Specifies the number of studies evaluated orselected
Steps, and targets of constructing a good review article are listed in Table 3 . To write a good review article the items in Table 3 should be implemented step by step. [ 11 – 13 ]
Steps of a systematic review
Formulation of researchable questions | Select answerable questions |
Disclosure of studies | Databases, and key words |
Evaluation of its quality | Quality criteria during selection of studies |
Synthesis | Methods interpretation, and synthesis of outcomes |
It might be helpful to divide the research question into components. The most prevalently used format for questions related to the treatment is PICO (P - Patient, Problem or Population; I-Intervention; C-appropriate Comparisons, and O-Outcome measures) procedure. For example In female patients (P) with stress urinary incontinence, comparisons (C) between transobturator, and retropubic midurethral tension-free band surgery (I) as for patients’ satisfaction (O).
In a systematic review on a focused question, methods of investigation used should be clearly specified.
Ideally, research methods, investigated databases, and key words should be described in the final report. Different databases are used dependent on the topic analyzed. In most of the clinical topics, Medline should be surveyed. However searching through Embase and CINAHL can be also appropriate.
While determining appropriate terms for surveying, PICO elements of the issue to be sought may guide the process. Since in general we are interested in more than one outcome, P, and I can be key elements. In this case we should think about synonyms of P, and I elements, and combine them with a conjunction AND.
One method which might alleviate the workload of surveying process is “methodological filter” which aims to find the best investigation method for each research question. A good example of this method can be found in PubMed interface of Medline. The Clinical Queries tool offers empirically developed filters for five different inquiries as guidelines for etiology, diagnosis, treatment, prognosis or clinical prediction.
As an indispensable component of the review process is to discriminate good, and bad quality researches from each other, and the outcomes should be based on better qualified researches, as far as possible. To achieve this goal you should know the best possible evidence for each type of question The first component of the quality is its general planning/design of the study. General planning/design of a cohort study, a case series or normal study demonstrates variations.
A hierarchy of evidence for different research questions is presented in Table 4 . However this hierarchy is only a first step. After you find good quality research articles, you won’t need to read all the rest of other articles which saves you tons of time. [ 14 ]
Determination of levels of evidence based on the type of the research question
I | Systematic review of Level II studies | Systematic review of Level II studies | Systematic review of Level II studies | Systematic review of Level II studies |
II | Randomized controlled study | Crross-sectional study in consecutive patients | Initial cohort study | Prospective cohort study |
III | One of the following: Non-randomized experimental study (ie. controlled pre-, and post-test intervention study) Comparative studies with concurrent control groups (observational study) (ie. cohort study, case-control study) | One of the following: Cross-sectional study in non-consecutive case series; diagnostic case-control study | One of the following: Untreated control group patients in a randomized controlled study, integrated cohort study | One of the following: Retrospective cohort study, case-control study (Note: these are most prevalently used types of etiological studies; for other alternatives, and interventional studies see Level III |
IV | Case series | Case series | Case series or cohort studies with patients at different stages of their disease states |
Rarely all researches arrive at the same conclusion. In this case a solution should be found. However it is risky to make a decision based on the votes of absolute majority. Indeed, a well-performed large scale study, and a weakly designed one are weighed on the same scale. Therefore, ideally a meta-analysis should be performed to solve apparent differences. Ideally, first of all, one should be focused on the largest, and higher quality study, then other studies should be compared with this basic study.
In conclusion, during writing process of a review article, the procedures to be achieved can be indicated as follows: 1) Get rid of fixed ideas, and obsessions from your head, and view the subject from a large perspective. 2) Research articles in the literature should be approached with a methodological, and critical attitude and 3) finally data should be explained in an attractive way.
Peer reviewed/refereed/scholarly articles, best databases for starting education research, find databases by subject and format: databases a-z list, find databases by subject or topic: research guides, what if the article i want isn't available full-text, google scholar, know the journal name of the article you want try publication finder.
Databases are collections of information. We purchase access to several databases that contain journals and magazines where you can find articles for your research.
There are two types of databases for articles:
Subject-specific: These databases gather articles from journals about specific disciplines or topics, such as Education or Art or Psychology.
Multidisciplinary: These databases gather articles from across multiple disciplines. It could be a database that covers a wide variety of social sciences or it could be a database that covers a wide variety across the arts, humanities, social sciences and sciences. Using a subject-specific database often means you can search for very specific topics and find materials.
Articles that are peer-reviewed can also be referred to as peer-reviewed, refereed or scholarly articles.
Scholarly articles are written by researchers or experts in a field to share the results of their original research or analysis with other researchers, experts and students. These articles go through a process known as "peer review" where the article is reviewed by a group of experts in the field and revised based on peer feedback before being accepted and published by a journal.
This short video further explains what peer review is and why it's important.
These databases are examples of good subject-specific databases for researching the disciplines of Art, Education, and Psychology:
Education journal articles (EJ references) and ERIC documents (ED references), 1967-present. EDs before 1997 are requestable using the Microforms Request page and usable in the Microforms Vewing Room in the LC.
A free version of ERIC is available for all to use at this link: https://eric.ed.gov/ .
Available on campus to all, or off-campus to UMass Amherst students, staff and faculty with an UMass Amherst IT NetID (user name) and password.
These are examples of multidisciplinary databases that also have a broader focus. Social Science Premium Collection covers multiple disciplines in the social sciences and Scopus has coverage in the arts, humanities, social sciences and sciences. With Scopus, you can sort by citation to see highly cited articles.
We have more than 600 databases on a wide variety of topics. The spectrum ranges from databases that have a very specific topic to databases that are multidisciplinary.
The easiest way to find databases with articles on your research topic is to use the Databases A-Z List. Use the link below to go the list.
You can use the following filters to find databases based on subject and format:
Library staff at the UMass Libraries have developed research guides by subjects, topics and collections. You can look at various guides and see what resources librarians recommend for those subjects, which includes databases where you can find articles.
If the article that you want doesn't have full-text available, look for this icon in the result for the article and click on it:
This will search our other databases to see if it's available full-text. You'll go to a page that may list several of the options if they are available:
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Click on the name of the database to go directly to the article. If it lists more than one option, make sure to look at the date ranges to make sure that the date of your article falls within the data range. Sometimes that link will send you to the database instead of the specific article. If that happens, search for the article in the new database. | |
If we don't have another database that has full-text, you can submit an Interlibrary Loan (ILL) request for the article (for free!). Clicking on this link will take you to the login for our ILL system. The best part is that it will fill in the article details needed for ILL for you! If you haven't used ILL before, please see the XXXXX page on the left for details on activating your account. | |
This will search Google Scholar to see if there's a full-text version available for the article. | |
This will search Unpaywall to see if there's a full-text version available for the article. Unpaywall is an open database of open access content from publishers and repositories. |
Google Scholar searches scholarly literature across many topics. However, we don't know what it searches - you can't tell if it's a comprehensive search of the literature. The benefit of using library databases is that you can see where the information in the database is from, such as a list of publications.
Use Our Google Scholar Link!
You want to use the Google Scholar link from the Databases A-Z list or use the link below (and use that link if you want a bookmark!)
This will allow you to search Google Scholar and if the article is in one our databases, you'll either see a link to the article on the right and/or you will see UMass Check for Full Text . The check for full text will do the same as the UMass icon described above.
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If you know the name of the journal of the article that you want, you can use Publication Finder to see if we have electronic access to the journal. You can search for the name of the publication and limit by publication type.
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Open Access
Peer-reviewed
Research Article
Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing
* E-mail: [email protected]
Affiliations Centre Hospitalier Agen-Nérac, Agen, France, UR 4139 Laboratoire de Psychologie, Université de Bordeaux, Bordeaux, France
Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing – review & editing
Affiliation UR 4139 Laboratoire de Psychologie, Université de Bordeaux, Bordeaux, France
Roles Methodology, Validation, Writing – review & editing
Roles Conceptualization, Methodology, Supervision, Validation, Writing – review & editing
Despite the growing body of literature on posttraumatic stress disorder (PTSD) and chronic pain comorbidity, studies taking into account the role of childhood exposure to traumatic and adverse events remains minimal. Additionally, it has been well established that survivors of childhood trauma may develop more complex reactions that extend beyond those observed in PTSD, typically categorized as complex trauma or CPTSD. Given the recent introduction of CPTSD within diagnostic nomenclature, the aim of the present study is to describe associations between childhood trauma in relation to PTSD/CPTSD and pain outcomes in adults with chronic pain.
Following PRSIMA guidelines, a systematic review was performed using the databases Pubmed, PsychInfo, Psychology and Behavioral Sciences Collection, and Web of Science. Articles in English or French that reported on childhood trauma, PTSD/CPTSD and pain outcomes in individuals with chronic pain were included. Titles and abstracts were screened by two authors independently and full texts were consequently evaluated and assessed on methodological quality using JBI checklist tools. Study design and sample characteristics, childhood trauma, PTSD/CPTSD, pain outcomes as well as author’s recommendations for scientific research and clinical practice were extracted for analyses.
Of the initial 295 search records, 13 studies were included in this review. Only four studies explicitly assessed links between trauma factors and pain symptoms in individuals with chronic pain. Findings highlight the long-term and complex impact of cumulative childhood maltreatment (e.g., abuse and neglect) on both PTSD/CPTSD and chronic pain outcomes in adulthood.
This review contributes to current conceptual models of PTSD and chronic pain comorbidity, while adding to the role of childhood trauma and CPTSD. The need for clinical and translational pain research is emphasized to further support specialized PTSD/CPTSD treatment as well as trauma-informed pain management in routine care.
Citation: Karimov-Zwienenberg M, Symphor W, Peraud W, Décamps G (2024) Childhood trauma, PTSD/CPTSD and chronic pain: A systematic review. PLoS ONE 19(8): e0309332. https://doi.org/10.1371/journal.pone.0309332
Editor: Inga Schalinski, Universitat der Bundeswehr München: Universitat der Bundeswehr Munchen, GERMANY
Received: March 21, 2024; Accepted: August 9, 2024; Published: August 30, 2024
Copyright: © 2024 Karimov-Zwienenberg et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Over the past two decades, the comorbidity between chronic pain (i.e., persistent pain >3 months) and post-traumatic stress disorder (PTSD) has been well established [ 1 – 3 ]. PTSD is a psychiatric diagnosis based on the presence of a set of specific symptoms (e.g., flashbacks, hypervigilance, avoidance) that might occur after experiencing or witnessing a life-threatening event such as a disaster or assault. A recent meta-analysis including 21 studies reported higher PTSD prevalence up to 57% in individuals with chronic pain compared to 2–9% in the general population [ 4 ]. In the context of pain management, this alarming comorbidity represents many challenges as it has been associated with higher levels of pain severity [ 5 ], pain disability [ 6 ], and opioid use [ 7 ]. Furthermore, individuals with chronic pain and comorbid PTSD typically report increased levels of PTSD severity, emotional distress and psychiatric comorbidity than controls [ 8 – 10 ].
Several conceptual frameworks have been proposed, such as shared vulnerability and mutual maintenance models suggesting the interplay of neurobiological, emotional and cognitive factors involved in comorbidity [ 2 , 11 , 12 ]. Despite different hypotheses of causality and interaction, the particular nature of the relationship between chronic pain and PTSD remains uncertain. Depending on the studied population or condition, pain could both contribute to and maintain PTSD. Similarly, PTSD has been considered an important risk factor in the development of chronic pain when compared to controls [ 13 ].
Studies agree however that a history of adverse childhood events may be associated with both PTSD and chronic pain in adulthood [ 14 – 16 ]. Childhood adversity typically includes experiences of abuse, neglect as well as exposure to household dysfunction, parental psychopathology and early parental loss [ 17 ]. There is cumulative systematic and meta-analytical evidence demonstrating increased risk of chronic pain and pain-related disability in individuals reporting single or cumulative exposure to adverse childhood events, in particular maltreatment (e.g., childhood abuse, neglect) [ 15 , 18 , 19 ]. Although psychological distress has been identified as a key aspect to this phenomenon, few studies examined the role of PTSD in this context, indicating a gap in clinical and translational pain research, particularly in regard to trauma-informed pain management [ 20 ] as well as psychological treatment for comorbid trauma and chronic pain [ 21 ].
Additionally, it has been well established that survivors of childhood adversity may develop more complex and multifaceted reactions that extend beyond those observed in PTSD. These reactions have been commonly categorized as complex trauma or complex PTSD (CPTSD) [ 22 , 23 ]. CPTSD describes the widespread and long-lasting consequences following exposure to ongoing and often inescapable interpersonal traumatic stress that occurs within the context of a significant relationship (e.g., childhood abuse, intimate personal violence) [ 22 , 24 ]. Disparate adaptations to interpersonal trauma were initially conceptualized as an associated feature of PTSD by Disorders of Extreme Stress Not Otherwise Specified (DESNOS) [ 25 ]. However, due to the lack of sufficient evidence to support its inclusion as a unique diagnostic entity, DESNOS was eventually dropped from the fifth version of the Diagnostic and Statistical Manual (DSM) [ 26 ]. More recently, the World Health Organization published the 11 th version of the International Classification of Diseases (ICD-11) [ 27 ] introducing CPTSD for the first time into diagnostic nomenclature. Alongside the crucial presence of PTSD symptoms, the current model shares many similarities with DESNOS, including affect dysregulation, negative self-concept and interpersonal difficulties which are typically referred to as disturbances in self-organization (i.e., DSO symptoms) [ 28 , 29 ]. Additionally, consistent with recent data [ 30 , 31 ] and earlier conceptual research [ 29 , 32 ], current ICD-11 guidelines expanded trauma exposure definition for PTSD and CPTSD by taking into account different types of interpersonal trauma, including childhood neglect and emotional abuse, in addition to DSM criterion A events. In the context of chronic pain, there is some preliminary evidence suggesting worsened pain outcomes in survivors of childhood abuse with CPTSD as opposed to PTSD symptoms alone [ 33 ]. As PTSD and CPTSD are currently considered related disorders, it seems of timely interest to address how these relate to pain chronicity in order to promote effective treatment options and pain management for individuals with comorbid PTSD/CPTSD and chronic pain.
