How Ultra-Processed Foods Are Killing Us - In the current issue of the online Journal of the World Public Health Nutrition Association (of which I am a charter member), Monteiro, a professor at the University of São o

[Guest guest]

In the current issue of the online Journal of the World Public Health

Nutrition Association (of which I am a charter member), Monteiro, a

professor at the University of São o writes, "

<http://www.wphna.org/wn_commentary_ultraprocessing_nov2010.asp> The big

issue is ultra-processing. " Because his commentary is so lengthy, I am

taking the liberty of extracting pieces from it, not always in the order

presented.

http://www.wphna.org/wn_commentary_ultraprocessing_nov2010.asp

World Nutrition

http://www.wphna.org/images/10white.gif

http://www.wphna.org/images/10white.gif

http://www.wphna.org/images/10white.gif

Volume 1, Number 6, November 2010

Journal of the World Public Health Nutrition Association

Published monthly at www.wphna.org

The Association is an affiliated body of the International Union of

Nutritional Sciences

For membership and for other contributions, news, columns and services, go

to: <http://www.wphna.org> www.wphna.org

http://www.wphna.org/images/10white.gifhttp://www.wphna.org/images/10white.g

if

Commentary

The big issue is ultra-processing

http://www.wphna.org/images/10white.gif

http://www.wphna.org/images/carlos_nov2010.jpg

Monteiro

Centre for Epidemiological Studies in Health and Nutrition

University of São o, Brazil

Biography posted at www.wphna.org

Email: carlosam@...

<http://www.wphna.org/downloadsnovember2010/10-11%20WN%20Comm%20Food%20proce

ssing.pdf> Access the pdf of this commentary here

Introduction

http://www.wphna.org/images/10white.gif

http://www.wphna.org/images/wn_burger1.jpg

The most important factor now, when considering food, nutrition and public

health, is not nutrients, and is not foods, so much as what is done to

foodstuffs and the nutrients originally contained in them, before they are

purchased and consumed. That is to say, the big issue is food processing -

or, to be more precise, the nature, extent and purpose of processing, and

what happens to food and to us as a result of processing. Specifically, the

public health issue is 'ultra-processing', as defined here. This is my basic

proposal. It is illustrated and symbolised by the mass-produced double

cheese-and-bacon burger above. Such products are made at distance as

separate items that are trucked in, assembled, and made ready-to-heat and

-to-eat at a fast food site.

The proposal that food processing has an impact on public health may seem

obvious. But it is largely overlooked by conventional nutrition science. As

now applied in policies, programmes and interventions, nutrition science has

failed to have much significant impact on what is currently the uncontrolled

pandemic of obesity. As a result, it is now seen by policy-makers and the

public as not particularly relevant to their needs. To be blunt, our science

has become somewhat discredited. One reason, as I maintain here, is that it

continues to depend on concepts and food classifications devised almost a

century ago, which are now obsolescent.

This commentary concerns the impact of food processing on human health. Its

scope is relatively modest. It only very briefly touches on cultural and

other social impacts of ultra-processed branded products, their use by

transnational and other giant industries to displace traditional food

systems and small businesses, and other economic impacts (1). It does not

touch on the effects of the globalised food system in its present form on

national and international stability, the living and physical environment,

and the biosphere (2,3). Proper discussion of these fundamental and crucial

issues is for a later paper.

Box 1

Food processing

Food processing, in any broad sense of this term, is not a public health

issue. To suppose so would be rather foolish. This would be like supposing

that food technology - or any other form of technology - is intrinsically

problematic. Much discussion of food, nutrition and health that mentions

processing as such as a factor is almost meaningless. To begin with, almost

all food and drink always has been processed, in some real sense. A

characteristic of many foodstuffs as found in nature, is that they are

unpalatable or inedible unless subjected to some process, such as

preparation or cooking. Also, all perishable foods, unless consumed

promptly, need to be preserved in some way. This is a point often and

rightly made by the food and drink manufacturing industry.

Here are the issues

The issue therefore is not processing as such. It is the nature, extent, and

purpose, of processing, and in particular, the proportion of meals, dishes,

foods, drinks, and snacks within diets that are 'ultra-processed' - a term I

will precisely define below in this text. Also, it would be absurd to

suppose that ultra-processed products, which characteristically are

ready-to-eat or ready-to-heat 'fast' or 'convenience' meals, dishes, foods,

drinks, and snacks, are some sort of poison. Indeed, one characteristic of

ultra-processed products, as manufactured by transnational and other large

firms, is that they are microbiologically safe. This is part of the pitch

made by transnational firms. Cola drink manufacturers for example point out

that in countries where water supplies are liable to be contaminated, their

products are a way to avoid diarrhoeal diseases. Such manufacturers are now

also big players in the bottled water business.

