures (odds ratios), univariate or multivariate?

Results

Comment 3. I would add the number of each dietary methods used between parentheses (lines 210-211).

Comment 4. The results showed in the lines 218-222 are repeated twice.

Comment 5. The range 10-19 years is a wide age range that puts together adolescents that might have significantly different dietary behaviours and food intake, especially comparing boys and girls. Consequently, I reckon that additional analyses stratified by age and sex, if it possible, would improve the quality of the evidence.

Discussion

Comment 6. I would add more details of the studies which results were reported from the line 288 to 296, focusing on the peculiarities and differences that these provides compared to the study conducted by the authors of this manuscript. In particular, since the authors stated that this work is the first that assessed the relationship between UPFs consumption and obesity/overweight in adolescents, it should be highlighted that the reviews used in support of their results are based on adult populations.

Comment 7. I would recommend to support your statements about the possible explanations of your result in lines 312-317 with proper references.

Comment 8. A conclusive statement (lines 328-329) is redundant in the discussion; thus, you should relegate your conclusions only to the “conclusion” paragraph of the manuscript. Therefore, I recommend to remove this short paragraph from the discussion. In case the authors would use it as the conclusion paragraph, I recommend to temper what is stated, since it might imply a causal relationship between UPFs consumption and overweight/obesity in adolescent (“…risk of becoming overweight/obese…”).

**********

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2026 Apr 15;21(4):e0344873. doi: 10.1371/journal.pone.0344873.r002

Author response to Decision Letter 1

25 Jan 2026

25 Jan, 2026

Dear Editors of the Plos One,

We are grateful for the time and expertise devoted to reviewing manuscript PONE-D-25-46416 titled “Ultra-Processed Food Consumption and the Risk of Overweight and Obesity in Adolescents: A Systematic Review and Meta-Analysis”. We sincerely appreciate the reviewers’ constructive feedback, which has helped us improve the scientific clarity and overall quality of the paper.

In response, we have carefully revised the manuscript and provided a detailed, point-by-point reply outlining how each comment has been addressed. Revisions within the manuscript are clearly marked for easy review. We believe these changes strengthen the analysis, interpretation, and presentation of our findings.

Thank you for the opportunity to revise our work.

Warm regards,

Mekuriaw Nibret Aweke

Corresponding Author

1. Editors comment

1. Please submit your revised manuscript

Authers response:

Dear Editor,

Thank you for the opportunity to revise our manuscript based on the reviewers’ comments and suggestions. We have carefully considered each point and revised the manuscript accordingly. The updated version has now been resubmitted for your review. We hope that these revisions adequately address all concerns and have strengthened the overall quality of the manuscript

2. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Authers response:

Dear editor, thank you very much for the reminder to meets the PLOS ONE’S style requirement. We have revised the manuscript in accordance with the journals style requirement including file naming.

3. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement.

Authers response:

Dear editor, we have revised the manuscript by removing funding information form the main manuscript document.

4. We note that you have referenced unpublished data which has currently not yet been accepted for publication. Please remove this from your References and amend this to state in the body of your manuscript: as detailed online in our guide for authors

Authers response:

Dear editor, thank you very much for your request to remove the unpublished article from the reference list. We have removed the unpublished article from the reference list and we cited with published articles.

5. Please ensure that you refer to Tables 1 and 3 in your text; if accepted, production will need this reference to link the reader to the Table.

Authers response:

Dear editor, thank you very much for your request to refer table 1 and 3 in the text of our manuscript. Accordingly we have corrected by referring table and table 3 with respective for each stetment and now the issue is resolved. Thank you very much again for your suggesions

2. Revewer #1 comments

Response to Reviewer:

Thank you for your positive feedback on the quality relevance and importance of our study. We are very pleased to hear your appreciation, and we value your comments and suggestions, which have helped us improve the manuscript.

1. Line 65 – missing a “to” in “are particularly vulnerable higher consumption”?

Response to Reviewer:

Dear Reviewer, Thank you for your helpful comment. We have add “to” in line 65 stetment and now the statement read as the follows:

“Adolescents are particularly vulnerable to higher consumption of UPF because of their growing independence, higher nutritional needs, heavy marketing, easy access to tasty foods, and often inactive lifestyles.”

2. Line 91 – typo “there is”

Authors response

Dear Reviewer, thank you for very much for your help to correct typo error. We have noticed that the word there was not written correctly. Now we have revised it accordingly thank you again for your valuable comments.

