nutrients Article Ultra-Processed Foods and Drinks Consumption Is Associated with Psychosocial Functioning in Adolescents Marta Reales-Moreno 1,2,† , Pietro Tonini 3,† , Rosa M. Escorihuela 4,5 , Montserrat Solanas 5,6 , Sílvia Fernández-Barrés 7 , Dora Romaguera 8,9 and Oren Contreras-Rodríguez 1,4,10, * 1 Medical Imaging, Girona Biomedical Research Institute (IdIBGi), Parc Hospitalari Martí i Julià-Edifici M2, 17190 Girona, Spain 2 Department of Medical Sciences, School of Medicine, University of Girona, 17071 Girona, Spain 3 Sostenipra Research Group (2017 SGR 1683), Unitat d’Excel·lència Maria de Maetzu MDM, CEX2019-000940-M, Institut de Ciència i Tecnologia Ambientals (ICTA-UAB), Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain 4 Department of Psychiatry and Legal Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain 5 Institut de Neurociències, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain 6 Physiology Unit, Department of Cell Biology, Physiology and Immunology, Faculty of Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain 7 Agència de Salut Pública de Barcelona, 08193 Bellaterra, Spain 8 Institut d’Investigació Sanitaria Illes Balears (IdISBa), 07120 Palma, Spain 9 CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), 28029 Madrid, Spain 10 Health Institute Carlos III (ISCIII) and CIBERSAM G17, 28029 Madrid, Spain * Correspondence: ocontreras@idibgi.org † The authors contributed equally to the manuscript. Citation: Reales-Moreno, M.; Tonini, Abstract: Adolescents show one of the highest rates of ultra-processed foods and drinks (UPF) con- P.; Escorihuela, R.M.; Solanas, M.; sumption, and studies indicate an association between their consumption and internalizing problems. Fernández-Barrés, S.; Romaguera, D.; We aim to investigate whether UPF consumption associates with dysfunctions in other psychosocial Contreras-Rodríguez, O. domains, as well as sex effects. In 560 Spanish adolescents (14–17 years old), we assessed the UPF Ultra-Processed Foods and Drinks products consumed in the previous day, fruits and vegetables consumption (servings/day), and Consumption Is Associated with physical activity (days/week). Psychosocial functioning (total and subscales) was assessed through Psychosocial Functioning in the Pediatric Symptom Checklist–Youth self-report. Associations between UPF and psychosocial Adolescents. Nutrients 2022, 14, 4831. https://doi.org/10.3390/ functioning were assessed using linear regression models, adjusting for sex, age, fruits and vegeta- nu14224831 bles consumption, and physical activity. Sex-specific associations were also explored. Participants reported a daily consumption of 7.72 UPF servings per day, with male adolescents showing higher Academic Editor: Rosa Casas consumption than female adolescents. Consumption of fruits and vegetables and physical activity Received: 12 October 2022 levels were lower than recommended. Psychosocial impairment was present in 26.2% of the partici- Accepted: 11 November 2022 pants. Higher UPF consumption was associated with higher presence of depressive symptoms and Published: 15 November 2022 internalizing and externalizing problems in the whole sample and in male adolescents. The present Publisher’s Note: MDPI stays neutral study supports previous studies suggesting that UPF consumption may interact with mental health with regard to jurisdictional claims in problems and indicates that these effects may go beyond internalizing problems. published maps and institutional affil- iations. Keywords: ultra-processed foods and drinks; fruits and vegetables; physical activity; psychosocial functioning; adolescence Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. 1. Introduction This article is an open access article The World Health Organization has warned that the consequences of not addressing distributed under the terms and mental health conditions during adolescence extend into adulthood [1]. Current epidemio- conditions of the Creative Commons Attribution (CC BY) license (https:// logical studies estimate that 1 in 7 (14%) adolescents experience mental health conditions, creativecommons.org/licenses/by/ with depression, anxiety, and behavioral disorders being among the leading causes of 4.0/). illness and disability [1]. Therefore, identifying factors interacting with mental health Nutrients 2022, 14, 4831. https://doi.org/10.3390/nu14224831 https://www.mdpi.com/journal/nutrients Nutrients 2022, 14, 4831 2 of 15 problems is a high priority in developing preventive strategies in adolescents [2]. Poor diet quality, characterized by a high consumption of ultra-processed foods and drinks (UPF in brief), is a potentially modifiable risk factor for mental disorders [3]. UPF are ingredient formulations that result from series of industrial processes [4]. They contain no or relatively small amounts of minimally processed foods that conserve their nutritional properties. In general, most UPF have low nutrient densities and are poor sources of protein, dietary fiber, and micronutrients. At the same time, they have high energy densities, together with high contents of saturated and trans fatty acids, added sugars, and salt compared to unprocessed foods [5]. Moreover, UPF usually contain addi- tives (i.e., sweeteners, colorants, emulsifiers) intended to intensify