Despite the growing body of research on the trauma-chronic pain relationship, evidence in relation to PTSD/CPTSD following childhood exposure to traumatic or adverse events remains scarce. The aim of this study is to conduct a systematic review exploring existing data on the described links, while taking into account authors’ recommendations for future research and clinical practice. For the purpose of this review, in line with previous conceptual research and current ICD-11 PTSD/CPTSD guidelines, the term childhood trauma is used to address the exposure of traumatic or adverse events before the age of 18 years.
Specifically, this review seeks to describe in individuals with chronic pain:
Before conducting this systematic review, a search in the Prospero database showed that, to our knowledge, no literature review is currently in progress on this subject ( https://www.crd.york.ac.uk/PROSPERO/ accessed on July 2023).
To conduct the present systematic review, we followed the guidelines described by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [ 34 ]. A search was performed from 1st of August 2023 using the following databases: Pubmed (Medline); PsychInfo (EBSCO host ), Psychology & Behavioral Sciences Collection (EBSCO host ), and Web of Science (Web of Knowledge). Search strategy terms are presented in Table 1 .
https://doi.org/10.1371/journal.pone.0309332.t001
As per guidance, PICOTS framework [ 35 ] was used to structure the review process by defining selection criteria as follows: [ 1 ] Population, [ 2 ] Intervention, [ 3 ] Comparison, [ 4 ] Outcome, [ 5 ] Time and [ 6 ] Setting. Predefined inclusion and exclusion criteria are presented in Table 2 .
https://doi.org/10.1371/journal.pone.0309332.t002
Studies were selected independently by two authors (MKZ and WS) by screening titles and abstracts in systematic review. The selected studies were then subject to full text screening by applying the selection criteria. Reasons were documented during the process. In case of disagreement, discrepancies were adjudicated by a third author (WP) until a consensus was reached among the three authors. Once study eligibility was confirmed, data was extracted between September 2023 and December 2023 by one author (MKZ) which was then verified by a second author (WS). The following items were identified for data collection: authors, year, country, study design, study sample, chronic pain condition, chronic pain symptomatology, childhood trauma exposure, PTSD/CPTSD, interaction data between trauma factors and chronic pain symptomatology, and finally, author’s recommendations for scientific research and clinical practice.
The methodological quality of each included study was independently assessed by two researchers (MKZ and WS) using the corresponding design-specific critical appraisal checklist tools provided by the Joanna Briggs Institute (JBI) [ 36 ]. The following JBI critical appraisal checklist tools were used for this review: case control studies, analytical cross-sectional studies, quasi-experimental, as well as cohort studies. Each component was rated as “Yes”, “No”, “Unclear, or “Not Applicable”. If needed, discrepancies were discussed between reviewers or by consulting a third author (WP) until consensus was reached. Based on previous systematic reviews [ 37 , 38 ], studies with a JBI score higher than 70% were considered as high quality, those with scores between 50% and 70% as moderate quality, and those with a score less than 50% as low quality.
The initial search returned 297 records, of which 36 were retained for full-text analysis. Finally, 13 articles [ 39 – 50 ] were included in this systematic review without disagreement (i.e., inter-judge agreement = 100%). Fig 1 presents a flow-diagram of the research article selection process.
https://doi.org/10.1371/journal.pone.0309332.g001
The 13 studies included in this review were published between 2005 and 2023 and conducted in Europe (Italy, n = 1; Belgium, n = 1; Spain, n = 2; Germany, n = 1), Turkey n = 1; Israel ( n = 3), and the US ( n = 4). Four were case-control studies, 7 cross-sectional studies, 1 quasi-experimental study and 1 cohort study. There was some variety in sample sizes across the studies, ranging from 70 to 295 participants, recruited both from clinical ( n = 9) and community settings ( n = 4). All study populations compromised exclusively ( n = 7) or predominantly female participants (>64%). Finally, Fibromyalgia (FM) was found to be the most studied pain condition ( n = 9), followed by unspecified chronic pain ( n = 3), and Interstitial cystitis/bladder pain syndrome (IC/BPS) ( n = 1). In terms of missing data, it was found that the majority of the included studies did not address all outcomes of interest to this review. Unreported information on outcomes was identified as “Not Reported” (N/R). Study findings are listed in Tables 3 and 4 .
https://doi.org/10.1371/journal.pone.0309332.t003
https://doi.org/10.1371/journal.pone.0309332.t004
The results of the quality assessment are summarized in Table 5 . Quality appraisal using the JBI checklist tools indicated overall moderate to high quality studies. Nine studies scored above 70% [ 39 , 40 , 42 – 44 , 46 – 49 ], three studies scored between 50% and 70% [ 41 , 45 , 51 ], and the remaining one study [ 50 ] scored 13%. The main limitations of the single low-quality study were lack of objective and valid methods of assessment regarding chronic pain outcomes.
https://doi.org/10.1371/journal.pone.0309332.t005
A. childhood trauma..
All but one study [ 47 ] included in this review reported childhood trauma in terms of maltreatment, demonstrating higher prevalence [ 39 , 41 , 42 ] and severity [ 45 , 48 ] for emotional abuse and neglect compared to other forms of childhood maltreatment in individuals reporting chronic pain. In addition, a cohort study [ 48 ] demonstrated significative interrelations between all types of abuse and neglect, except for sexual abuse and neglect in a clinical sample of FM patients. Ciccone et al. [ 40 ] found no differences in childhood physical or sexual abuse between women reporting FM and healthy controls.
When compared with other medical conditions, studies found higher childhood maltreatment rates and severity in individuals with chronic pain, in particular with regards to neglect [ 39 , 41 , 45 ], sexual abuse [ 39 , 41 ], and emotional abuse [ 41 , 45 ].
Only two studies assessed childhood trauma exposure based on PTSD qualifying stressors following DSM criteria [ 42 , 47 ]. For example, Gardoki-Souto et al. [ 42 ] found that most prevalent traumatic events were reported during childhood compared to adulthood. Physical, sexual, and emotional abuse were identified as most commonly reported traumatic events during childhood. McKernan et al. [ 47 ] demonstrated differences in gender, with higher rates of childhood neglect observed in women, while men seemed to report more general disaster/trauma [ 47 ].
Finally, Hart-Johnson & Green [ 43 ] identified confounding effects of race and sex showing higher physical abuse under the age of 14 in male participants with chronic pain as opposed to women reporting chronic pain, with highest rates of abuse reported in black male participants and lowest in white female participants. Sexual penetration during childhood was found to be most prevalent among black female participants when compared with male or white female participants.
In this review, the majority of the included studies described PTSD prevalence exclusively for predominantly female FM study samples with rates ranging from 10.7% to 37% [ 39 – 41 , 44 , 45 , 48 , 51 ]. One study [ 42 ] reported PTSD prevalence up to 71% following exposure to cumulative trauma as categorized by age. Results showed that most prevalent traumatic events occurred during childhood but continued into adulthood in the form of both different and recurrent types of events favoring a process of continuous re-traumatization. The lifelong impact of childhood trauma was further emphasized by high levels of current perceived distress in relation to past experiences of early life adversity.
When compared to controls, multiple studies showed higher PTSD prevalence and severity in individuals with chronic pain versus other medical conditions, including rheumatoid arthritis (RA) [ 45 ], functional disorders and achalasia [ 41 ], as well as healthy individuals [ 40 ]. Only one study [ 40 ] investigated PTSD symptom clusters, and found significatively higher rates for Intrusion and Arousal clusters, but not Avoidance when comparing a community sample of women with FM to healthy controls. Groups did not differ in childhood exposure to physical and/or sexual abuse.
Two studies included CPTSD measures in addition to PTSD [ 49 , 50 ] providing evidence for CPTSD and chronic pain comorbidity following childhood sexual abuse. For example, Peles et al. [ 49 ] demonstrated CPTSD prevalence rates between 19.1% and 60% in female survivors of childhood sexual abuse receiving methadone maintenance treatment versus those without a history of opioid addiction. Chronic pain comorbidity rates differed between CPTSD versus non CPTSD patients (100% vs 50%) without a history of addiction. Tsur [ 50 ] investigated PTSD/CPTSD in association with trauma-related pain symptoms and found higher levels of CPTSD symptoms (i.e., PTSD + DSO) linked to higher rates of pain flashbacks (23.1%), which is considered a posttraumatic stress response centralizing around pain, compared to women reporting non-pain flashbacks (36.3%) and no flashback symptoms (40.6%). In both studies, chronic pain was a self-reported outcome based on the presence of persistent pain lasting for more than six months. None of the included studies in this review reported on CPTSD in clinically diagnosed chronic pain patients or those receiving care for pain management.
A. childhood trauma, ptsd/cptsd in individuals with chronic pain..
Except for two studies [ 49 , 50 ], all included studies assessed childhood trauma in relation to PTSD as opposed to CPTSD. Several studies found that more severe childhood trauma, in particular maltreatment, was associated with PTSD in individuals with chronic pain [ 42 , 48 ] when compared to those without PTSD and healthy controls [ 46 ]. For example, in a community sample, higher rates of childhood trauma exposure, including sexual abuse, were found in participants with IC/BPS and comorbid PTSD as opposed to those without PTSD, represented by medium to large effect sizes. No differences were found regarding adult trauma exposure, including physical and sexual abuse, between these groups [ 47 ]. As for evidence on CPTSD outcomes, Tsur [ 50 ] associated higher childhood sexual abuse severity with increased experiences of pain flashbacks as well as CPTSD symptoms compared to controls (i.e., non-pain flashbacks, no flashbacks).
Four studies included in this review explicitly investigated the association between childhood trauma, PTSD/CPTSD, and pain symptoms in individuals with chronic pain [ 41 , 47 , 49 , 50 ]. For example, Coppens et al. [ 41 ] assessed childhood maltreatment in relation to perceived pain experiences and found an indirect effect of childhood abuse and neglect on both quantitative and qualitative pain reports through PTSD severity, representing medium effect sizes. No relationship between childhood maltreatment severity and pain reports was revealed, nor a moderator effect of PTSD, suggesting a mediation effect. Other studies included in this review found direct effects of childhood trauma, in particular neglect and emotional abuse, on pain outcomes, including pain-related health impact and disability [ 39 , 42 ].
McKernan et al. [ 47 ] investigated the role of criterion A trauma on the relationship between chronic pain phenotypes and PTSD. In a convenience sample of participants with IC/BPS and comorbid PTSD, higher rates of current pain and clinically relevant central sensitization (CS) were observed in individuals as opposed to those without PTSD, represented by medium to large effect sizes. When comparing IC/BPS subgroups based on CS levels, all patients with PTSD corresponded to criteria of the widespread IC/BPS phenotype, associated with higher rates of polysymptomatic complaints, psychosocial distress and pain levels. While IC/BPS participants with CS reported higher rates of childhood trauma as well as lifetime physical and sexual abuse, PTSD was shown to be uniquely related over and above trauma exposure to widespread pain phenotype of IC/BPS.
Another study, using quasi-experimental design assessed analgesic responses in FM patients with and without PTSD based on stress-induced changes in pain and intolerance thresholds during a Social Stress Test task [ 46 ]. Results revealed lower basal pressure pain and intolerance thresholds during recovery when compared to healthy controls, indicating hyper sensitivity at basal function in FM patients, regardless the presence of PTSD. In response to acute stress, however, FM patients showed differences in hypo reactivity during the task, such as a lack of hyperalgesic response in FM with PTSD during and after exposure as opposed to a delay of a hyperalgesic response in FM patients without PTSD. Higher childhood trauma severity was found in FM patients with PTSD than those without PTSD. Groups did not vary in pain intensity or chronicity levels of FM symptoms.
Regarding CPTSD, two studies investigated associations with chronic pain comorbidity in female survivors of childhood sexual abuse. For example, a cross-sectional study conducted in a clinical sample, demonstrated positive correlations between chronic pain symptoms (e.g., pain severity, number of painful body regions), sexual abuse-related PTSD and CPTSD severity in adulthood. Age of onset of first experience of sexual abuse was negatively associated with pain duration [ 49 ]. Another study provided evidence for understanding the link between childhood sexual abuse, CPTSD and chronic pain by highlighting the role of somatic pain-related manifestations of PTSD/CPTSD, in particular pain flashbacks. Further, results identified peritraumatic pain during childhood sexual abuse as a risk factor for chronic pain in adulthood [ 50 ]. Overall, both studies including CPTSD measurement highlighted high prevalence of chronic pain in survivors of childhood sexual abuse associated with higher psychiatric comorbidity, namely CPTSD.