3.Line 92 – typo “during adolescence”, check the entire manuscript.

Authors response

Dear Reviewer, thank you for very much for your help to correct typo error. We have noticed that the phrase “during adolescent” has typo error and now revised it as “during adolescence”. Thank you for your detail reviewing and crucial comments.

4 Line 120 – The meaning of this sentence is somewhat unclear; rephrasing it might help improve clarity.

Authors response:

Dear reviewer thank you very much for your valuable comment to revise the sttement in line 120. We have recognized that the sttement was not clear and now we have corrected it and reads as the following;

“Database searches were conducted to retrieve articles published up to July 21, 2025.”

5 Line 123 – when Endnote is cited, the software version and license should be added.

Authors response:

Dear reviewer thank you very much for your valuable comment to add the software version and license of endnote in line 123. We have revised the sttement by adding the version of endnote.

6 Line 217 – “overall”

Authors response:

Dear Reviewer, we appreciate your careful reading of the manuscript and your valuable comments on each section. Based on your observation, we identified a typographical error (“over all”) and have corrected it to “Overall” in the manuscript.

7 Line 246 – please, remove the double dot.

Authors response:

Dear Reviewer, we have removed the double dot in line 246. Thank you for your observation.

8 Line 279-282 – The paragraph currently lacks references, and including some would help

Authors response:

Dear Reviewer, thank you very much for your suggesions to include reference for line 279-282. We have included the citations for each stetments. Thank you again for your valuable suggestions.

9 Line 286 – the phrase “increases the likelihood of overweight/obesity in adolescents by 63%” may be misleading, as it could be interpreted as an increase in absolute risk or probability. To improve clarity and avoid potential misinterpretation by non-technical readers, the authors may consider explicitly stating that this figure refers to an increase in odds.

Authors response:

Dear Reviewer, thank you for your recommendation to revise the line 286 stement for better clarity for non-technical reads and we have revised the statment and reads as the following:

“According to the findings, higher consumption of UPFs was associated with a 63% increase in the odds of overweight/obesity among adolescents....”

Authors response:

Dear Reviewer, we thank the reviewer for this suggestion. We have expanded the Discussion to specify that the cited systematic reviews and meta-analyses focused on the general population, while our study addresses adolescents specifically. We have also revised the stetments with the percentages of odds in each study findings for more clarity. We also clarified how our findings are consistent with previous work that consistently reported the association of ultra processed food consumption and overweight/obesity.

11. Please ensure that all acronyms used in the text are clearly defined and explained.

Authors response:

Dear Reviewer, we thank you for your comment regarding the clear definition and explanation of all acronyms in the text. We identified a typographical error where “MI” was written instead of “BMI,” which has now been corrected, and the acronym is clearly defined in the manuscript. We appreciate your suggestion.

12. Tables: all Tables lack footnotes with abbreviations, which would help the readers to understand the information included.

Authors response:

Dear Reviewer, we thank you for your comment regarding the lack of footnotes in the table. We have added the footnotes with abrivation where abrivations are not explained with the table. Thank you for your valuable comments.

13. Figures 1-3-4-6 quality needs to be improved.

Authors response:

Dear Reviewer, we thank you for your comment suggestion to improve the quality of figure 1, 3, 4, 6. We have improved the quality of figure 3 4 and 6 by redesigning the figure output and we hope now the texts are readable and the quality of the figure is improved. We appreciate your valuable comment and suggesions.

14. Figure 8 needs a proper description and legend.

Authors response:

Dear Reviewer, thank you very much for your suggestion to add proper discription of the figure 8 and its legend. We have revise the stetments to make it more explanatory. We are open to accept additional comments and to revise if any unaddressed issues. Thank you again..

15. Figure 4 represents the stratification by year of publication, not by region. Figure 4 needs to be updated.

Author response

Dear Reviewer, we apologize for the mismatch between the text and the figure. Upon review, we realized that Figure 4 did not represent the geographical subgroup analysis. This has now been corrected, and Figure 4 accurately displays the geographical variation in effect size. We sincerely appreciate your guidance in helping us address this issue.

Author response

Dear Reviewer, we appreciate valuable comments we have revised the sensetivity paragraph explanation to improve the methodological transparency and the revised paragraph reads as the following:

“..However, as shown in the sensitivity plot, the pooled odds ratios obtained after excluding individual studies were generally lower than the overall estimate, decreasing from 1.62 to approximately 1.46 when each study was omitted in turn.”