their sensory qualities and imitate the appearance of minimally processed foods—making them edible, palatable, highly attractive, and habit-forming [6]. Recent research has warned about the presence in UPF of chemicals acquired through contact materials, such as sophisticated packaging (e.g., bisphenol), and neo-formed contaminants generated during food processing practices [7]. Adolescents show one of the highest rates of UPF consumption, with recent studies estimating the percentage of their total energy intake obtained from UPF consumption being between 29% and 68% [8,9]. In Spain, the percentage of ultra-processed foods among all food purchases almost tripled between 1990 and 2010 (from 11.0% to 31.7%) [10]. In adolescents, UPF consumption is associated with specific nutritional deficiencies, including lower levels of micronutrients and vitamins [11], proteins, and dietary fiber, and higher ingestion of saturated and trans fatty acids, added sugars, and sodium [9,12]. Alongside these concerns, recent studies have started to shed light on the adverse effects that UPF consumption has on mental health [3,13]. Studies showed an association between UPF consumption and internalizing problems [14], depressive symptoms [15], anxiety-induced disturbances [16], and the risk for common mental health disorders [17]. Some of these effects have been reported to be sex-specific [14]. These findings are congruent with pre- clinical evidence that UPF components (i.e., nanosized particles contained in some additives, trans fatty acids, chemicals) impair several brain regions, including the hippocampus and the cortex, implicated in emotional processes [18]. In contrast, substantial evidence points toward the mental health benefits associated with healthy habits, including achieving the recommendations of fruits and vegetables consumption (≥5 servings/day, [19]) and physical activity [20]. For instance, a systematic review showed a relationship between healthy dietary habits and internalizing disorders in adolescents [21]. In another study, a low consumption of fruits and vegetables was associated with low mental health across adolescence [22]. Indeed, randomized controlled trials have demonstrated that healthy dietary changes can improve depression [23]. Physical activity is also identified as a key factor in reducing adverse physical, mental, and social health outcomes in the population [24]. In adolescents, more frequent physical activity and participation in sports independently contributed to greater well-being and lower levels of anxiety and depressive symptoms in both sexes [25]. Therefore, there is some preliminary evidence that UPF consumption may be related to poorer mental health, particularly to internalizing problems in adolescents [3]. However, there is a need to study whether UPF consumption may associate with dysfunctions in other psychosocial domains and whether its effects are different between sexes. The main objective of the present study was to provide estimations of the daily consumption of UPF and fruits and vegetables, as well as the weekly physical activity, in a large sample of Spanish adolescents. Then, we aimed to comprehensively explore the associations between UPF consumption and different domains of psychosocial functioning while adjusting for sex, age, fruits and vegetables consumption, and physical activity. Specific sex effects on the above associations were explored. Nutrients 2022, 14, 4831 3 of 15 2. Methods and Materials 2.1. Study Overview and Participants Five hundred and sixty adolescents from five high schools and educational centers participated in this cross-sectional study as part of the health education program of the involved centers. The study was conducted between February and April 2022 in Spain (in the region of Catalonia). Participants attended a brief presentation to familiarize them with the questionnaires. We also introduced the concept of servings, the types of UPF products, and the way they should provide the answers. Afterward, they completed three self-report questionnaires. These questionnaires compiled information regarding age, sex, UPF and fruits and vegetables consumption, physical activity, and psychosocial functioning. The biological sex variable used in this study was labeled as female, male, and indeterminate sex [26]. Indeterminate sex refers to unknown biological sex and included those who did not want to answer this question, those whose biology did not allow them to define themselves (e.g., intersex, medical syndromes, etc.), or any other personal case. Data were collected on a single day from Tuesday to Friday, to estimate the usual weekday diet and avoid dietary changes between weekdays and weekends [27]. No exclusion criteria were considered, so that the sample represents the population as much as possible. The information of the study participants is shown in Table 1. Table 1. Demographic and questionnaires information of the study participants. Total Male Female Indeterminate p (N = 560) (N = 217) (N = 327) (N = 16) Age (years) a 15.24 ± 1.11 15.26 ± 1.13 15.25 ± 1.10 14.67 ± 0.98 0.129 UPF consumption (number +++ 7.72 ± 5.10 8.67 ± 5.11 7.06 ± 4.97 8.31 ± 5.68 0.001 products/24 h) Physical activity (days/week) 2.90 ± 1.96 3.63 ± 1.99 2.39 ± 1.78 +++ 3.25 ± 1.91 <0.001 