Finally, two studies demonstrated transcultural validity for associations between childhood trauma, PTSD and chronic pain symptoms drawing from evidence obtained in clinical settings across Europe, North America, and the Middle-East [ 44 , 45 ]. A study conducted in a community sample elucidated differences in chronic pain experiences in relation to abuse history based on sex differences [ 43 ]. Particularly, molestation was associated with higher affective pain, but only in men with chronic pain when compared with female participants. Similarly, childhood molestation predicted pain-related PTSD only in men, when controlling for race, sex and education. Female survivors of childhood sexual abuse were equally likely to have pain-related PTSD as women without a history of abuse.
A. scientific research..
In the study of etiology and pathophysiology of chronic pain, comorbid mental disorders and psychological distress should be considered [ 44 ]. Additional research is also needed identifying mediating or moderating factors on the childhood trauma–HPA axis dysregulation relationship in chronic pain, using psychophysiological measures [ 48 , 51 ]. Suggested characteristics of childhood trauma typically include developmental timing and subtypes, while calling for empirical attention to childhood neglect [ 45 ], as well as subsequent experiences of violence or abuse, and ongoing interpersonal relations later in life [ 48 ]. Concurrently, more attention should be addressed to pain-specific posttraumatic stress symptoms (e.g., pain flashbacks, avoidance of trauma-related pain sensations), as well as somatic manifestations of CPTSD in relation to chronic pain [ 50 ]. Future research should assess trauma focused-interventions in FM in order to further clarify trauma-based etiology of FM in comparison to other functional somatic syndromes, medically unexplained symptoms, somatic symptoms, and related psychopathology [ 42 ]. Some findings included in this review also warrant further investigation on whether some psychological states of detachment (e.g., dissociation) might explain hypo reactivity in FM patients as a coping strategy. When addressing trauma in the context of chronic pain, differences in patients based on the presence of PTSD should be considered in future research by using a differential profile approach [ 46 ]. Finally, in the study of abuse and trauma in relation to chronic pain, more research should include men [ 43 ].
The majority of the included studies recommend systematic screening for trauma factors such as childhood trauma and PTSD/CPTSD [ 41 , 42 ], regardless of race, age or gender [ 43 ]. Specific training might be needed to reduce identified barriers (e.g., lack of time, discomfort with subject, or lack of familiarity with the role of abuse) to appropriate and effective screening methods [ 43 ]. Screening procedures should also include detection for potential comorbid mental disorders in relation to abuse, such as somatoform dissociation disorder and alexithymia, using appropriate tools [ 44 , 51 ]. Trauma-focused therapies may include Eye Movement Desensitization and Reprocessing (EMDR) [ 42 ], as well as intervention techniques based on Eccleston’s model of tripartite system of threat protection in order to support FM patients with and without PTSD to engage in more adaptive stress responses [ 46 ]. As PTSD appears to be associated with the “widespread” pain phenotype, multimodal treatment should be considered for these patients [ 47 ]. Trauma-informed care is recommended in a more general way, emphasizing patient-care provider trust and rapport, reducing anxiety and increasing patient control and safety during appointments and medical examination procedures [ 47 ]. Finally, clinicians treating survivors of abuse should specifically inquire about chronic pain complaints, in order to facilitate tailored adequate approaches in comprehensive treatment [ 49 ].
Despite the growing evidence on the trauma-pain relationship, literature examining the association between childhood trauma and PTSD in relation to pain outcomes remains limited. This review further adds on existing systematic data by including evidence on CPTSD in individuals with chronic pain. In total, 13 studies were included in this systematic review. Study highlights have been summarized into the following sections in order to guide future research as well as recommended evidence-based clinical practice and policy in routine pain management.
Different aspects of childhood trauma have been previously identified as risk factors for chronic pain conditions, such as nature of trauma [ 15 , 52 ], and cumulative experiences of maltreatment to [ 19 , 53 , 54 ]. In addition to existing systematic and metanalytical data, studies included in this review particularly emphasize the long-term consequences of emotional abuse and neglect as opposed to physical and sexual abuse. Consistent with DSM A-criterion type of traumatic events, other reviews typically focused on the impact of abuse specific childhood trauma (e.g., physical abuse, sexual abuse) [ 10 , 52 , 55 , 56 ]. There is some research, however, indicating an independent relationship between PTSD symptoms and chronic pain outcomes following the presence of criterion A trauma history [ 57 ]. Moreover, present findings provide evidence for the expanded definition of trauma exposure by current PTSD/CPTSD ICD-11 guidelines, in particular with respect to the inclusion of childhood neglect and emotional abuse, in addition to DSM A criterion events. Despite suggested relevance to chronic pain etiology and PTSD/CPTSD comorbidity, research clarifying the differential impact of neglect and emotional abuse alongside events of childhood physical and sexual abuse remains minimal and warrants further investigation whether and to what extent these forms of trauma are associated with unique healthcare needs in chronic pain management.
In total, only four studies included in this review explicitly investigated relationships between childhood trauma, PTSD/CPTSD and pain outcomes in individuals with chronic pain. The present findings are in accordance with other research demonstrating the negative impact of PTSD on pain outcomes when linked to childhood maltreatment compared to lower levels of pain typically experienced by individuals who have been diagnosed with PTSD alone [ 54 , 58 ]. The long-term impact of cumulative childhood trauma was further recognized by an indirect dose-response relationship associated with increased risk of re-traumatization, higher levels of PTSD and perceived distress when compared to adulthood trauma. Similar to results of a recent systematic review [ 1 ], certain chronic pain phenotypes (e.g., “widespread pain”) were identified as risk factors for described links.
This review also included evidence on biomarkers involved in pain modulation processes (e.g., cortisol secretion, pressure pain thresholds). In addition to existing systematic data [ 59 ], study findings support inhibitory capacity of adaptive allodynic responses in chronic pain patients with a history of childhood trauma by adding information to the role of PTSD. In this connection, differential neurophysiological patterns in chronic pain patients with PTSD compared to those without PTSD were associated with two main psychological/behavioral responses, namely hyperarousal and dissociation [ 46 , 48 ]. This hypothesis is in line with previous studies, suggesting a unique paradoxical pain profile in individuals with chronic pain and PTSD, characterized by both pain-related hypo- and hyperresponsivity when compared to controls [ 8 , 60 ]. Other research has emphasized the role of childhood versus adulthood trauma exposure in advancing current understanding of differential PTSD-related conditions (e.g., dissociation, depression) and physical health symptoms, including pain [ 61 ].
It is important to note, however, that results associating childhood trauma, PTSD, and pain are typically obtained in the absence of any CPTSD assessment. Only one study included in this review examined differential role of CPTSD symptoms in relation to childhood trauma, while identifying pain-related somatic manifestations (e.g., pain flashbacks) both as maintaining and worsening factors of chronic pain outcomes. These results are consistent with some preliminary research demonstrating associations between CPTSD symptoms (i.e., DSO symptoms) and higher rates of somatization [ 62 ] as well as abusive pain personification in individuals with childhood trauma compared to those with PTSD [ 33 ]. Despite important implications for empirical and clinical efforts as argued by a recent review [ 63 ], our understanding of trauma-related bodily experiences remains an underdeveloped realm of translational pain research. In particular, findings in this review corroborate the current lack of validated and standardized assessment for pain-related trauma factors (e.g., peri and posttraumatic pain) which was identified as a major barrier to more robust methodological evidence. The need for future research adopting a differential analytical approach (e.g., cluster analysis), has also been issued to verify theorized relationships in order to extend current conceptual models of comorbidity and pain phenotypes by considering the unique features of CPTSD alongside PTSD symptoms.
Although transcultural validity of trauma factors in chronic pain outcomes was consistently reported in this review [ 44 , 45 ], the majority of the included study samples represented predominantly Caucasian and female individuals suffering from FM. Only one study provided some insight into intersectional disparities regarding childhood abuse in adults with chronic pain [ 43 ]. Findings corroborate the lack of available evidence identified by a recent review [ 64 ], emphasizing the critical need for more inclusive research to ensure that underrepresented groups receive equitable benefit from chronic pain research in terms of health and social policy. The same applies to trauma factors that remain oftentimes under-recognized, under-treated, or inadequately treated among marginalized groups [ 65 ]. More research is needed to explore the interplay of social factors (e.g., socioeconomic status, gender, race) and health disparities, while building on evidence for a more precise understanding of trauma-pain comorbidity and management within social context.
Considering the widespread prevalence of childhood trauma and both its long-term and complex impact on posttraumatic symptoms and pain related outcomes later in life, recommendations for clinical practice included in this review address the need for systematic screening of trauma factors in individuals seeking care for chronic pain. Consequently, psychotherapeutic strategies should target PTSD/CPTSD to relief illness burden, helping individuals with chronic pain to engage in more adaptive stress responses and promote general functioning [ 41 , 42 , 46 ]. Despite extensive literature on psychological treatment for PTSD, there is currently no “gold standard” for CPTSD screening or intervention methods. Furthermore, numerous limitations have been associated with first-line, evidence-based treatments for PTSD, including early dropout and worsening of symptoms in survivors of interpersonal trauma [ 66 – 68 ]. In this regard, Trauma Center Trauma Sensitive Yoga (TCTSY) [ 69 ]’, an evidence-based protocol for complex trauma or treatment-resistant PTSD, appears to be a particularly promising therapeutic strategy, drawing specific focus to interoception (i.e., awareness of bodily sensations) and empowerment processes. While there is cumulative qualitative and quantitative evidence demonstrating protocol efficacity compared to conventional psychotherapy modalities [ 70 – 72 ], the use of TCTSY in individuals with chronic pain has not yet been investigated. In addition to trauma specialized treatment, and in line with a recent topical review [ 73 ], the present findings further support the importance of a systems approach to trauma care in pain management and rehabilitation services. Future research is needed to investigate comprehensive models of trauma-informed care based on principals such as safety, collaboration and choice within routine practice as a means to improve patient adherence, pain outcomes and prevent re-traumatization.
This systematic review was conducted following recommended guidelines for search strategy as well as quality assessment allowing for a more rigorous process regarding methodological appraisal. Some limitations, however, should be taken into consideration in analyzing key findings. The search was not limited to study design, year of publication or methodological quality. Further, inclusion criteria for chronic pain and trauma factors were generally defined such as to provide a broad overview of the current state of art, limiting therefore conclusive or generalizing evidence regarding subtypes of trauma in relation to specific pain syndromes or phenotypes. Despite the inclusive approach to this review, only a short list of mostly moderate to high quality evidence, was identified, highlighting the preliminary nature of research in this area. Overall, the selected studies used appropriate and validated measurement for childhood trauma, PTSD/CPTSD and chronic pain which included a variety of self-reported as well as physician-based assessment. However, the heterogeneity of tools included in this review, in particular for PTSD/CPTSD, warrants vigilance to generalization of findings. Further, the majority of selected studies used the Childhood Trauma Questionnaire [CTQ; 74 ] as primary measurement for childhood trauma. While this is a validated and widely utilized instrument in the study of childhood trauma history, it provides assessment limited only to childhood maltreatment (i.e., abuse and neglect). Only two studies in this review assessed childhood trauma exposure based on PTSD qualifying stressors following DSM diagnostic criteria. This review recognizes the instability around diagnostic consensus of PTSD/CPTSD proposed by distinct classification models over the past two decades. For example, based on earlier diagnostic and clinical literature [ 22 , 25 ], somatization was typically considered a core feature of DSM DESNOS, but does not appear in the current WHO ICD-11 model of CPTSD. Finally, to the best of our knowledge, there is currently no randomized controlled, longitudinal or case study evidence investigating intervention modalities for PTSD/CPTSD and chronic pain comorbidity in individuals with a history of childhood trauma.
The findings of this systematic review highlight the importance of taking into account childhood trauma, in particular neglect and emotional abuse, in the study of PTSD/CPTSD and chronic pain comorbidity in adults. The long-term impact of childhood trauma was further emphasized by an indirect dose-response relationship associated with increased risk of re-traumatization, higher levels of PTSD and perceived distress later in life when compared to adulthood trauma. This review also included evidence on specific neurophysiological patterns in chronic pain patients with PTSD suggesting differential pain modulation processes following trauma, in particular childhood maltreatment. Only a few selected studies reported on CPTSD and chronic pain comorbidity, providing preliminary evidence on the role of trauma-related physical pain (e.g., pain flashbacks). The need for future research adopting a differential approach has been issued in order to extend current models of comorbidity in relation to pain phenotypes, while also accounting for intersectional disparities. Considering the widespread prevalence of childhood trauma and its long-term and complex impact on both PTSD/CPTSD and pain chronicity later in life, recommendations for clinical practice draw attention to the need for PTSD/CPTSD specialized treatment as well as trauma-informed pain management in routine care.