17. Line 334-335 – I recommend rephrasing this sentence for improved clarity.

Author response

Dear Reviewer, we appreciate the thoughtful feedbacks, suggestions and comments. In response, we have revised the sentence in Lines 334–335 for improved clarity. We have also enhanced the descriptions of the tables and figures to offer clearer guidance and improve readers’ understanding of the statistical and methodological results. We are also open to making any revision if unaddressed concerns. Thank ypu again for your valuable comments that helps to enhance the quality of the work.

3. Reviewer 2 comments and responses

Author response

Dear Reviewer, we are very glad to hear this positive feedback about the gap filling of our work. We have revised all the concerns raised and we hope the manuscript is now improved and fully comprehensible.

Author response

Dear Reviewer, we thank the reviewer for this comment. The NOVA classification was not included as an eligibility criterion to avoid unnecessarily restricting the evidence base, as many relevant studies assessed food processing using alternative definitions. Restricting inclusion only to studies that explicitly applied the NOVA classification would have introduced selection bias and that is why we didn’t use the inclusion criteria.

Comment 2. Please, add a reference for each criteria used to define overweigh and obesity.

Author response

Dear Reviewer, thank you very much for your recommendation to include reference for each criteria define overweight and obesity. We have included the reference for each classification criteria.

Author response

Dear Reviewer, we thank the reviewer for this valuable suggestion. Although subgroup analyses by age and sex would be methodologically informative, they were not feasible because most included studies reported findings for mixed age groups and combined sexes, without providing stratified data. We have now explicitly acknowledged the lack of age- and sex-specific subgroup analyses as a limitation in the revised manuscript. Thank you for this important comment.

Comment 4. I suggest to specify the nature of the pooled measures (odds ratios), univariate or multivariate?

Author response

Dear Reviewer, we appreciate for this valuable comment to make specify the nature of the pooled measure(odds ratios). We have specified the nature of the pooled measures and the revised stetement reads as the follows:

“For the meta-analysis, we extracted and pooled multivariable-adjusted odds ratios (ORs) whenever reported; in cases where adjusted estimates were unavailable, crude ORs were used.”

Results

Comment 3. I would add the number of each dietary methods used between parentheses (lines 210-211).

Author response

Dear Reviewer, we appreciate the valuable comment to add the number studies used diatary assessment methods. Based on the comment we have revised the statement and specified the number of studies used types of diatary assessment methods. Thank you again for this crucial suggesions. The revised stetment reads as the following:

“Among the 23 studies that reported their dietary assessment methods, 19 primarily used food frequency questionnaires (FFQs), while two studies employed 24-hour dietary recalls or food records methods.”

Comment 4. The results showed in the lines 218-222 are repeated twice.

Author response

Dear Reviewer, we thank the reviewer for this comment. We carefully re-examined lines 218–222 of the manuscript but were unable to identify duplicated statements. We are open to making correction if the repeated sttements are found in any parts of the documents. Thank you for your detail reading and valuable comments.

Author response

Dear Reviewer, we thank the reviewer for this important observation. While age- and sex-stratified analyses would strengthen the evidence,

Attachment

Submitted filename: Resposnse to reviewer.docx

pone.0344873.s006.docx^{(35.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0344873.r003

Decision Letter 1

Giulia Squillacioti

17 Feb 2026

Dear Dr. Aweke,

Please address the Reviewer #2 suggestions
Please formally justify the inclusion of the new Author in the co-authors list

plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
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An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Giulia Squillacioti

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: No

**********

Reviewer #1: The authors have satisfactorily addressed all the questions and comments raised in my previous review, and I believe the manuscript is now suitable for publication. However, I would like to point out that Figure 8 still lacks a legend and the axes are not defined, which makes the figure difficult to interpret. I recommend addressing this minor issue before final acceptance.

Reviewer #2: The manuscript appears to have improved following the reviewers’ suggestions. However, I still have reservations regarding the authors’ response to Comment 1 from Reviewer 2.

In my opinion, the decision to include all classifications available in the literature to categorise UPFs necessitates the provision of additional methodological detail. First, I recommend adding a new table (similar to Table 2) that includes a column describing the method used to classify UPFs in each study included in the review. Furthermore, a similar level of detail should be provided for the outcomes, specifying the methods used to assess overweight and obesity.