Fruits and vegetables consumption + 1.93 ± 1.59 1.78 ± 1.45 2.06 ± 1.69 1.24 ± 1.06 0.027 (servings/day) Psychosocial functioning b Y-PSC total score 24.92 ± 9.06 22.28 ± 8.26 ** 26.49 ± 8.87 +++ 28.69 ± 14.10 <0.001 Attention deficit and hyperactivity 6.81 ± 3.11 6.44 ± 3.01 * 6.98 ± 3.09 + 8.31 ± 4.27 0.022 symptoms score Depressive symptoms score 9.41 ± 4.59 8.08 ± 4.10 * 10.21 ± 4.61 +++ 10.88 ± 6.27 <0.001 Behavior symptoms score 5.44 ± 2.92 5.06 ± 2.78 ** 5.60 ± 2.87 + 7.38 ± 4.66 ˆ 0.003 Anxiety symptoms score 6.36 ± 2.37 5.66 ± 2.21 6.84 ± 2.31 +++ 6.31 ± 3.40 <0.001 Internalizing problems score 4.50 ± 2.33 3.46 ±1.99 5.20 ± 2.24 +++ 4.44 ± 2.97 <0.001 Externalizing problems score 3.33 ± 2.16 3.29 ± 2.06 * 3.28 ± 2.13 4.75 ± 3.49 ˆˆ 0.028 Attention problems score 5.14 ± 1.91 4.94 ± 1.87 5.30 ± 1.90 + 4.75 ± 2.35 0.065 Mean ± standard deviations are provided. UPF, Ultra-processed foods and drinks; Y-PSC, Pediatric Symptom Checklist–Youth Report. a Age provided for N = 530/560 b Data from Y-PSC provided for N = 555/560. + p < 0.05, +++ p < 0.001 vs. male adolescents. * p < 0.05, ** p < 0.01 vs. indeterminate group. ˆ p < 0.05, ˆˆ p < 0.01 vs. female adolescents. The Research Ethics Committee of Bellvitge University Hospital (Barcelona, Spain) approved this study protocol. All procedures were in accordance with the ethical standards established by the Declaration of Helsinki (Fortaleza, 2013). All participants were informed about the study’s purpose and gave their consent. The processing of personal data complies with current Spanish and European legal regulations on data protection. 2.2. UPF, Fruits and Vegetables Consumption, and Physical Activity Participants received descriptive information and visual examples to help them iden- tify and appropriately report the type of UPF products consumed. We used a screening tool previously designed for the specific assessment of the consumption of these products during the previous 24 h [28]. The original screening tool was slightly modified to reflect the types of UPF products available to the targeted Spanish adolescent population. This Nutrients 2022, 14, 4831 4 of 15 resulted in a list of 24 UPF products, which are listed in Table 2. Participants were asked to report if they had consumed each type of UPF products during the previous day. For each individual, we calculated the total UPF products consumed during the last 24 h, which ranged from 0 to 24. Table 2. Percentage of participants consuming each of the 24 ultra-processed foods and drinks on the day prior to the interview, for all participants and stratifying by sex. Total Male Female Indeterminate Product p (N = 560) (N = 217) (N = 327) (N = 16) Cold meats. Fuet, salami, mortadella, packaged 353 141 203 9 0.673 sweet ham, pâté, and/or other similar. (63.04%) (64.98%) (62.08%) (56.25%) 302 116 180 6 Cookies. Plain cookies, cookies with chocolate. 0.384 (53.93%) (53.46%) (55.05%) (37.50%) Processed meats. Frankfurt sausages, hamburgers, 292 129 152 ++ 11 0.005 fish or meat sticks, and/or other similar. (52.14%) (59.45%) (46.48%) (68.75%) Chocolate products. Chocolate, chocolate bars, 276 110 160 6 and other chocolate products (including 0.585 (49.29%) (50.69%) (48.93%) (37.50%) chocolate creams). Snacks. Snacks, crackers, potato chips, and other 270 103 159 8 0.956 salty or flavored snacks. (48.21%) (47.47%) (48.62%) (50.00%) Chocolate drinks. Powdered chocolate drinks, or 258 101 146 11 0.166 packaged with or without milk. (46.07%) (46.54%) (44.65%) (68.75%) Sauces. Mayonnaise, ketchup, mustard, and/or 236 111 119 +++ 6 0.003 other similar. (42.14%) (51.15%) (36.39%) (37.50%) 218 104 107 +++ 7 Flavored yogurts. 0.002 (38.93%) (47.93%) (32.72%) (43.75%) Processed breads. Sliced, hamburger, or hot 206 88 113 5 0.328 dog bread. (36.79%) (40.55%) (34.56%) (31.25%) Bakery. Bakery products (e.g., donuts, croissants, 206 83 119 4 0.556 etc., except the homemade products). (36.79%) (38.25%) (36.39%) (25.00%) 197 83 107 7 Sugary breakfast cereals. 0.321 (35.18%) (38.25%) (32.72%) (43.75%) Soft drinks. Sugary drinks, light and/or without sugar. Carbonated drinks with or without flavors 188 96 87 +++ 5 <0.001 (e.g., cola, lemon, orange, etc.). Non-carbonated (33.57%) (44.24%) (26.61%) (31.25%) drinks (e.g., isotonic drinks with flavors, etc.). Packaged fruit juices. Fruit juices with or without 186 88 94 ++ 4 0.013 dairy products, fruity drinks. (33.21%) (40.55%) (28.75%) (25.00%) Processed fries. Frozen fries or from 171 77 89 5 0.122 fast-food chains. (30.54%) (35.48%) (27.22%) (31.25%) 160 67 87 6 Sweets. Gummies, lollipops, and other sweets. 0.406 (28.57%) (30.88%) (26.61%) (37.50%) Processed pizzas. Pre-frozen, frozen, or 151 74 73 ++ 4 0.010 chain-restaurant pizza. (26.96%) (34.10%) (22.32%) (25.00%) 116 53 59 4 Ice creams. 0.182 (20.71%) (24.42%) (18.04%) (25.00%) Nutrients 2022, 14, 4831 5 of 15 Table 2. Cont. Total Male Female Indeterminate Product p (N = 560) (N = 217) (N = 327) (N = 16) Pre-cooked dishes. Frozen pre-cooked dishes such 99 50 44 ++ 5 0.006 as lasagna and/or other similar. (17.68%) (23.04%) (13.46%) (31.25%) 88 37 * 45 6 ˆˆ Tea soft drinks. 0.031 (15.71%) (17.05%) (13.76%) (37.50%) 87 40 44 3 Instant soups. Noodles or other instant soups. 