The issue is also one of proportion. This commentary does not say, nor does

it imply, that the only healthy diets are those consisting solely or

predominantly of unprocessed or minimally processed foods. Nor is anybody

going to suffer as a result of genuinely occasional consumption of for

example chips (French fries), crisps (chips), confectionery (candy),

pastries, biscuits (cookies), sugared soft drinks, uncontaminated burgers,

or packaged pizzas, to name some ultra- processed products, although it is

true that any of these can be so habit-forming as to amount to a form of

'soft addiction'.

The public health problem caused by ultra-processing becomes evident and

then an acute crisis, as the proportion of ultra-processed products within

food systems, food supplies and diets rises, as it rapidly has throughout

the world especially since the 1980s. A theme of this commentary is that

ultra-processed products now are becoming, or already are, so dominant

within industrialised food systems, that the one and only really useful way

to classify foods from a health point of view (and other points of view

also) is in terms of the nature, extent, and purpose of their processing.

As stated in the boxed text here, there is no issue with food processing as

such. Even the foods and drinks we think of as fresh have in a sense been

processed by plant and animal breeding. Tap water has been filtered and

purified. Food and drink manufacturers rightly point out that the human

species has evolved and developed by means of discovering and developing

processes such as those that use fire and water, and such as drying,

fermentation and salting, to make raw foods eatable, palatable and

enjoyable, and to preserve them at times of scarcity and in winter. In doing

so, manufacturers give us the impression that their ultra-processed products

really are nothing more than an extension of artisanal foods produced in

family farms or prepared and cooked at home. Any such impression is

misleading.

Examples of ultra-processing

To understand the impact of various types of processing now on industrial

food systems, it is necessary to be more precise. Take the double

cheese-bacon burger shown in the picture above. It delivers almost 1,000

calories, or close to half the daily energy turned over by a basically

sedentary adult. This 'fast food', whose constituent parts are mass

manufactured off-site and trucked to the burger outlet to be assembled and

heated on-site, is an example of what is termed in this commentary, an

'ultra- processed product'. Its substrates, and the product as a whole, are

the result of a series of sophisticated technical processes. Also - another

characteristic of ultra-processed products - it features a 'wholesome' or

'natural' touch, in this case the sesame seeds scattered on top of the bun.

Burgers were first formulated for the mass market over a generation ago, and

in a sense are rather old-fashioned ultra-processed products. Extrusion

technology is now increasingly used to fabricate products. For example,

'economy' chicken and other nuggets often have as an ingredient, a slurry

'mechanically recovered' from remnants of the animals that otherwise would

be discarded, by use of high-pressure grinders and centrifuges. The

animal-source material becomes an ingredient much like the refined starches,

oils and other substrate of the product, reconstituted to look, smell and

taste like a juicy battered slice of chicken.

As well as products using animal-source material, increasingly typical now,

are a vast number of other novel branded products that are attractively

packaged, powerfully promoted, and formulated to smell, taste and feel good.

Examined out of such stimulating contexts, they often do not look like food,

being completely removed from anything found in or directly derived from

nature. They are confected from various refined and processed materials

whose total cost is a small fraction of the price of the product. Any

'wholesome' touch is often supplied by added micronutrients, whose presence

is emphatically advertised. Some food technologists have celebrated products

like these as 'space age food'. Critics who prefer relatively unprocessed

food call them 'edible food-like substances' (4)

Box 2

Industry

This commentary is not an attack on industry as a whole. Nor is it an attack

on the food industry, or more specifically, the food and drink production,

manufacturing, distribution, catering and associated industries and their

trade organisations, as a whole. It might be read as such, perhaps in

particular by those with an interest in evading the issues it raises by

labelling it, its author, and his colleagues, as 'anti-industry'. But it is

not.

It should go without saying that the development and survival of the human

species, and of civilisation in any sense of the word, has always depended

on

reliable and sustained production of food. Gatherer-hunters prepare food.

Peasant farmers cultivate and breed food. The creation and sustenance of

towns and cities depend on food systems. Trade in food as well as other

things, has built empires and cultures. More recently in history, the

emergence of most of of the populations of most industrialised nations from

misery, famine, starvation, and deficiency diseases, has been achieved by

partnerships of legislators, public health leaders and other campaigners,

with food producers, manufacturers, distributors, and sellers. Modern

methods of production, manufacture, distribution and sale, create secure

food supplies for all populations and communities with adequate and secure

disposable incomes, all over the world. To demonise the food industry as a

whole would be ignorant, foolish, and in effect irresponsible.