The proposed table could include the following columns: S. No., Author, Exposure Assessment, Outcome Assessment, Results, and Conclusion.

Second, if feasible, the authors should consider conducting subgroup analyses based on the different methods used to assess both exposure and outcomes.

Finally, the statement that the use of the Nova system represents a strength of this review (lines 352–355) should be supported strictly by the results obtained. Such a claim should be made cautiously and only if clearly justified by the findings.

In conclusion, in addition to the suggestions mentioned above to improve the scientific quality of the manuscript, I strongly recommend that the authors seek professional English language editing prior to resubmission. The manuscript contains frequent grammatical errors, awkward sentence constructions, and typographical mistakes, which significantly affect its overall clarity.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #1: No

Reviewer #2: No

**********

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

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PLoS One. 2026 Apr 15;21(4):e0344873. doi: 10.1371/journal.pone.0344873.r004

Author response to Decision Letter 2

19 Feb 2026

18 Feb, 2026

Dear Editors of the Plos One,

Thank you for the opportunity to revise our work.

Warm regards,

Mekuriaw Nibret Aweke

Corresponding Author

1. Editors comment

1. Please address the Reviewer #2 suggestions

Authers response:

Dear Editor,

We are very pleased to have recived the quick feedback from the editor and reviewers after revision. Accordingly we have corrected and revised the manuscript based on the suggesions of reviewer #2. Thank you very much for the opportunity .

2. Please formally justify the inclusion of the new Author in the co-authors list

Authers response:

We respectfully request approval to add Anas Ali Alhur to the list of authors for this manuscript. The Authors had substantial contributions to analysis, interpretation of data critically revising the manuscript for important intellectual content; and final approval of the version to be published.

He also provided critical intellectual revisions to the manuscript that enhanced its scientific rigor and clarity. Anas Ali Alhur has reviewed and approved the final version of the manuscript and agrees to be accountable for all aspects of the work, ensuring the accuracy and integrity of the research. This authorship update does not affect the study’s results, conclusions, or disclosures, and no conflicts of interest arise from this change.

2. Revewer #1 comments

The authors have satisfactorily addressed all the questions and comments raised in my previous review, and I believe the manuscript is now suitable for publication. However, I would like to point out that Figure 8 still lacks a legend and the axes are not defined, which makes the figure difficult to interpret. I recommend addressing this minor issue before final acceptance.

Response to Reviewer:

Dear reviewer thank you very much for your acceptance that we have addressed the questions and comments. In addition we have revised figure to by including legend and defined the axes which will now easy to interpret.

We appreciate your invaluable feedback to enhance the quality of manuscript.

3. Reviewer 2 comments and responses

The manuscript appears to have improved following the reviewers’ suggestions.

Author response

Dear Reviewer, we are very glad to hear this positive feedback about the improvement of the manuscript after reviewers suggesions.

Comment 1. In my opinion, the decision to include all classifications available in the literature to categorise UPFs necessitates the provision of additional methodological detail. First, I recommend adding a new table (similar to Table 2) that includes a column describing the method used to classify UPFs in each study included in the review. Furthermore, a similar level of detail should be provided for the outcomes, specifying the methods used to assess overweight and obesity. The proposed table could include the following columns: S. No., Author, Exposure Assessment, Outcome Assessment, Results, and Conclusion.

Author response

Dear Reviewer, thank you for this valuable comment. We agree that providing additional methodological detail strengthens the clarity and transparency of the review. Accordingly, we revised the manuscript by adding a new table (Table 3), structured similarly to Table 2, which explicitly details the methods used to classify ultra-processed foods in each included study. This table now includes information on the exposure assessment (including UPF classification approaches), outcome assessment methods for overweight and obesity, as well as the corresponding results and conclusions of each study. These revisions enhance comparability across studies and improve the methodological rigor of the review.

Comment 2 Finally, the statement that the use of the Nova system represents a strength of this review (lines 352–355) should be supported strictly by the results obtained. Such a claim should be made cautiously and only if clearly justified by the findings.

Author response

Dear Reviewer, thank you for this important comment. We agree that claims regarding methodological strengths should be made cautiously and be directly supported by the findings. Accordingly, we have removed the statement asserting the use of the NOVA classification as a strength of the review (formerly lines 352–355) to avoid overstating its contribution beyond what is clearly justified by the results.