0.275 (15.54%) (18.43%) (13.46%) (18.75%) Energy drinks. Energy drinks, with stimulants, 81 43 34 ++ 4ˆ 0.004 with or without sugar. (14.46%) (19.82%) (10.40%) (25.00%) 76 33 40 3 Margarine. 0.508 (13.57%) (15.21%) (12.23%) (18.75%) 73 39 33 ++ 1 Cereal bars. 0.020 (13.04%) (17.97%) (10.09%) (6.25%) 35 16 16 3 Alcoholic drinks. Liquors, and/or other similar. 0.056 (6.25%) (7.37%) (4.89%) (18.75%) Percentages correspond to: ([total of participants consuming an UPF product/total number of participants] × 100). ++ p < 0.01, +++ p < 0.001 vs. male adolescents. * p < 0.05 vs. indeterminate group. ˆ p < 0.05, ˆˆ p < 0.01 vs. female adolescents. Fruits and vegetables consumption was assessed as the frequency (i.e., number of days a week, from 0 to 7 days), and the quantity (i.e., number of standard servings in the days of consumption, from ‘almost never’ to ‘five or more servings’). Particularly, we asked the following questions: ‘In a regular week, on how many days do you eat fruits?’, and ‘How many servings of fruits did you eat in one day when you consumed them?’ The same questions were applied to the consumption of vegetables. From these questions, we derived the habitual servings per day of fruits and vegetables. The definitions of the fruits and vegetable groups were taken from the Food and Agriculture Organization of the United Nations (FAO) guidelines [29]. According to the number and size of the products, a standard serving has been identified using the graphical image taken by the database of the Spanish Food Safety and Nutrition Agency (AESAN) [30]. Physical activity was assessed as the number of practice days during a week (range 0 to 7 days). Particularly, we asked the adolescents, ‘How many days a week do you do physical activity?’ Since physical education is mandatory during secondary school, it was explicitly excluded from the quantification. 2.3. Psychosocial Functioning Psychosocial functioning was assessed using the validated Spanish version of the Pediatric Symptom Checklist–Youth self-report (Y-PSC), for which the sensitivity is 95% and the specificity is 68% [31]. The Y-PSC has 35 items and uses a 3-point response format scale (‘Never’ = 0, ‘Sometimes’ = 1, or ‘Often’ = 2). Total and subscales scores (i.e., attention deficit and hyperactivity symptoms, depressive symptoms, behavior symp- toms, anxiety symptoms, internalizing problems, externalizing problems, and attention problems) were derived from the Y-PSC [32]. A total score of 30 or above suggests a psy- chosocial impairment in the adolescent. The Internalizing subscale has a clinical cutoff of ≥5. The Externalizing and Attention subscales have a clinical cutoff of ≥7 [31]. If 1 to 3 items were left blank, each was scored 0. Five participants were excluded because 4 or more items were left blank, based on the Y-PSC scoring guidelines. 2.4. Statistical Analyses All analyses were performed using IBM SPSS Statistics, version 23. The presence of outlier values in all the study variables was explored, and values > 2 standard deviation Nutrients 2022, 14, 4831 6 of 15 (SD) were eliminated from subsequent analyses. Data were used as numerical variables, and the descriptive analysis was explored with means, min-max values, and SD, in the total sample and by sex. We also characterized the proportion of participants that reported the consumption of each of the 24 UPF products. Differences in the study variables between sexes (female, male, indeterminate) were tested with an analysis of variance (ANOVA) test, followed by independent sample t-tests to evaluate differences among groups. The association between UPF consumption, physical activity, and the consumption of fruits and vegetables was assessed through Pearson correlation analyses. Also, we categorized the participants’ UPF consumption in the previous day into quartiles to represent low (0–4), low-medium (5–6), high-medium (7–8), and high consumption (9–24). We compared the level of physical activity and the consumption of fruits and vegetables between those participants that fall in the low vs. the high quartiles using independent samples t-tests. Linear regression analyses were used to assess the association between UPF consump- tion (total consumption) and psychosocial functioning (total and subscales Y-PSC scores). Model 1 included as covariates sex and age. Model 2 was further adjusted for physical activity and fruits and vegetables consumption. All models were repeated dividing by sex. 3. Results The demographic, dietary, and physical activity information of the study participants, as well as for the sample stratified by sex, are provided in Table 1. Participants were between 14 and 17 years old, most of them female adolescents (58.4% female adolescents, 38.8% male adolescents, 9% indeterminate). 