The makers of ultra-processed products

That said, this commentary is indeed implicitly sharply critical of the

current

policies and practices of food and drink manufacturers, caterers and

associated industries, whose profits currently depend on the sale of what

are termed here, ultra-processed products. The conventional evidence that

some of these products - in particular sugared soft drinks - as now consumed

in typical quantities, are seriously harmful to public health, is

conclusive. I doubt that anybody independent of the indicted industries

would now say otherwise.

What makes matters worse, is that transnational food and drink manufacturers

continue to spend what overall amounts to many $US billions a year, making

claims for their products, some of which they surely must know are

misleading or even untrue. No uncontaminated food or drink product is as

toxic as tobacco products are, but some of the techniques being used by some

manufacturers to protect their bottom lines, their share price and their

investors, and the salaries and pensions of their executives, are

reminiscent of the methods used by the cigarette industry until these were

blocked by legislation, including the imposition of gigantic fines.

Support or sympathy for the prevailing policies and practices certainly of

some transnational and other big food and drink manufacturers, would also be

irresponsible, or at least foolish and ignorant.

The picture below is of part of the package of a branded sugary breakfast

cereal made by the leading transnational food manufacturer. It has been a

popular product on supermarket shelves in my own country of Brazil,

formulated and marketed to attract children above the age of 18 months. Such

products, most of which are made by three transnational manufacturers, are

sold all over the world. Singling out any specific ultra-processed products,

may give the false impression that they are unusual novelties. It would also

be mistaken to single out any specific manufacturer, no matter how large.

Supermarket lead lines are the result of lightly regulated 'market forces'.

Production and consumption of ultra-processed foods and drinks has sharply

risen, especially since the 1980s. As defined below, they now add up to a

large proportion of the diets consumed in most lower-income countries, and

supply most of the calories consumed in various high-income countries,

including the USA and the UK (5). Readers with access to supermarkets are

encouraged to go and see for themselves.

http://www.wphna.org/images/wn_cereal.jpg

The thesis

http://www.wphna.org/images/10white.gif

http://www.wphna.org/images/wn_burger2.jpg

This commentary distinguishes between three types of food and drink

processing, and in turn three groups of foods and drinks, depending on the

nature, extent and purpose of their processing. The first group are

unprocessed (as defined here) or minimally processed foods. The second group

are processed culinary or food industry ingredients. The third group are

ultra-processed products - two examples of which are ready-to-eat eat

breakfast cereals and burgers. Other papers of which I am author or

co-author have also outlined this classification (5-6).

The fairly recent Brazilian advertisement for the 'big tasty' burger shown

above says that it is 'The big hunger-killer'. The copy says 'Você vai

precisar de muita energia para levantar o Big Tasty', meaning that the

burger is so enormous that the customer will need a lot of energy just to

pick it up. As can be seen, the advertisement also carries a logo

celebrating the manufacturer as sponsor of the Beijing Olympic Games. In the

advertisement, which is for the leading global fast-food and burger catering

chain, the Big Tasty is accompanied by a packet of thin-cut French fries,

and for the figure-conscious, a small cardboard bucket filled with

chemically sweetened cola. These are also ultra-processed products.

The impact of ultra-processed products

This commentary claims that the rapid rise in consumption of ultra-processed

food and drink products, especially since the 1980s, is the main dietary

cause of the concurrent rapid rise in obesity and related diseases

throughout the world.

There are a number of plausible reasons for this claim. For a start,

ultra-processed products, as a group, are much more energy-dense than

unprocessed and minimally processed foods and processed culinary ingredients

taken together. This has been demonstrated at least in two countries. In UK,

at typical fast-food outlets the average energy density of the entire menus

is 65 per cent higher than the average UK diet (7). In Brazil, the average

energy density of ultra-processed products purchased by urban households for

consumption at home is 66 per cent higher than all the other foods that are

purchased (5).

Box 3

Evidence

This commentary is proposing a theory, in the dictionary sense of 'a system

of ideas or statements explaining something'. What is claimed and proposed

here is new, and therefore is not and cannot yet be consensual. Likewise,

the conclusions of this commentary do not directly derive from studies whose

results are now generally identified as 'strong' or 'hard' evidence. Such

studies, and in particular randomised controlled trials (RCTs) whose

conclusions are made more powerful by meta-analyses and systematic reviews,

have not been undertaken. Until now they could not be. This is because RCTs

in the field of nutrition and health depend on a system of classification of

food - itself dependent on the concept that foods should be grouped roughly

according to their relative content of chemical macro- and

micro-constituents - which still almost completely ignores or at best

marginalises the significance of food processing.