S1 file. prisma checklist 2020..
https://doi.org/10.1371/journal.pone.0309332.s001
https://doi.org/10.1371/journal.pone.0309332.s002
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The New York Times Book Review I've I want THE 100 BEST BOOKS OF THE 21ST CENTURY read to it read it 1 My Brilliant Friend, by Elena Ferrante 26 26 Atonement, by lan McEwan 2 The Warmth of Other Suns, by Isabel Wilkerson 27 Americanah, by Chimamanda Ngozi Adichie 3 Wolf Hall, by Hilary Mantel 28 Cloud Atlas, by David Mitchell 4 The Known World, by Edward P. Jones 29 The Last Samurai, by Helen DeWitt 5 The Corrections, by Jonathan Franzen 30 Sing, Unburied, Sing, by Jesmyn Ward 6 2666, by Roberto Bolaño 31 White Teeth, by Zadie Smith 7 The Underground Railroad, by Colson Whitehead 32 The Line of Beauty, by Alan Hollinghurst 8 Austerlitz, by W.G. Sebald 33 Salvage the Bones, by Jesmyn Ward 9 Never Let Me Go, by Kazuo Ishiguro 34 Citizen, by Claudia Rankine 10 Gilead, by Marilynne Robinson 35 Fun Home, by Alison Bechdel 11 The Brief Wondrous Life of Oscar Wao, by Junot Díaz 36 Between the World and Me, by Ta-Nehisi Coates 12 The Year of Magical Thinking, by Joan Didion 37 The Years, by Annie Ernaux 13 The Road, by Cormac McCarthy 38 The Savage Detectives, by Roberto Bolaño 14 Outline, by Rachel Cusk 39 A Visit From the Goon Squad, by Jennifer Egan 15 Pachinko, by Min Jin Lee 40 H Is for Hawk, by Helen Macdonald 16 The Amazing Adventures of Kavalier & Clay, by Michael Chabon 41 Small Things Like These, by Claire Keegan 17 The Sellout, by Paul Beatty 42 A Brief History of Seven Killings, by Marlon James 18 Lincoln in the Bardo, by George Saunders 43 Postwar, by Tony Judt 19 Say Nothing, by Patrick Radden Keefe 44 The Fifth Season, by N.K. Jemisin 20 Erasure, by Percival Everrett 45 The Argonauts, by Maggie Nelson 21 Evicted, by Matthew Desmond 46 The Goldfinch, by Donna Tartt 22 22 Behind the Beautiful Forevers, by Katherine Boo 47 A Mercy, by Toni Morrison 23 Hateship, Friendship, Courtship, Loveship, Marriage, by Alice Munro 48 Persepolis, by Marjane Satrapi 24 The Overstory, by Richard Powers 49 The Vegetarian, by Han Kang 25 25 Random Family, by Adrian Nicole LeBlanc 50 Trust, by Hernan Diaz I've I want read to it read it
The New York Times Book Review I've I want THE 100 BEST BOOKS OF THE 21ST CENTURY read to it read it 51 Life After Life, by Kate Atkinson 52 52 Train Dreams, by Denis Johnson 53 Runaway, by Alice Munro 76 77 An American Marriage, by Tayari Jones 78 Septology, by Jon Fosse Tomorrow, and Tomorrow, and Tomorrow, by Gabrielle Zevin 54 Tenth of December, by George Saunders 55 The Looming Tower, by Lawrence Wright 56 The Flamethrowers, by Rachel Kushner 57 Nickel and Dimed, by Barbara Ehrenreich ཤྲཱ རྒྱ སྐྱ A Manual for Cleaning Women, by Lucia Berlin The Story of the Lost Child, by Elena Ferrante Pulphead, by John Jeremiah Sullivan. Hurricane Season, by Fernanda Melchor 58 Stay True, by Hua Hsu 83 When We Cease to Understand the World, by Benjamín Labatut 59 Middlesex, by Jeffrey Eugenides 84 The Emperor of All Maladies, by Siddhartha Mukherjee 60 Heavy, by Kiese Laymon 85 Pastoralia, by George Saunders 61 Demon Copperhead, by Barbara Kingsolver 86 Frederick Douglass, by David W. Blight 62 10:04, by Ben Lerner 87 Detransition, Baby, by Torrey Peters 63 Veronica, by Mary Gaitskill 88 The Collected Stories of Lydia Davis 64 The Great Believers, by Rebecca Makkai 89 The Return, by Hisham Matar 65 The Plot Against America, by Philip Roth 90 The Sympathizer, by Viet Thanh Nguyen 66 We the Animals, by Justin Torres 91 The Human Stain, by Philip Roth 67 Far From the Tree, by Andrew Solomon 92 The Days of Abandonment, by Elena Ferrante 68 The Friend, by Sigrid Nunez 93 Station Eleven, by Emily St. John Mandel 69 59 The New Jim Crow, by Michelle Alexander 94 On Beauty, by Zadie Smith 10 70 All Aunt Hagar's Children, by Edward P. Jones 95 Bring Up the Bodies, by Hilary Mantel 71 The Copenhagen Trilogy, by Tove Ditlevsen 96 Wayward Lives, Beautiful Experiments, by Saidiya Hartman 72 22 Secondhand Time, by Svetlana Alexievich 97 Men We Reaped, by Jesmyn Ward 73 The Passage of Power, by Robert A. Caro 98 Bel Canto, by Ann Patchett 74 Olive Kitteridge, by Elizabeth Strout 99 How to Be Both, by Ali Smith 75 15 Exit West, by Mohsin Hamid 100 Tree of Smoke, by Denis Johnson I've I want read to it read it
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Speaker 1: What are the potential outcomes when you submit a journal article? Stick around and find out today on this episode of Navigating Academia. Music What's up everybody? My name is Dr. J. Phoenix Singh. I want to welcome you to Navigating Academia, your leading source for career guidance on how to be able to progress in academia. As always, I appreciate the love, so please do like and share this video with your colleagues and your students. Subscribe to our channel, hit that bell, and comment below. You can follow us at the social media accounts below. So, today we're going to be talking about the potential outcomes when you decide to take the plunge and submit your article to a peer-reviewed academic journal. This can be a very daunting process, especially if it's your first go-around, even if you're very experienced. These articles that you've been working on, usually you don't work on them for a month. You could be working on these things for years. And this is your baby, and I completely understand that. And to give your baby to somebody else, and for them to be like, eh, that's okay, and just give your baby back, doesn't feel very good. Especially if it's something where the peer-review process can take time. It can take six months, it can even take a year for bigger journals. And because of this, it's something where you can get real frustrated submitting something, waiting for what seems like forever to get feedback from the peer reviewers. And then they say, we're just not into it, and you don't even get a chance to respond. But at the end of the day, what we're going to be talking about today is the two-step process of what can the outcomes be when you submit that journal article. Now the reason I say it's a two-step process is because when you initially submit your article, it's going to go to the editor of the journal. And they're going to look at it and basically do a pretty rapid screen of it to say this either has a general fit for the journal or not. And they're going to be taking a look at things like, you know, is the article even in our field? Is it an area that has maybe sufficient interest for their readership? Because they're going to know the demographics of the people who are reading their stuff. Is it written and organized in a way that meets the instructions for authors for that journal? And we're going to make another video on that in terms of making sure that before you submit, you can maximize the likelihood that your piece will, if not only get through that screen, end up getting published. So be sure to check out that video as well. I'll post a link down in the description below. Now after the editor has had a chance to be able to take a look at it, they're going to give it to an associate editor for the journal. That associate editor is going to assign peer reviewers, usually folks on that journal's editorial board, or if the people there either don't have the time, don't have the expertise that's very unique to your piece, they're going to send it out for review for other people who are considered experts in whatever field you happen to be in. And then that peer review process starts. The peer reviewer is going to get the piece, they're going to be expected to read it in detail, provide you with comprehensive comments that you're going to need to respond to afterwards. And the idea is that it's really going to sharpen your piece and it's really kind of a quality control mechanism for the journal, making sure that the stuff that actually ends up getting published, not only is really high quality and hence makes the journal look good, but these publishers of these journals, they're for-profit businesses most of the time. And this is how they make money. They make money by selling your articles or by having this journal as part of a package where they're selling different institutions or facilities, for example, a prison or could be anything from Tufts University where I did my undergrad work, their library and these things. And in some cases, even individuals buy subscriptions to these kind of package deals. So it's really important that the piece that they end up publishing be of high quality to make that journal look good, to make that publisher money. And also the hope obviously is that that piece is going to get cited and the impact factor of that journal is going to significantly increase. So the peer reviewers do their thing. They end up submitting their recommendations for either acceptance or rejection to the associate editor who sends it up to the editor. And the editor ends up making that final call as to whether or not to accept the piece or not. But they really rely on the associate editor here to kind of make that decision, but they're the end gatekeepers of everything. So usually the associate editor is the first one who's going to take a look at those peer reviewer comments. And either they or the editor is going to assign one of five different outcomes. And so those are the things that we're going to be briefly going through today. Number one is accept. And we're talking here about accept without revision. This is not only the chupacabra of journal review outcomes, it's something where you should be really puzzled if you get this. No article has no revisions that would make it better. There is no such thing as a perfect submission. If the peer reviewers come back and say, this is the greatest thing since sliced bread, don't change a word, don't change anything, just publish it straight up. Again, alarm bells should be going out because it really suggests that the peer reviewers didn't do their job. Which could be a really critical thing to say, but it's true. It's something where you really need to make sure that the peer review process is improving your writing, improving your piece. It's one of the reasons why the peer review process exists, remember, is to be able to sharpen that piece up. And to make it of even higher quality. So if it's just accepted straight up, that's a really bad sign. And you should really consider whether you want that piece in that journal. But of course we will be talking about in another video the times where it is versus the majority of times where it's not appropriate to be able to pull a journal article out. And I'll link that also in the description below, that video. So it's really important to take this into consideration, guys. And the second outcome is related, but it's basically accept with minor revision. And this is, if you have got accept with minor revision, kudos to you. Really, I bow down because this is a very rare outcome. And especially for higher impact journals, it very rarely happens. I'm talking about a real minority percentage. Maximum 5-10% of articles, we're going to get this treatment. And really what it suggests is that the piece is in great shape, it needs some minor polishing. But the peer reviewers are recommending to the associate editor and editor, this is a piece you want. Let them do some polishing in terms of let the authors do their thing. But then you need to accept this piece. Because it's going to make a big contribution, it's going to make the journal look good. And it is worthwhile to be able to be part of the literature. And you should be very humbled and almost honored to be able to get this decision. It's a big deal. And I really congratulate you if this has happened or happens to you in the future. So that's outcome number two. Outcome number three is to accept with major revision. And this is really par for the course. Either accept with major revision or outcome four that we'll talk about in a moment, which is revise and resubmit. But accept with major revision is a really great sign as well. Again, focus on the accept part and not on the major revision part. Very rarely do peer reviewers, even if they give minor revisions in terms of their comments, very rarely do they give the recommendation of accept with minor revision. It's almost something where they want you as the author to accept that the piece is good. But it ain't that good to be able to do accept with minor revision. They're really trying to give you as the author the message that we love the piece. It's got a lot of potential. Make these changes and then you're good to go. Very rarely are you going to have to go through a second peer review process if you get accept with major revision, let alone accept with minor revision. That basically doesn't happen. In most cases, the associate editor is going to look at it, give it the yay or nay, and then send it up to the editor for the final approval. So that's accept with major revision. Outcome number four is revise and resubmit. This is pretty common, I would say. It's unfortunate if you end up getting this because it usually means that the piece is essentially rejected, but the journal's open to publishing it if you make a lot of changes and then they're going to put you through another peer review, usually. And it could be with the same peer reviewers. Usually peer reviewers are even asked during their submission process for their comments, would you be opening to re-reviewing the piece? And they can choose yes or no. But revise and resubmit basically means that, again, they're open to it, but the piece isn't there yet for them to seriously consider accepting it. This is a really common thing for people to end up making this decision. They don't want to say reject because maybe the piece, you know, there's a realm of possibility you could make it good, but right now they're not going to give the green light, they're not going to give the thumbs up on it. So that's revise and resubmit. If you get it, don't feel too upset, alright? It happens to everybody, it's certainly happened to me many times. And you can decide then, do you want to resubmit to that journal, or do you want to go to another journal? You can even be straightforward, especially if you know the associate editor, whether, you know, professionally or personally. You can just let them know, you know, do you think this is a piece that's worthwhile if I, you know, really take care of all these comments the peer reviewers gave and resubmit it to you? Do you think it has a fighting chance, or, you know, just be straight with me, do you think it's something where I explore a different outlet? Just ask, especially if it's a really high impact journal, maybe worth revising and resubmitting if they say, yeah, it's actually not a bad piece, I would give it serious consideration if you resubmitted it and it went through another peer review process. So that's outcome number four. Finally, outcome number five, it's an unfortunate outcome, it's certainly happened to me on some papers, it's just straight up rejection. It's not revise and resubmit, certainly neither of the except options. It's just straight up reject. You know, the peer reviewers look at it and for whatever reason, they're like, this just is not adequate. Remember the associate editor and the editor, they're probably not going to be experts in your niche, but the editorial board members who are, or the folks who they end up referring out to, if no associate editor, sorry, if no editorial board member is perfect for your piece, they may have a lot better sense whether or not you're really making a contribution or it's something where they've peer reviewed stuff of yours in the past. And this is what's called a salami, meaning that it's basically, you know, you take in a data set that you have and you've been mining that data set, publishing all kinds of stuff from it. And they're like, I've already reviewed stuff from this data set, you know, this is such a minor set of analyses, doesn't contribute a lot. And to be honest with you, the researcher should have just put this into the main article that they published on that data set. Because otherwise it's something where, you know, you go to five journals, find five pieces on the same data set by the same authors. It doesn't really give you a good reputation as a researcher and you should know that going in. All right, y'all. Thank you so much for watching this episode. I want to hear from you in the comments below. Are you nervous about submitting your articles because of the possibility of rejection? And what strategies are you using, or maybe that you've used in the past to be able to overcome this? Remember that we're all a community here in academia. Let's share our stories. Let's talk about what's helped us. And let's really pay it forward because all of us in academia have had folks who've helped us in the past as well. Don't forget to like and share this video with your colleagues and students. Subscribe and follow us on social media. If you're interested in one-on-one career mentoring in academia, please do set up a consultation call with me via the website below. And let's see how I can help you get to the top of your field. I'm signing off, everybody. Have a great day. And remember to get out there, take chances, and be your best self. Thank you so much for stopping by, everyone. It's a pleasure to have you here as always. If you enjoyed this video and you'd like to see more in this series on navigating academia, please click on one of these links over here to be able to view more original content. I hope to see you there.