Comment 3 In conclusion, in addition to the suggestions mentioned above to improve the scientific quality of the manuscript, I strongly recommend that the authors seek professional English language editing prior to resubmission. The manuscript contains frequent grammatical errors, awkward sentence constructions, and typographical mistakes, which significantly affect its overall clarity..

Author response

Dear reviewer, we thank the reviewer for this valuable suggestion. We have revised spelling errors typographical and other mistakes and we hope this revision will improve the updated version of the manusrcipt.

Attachment

Submitted filename: Resposnse_to_reviewer_auresp_2.docx

pone.0344873.s007.docx^{(28.6KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0344873.r005

Decision Letter 2

Giulia Squillacioti

27 Feb 2026

Ultra-Processed Food Consumption and the Risk of Overweight and Obesity in Adolescents: A Systematic Review and Meta-Analysis

PONE-D-25-46416R2

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PLoS One. doi: 10.1371/journal.pone.0344873.r006

Acceptance letter

Giulia Squillacioti

PONE-D-25-46416R2

PLOS One

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. Key words and searching UPF SRMA.

(DOCX)

pone.0344873.s001.docx^{(19KB, docx)}

S2 File. Data extraction table.

(XLSX)

pone.0344873.s002.xlsx^{(24.2KB, xlsx)}

S3 File. Quality assessment of the included studies.

(DOCX)

pone.0344873.s003.docx^{(18.4KB, docx)}

S4 File. PRISMA checklist.

(DOCX)

pone.0344873.s004.docx^{(28.9KB, docx)}

Attachment

Submitted filename: Resposnse to reviewer.docx

pone.0344873.s006.docx^{(35.4KB, docx)}

Attachment

Submitted filename: Resposnse_to_reviewer_auresp_2.docx

pone.0344873.s007.docx^{(28.6KB, docx)}

Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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PERMALINK

Ultra-processed food consumption and the risk of overweight and obesity in adolescents: A systematic review and meta-analysis

Mekuriaw Nibret Aweke

Habtamu Wagnew Abuhay

Miteku Andualem Limenih

Anas Ali Alhur

Nebebe Demis Baykemagn

Gebrie Getu Alemu

Makda Fekadie Tewelgne

Tirualem Zeleke Yehuala

Roles

Abstract

Introduction

Objective

Methods

Results

Conclusion

Introduction

Methods

Study protocol and registration

Search strategy

Study selection

Inclusion and exclusion criteria

Table 1. Criteria for Inclusion of Quantitative Studies Based on the Population, Exposure, Comparator, Outcome (PECO) Framework.

Outcomes of interest

Assessment of the quality of the individual studies

Data extraction

Statistical analysis

Results

Selection and identification of studies

Fig 1. PRISMA flow diagram for the systematic review and meta-analysis on the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Characteristics of included studies

Table 2. Characteristics of included studies on ultra-processed food consumption and adolescent obesity.

Table 3. Characteristics and Key Findings of Studies on Ultra-Processed Foods and Adolescent Obesity.

Overall association of ultra-processed foods consumption and obesity/overweight

Fig 2. Forset plot for systematic review and meta-analysis on the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Fig 3. Subgroup analyses by study designs for the systematic review and meta-analysis on the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Fig 4. Subgroup analysis by geographical region in the systematic review and meta-analysis of the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Fig 5. Subgroup analysis by sampling methods in the systematic review and meta-analysis of the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Fig 6. Subgroup analysis by year of publication in the systematic review and meta-analysis of the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Publication Bias.

Table 4. Egger’s for publication bias in the systematic review and meta-analysis of the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Fig 7. Funnel plot for publication bias in the systematic review and meta-analysis of the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Fig 8. Trim and fill analysis for publication bias in the systematic review and meta-analysis of the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Sensitivity analysis.

Fig 9. Sensetivity analysis in the systematic review and meta-analysis of the association between ultra-processed food (UPF) consumption and obesity among adolescents.

Discussion

Strengths and limitations of the review

Conclusions and recommendations

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Giulia Squillacioti

Roles

Author response to Decision Letter 1

Decision Letter 1

Giulia Squillacioti

Roles

Author response to Decision Letter 2

Decision Letter 2

Giulia Squillacioti

Roles

Acceptance letter

Giulia Squillacioti

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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