3.1. UPF Consumption Participants reported the consumption of 7.72 UPF in the previous 24 h. Scores ranged from 0 to 24 categories, but 3 (8.6%), 4 (10%), 5 (12%), and 6 (12.3%) were the most common. Total UPF consumption was higher in male than in female adolescents (Table 1). Table 2 describes the proportion of participants consuming each of the UPF products on the day prior to the interview. Over 60% of the participants consumed cold meats and similar. From 50–60% reported the consumption of cookies and processed meats, 40–50% chocolate products, drinks, snacks, and sauces, and 30–40% consumed flavored yogurts, processed breads, bakery products, sugary breakfast cereals, soft drinks, packaged fruit juices, and processed fries. Lower percentages of consumption (<15%) were observed for energy drinks, margarine, cereal bars, and alcoholic drinks. Between sexes, male adolescents consumed significantly more sauces, flavored yogurts, soft and energy drinks, packaged fruit juices, processed pizza and meats, and cereal bars than female adolescents (Figure 1, Table 2). Those in the indeterminate group consumed significantly more tea soft drinks than male and female adolescents, and more energy drinks than female adolescents. On the contrary, female adolescents do not have a significantly higher consumption of any UPF products compared with the male adolescents and the indeterminate group. 3.2. Fruits and Vegetables Consumption, and Physical Activity Participants reported their consumption of fruits and vegetables (1.93 servings/day) and amount of physical activity (2.9 days/week) (Figure 2; Table 1). Male adolescents reported significantly more physical activity than the female adolescents, while this latest group reported a significantly higher consumption of fruits and vegetables compared to the male adolescents. There was a positive correlation between level physical activity and fruit and vegetable consumption (r = 0.177, p = 0.000), but no association emerged between these variables and the consumption of UPF. A total of 163 subjects fall in the low quartile of consumption, 152 in the low-medium, 125 in the high-medium, and 120 in the high. Participants in the high quartile of UPF consumption showed lower consumption of fruits and vegetables compared to those in the lowest quartile (1.25 vs. 2.24 servings/day, respectively, p = 0.027), but no differences in the level of physical activity (p > 0.05). Nutrients 2022, 14, Nutrients 2022, 14, x4831 FOR PEER REVIEW 7 7ofof 16 15 Graphical Figure 1.1.Graphical Figure display display of the of the percentage percentage of male of male and female and female adolescents adolescents consuming consuming those those ultra- ultra-processed processed foods foods and drinks and drinks that statistically that statistically differ differ betweenbetween these these groups. groups. 3.3. Psychosocial Functioning We found psychosocial impairment in 26.2% of the participants. Across specific sub- scales, 33.9% showed internalizing problems, 3.9% externalizing problems, and 9.5% attention problems (Table 1). Female compared to male adolescents showed a higher presence of total psychosocial impairment and scored higher for all symptoms and prob- lems, except for externalizing problems (Table 1). Those in the indeterminate group showed a higher presence of behavioral symptoms and externalizing problems than the female adolescents, and higher presence of total psychosocial impairment, attention deficit and hyperactivity symptoms, depressive and behavioral symptoms, and externalizing problems than the male adolescents. 3.4. Association between UPF Consumption and Psychosocial Functioning Total UPF consumption showed a trend towards a positive association with the total score of the Y-PSC, and a significant positive association with depressive symptoms and internalizing and externalizing problems (Figure 3, Table 3). In the sex-stratified models, these associations remained significant only in male adolescents. The indeterminate sex showed a positive association between UPF consumption and attention deficit and hyperac- tivity symptoms, behavior symptoms, and externalizing problems. These associations were also significant when adjusting for sex, age, physical activity, and fruits and vegetables consumption, as appropriate. the male adolescents. There was a positive correlation between level physical activity and fruit and vegetable consumption (r = 0.177, p = 0.000), but no association emerged between these variables and the consumption of UPF. A total of 163 subjects fall in the low quartile of consumption, 152 in the low-medium, 125 in the high-medium, and 120 in the high. Participants in the high quartile of UPF consumption showed lower consumption of fruits Nutrients 2022, 14, 4831 and vegetables compared to those in the lowest quartile (1.25 vs. 2.24 servings/day,8 of re-15 spectively, p = 0.027), but no differences in the level of physical activity (p > 0.05). Nutrients 2022, 14, x FOR PEER REVIEW 9 of 16 hyperactivity symptoms, depressive and behavioral symptoms, and externalizing prob- lems than the male adolescents. 