Accompanied by her running mate, Minnesota Gov. Tim Walz, Vice President Kamala Harris told CNN her “values have not changed” even as she is “seeking consensus.” Harris also spoke about her stances on issues such as fracking and the southern border.
Democratic presidential nominee Vice President Kamala Harris waves at a campaign rally Thursday, Aug. 29, 2024, in Savannah, Ga. (AP Photo/Stephen B. Morton)
Democratic presidential nominee Vice President Kamala Harris and running mate Minnesota Gov. Tim Walz appear at the Fiserv Forum during a campaign rally in Milwaukee, Tuesday, Aug. 20, 2024. (AP Photo/Jacquelyn Martin)
After avoiding a probing interview by a journalist for the first month of her sudden presidential campaign, Vice President Kamala Harris’ first one Thursday was notable mostly in how routine it seemed.
CNN’s Dana Bash, sitting down with Harris and running mate Tim Walz in a Georgia restaurant, asked her about some issues where she had changed positions, the historical nature of her candidacy, what she would do in her first day as president and whether she’d invite a Republican to be a Cabinet member (yes, she said).
What Bash didn’t ask — and the Democratic nominee didn’t volunteer — is why it took so long to submit to an interview and whether she will do more again as a candidate.
With no clips from interviews or extended news conferences as a candidate to pick apart, Republican Donald Trump and his campaign had made Harris’ failure to take on journalists an issue in itself. She had promised to rectify that by the end of August, and made it in just under the wire.
In the interview, taped earlier Thursday at Kim’s Cafe in Savannah, Georgia, Bash occasionally had pressed Harris when the vice president failed to answer a question directly. She asked four times, for example, about what led Harris to change her position on fracking — a controversial way to extract natural gas from the landscape — from her brief presidential candidacy in 2020.
“How should voters be looking at some of the changes in policy?” Bash asked, wondering whether experience led Harris down another path. “Should they be completely confident that what you’re saying now is going to be the policy moving forward?”
Bash asked Harris twice whether she would do something different, like withhold some military aid to Israel, to help reach a peace deal in the Mideast. Harris stressed the importance of a deal, but offered no new specifics on achieving it.
When Bash sought a response to Trump suggesting that Harris had only recently been emphasizing her Black roots, the vice president swiftly brushed it aside. “Next question,” she said.
CNN political analyst David Axelrod suggested that Harris, by not doing interviews previously, had raised the stakes on what is usually a typical test that presidential candidates face. But after the Bash session aired, Axelrod said that she “did what she needed to do.”
“What she needed to do was be the same person she has been on stage the past month,” said Axelrod, onetime aide to Obama when he was in the White House. He predicted the interview would ultimately make little difference in the campaign.
In seeking a personal connection with viewers, Bash asked Walz for his feelings about his son’s emotional response to this Democratic convention speech, and a memorable photo that depicted Harris’ niece from behind, watching her aunt deliver her address to Democrats.
By including Walz in the interview, Harris joined a tradition followed by Donald Trump and Mike Pence, Barack Obama and Joe Biden, and Biden and Harris themselves. But that decision stood out because of her lack of solo interviews and the compressed nature of her campaign.
Republicans complained she would use Walz as a crutch, someone who could smooth over his boss’ rough moments and simply take up time that could have been used for questions directed at Harris.
What to know about the 2024 Election
“This is one more Harris campaign insult to American voters,” the Wall Street Journal said in an editorial Thursday.
Ultimately, Bash directed only four questions to Walz — one a followup — and the vice presidential candidate didn’t interject or add to Harris’ responses.
This was the second high profile moment for Bash already this campaign. The “Inside Politics” anchor moderated June’s debate between Trump and President Biden, an event where the journalists were overshadowed by the poor performance by Biden that eventually led to him abandoning his re-election bid .
David Bauder writes about media for the AP. Follow him at http://twitter.com/dbauder .
BMC Medicine volume 22 , Article number: 340 ( 2024 ) Cite this article
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Increasing consumption of ultra-processed foods (UPF) has been identified as a risk factor for obesity and various diseases, primarily in adults. Nonetheless, research in children is limited, especially regarding longitudinal studies with metabolic outcomes. We aimed to evaluate the longitudinal association between consumption of UPF, adiposity, and metabolic indicators in Chilean preschool children.
We conducted a prospective analysis of 962 children enrolled in the Food and Environment Chilean Cohort (FECHIC). Dietary data were collected in 2016 at age 4 years with 24-h recalls. All reported foods and beverages were classified according to the NOVA food classification, and the usual consumption of UPF in calories and grams was estimated using the Multiple Source Method. Adiposity ( z -score of body mass index [BMI z -score], waist circumference [WC], and fat mass [in kg and percentage]) and metabolic indicators (fasting glucose, insulin, HOMA-IR, triglycerides, total cholesterol, and cholesterol fractions) were measured in 2018, at the age of 6 years. Linear regression models ((0) crude, (1) adjusted for covariables, and (2) adjusted for covariables plus total caloric intake) were used to evaluate the association between UPF and outcomes. All models included inverse probability weights to account for the loss to the follow-up.
At 4 years, usual consumption of UPF represented 48% of the total calories and 39% of the total food and beverages grams. In models adjusted for covariables plus caloric intake, we found a positive association between UPF and BMI z -score (for 100 kcal and 100 g, respectively: b = 0.24 [95%CI 0.16–0.33]; b = 0.21 [95%CI 0.10–0.31]), WC in cm ( b = 0.89 [95%CI 0.41–1.37]; b = 0.86 [95%CI 0.32–1.40]), log-fat mass in kg b = 0.06 [95%CI 0.03–0.09]; b = 0.04 [95%CI 0.01–0.07]), and log-percentage fat mass ( b = 0.03 [95%CI 0.01–0.04]; b = 0.02 [95%CI 0.003–0.04]), but no association with metabolic indicators.
In this sample of Chilean preschoolers, we observed that higher consumption of UPF was associated with adiposity indicators 2 years later, but not with metabolic outcomes. Longer follow-up might help clarify the natural history of UPF consumption and metabolic risks in children.
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Childhood obesity has become an escalating health concern worldwide. According to the 2019 projections by the World Obesity Federation, it is anticipated that by 2025, approximately 206 million children and adolescents aged 5–19 years will be affected by obesity, mainly due to increasing rates in emerging countries [ 1 ]. In Latin America, 7% of children under 5 years of age and 20–25% of children and adolescents up to 19 years are estimated to living with overweight or obesity [ 2 ]. In Chile, data from a survey including students in the public education system in 2019 revealed that 26.5 and 24.9% of preschool children (kinder) presented overweight and obesity, respectively [ 3 ]. Childhood obesity tends to persist over time and is associated with metabolic disturbances, which increasingly manifest at younger ages [ 4 ]. Several determinants are associated with childhood obesity, with changes in eating patterns being described as one of the main ones.
During the last decades, the food system has changed in different countries, and traditional diets have been increasingly replaced by ultra-processed foods (UPF) [ 5 ]. UPF are industrial formulations made mainly of substances extracted or derived from foods (e.g., sugar and fats), with little or no whole food in their composition and which typically contain added additives such as flavorings, colorings, and other additives used to modify the sensory attributes of the final product [ 6 ]. Children and adolescents have been described as the primary consumers of UPF in national surveys from Australia [ 7 ], Canada [ 8 ], the USA [ 9 ], Mexico [ 10 ], and Chile [ 11 ]. In developed countries such as the UK and the USA, UPF represents more than 60% of the calories consumed in children’s and adolescents’ diets [ 12 , 13 ]. In some Latin American countries such as Chile and Mexico, it is more than one-third of the total calories consumed by children 1–19 years old [ 10 , 11 ]. Non-representative studies in Brazil and Chile have reported that more than 40% of the total caloric intake comes from UPF in preschoolers at 4 years old [ 14 , 15 ].
Nationally representative data from food purchases and consumption from different countries showed that high amounts of UPF in diets are related to higher amounts of sugar and sodium, high energy density, and lower quantities of protein, micronutrients, and fiber [ 5 , 16 , 17 , 18 , 19 , 20 ]. In adults, systematic reviews and meta-analyses indicated a direct association between UPF consumption and overweight, obesity, metabolic syndrome, diabetes, and all-cause mortality [ 21 , 22 , 23 , 24 ]. However, evidence regarding health impacts in children is still scarce and inconsistent [ 25 ]. A recent systematic review of the effects of UPF, as defined by NOVA, on obesity and cardiometabolic comorbidities in children and adolescents showed that higher consumption of UPF was associated with greater adiposity in most studies. In the case of metabolic indicators, studies available are only a few and mostly from Brazil. Moreover, results have shown conflicting results [ 25 ]. For instance, prospective studies with children aged between 3 and 6 years found a direct relationship between the consumption of UPF and total cholesterol [ 26 , 27 ], LDL cholesterol [ 26 ], and triglycerides [ 27 ], but not with the glycemic profile [ 14 ].
Given the extent of the public health burden related to poor nutrition in children and the exponential increase in the consumption of UPF, a better understanding of the effects of UPF on indicators of metabolic risk in children is crucial. To our knowledge, no previous study on this topic has been conducted in Chile, so we aimed to prospectively evaluate the association between the consumption of ultra-processed foods, adiposity, and metabolic indicators in a sample of low-to-middle-income Chilean preschool children after 2 years of follow-up.
We used data from the Food and Environment Chilean Cohort (FECHIC), a cohort of 962 Chilean low-to-middle-income preschoolers from Southeast Santiago, Chile, started in 2016. Mothers were recruited in public schools to participate in the study with their 4- to 6-year-old children. Details on the recruitment and inclusion criteria are available elsewhere [ 28 ]. Briefly, the inclusion criteria were mothers as the primary caregivers for food purchases and childcare, absence of mental illness in the mother and child, and of other diseases with an impact on food consumption and child development, besides children of non-twin gestation, born at term and with normal birth weight. The present study included children with dietary data at baseline (year 2016, average age: 4.9 years) and anthropometric, body composition, or metabolic indicators measured after 2 years (year 2018, average age: 6.1 years).
At baseline, trained dietitians collected 24-h dietary recalls (24HR) following the United States Department of Agriculture (USDA) Automated Multiple-Pass method [ 29 ]. They used a photographic atlas to help estimate portion sizes accurately [ 30 ], and recorded data on portion size, type of preparation, type of food, and product brand and flavor in the case of packaged foods, as well as the source of the food and eating location. This information was entered into SER-24, a software developed by the Center for Research in Food Environment and Prevention of Obesity and Non-Communicable Diseases (CIAPEC), INTA, that includes over 6000 foods and beverages and 1400 standard recipes of traditional Chilean dishes and estimates nutrient intake using the Food Composition Table of the USDA [ 28 , 31 ]. The mother was the primary respondent and reported 1 day of their child’s food consumption in a face-to-face interview. Children were present during the interview and complemented the information for the eating occasions when the respondent was absent (e.g., school time). In the case of receiving meals from the School Feeding Program, these preparations were also recorded to link them to the recipes and nutrient contents of the food providers. A second dietary recall was collected within 30 days in a random subsample of 20.1% of participants.
Briefly, the NOVA classification considers the extent and purpose of industrial processing and classifies all foods and beverages into four groups: group 1—natural or minimally processed foods (MPF); group 2—processed culinary ingredients (PCI); group 3—processed foods (PF); and group 4—ultra-processed foods (UPF). Examples of UPF include industrialized sodas, toddler milk, confectionaries, chocolates, ice cream, hamburgers, reconstituted meat products, pizzas and other frozen dishes, instant soups, and packaged bakery products, among others [ 6 ]. We identified UPF based on food descriptions, food categories and type of food, whether packaged or unpackaged, brand, and flavor, when available. Simple preparations included in the software SER-24 (e.g., cooked rice) were classified based on their main component. Other homemade recipes were disaggregated into their components, and each of them was individually classified. Food classification was carried out by a postgraduate dietitian at CIAPEC and reviewed by a second dietitian. Disagreements (0.4%) were discussed and resolved by consensus. To verify the interrater agreement, a third dietitian independently classified a random subset of 5% of SER-24 records ( n = 306). We found an agreement of 97.4% and a kappa coefficient of 0.95, indicating almost perfect agreement between the raters. More details about the methodology applied were published elsewhere [ 32 ].
We calculated the consumption of UPF in calories and in grams for each participant. Most published studies used the caloric share of UPF; however, presenting UPF grams allowed us to consider the consumption of low or non-calorie UPF, such as artificially sweetened beverages commonly consumed by Chilean children at this age [ 33 ].
We identified outliers using two techniques: comparing the total calories consumed and the energy requirements of each participant and considering the extremes in the distribution of UPF (both in calories and grams).