3.4. Association between UPF Consumption and Psychosocial Functioning Total UPF consumption showed a trend towards a positive association with the total score of the Y-PSC, and a significant positive association with depressive symptoms and internalizing and externalizing problems (Figure 3, Table 3). In the sex-stratified models, these associations remained significant only in male adolescents. The indeterminate sex showed a positive association between UPF consumption and attention deficit and hyper- activity symptoms, behavior symptoms, and externalizing problems. These associations were also significant when adjusting for sex, age, physical activity, and fruits and vegeta- Figure 2. Physical exercise (days/week) and consumption of fruits and vegetables (servings/day) Figure bles 2. Physical exercise consumption, (days/week) and consumption of fruits and vegetables (servings/day) as appropriate. amongthe among thestudy studyparticipants participantsstratified stratifiedby bysex. sex. 3.3. Psychosocial Functioning We found psychosocial impairment in 26.2% of the participants. Across specific sub- scales, 33.9% showed internalizing problems, 3.9% externalizing problems, and 9.5% at- tention problems (Table 1). Female compared to male adolescents showed a higher pres- ence of total psychosocial impairment and scored higher for all symptoms and problems, except for externalizing problems (Table 1). Those in the indeterminate group showed a higher presence of behavioral symptoms and externalizing problems than the female ad- olescents, and higher presence of total psychosocial impairment, attention deficit and Figure 3. Association Figure 3. Associationbetween between thethetotal totalconsumption consumption of of ultra-processed foodsand ultra-processed foods anddrinks drinksand and de- pressive symptoms, internalizing and externalizing problems in all participants, adjustingfor depressive symptoms, internalizing and externalizing problems in all participants, adjusting for age, sex,age, fruits sex,and vegetables fruits consumption, and vegetables consumption,and physical activity and physical (Model activity (Model2).2). ß are standardized ß are standardizedcoeffi- cients adjustedadjusted coefficients for sex,for age, sex,physical activity, age, physical andand activity, fruits and fruits vegetables and vegetablesintake intakeas as in in Model Model 2.2. Nutrients 2022, 14, 4831 9 of 15 Table 3. Association between total consumption of ultra-processed foods and drinks and psychosocial functioning in all participants and stratifying by sex. MODEL 1 MODEL 2 (Adjusted for Sex and Age) (Adjusted for Sex, Age, Physical Activity, and Fruits and Vegetables Intake) (N = 530) 95% CI 95% CI ß p (Lower Bound, ß p (Lower Bound, Upper Bound) Upper Bound) Y-PSC total 0.085 0.052 −0.001, 0.290 0.084 0.053 −0.002, 0.288 Attention deficit and hyperactivity 0.051 0.239 −0.021, 0.082 0.050 0.248 −0.021, 0.082 symptoms Depressive 0.107 0.013 0.019, 0.167 0.107 0.014 0.019, 0.166 symptoms Behavior 0.076 0.079 −0.005, 0.090 0.074 0.087 −0.006, 0.088 symptoms Anxiety 0.010 0.812 −0.034, 0.043 0.013 0.760 −0.032, 0.044 symptoms Internalizing 0.101 0.020 0.007, 0.079 0.104 0.017 0.008, 0.080 symptoms Externalizing 0.138 0.002 0.022, 0.092 0.135 0.002 0.021, 0.091 symptoms Attentional −0.042 0.340 −0.046, 0.016 −0.040 0.356 −0.046, 0.017 symptoms Nutrients 2022, 14, 4831 10 of 15 Table 3. Cont. MODEL 10 MODEL 20 (Adjusted for Age) (Adjusted for Age, Physical Activity, and Fruits and Vegetables Intake) Stratifying for Male Female Indeterminate Male Female Indeterminate Sex (N = 201) (N = 314) (N = 15) (N = 201) (N = 314) (N = 15) 95% 95% 95% 95% 95% 95% ß P ß P ß P ß P ß P ß P CI CI CI CI CI CI −0.027, −0.134, −0.169, −0.023, −0.147, −0.065, Y-PSC total 0.122 0.085 0.036 0.523 0.453 0.090 0.124 0.079 0.028 0.615 0.491 0.063 0.416 0.263 2.076 0.421 0.249 2.159 Attention deficit −0.090, −0.036, 0.056, −0.091, −0.037, 0.060, and hyperactivity −0.014 0.844 0.053 0.353 0.576 0.025 −0.014 0.838 0.051 0.365 0.581 0.023 0.074 0.101 0.691 0.074 0.100 0.694 symptoms Depressive 0.025, −0.051, −0.144, 0.027, −0.059, −0.081, 0.169 0.017 0.056 0.324 0.403 0.136 0.172 0.015 0.047 0.404 0.453 0.090 symptoms 0.245 0.154 0.939 0.247 0.145 0.983 Behavior −0.015, −0.062, 0.089, −0.015, −0.065, 0.115, 0.111 0.117 0.004 0.949 0.599 0.018 0.108 0.126 −0.005 0.934 0.620 0.014 symptoms 0.131 0.066 0.808 0.131 0.060 0.837 Anxiety −0.055, −0.041, −0.330, −0.053, −0.042, −0.310, 0.010 0.884 0.023 0.685 −0.030 0.916 0.014 0.844 0.020 0.728 −0.001 0.997 symptoms 0.064 0.062 0.298 0.067 0.061 0.308 Internalizing 0.019, −0.017, −0.260, 0.023, −0.022, −0.219, 0.187 0.008 0.074 0.191 0.062 0.827 0.190 0.007 0.063 0.265 0.133 0.637 symptoms 0.125 0.083 0.320 0.127 0.079 0.345 Externalizing 0.015, −0.019, 0.044, 0.014, −0.021, 0.058, 0.177 0.012 0.068 0.231 0.569 0.027 0.174 0.014 0.062 0.274 0.585 0.022 symptoms 0.121 0.077 0.612 0.120 0.073 0.627 Attentional −0.090, −0.044, −0.147, −0.089, −0.044, −0.141, −0.116 0.101 −0.003 0.959 0.175 0.534 −0.115 0.105 −0.003 0.952 0.186 0.508 symptoms 0.008 0.041 0.270 0.009 0.041 0.271 Standardized ß coefficients and 95% CI estimated using linear regression models. Significant and trend p-values are shown in bold (p < 0.05) and italics, respectively. UPF, Ultra-processed foods and drinks; Y-PSC, Pediatric Symptom Checklist–Youth Report. Adjusting by age N = 530. Nutrients 2022, 14, 4831 11 of 15 4. Discussion In this cross-sectional study, Spanish adolescents from the general population reported a daily consumption of 7.72 UPF servings per day, with male adolescents showing higher consumption than female adolescents. More than 50% of the participants reported the con- sumption of cold and processed meats and cookies. Consumption of fruits and vegetables and physical activity levels were overall lower than recommended, although female ado- lescents reported the highest consumption of fruits and vegetables, and male adolescents reported more physical activity per week. Psychosocial impairment was present in 26.2% of the participants, predominantly of depressive symptoms. Female adolescents overall reported more psychosocial impairment, specifically concerning depressive symptoms, anx- iety symptoms and internalizing problems congruently with previous research, including that performed with a Spanish sample aged 15–24 years [33,34]. Higher UPF consumption was associated with a higher presence of depressive symptoms and internalizing and externalizing problems in the whole sample. In sex-stratified analyses, the associations were significant only in male adolescents. Overall, associations remained significant when adjusting for sex, age, fruits and vegetables consumption, and physical activity. The consumption of UPF products on the day prior to the interview is higher than that reported by a previous study using the same assessment instrument in a sample of Brazilian adults [28]. In particular, the adolescents in our study showed a higher range of UPF consumption, with most reporting the consumption of five or six of these products, whereas dos Santos Costa and colleagues [28] reported a common consumption of between one and three products. The higher consumption found in male adolescents herein is congruent with a previous study with Canadian participants including different age groups [35], although female Spanish adults have been reported to have a higher UPF consumption [36]. Most products consumed by adolescents were cold meats, cookies, processed meats, chocolate products, different types of snacks, chocolate drinks, and sauces. It is interesting that, among adults, the study of Romero-Ferreiro also found processed meats and cookies to be main groups of UPF consumed in Spain [36]. In agreement, Brazilian participants in the study of dos Santos Costa [28] and Belgian children [37] also showed these foods among their most consumed. Differences in the population of study (e.g., age, sex), cultural factors, and the country food system may explain differences in the amounts of UPF consumption and types of products across the studies. The association found between UPF consumption, internalizing problems, and depres- sion symptoms among adolescents herein is congruent with previous studies conducted in similar samples of Brazilian adolescents [14–16]. These studies obtained similar results, although they used different questionnaires for the assessment of UPF consumption (a food frequency questionnaire in [14], and self-reported questionnaires of consumption in the previous seven days [15,16]). In addition, we found an association between UPF consumption and externalizing problems, which include behaviors suggestive of conduct disorder or oppositional defiant disorder, including fighting or teasing others, not listening to rules, refusing to share, not understanding others’ feelings, and taking things that belong to others. This is a new finding not reported in previous studies using a food classifica- tion based on the level of food processing. However, this finding may be congruent with previous research showing an association between the consumption of low nutritional content (i.e., junk foods) and violent behaviors in adolescent samples [38,39]. Further research is needed to determine the specific effects of food processing beyond nutritional variables. No associations with attention-deficit/hyperactivity symptoms were found in our sample of adolescents. This finding is contrary to a previous cohort-based study in humans that found UPF consumption during pregnancy to be associated with increased attention-deficit/hyperactivity symptoms in the offspring at the age of eight [40]. Further evidence supporting the idea that eating ultra-processed foods, as part of an unhealthy eating pattern, may associate with attention-deficit/hyperactivity symptoms comes from a meta-analysis [41]. Nutrients 2022, 14, 4831 12 of 15 Associations with depression symptoms, internalizing and externalizing problems remained significant only in the group of male adolescents. Although the reason why this association was significant in the male but not in the female adolescents cannot be answered by the present study, some hypotheses can be raised. For instance, male adolescents reported higher consumption of some UPF products. These included sugar- and artificially- sweetened beverages (i.e., soft and energy drinks and packaged fruit juices) and processed meats that a previous meta-analysis [42] and a systematic review [43] have associated with the risk of depression or depressive symptoms (e.g., feeling worthless). Two of the studies considered included adolescents [38,44]. Depressive symptoms, as well as aggression, were also associated with a higher consumption of fast food in the study of Zahedi and colleagues [38], including pizza, which was more often consumed by the male adolescents herein. However, these studies did not explore for sex-specific effects. Differences in brain development between male and female adolescents, as well as the described dimorphic states of the brain should be considered to understand the specific effect of food processing [45,46]. For example, a recent study demonstrates a sexually divergent process of the adolescent development of a cortico-subcortical system that was relevant to depression [47]. In addition, differential sex-effects of food processing on potential