We estimated the energy requirements with the Dietary Reference Intake (DRI) equation according to age and sex [ 34 ], using sedentary and very active levels of physical activity to calculate the lower and the higher cutoff points, respectively [ 35 ]. We used the subsample with two dietary recalls to calculate the standard deviation (SD) for the ratio (in %) between reported energy intake (rEI) and predicted energy requirement (pER), using the formula provided by Huang [ 36 ]. The formula considers the pooled coefficient of variation (CV) of the rEI (CVrEI = 32.6%, calculated for our sample [ 37 ]), the number of days of dietary assessment ( d = 2), the CV of the pER (CVpER = 12.1%, calculated with the mean and SD for the total energy of 3- to 18-year-old boys and girls described in the DRI [ 34 ]), and the coefficient of variation in the measured total energy expenditure (CVmTEE = 8.2%, obtained from literature [ 36 , 37 ]). The value of SD for our sample was 27.3%, and we defined implausible diets as those in which reported energy was from < − 3 or + 3 SD away from predicted energy requirements (i.e., < 18.1% or > 181.9% of the pER).
Additionally, diets under the 1st and above the 99th percentile of UPF consumption in calories and grams were excluded (UPF consumption < 42 kcal or > 1478.5 kcal and < 27 g or > 1554.5 g).
Of the 1154 records collected at the beginning of the study, 15 were considered implausible, and 30 were considered extreme UPF consumption. Then, the estimates of usual consumption included 743 children with a unique and 183 with two measures of 24HR.
We estimated the usual consumption of UPF using the Multiple Source Method (MSM). This method assumes that the 24HR is not biased for the usual consumption and models the probability of consumption—with logistic regression—and the amount consumed in a day of consumption—with linear regression—allowing the incorporation of covariates and is based on the premise that habitual consumption is equal to the probability of consumption times the usual amount consumed. Usual consumption can be estimated for dietary components that have frequent or daily consumption (e.g., nutrients), but also for those that have episodic consumption (e.g., food categories), as long as at least two measurements for a part of participants are available [ 38 ]. A minimum of 50 individuals with at least two 24HR is required to apply statistical methods to account for within- and between-person variation and estimate the usual consumption for food groups consumed almost every day [ 39 ].
The MSM was applied using free access online software developed by the Department of Epidemiology of the German Institute of Human Nutrition Potsdam-Rehbrücke, available at https://nugo.dife.de/msm/ . Covariables included for the estimates were sex, age, baseline body mass index (BMI) z -score for sex and age, and maternal variables (age, BMI, work outside the home, and education level).
All outcomes were measured after approximately 2 years of follow-up when the children were, on average, 6.1 years old.
We used data collected by trained dietitians following standard procedures. Height was measured using a portable stadiometer (Seca 217, to the nearest 0.1 cm), and weight was measured using a digital electronic scale (Seca 803 or 813, precision of 0.1 kg). Weight and height were taken in duplicate, and we used their average to calculate BMI. We compared the BMI of each child with the World Health Organization (WHO) growth references specific for age and sex [ 40 ] to obtain their z -score value (BMI z -score). Waist circumference (WC) was measured with a metal tape (Lufkin W 606 PM, USA, precision 0.1 cm) and taken in duplicate. A third measurement was required if the difference between both measurements was greater than 0.5 cm. We calculated the average WC for each child in cm.
Body composition was estimated using the bioelectrical impedance (BIA) method using Tanita BC-418 (Tanita Corp.) and following the manufacturer’s recommendations. The child’s age, sex, and height were entered manually. Children stood barefoot on the appliance while holding the handles for approximately 30 s. We used predicted values of fat mass (kg) and percentage of fat mass calculated by the device using impedance, weight, height, and age with standard calibrated equations based on data from dual-energy X-ray absorptiometry [ 41 ].
A nursing team collected the blood samples from the children after 8 to 12 h of fasting. We used the serum triglycerides, total cholesterol, high-density cholesterol (HDL-c), and low-density cholesterol (LDL-c) levels as lipid profile variables. For the glycemic profile, we used fasting glucose, insulin, and the HOMA-IR (acronym in English for homeostatic model to assess insulin resistance). Triglycerides, total cholesterol, and HDL-c were measured using enzymatic colorimetric assays. LDL-c was calculated using the Friedewald formula [ 42 ]. All lipid profile markers were expressed in mg/dl. Glycemia was measured by the enzymatic colorimetric method and expressed in mg/dL, and insulin by electrochemiluminescent immunoassay and expressed in μU/ml. HOMA-IR was calculated as insulin (μU/ml) × glucose (mmol/l) /22.5. All metabolic outcomes were considered continuous variables in the analysis.
Directed acyclic graphs (DAGs) were used to represent the structures of the causal networks that link exposure (consumption of UPF) and the outcomes of interest (adiposity and metabolic profile) and support the identification of confounding variables in the associations studied [ 43 ]. Given that we have two primary groups of outcomes (adiposity and metabolic indicators), we constructed two separate DAGs using the online application DAGitty (Fig. 1 ) [ 44 ].
Conceptual framework for the relationship between UPF consumption at 4 years and adiposity ( A ) and metabolic indicators ( B ) at 6 years. Notes: UPF – ultra-processed foods, SES – socioeconomic status, BMI – body mass index, (i) – initial values at 4 years, (p) – other values during the study period, (f) – final values at 6 years
Considering the DAGs, to estimate the total effect of the consumption of ultra-processed foods at 4 years on adiposity and metabolic responses at 6 years of age, the minimally sufficient adjustment set of variables included socioeconomic status (SES), maternal BMI and age, sex, age, and children’s television time (displayed in white in Fig. 1 ).
To approximate SES, we considered in the models mother’s educational level, categorized as “low” (less than high school), “medium” (at least high school), or “high” (more than high school), and whether they worked outside the home (“yes” or “no”), considering that in Chile the unemployment rate is higher in poor than in non-poor [ 45 ] and women with higher educational levels more often work outside the home [ 46 ]. We also included other maternal variables such as maternal age (self-reported) and BMI (calculated using maternal weight and height measurements collected by trained dietitians).
Among the variables for the children, we considered sex (male or female), age (in months), and television time. To estimate the total hours children spent watching television on weekdays, we summed the time spent watching TV before and after school and in the evening based on information provided by the mothers.
Full completeness was obtained for all covariates except maternal BMI, for which data for 4.2% of the total sample were missing. All covariables included in the models were measured at baseline.
Descriptive analyses were presented using mean and SD for quantitative variables and absolute and relative frequency for qualitative variables.
All participants whose dietary reports did not fulfill the above exclusion criteria and who provided data for at least one or more health outcomes were included in the association models. The proportion of loss to follow-up was 23.7% for anthropometric indicators, 33.5% for body composition, and 39.9% for metabolic indicators. We compared the characteristics of participants included and lost in the analysis by presenting the percentual difference between them and applying a T -test for quantitative and chi-square for qualitative variables, and differential loss related to maternal educational level was identified. Given the loss to follow-up and to address the potential selection bias, we incorporated the stabilized inverse probability of censuring weights (SW) in all models. This method creates a pseudo-population with characteristics comparable to the initial population to simulate random censuring of covariates of interest [ 47 ]. We calculated different SW for anthropometric, body composition, and metabolic indicators since the number of participants in each analysis differed. The calculation of SW uses as a numerator the probability of censuring (i.e., proportion of participants lost in the follow-up) and as a denominator the probability of censuring based on the covariables included in the model [ 47 , 48 ]. The probability of censorship was obtained with logistic regression with loss of follow-up as the response variable (yes or no), and the covariates included were sex, age, and initial BMI z -score of the child, and maternal age, BMI, work outside the home, and educational level of the mother. Using SW results in the same estimate as unstabilized inverse probability weights, but typically in narrower 95% confidence intervals and increased statistical efficiency [ 47 , 48 ]. SW were included in all regression analysis using the option pweight.
We used linear regression models to investigate the associations between the consumption of UPF at 4 years (in 100 cal and grams), adiposity, and metabolic indicators at 6 years. We reported regression coefficients and 95% confidence intervals (95% CI) for crude and adjusted models.
The model 1 was adjusted for covariables presented in the DAG: socioeconomic status (represented by maternal education and work outside the home), maternal BMI and age, and sex, age, and television time of children. The model 2 was adjusted for the same covariables plus caloric intake. The coefficient is then interpreted as the effect of substituting 1 unit of UPF with 1 unit of non-UPF, maintaining a constant caloric intake [ 49 , 50 ].
Given the low prevalence of missing data in the covariates (less than 5% and in only one variable), we assumed that missing data were completely at random and performed regressions with complete case analysis [ 51 ]. The goodness-of-fit of the models was evaluated via graphical analysis of the residuals and inflation factors of variance. The distribution of residues was not random for insulin, HOMA-IR, triglycerides, fat mass, and fat mass percentage, so the final models included the log-transformed version of these variables. As sensibility analysis, we considered models without SW and models with quartiles of UPF as the exposure variable. All analyses were conducted using Stata v18.0 (College Station, TX).
The baseline characteristics of all FECHIC children and sub-samples with anthropometric, body composition, and metabolic indicators are presented in Table 1 . The characteristics of the children included in each evaluation were similar to those of the reference cohort. At the start of the FECHIC cohort study, the children had an average age of 4.9 ± 0.5 years old, were comparable by sex (51.9% girls), and had a mean BMI z -score of 1. The mothers were 31.4 ± 6.7 years old, and most had a medium education level (55.1%). Children lost in the follow-up presented differences primarily related to their mothers’ educational level; more children from mothers of low education level were lost for anthropometric indicators ( p = 0.003) and body composition ( p < 0.001), and more children from mothers of high education level were lost for metabolic outcomes ( p < 0.001).
Table 2 shows the estimated usual consumption of each NOVA food group at baseline (4 years of age). Children consumed approximately 48% of their diet by calories from UPF and 39% of their diet by grams from UPF. Among the NOVA groups, UPF contributed the highest percentage of children’s calories, while MPF contributed the highest percentage of grams to children’s diet (57.0%).
A description of the outcomes included in the study is available in Table 3 . After 2 years of follow-up, the mean BMI z -score was 1.1 ± 1.3, and the mean fat mass percentage was 24.2 ± 5.3%. The mean fasting blood glucose was 81.8 mg/dL.
Tables 4 and 5 present the associations between the usual consumption of UPF at 4 years and adiposity and metabolic indicators at 6 years, considering the three types of models (crude, adjusted for covariables, adjusted for covariables plus total caloric intake). We did not find an association between UPF and adiposity in crude and covariable adjustment models. However, when UPF was adjusted for covariables plus total caloric intake, we observed a positive association of small magnitude with BMI z -score (respectively for 100 kcal and 100 g of UPF: b = 0.24 [95% CI 0.16–0.33]; b = 0.21 [95% CI 0.10–0.31]), WC ( b = 0.89 [95% CI 0.41–1.37]; b = 0.86 [95% CI 0.32–1.40]), log-fat mass ( b = 0.06 [95% CI 0.03–0.09]; b = 0.04 [95% CI 0.01–0.07]), and log-percentage fat mass ( b = 0.03 [95% CI 0.01–0.04]; b = 0.02 [95% CI 0.003–0.04]). For metabolic outcomes, the coefficients of UPF and their 95% CI for both 100 cal and 100 g were close to null values for all models.
The results obtained in models without SW (Additional file 1 : Tables S1 and S2) and in models with the consumption of UPF in quartiles (Additional file 1 : Tables S3 and S4) were consistent with those obtained in main analysis.
In this study, we found a high consumption of UPF in terms of calories and grams in a sample of low- and middle-income preschoolers from Santiago, Chile. We also found a positive association between the consumption of UPF at the age of 4 years and several markers of adiposity measured at 6 years old. However, we did not find an association between UPF consumption and metabolic indicators after 2 years of follow-up.
We remark that we found associations only in models that included a total caloric intake adjustment. In nutritional epidemiology, an energy adjustment is used to study the consumption of nutrients or foods in terms of total energy. The underlying reason is that interventions at the individual or population level usually aim to modify the consumption of certain nutrients or foods, with changes in the composition of the diet, but not in the overall amount of food consumed. The energy adjustment also controls for the confounding effect resulting from the association between total energy intake with physical activity, differences in body size, and metabolic efficiency [ 49 , 50 ]. On this basis, we consider the estimates that include the energy adjustment as the more reliable in our study. Analysis that takes into account the total calories by using the caloric share of UPF is the most prevalent in studies focused on investigating UPF and health outcomes [ 52 ]. The fact our results showed associations between UPF and adiposity markers only when adjusting for total calories provides further support to suggest that the relative contribution of UPF in the diet is more important than their absolute amount, and the health effects observed are a consequence of a displacement of traditional dietary patterns [ 53 ].
In the present study, we found that almost half of the calories of preschool children were derived from UPF, in line with the findings of previous studies with similar populations [ 14 , 15 ]. We also found that consumption of UPF during preschool years was positively associated with increases in BMI z -score and WC after 2 years of follow-up. Similarly, a study with 307 children of low socioeconomic status from Brazil found that the consumption of UPF in 4 year-old children predicted a higher increase in WC at 8 years old [ 14 ]. On the other hand, our findings do not align with the results of a previous study conducted on 7-year-old children from Portugal. In Portuguese children, there was no association between UPF and BMI z -score and WC z -score after 3 years of follow-up [ 54 ]. One potential explanation for the discrepancy in results is the difference in the amount of UPF consumed between both populations. Chilean children consumed more UPF than did Portuguese children. The percentage of grams and calories from UPF in the diet of Chilean children was 39 and 48%, while in Portuguese children, UPF represented 25 and 31% of the total grams and calories consumed, respectively. Another potential explanation is the age difference of the participants between studies. Our study followed children from 4 to 6 years, when they were starting the adipose rebound [ 55 ], while the study from Portugal followed children between 7 and 10 years old. Age and duration of follow-up could be a relevant factor. For example, a prior study from the Avon Longitudinal Study of Parents and Children that assessed longitudinal associations between UPF and adiposity trajectories from 7 to 24 years old showed that differences in BMI and fat mass by UPF consumption become more accentuated starting adolescence, another critical period for development [ 56 ].