biological mechanisms that have been associated with mental diseases should be also explored (e.g., monoamine synthesis, inflammation processes, hypothalamic-pituitary- adrenal axis regulation, and neurogenesis). The previous should be considered together with the fact that female adolescents showed a moderate consumption of UPF products compared to the other groups, but the highest consumption of fruits and vegetables. Conversely, although male adolescents showed more days of physical activity, the higher consumption of UPF products in this group was accompanied by a low consumption of fruits and vegetables. Despite the evidence in the literature related to the protective effect of physical activity and healthy dietary patterns on mental health [21,23–25], the associations found with UPF consumption remained even when adjusting for these variables, in congruence with similar studies on adolescents [14]. However, it is important to note that the average consumption of fruits and vegetables was lower than that indicated by the international guidelines [19]. Indeed, the participants with the highest UPF consumption also showed lower consumption of fruits and vegetables, compared to those with the lowest UPF consumption, according to previous research [48]. However, and in contrast with previous studies [17,49], we did not find an association between UPF consumption and physical exercise. Only 10% of the participants in the present study met the established recommendations of 7 days of physical activity a week [20]. The advantages of this study include the detailed assessment of UPF products con- sumed in the 24 h before the assessment, as well as the large sample of adolescents assessed. The UPF products included were carefully defined based on a previously validated tool [28], which was revised and adapted to Spanish UPF products by a panel of nutritionists (SFB and DR). Therefore, the results are able to show the UPF consumption of a specific, targeted population. However, the assessment could be improved by also asking participants about the amount consumed within each of the UPF product categories, as it is uncertain whether the specific associations in male adolescents may be linked to higher amounts of UPF consumption. Similarly, further studies should improve the measurement of physical activ- ity by coding its intensity and duration, and not only its frequency, which may facilitate comparison with previous studies using similar samples of adolescents [14,16]. Additional information about participants’ whole diets may also complement the results in the present study. Finally, the findings in the indeterminate sex, although reported, should be repli- cated in larger samples of participants. Other limitations refer to the lack of additional confounding variables that also associate with mental health, as, for instance, educational level, smoking, or the presence of prior stressful life events. Finally, the cross-sectional design of the present study cannot shed light on causality between UPF consumption and Nutrients 2022, 14, 4831 13 of 15 the variables explored. The present study should be complemented by additional research to understand the effect of prolonged UPF consumption on mental health. 5. Conclusions The present cross-sectional study supports previous studies suggesting that UPF consumption may interact with mental health problems. Furthermore, associations in the present study suggest that the effects of food processing on mental health may extend beyond internalizing problems, also increasing the presence of externalizing problems. In addition, future studies in adolescents and with instruments assessing the amount of long-term UPF consumption are warranted to confirm our findings on mental health, as well as the sex-specific effects. Author Contributions: Conceptualization, R.M.E., M.S. and O.C.-R.; methodology, M.R.-M., P.T., S.F.-B., D.R. and O.C.-R.; formal analysis, M.R.-M., P.T. and O.C.-R.; investigation, M.R.-M. and P.T.; data curation, M.R.-M. and P.T.; writing—original draft preparation, M.R.-M., P.T. and O.C.-R.; writing—review and editing, R.M.E., M.S., S.F.-B., D.R. and O.C.-R.; supervision, and project administration, O.C.-R.; funding acquisition, R.M.E., M.S. and O.C.-R. All authors have read and agreed to the published version of the manuscript. Funding: This study was funded by Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM, Proyectos Intramurales 2021), Spanish Ministry of Science and Innovation (projects: PID2020-119391GB-I00 and PI22/00645), and PANDÈMIES (AGAURPANDE00021). O.C.-R. is sup- ported by a Miguel Servet contract (CP20/00165) from the Instituto de Salud Carlos III. Institutional Review Board Statement: The study was conducted in accordance with the Declara- tion of Helsinki, and approved by the Research Ethics Committee of Bellvitge University-Hospital (PR261/21, approved on the 23rd of August 2021). Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Data Availability Statement: Data is available under request. Acknowledgments: The research team would like to thank the individuals who generously shared their time for the purposes of this study. Conflicts of Interest: The authors declare no conflict of interest. References 1. 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