Regarding metabolic indicators, we did not find an association with any included indicator. A recent review assessing the effect of UPF on metabolic syndrome components in children and adolescents based on nine cohort studies found mixed results. Some longitudinal studies have reported a positive association between UPF and blood lipids, but not with blood glucose; it is important to highlight that only a few prospective studies on metabolic outcomes in children are available in the literature to date [ 57 ]. Our results suggest that adiposity indicators could be altered before we observe metabolic marker alterations. However, metabolic alterations associated with adiposity during childhood are an increasingly common problem. A study with more than 26,000 children with obesity (average: 12.6 ± 2.9 years) from European countries found metabolic alterations in more than half of the participants, the most prevalent being high blood pressure (34%), dyslipidemias (32%), and less common alterations in glucose metabolism (3.3%) [ 58 ]. Similar results were also described in Mexico [ 59 ]. The results of these studies could indicate that alterations in blood pressure and lipid metabolism occur early in children with obesity. It is proposed that, with respect to glucose parameters, alterations may occur in the late stage of the development of metabolic alterations [ 60 , 61 ]. There is also evidence of the role of diet in metabolic risk from an early age. In a population-based cohort analyzing diet trajectories from ages 2–3 to 11–12 years, individuals who consistently adhered to an “unhealthy” diet trajectory showed compromised cardiovascular function and poorer metabolic health when compared to children consistently following a “healthy” diet, again suggesting that adolescence would be a critical period for observing the emergence of metabolic traits [ 62 ].
Various UPF characteristics have been examined to explain their detrimental impact on health. The most explored explanation revolves around the inadequate nutritional profile of UPF, characterized by a higher density of added sugars and saturated fats, and a lower density of vitamins and minerals compared to non-ultra-processed foods [ 16 ]. However, the nutritional imbalance in UPF seems incapable of fully explaining the observed effects. Findings from different studies have shown that the association between consumption of UPF and health outcomes persists even after adjusting for the nutritional profile of the diet [ 63 , 64 ]. UPF manufacturing often involves processed and refined ingredients that lack the natural food matrix, leading to reduced satiety and heightened glycemic response [ 65 ]. Additionally, UPF tend to have a higher energy density due to their ingredients and low water content, making them easy to consume rapidly in terms of volume and calories, facilitating excessive intake [ 66 , 67 ]. Furthermore, UPF typically exhibit a lower protein density, and it has been hypothesized that this lower protein content could lead individuals to overconsume other foods and, consequently, excess energy [ 68 ]. Another hypothesis considered to explain these associations beyond the nutritional profile is that the widespread consumption of UPF may result in increased intake of substances that are rare or absent in nature, such as food additives [ 69 ].
The consumption of UPF by children is a matter of concern. We know that children are the main consumers of these products in several countries, with the percentage of consumption higher than that observed in adults [ 70 ]. In fact, media marketing that encourages increased consumption of UPF targets children, given their high vulnerability. Additionally, eating habits built during childhood tend to persist throughout life [ 71 ]; therefore, becoming accustomed to consuming high levels of sugars, sodium, and fats is worrisome. Moreover, children have a lower body size; thus, they have a higher risk of exposure to critical levels of substances found in UPF. Thus, several countries, mostly in the Latin-American region, have adopted food-based guidelines with messages advising against the consumption of UPF [ 72 , 73 , 74 , 75 ]. In Brazil, dietary guidelines for children under 2 years of age explicitly recommend offering MPF and avoiding UPF [ 76 ]. Additionally, in Brazil, the legislation of the school feeding program prohibits the provision of UPF for children under 3 years of age and mandates that at least 75% of resources be allocated to the acquisition of MPF [ 77 ]. While not explicitly incorporating the concept of UPF into its regulations, Chile has one of the most comprehensive frameworks to protect children from packaged foods and beverages high in nutrients of concern, such as sugar, salt, and saturated fats (mostly UPF). The Chilean Food-Labeling and Advertising Law implemented in 2016 (after our dietary data collection) mandates the inclusion of warning labels “high in” on the front of the package, restricts the marketing of regulated foods to children under 14 years of age, and prohibits selling or offering of these foods in schools [ 78 ]. These measures should be reinforced and globally promoted to create environments in which children have restricted or no access to UPF given the risks associated with their consumption.
Our study has several strengths, including its longitudinal design, detailed dietary information that includes specific brand names of packaged foods, objective measurements of adiposity and metabolic profiles, and the estimation of usual consumption of UPF employing statistical methods to account for within-person variability in food consumption. However, some limitations should also be considered for interpreting our results. In observational studies, there is an inherent measurement error in the dietary data, which refers to the difference between the reported dietary intake and the true usual dietary intake. However, we attempted to select only plausible reports by excluding diets very far from the estimated considered children’s sex and age, and we also excluded diets with extreme values of UPF (< p1 and > p99). We also gathered dietary information using the standardized 24-h dietary recall technique, deemed the method with the least misreporting in children [ 79 ], and included children in the interviews which could reduce errors due to lack of awareness of parents regarding children’s dietary consumption. Additionally, we applied a statistical method to estimate the usual consumption of UPF; however, our estimate could not represent the usual consumption over the entire follow-up period. Still, dietary recalls can be subjected to social desirability bias, which may lead to the underestimation of UPF and bias in the associations toward the null. The proportion of loss on the follow-up was significant, especially for metabolic indicators, and we found differential losses related to mothers’ education. However, maternal education was not associated with outcomes, except glycemia (data not shown), so the estimates should not be importantly modified with the observed differential loss to follow-up; besides, we applied inverse probability of censoring weights to adjust all analyses to make more correct inferences considering the characteristics of our initial sample. Although we controlled for potential confounders, we cannot rule out unmeasured or residual confounding as this was an observational study. Finally, the findings might lack broad generalizability because our sample consisted of preschoolers attending public schools in Santiago’s low- to middle-income region.
We observed that a higher consumption of UPF was associated with adiposity indicators in this sample of Chilean preschoolers. Our results suggest the need for a longer exposure time for metabolic effects to emerge, so strategies to prevent the consumption of UPF aimed at schoolchildren could still improve these trajectories. Therefore, policies promoting food environments that facilitate the consumption of minimally processed foods and make it difficult for children to access UPF should be encouraged.
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
24-H Diet Recall
Body mass index
Center of Research in Food Environment and Prevention of Obesity and Non-Communicable Diseases
Coefficient of variation
Directed acyclic graph
Dietary Reference Intake
Food and Environment Chilean Cohort
High-density cholesterol
Homeostatic Model to Assess Insulin Resistance
Institute of Nutrition and Food Technology
Low-density cholesterol
Minimally processed foods
Multiple Source Method
Predicted energy requirement
Processed culinary ingredients
Processed foods
Reported energy intake
Socioeconomic status
Stabilized inverse probability of censuring weights
United States Department of Agriculture
Waist circumference
World Health Organization
Global Atlas on Childhood Obesity. World Obesity Federation. https://www.worldobesity.org/membersarea/global-atlas-on-childhood-obesity . Accessed 10 Nov 2023.
Rivera JÁ, de Cossío TG, Pedraza LS, Aburto TC, Sánchez TG, Martorell R. Childhood and adolescent overweight and obesity in Latin America: a systematic review. Lancet Diabetes Endocrinol. 2014;2:321–32.
Article PubMed Google Scholar
Junta Nacional de Auxilio Escolar y Becas. Informe Mapa Nutricional 2019. 2021. https://www.junaeb.cl/wp-content/uploads/2023/03/Informe-Mapa-Nutricional-2019-1.pdf .
Al-Hamad D, Raman V. Metabolic syndrome in children and adolescents. Transl Pediatr. 2017;6:397–407.
Article PubMed PubMed Central Google Scholar
Monteiro CA, Moubarac J-C, Cannon G, Ng SW, Popkin B. Ultra-processed products are becoming dominant in the global food system. Obes Rev. 2013;14:21–8.
Monteiro CA, Cannon G, Levy RB, Moubarac J-C, Louzada ML, Rauber F, et al. Ultra-processed foods: what they are and how to identify them. Public Health Nutr. 2019;22:936–41.
Machado PP, Steele EM, Louzada ML da C, Levy RB, Rangan A, Woods J, et al. Ultra-processed food consumption drives excessive free sugar intake among all age groups in Australia. Eur J Nutr. 2020;59:2783–92.
Moubarac J-C, Batal M, Louzada ML, Martinez Steele E, Monteiro CA. Consumption of ultra-processed foods predicts diet quality in Canada. Appetite. 2017;108:512–20.
Baraldi LG, Martinez Steele E, Canella DS, Monteiro CA. Consumption of ultra-processed foods and associated sociodemographic factors in the USA between 2007 and 2012: evidence from a nationally representative cross-sectional study. BMJ Open. 2018;8.
Marrón-Ponce JA, Sánchez-Pimienta TG, Louzada ML da C, Batis C. Energy contribution of NOVA food groups and sociodemographic determinants of ultra-processed food consumption in the Mexican population. Public Health Nutr. 2018;21:87–93.
Cediel G, Reyes M, da Costa Louzada ML, Martinez Steele E, Monteiro CA, Corvalán C, et al. Ultra-processed foods and added sugars in the Chilean diet (2010). Public Health Nutr. 2018;21:125–33.
Martines RM, Machado PP, Neri DA, Levy RB, Rauber F. Association between watching TV whilst eating and children’s consumption of ultraprocessed foods in United Kingdom. Matern Child Nutr. 2019;15:e12819.
Neri D, Martinez-Steele E, Monteiro CA, Levy RB. Consumption of ultra-processed foods and its association with added sugar content in the diets of US children, NHANES 2009–2014. Pediatr Obes. 2019;14:e12563.
Costa CS, Rauber F, Leffa PS, Sangalli CN, Campagnolo PDB, Vitolo MR. Ultra-processed food consumption and its effects on anthropometric and glucose profile: A longitudinal study during childhood. Nutr Metab Cardiovasc Dis. 2019;29:177–84.
Article PubMed CAS Google Scholar
Araya C, Corvalán C, Cediel G, Taillie LS, Reyes M. Ultra-Processed Food Consumption Among Chilean Preschoolers Is Associated With Diets Promoting Non-communicable Diseases. Front Nutr. 2021;8:601526.
Article PubMed PubMed Central CAS Google Scholar
Louzada ML da C, Ricardo CZ, Steele EM, Levy RB, Cannon G, Monteiro CA. The share of ultra-processed foods determines the overall nutritional quality of diets in Brazil. Public Health Nutr. 2018;21:94–102.
Cediel G, Reyes M, Corvalán C, Levy RB, Uauy R, Monteiro CA. Ultra-processed foods drive to unhealthy diets: evidence from Chile. Public Health Nutr. 2020;:1–10.
Machado PP, Steele EM, Levy RB, Sui Z, Rangan A, Woods J, et al. Ultra-processed foods and recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from a nationally representative cross-sectional study. BMJ Open. 2019;9:e029544.
Rauber F, Louzada ML da C, Martinez Steele E, Rezende LFM de, Millett C, Monteiro CA, et al. Ultra-processed foods and excessive free sugar intake in the UK: a nationally representative cross-sectional study. BMJ Open. 2019;9:e027546.
Liu J, Steele EM, Li Y, Karageorgou D, Micha R, Monteiro CA, et al. Consumption of Ultraprocessed Foods and Diet Quality Among U.S. Children and Adults. Am J Prev Med. 2022;62:252–64.
Askari M, Heshmati J, Shahinfar H, Tripathi N, Daneshzad E. Ultra-processed food and the risk of overweight and obesity: a systematic review and meta-analysis of observational studies. Int J Obes. 2020;44:2080–91.
Article Google Scholar
Pagliai G, Dinu M, Madarena MP, Bonaccio M, Iacoviello L, Sofi F. Consumption of ultra-processed foods and health status: a systematic review and meta-analysis. Br J Nutr. 2021;125:308–18.
Yuan L, Hu H, Li T, Zhang J, Feng Y, Yang X, et al. Dose-response meta-analysis of ultra-processed food with the risk of cardiovascular events and all-cause mortality: evidence from prospective cohort studies. Food Funct. 2023;14:2586–96.
Taneri PE, Wehrli F, Roa-Díaz ZM, Itodo OA, Salvador D, Raeisi-Dehkordi H, et al. Association Between Ultra-Processed Food Intake and All-Cause Mortality: A Systematic Review and Meta-Analysis. Am J Epidemiol. 2022;191:1323–35.
Petridi E, Karatzi K, Magriplis E, Charidemou E, Philippou E, Zampelas A. The impact of ultra-processed foods on obesity and cardiometabolic comorbidities in children and adolescents: a systematic review. Nutrition Reviews. 2023;:nuad095.
Rauber F, Campagnolo PDB, Hoffman DJ, Vitolo MR. Consumption of ultra-processed food products and its effects on children’s lipid profiles: a longitudinal study. Nutr Metab Cardiovasc Dis. 2015;25:116–22.
Leffa PS, Hoffman DJ, Rauber F, Sangalli CN, Valmórbida JL, Vitolo MR. Longitudinal associations between ultra-processed foods and blood lipids in childhood. Br J Nutr. 2020;124:341–8.
Venegas Hargous C, Reyes M, Smith Taillie L, González CG, Corvalán C. Consumption of non-nutritive sweeteners by pre-schoolers of the food and environment Chilean cohort (FECHIC) before the implementation of the Chilean food labelling and advertising law. Nutr J. 2020;19:69.
Steinfeldt L, Anand J, Murayi T. Food Reporting Patterns in the USDA Automated Multiple-Pass Method. Procedia Food Science. 2013;2:145–56.
Cerda R, Barrera C, Arena M, Bascuñan K, Jimenez G. Atlas fotográfico de alimentos y preparaciones típicas chilenas: Encuesta Nacional de Consumo Alimentario 2010. Universidad de Chile. Facultad de Economía y Negocios. Universidad de Chile. Facultad de Medicina. Ministerio de Salud; 2010.
Rebolledo N, Reyes M, Corvalán C, Popkin BM, Smith TL. Dietary Intake by Food Source and Eating Location in Low- and Middle-Income Chilean Preschool Children and Adolescents from Southeast Santiago. Nutrients. 2019;11:1695.
Zancheta Ricardo C, Duran AC, Grilo MF, Rebolledo N, Díaz-Torrente X, Reyes M, et al. Impact of the use of food ingredients and additives on the estimation of ultra-processed foods and beverages. Front Nutr. 2022;9:1046463.
Rebolledo N, Reyes M, Popkin BM, Adair L, Avery CL, Corvalán C, et al. Changes in nonnutritive sweetener intake in a cohort of preschoolers after the implementation of Chile’s Law of Food Labelling and Advertising. Pediatr Obes. 2022;17:e12895.
Dietary Reference Intakes for Energy. Washington, D.C.: National Academies Press; 2023.
Mendez MA, Miles DR, Poti JM, Sotres-Alvarez D, Popkin BM. Persistent disparities over time in the distribution of sugar-sweetened beverage intake among children in the United States. Am J Clin Nutr. 2019;109:79–89.
Huang TT-K, Roberts SB, Howarth NC, McCrory MA. Effect of screening out implausible energy intake reports on relationships between diet and BMI. Obes Res. 2005;13:1205–17.
Black AE, Cole TJ. Within- and between-subject variation in energy expenditure measured by the doubly-labelled water technique: implications for validating reported dietary energy intake. Eur J Clin Nutr. 2000;54:386–94.
Haubrock J, Nöthlings U, Volatier J-L, Dekkers A, Ocké M, Harttig U, et al. Estimating Usual Food Intake Distributions by Using the Multiple Source Method in the EPIC-Potsdam Calibration Study1–3. J Nutr. 2011;141:914–20.
Tooze JA. Estimating Usual Intakes from Dietary Surveys: Methodologic Challenges, Analysis Approaches, and Recommendations for Low- and Middle-Income Countries. Washington, D.C: Intake - Center for Dietary Assessment/FHI Solutions; 2020.
The WHO Child Growth Standards. https://www.who.int/tools/child-growth-standards . Accessed 8 Nov 2023.
Tanita Corporation. Body composition analyser BC-418. Instruction manual.
Vujovic A, Kotur-Stevuljevic J, Spasic S, Bujisic N, Martinovic J, Vujovic M, et al. Evaluation of different formulas for LDL-C calculation. Lipids Health Dis. 2010;9:27.
Glass TA, Goodman SN, Hernán MA, Samet JM. Causal Inference in Public Health. Annu Rev Public Health. 2013;34:61–75.
Textor J, van der Zander B, Gilthorpe MS, Liskiewicz M, Ellison GT. Robust causal inference using directed acyclic graphs: the R package “dagitty.” Int J Epidemiol. 2016;45:1887–94.
PubMed Google Scholar
Chile. Ministerio de Desarrollo Social y Familia. Encuesta de Caracterización Socioeconómica Nacional - CASEN 2017. Situación de pobreza: Síntesis de resultados. 2017.
Chile. Instituto Nacional de Estadísticas. Mujeres en Chile y mercado de trabajo: Participación laboral femenina y brechas salariales. Santiago, Chile; 2015.
Hernán MA, Robins JM. Causal Inference: What If. Boca Raton: Chapman & Hall/CRC; 2020.
Google Scholar
van der Wal WM, Geskus RB. ipw: An R Package for Inverse Probability Weighting. J Stat Softw. 2011;43:1–23.
Willett W, Howe G, Kushi L. Adjustment for total energy intake in epidemiologic studies. Am J Clin Nutr. 1997;65:1220S–1228S.
Tomova GD, Arnold KF, Gilthorpe MS, Tennant PW. Adjustment for energy intake in nutritional research: a causal inference perspective. Am J Clin Nutr. 2022;115:189–98.
Schafer JL. Multiple imputation: a primer. Stat Methods Med Res. 1999;8:3–15.
Vitale M, Costabile G, Testa R, D’Abbronzo G, Nettore IC, Macchia PE, et al. Ultra-Processed Foods and Human Health: A Systematic Review and Meta-Analysis of Prospective Cohort Studies. Adv Nutr. 2024;15:100121.
Scrinis G, Monteiro C. From ultra-processed foods to ultra-processed dietary patterns. Nat Food. 2022;3:671–3.
Vilela S, Magalhães V, Severo M, Oliveira A, Torres D, Lopes C. Effect of the food processing degree on cardiometabolic health outcomes: A prospective approach in childhood. Clin Nutr. 2022;41:2235–43.
Dietz W. Critical periods in childhood for the development of obesity. Am J Clin Nutr. 1994;59:955–9.
Chang K, Khandpur N, Neri D, Touvier M, Huybrechts I, Millett C, et al. Association Between Childhood Consumption of Ultraprocessed Food and Adiposity Trajectories in the Avon Longitudinal Study of Parents and Children Birth Cohort. JAMA Pediatr. 2021;175:e211573.
Frías JRG, Cadena LH, Villarreal AB, Piña BGB, Mejía MC, Cerros LAD, et al. Effect of ultra-processed food intake on metabolic syndrome components and body fat in children and adolescents: A systematic review based on cohort studies. Nutrition. 2023;111:112038.
I’Allemand D, Wiegand S, Reinehr T, Müller J, Wabitsch M, Widhalm K, et al. Cardiovascular risk in 26,008 European overweight children as established by a multicenter database. Obesity (Silver Spring). 2008;16:1672–9.
Velázquez-López L, Santiago-Díaz G, Nava-Hernández J, Muñoz-Torres AV, Medina-Bravo P, Torres-Tamayo M. Mediterranean-style diet reduces metabolic syndrome components in obese children and adolescents with obesity. BMC Pediatr. 2014;14:175.
Marcovecchio ML, Bagordo M, Marisi E, de Giorgis T, Chiavaroli V, Chiarelli F, et al. One-hour post-load plasma glucose levels associated with decreased insulin sensitivity and secretion and early makers of cardiometabolic risk. J Endocrinol Invest. 2017;40:771–8.
Tricò D, Galderisi A, Mari A, Santoro N, Caprio S. The one-hour post-load plasma glucose predicts progression to prediabetes in a multiethnic cohort of obese youths. Diabetes Obes Metab. 2019;21:1191–8.
Kerr JA, Liu RS, Gasser CE, Mensah FK, Burgner D, Lycett K, et al. Diet quality trajectories and cardiovascular phenotypes/metabolic syndrome risk by 11–12 years. Int J Obes. 2021;45:1392–403.
Article CAS Google Scholar
Louzada ML da C, Baraldi LG, Steele EM, Martins APB, Canella DS, Moubarac J-C, et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Preventive Medicine. 2015;81:9–15.
Srour B, Fezeu LK, Kesse-Guyot E, Allès B, Méjean C, Andrianasolo RM, et al. Ultra-processed food intake and risk of cardiovascular disease: prospective cohort study (NutriNet-Santé). BMJ. 2019;365:l1451.
Fardet A. Minimally processed foods are more satiating and less hyperglycemic than ultra-processed foods: a preliminary study with 98 ready-to-eat foods. Food Funct. 2016;7:2338–46.
Forde CG, Mars M, de Graaf K. Ultra-Processing or Oral Processing? A Role for Energy Density and Eating Rate in Moderating Energy Intake from Processed Foods. Curr Dev Nutr. 2020;4:nzaa019.
Hall KD, Ayuketah A, Brychta R, Cai H, Cassimatis T, Chen KY, et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake. Cell Metab. 2019;30:67–77.e3.
Steele EM, Raubenheimer D, Simpson SJ, Baraldi LG, Monteiro CA. Ultra-processed foods, protein leverage and energy intake in the USA. Public Health Nutr. 2018;21:114–24.
Ayton A, Ibrahim A. The Western diet: a blind spot of eating disorder research?—a narrative review and recommendations for treatment and research. Nutr Rev. 2020;78:579–96.
Khandpur N, Neri DA, Monteiro C, Mazur A, Frelut M-L, Boyland E, et al. Ultra-Processed Food Consumption among the Paediatric Population: An Overview and Call to Action from the European Childhood Obesity Group. ANM. 2020;76:109–13.
CAS Google Scholar
Birch LL. Development of food preferences. Annu Rev Nutr. 1999;19:41–62.
Brasil. Ministério da Saúde. Guia alimentar para a população brasileira. 2nd edition. Brasília; 2014.
Lázaro Serrano ML, Domínguez Curi CH. Guías alimentarias para la población peruana. Instituto Nacional de Salud. 2019.
Uruguay. Ministerio de Salud. Guía alimentaria para la población uruguaya. 2016.
Chile. Ministerio de Salud. Guías Alimentarias para Chile. Santiago; 2022.
Brasil. Ministério da Saúde. Guia alimentar para crianças brasileiras menores de 2 anos. Brasília: Ministério da Saúde; 2019.
Brasil. Fundo Nacional de Desenvolvimento da Educação. NOTA TÉCNICA N o 1879810/2020/COSAN/CGPAE/DIRAE. Alterações dos aspectos de Alimentação e Nutrição e de Segurança Alimentar e Nutricional da Resolução CD/FNDE n o 6, de 8 de maio de 2020. 2020.
Corvalán C, Reyes M, Garmendia ML, Uauy R. Structural responses to the obesity and non-communicable diseases epidemic: Update on the Chilean law of food labelling and advertising. Obes Rev. 2019;20:367–74.
Forrestal SG. Energy intake misreporting among children and adolescents: a literature review. Matern Child Nutr. 2011;7:112–27.
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We thank the participants of the Food and Environment Chilean Cohort. We also thank the research teams at CIAPEC (Center of Research in Food Environment and Prevention of Obesity and Non-Communicable Diseases) at INTA (Institute of Nutrition and Food Technology), University of Chile, and at the Global Food Research Program, University of North Carolina at Chapel Hill.
This work was supported by Bloomberg Philanthropies, and the ANID/Fondo Nacional de Desarrollo Científico y Tecnológico-FONDECYT Regular (#1201633 and #1181370). CZ is supported by the National Agency for Research and Development (ANID)/Scholarship Program/Doctorado Becas Chile #21200883. NR is supported by the ANID/Fondo Nacional de Desarrollo Científico y Tecnológico-FONDECYT Postdoctorado (#3230125). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Doctoral Program in Public Health, School of Public Health, University of Chile, Santiago, Chile
Camila Zancheta
Center of Research in Food Environment and Prevention of Obesity and Non-Communicable Diseases (CIAPEC), Institute of Nutrition and Food Technology (INTA), University of Chile, Santiago, Chile
Camila Zancheta, Natalia Rebolledo, Marcela Reyes & Camila Corvalán
Carolina Population Center, Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Lindsey Smith Taillie
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Conceptualization: CZ and CC. Methodology: CZ and CC. Investigation: CZ. Funding acquisition: LST, MR and CC. Supervision: CC. Writing—original draft: CZ. Writing—review and editing: CZ, NR, LST, MR, and CC. All authors read and approved the final manuscript.
Correspondence to Camila Corvalán .
Ethics approval and consent to participate.
The original study was approved by the ethics committee of the Institute of Nutrition and Food Technology (INTA), University of Chile (Nº 7–2016, Nº 19–2017). All mothers signed an informed consent form on behalf of their children. The ethics committee of the Faculty of Medicine, University of Chile, also approved the current analyses (Nº 159–2021).
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The authors declare that they have no competing interests. CC is a Guest Editor in BMC Medicine, for the article collection “Food Environments and Health”.
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Additional file 1: Tables S1-S4. Table S1 – Associations between the consumption of UPF at 4 y, anthropometric indicators, and body composition at 6 y without considering SW. Table S2 – Associations between the consumption of UPF at 4 y and metabolic indicators at 6 y without considering SW. Table S3 – Associations between quartiles of consumption of UPF at 4 y, anthropometric indicators and body composition at 6 y. Table S4 – Associations between quartiles of consumption of UPF at 4 y and metabolic indicators at 6 y
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Zancheta, C., Rebolledo, N., Smith Taillie, L. et al. The consumption of ultra-processed foods was associated with adiposity, but not with metabolic indicators in a prospective cohort study of Chilean preschool children. BMC Med 22 , 340 (2024). https://doi.org/10.1186/s12916-024-03556-z
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DOI : https://doi.org/10.1186/s12916-024-03556-z
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