The theory of this commentary is eminently testable. It is consistent with

the narratives of independent expert reports such as those produced by

relevant United Nations agencies and authoritative national bodies. It is, I

believe, a more plausible and powerful account of the impact of modern food

systems on human health, than is contained in such reports.

Why processing is overlooked

There are a number of reasons why the significance of food processing is

generally overlooked or marginalised. One is that food technology is not

included as a significant part of the nutrition science curriculum. Another

is that nutrition scientists continue to depend on a conceptual framework of

their discipline elaborated from the discoveries of biochemists between the

early 19th and early 20th century, which has diminishing relevance.

Another is that any approach to nutrition and human health that gives

special attention to food processing, is a 'hot potato'. Even more now in

these days of 'public-private partnerships', much of the discourse of food

and nutrition policy involves collaboration between international and

national civil servants, their scientific advisors, and university and

research centre departments and senior scientists, with representatives of

the transnational and other big food and drink manufacturers whose profits

depend on ultra-processed products. It may be fair to say that most

nutrition scientists now do not see this as a problem. But it is.

Perhaps the greatest impediment to seeing the significance of food

processing in all its aspects, is the identification of nutrition as solely

or mainly a biological discipline, a branch of biochemistry heavily

influenced by the clinical 'medical model'. Many of the points made in this

commentary, including those made in this section, are outside the scope of

conventional nutrition science, and therefore identified as not relevant.

But they are.

The scope of nutrition science

The significance and impact in particular of ultra-processing on human

health, can be seen only with a 'big picture' vision, which identifies

nutrition - or at least public health nutrition - as also a social, economic

and environmental discipline (8). For older nutrition scientists whose

training is solely or principally biological and medical, this is a

challenge.

Much depends on what is counted as evidence, in the dictionary sense of

'facts in support of a conclusion, statement or belief'. Thus, findings from

the so-called 'soft' social sciences need to be admitted as evidence, and as

a necessary contribution to any soundly based conclusions and

recommendations on nutrition and human health. Also, wise conclusions are

not mechanical. They require common sense and considered judgement. Further,

there are occasions in public life that are so urgent, important and

critical, that action must be taken before all the evidence that makes

scientists and civil servants comfortable is in. The impact of the action

can then be examined and monitored, and if necessary the action revised. The

pandemic of obesity, in particular among children and young people, is such

a case.

Ultra-processed products are characteristically formulated from 'refined'

and 'purified' ingredients freed from the fibrous watery matrix of their

original raw materials. They are formulated to be sensually appealing,

hyper-palatable, and habit-forming, by the use of sophisticated mixtures of

cosmetic and other additives, and state-of-the-craft packaging and

marketing. Further, ultra-processed products are 'convenient' - meaning,

ready-to-eat (or drink) or ready-to-heat.

The leading branded ultra-processed foods and drinks are manufactured by

transnational companies most able to purchase substrates for their products

at rock-bottom or even subsidised prices. They penetrate new markets in

lower-income countries, with massive marketing and advertising budgets, and

may undercut local industries, drive them out of business, or take them

over.

In the last decades, ultra-processed products have usually become relatively

or even absolutely cheaper to manufacture, and sometimes - not always -

relatively cheaper to buy. They are often manufactured in increasingly

supersized packages and portions at discounted prices with no loss to the

manufacturer. The packaging may cost more than the contents.

Ultra-processed snacks and soft drinks are available in 'convenience' stores

and other outlets often open late or even 24/7, and vended in machines

placed in streets, gas stations, hospitals, schools and many other

locations. Ultra-processed fast foods and soft drinks are the main business

of transnational and big national catering chains, whose outlets are also

often open until late at night, and whose products are designed to be

consumed also in the street, while working or driving, or watching

television. Over-consumption is also pushed by lightly regulated or often

practically unregulated advertising that identifies fast and convenience

food, soft drinks and other ultra-processed products as a necessary and

integral part of the good life, and even, when the products are 'fortified'

with micronutrients, as essential to the growth, health and well-being of

children.

A feature of the promotion of ultra-processed products in Brazil, and no

doubt other lower-income countries, is incitement to over-consumption much

more blatant than any now commonly found in the US, the UK and other

high-income countries where obesity is understood by all to be a crisis.

Another feature is the direct marketing of branded products to impoverished

communities (9). A variant is the 'floating supermarket' that recently has

been visiting riverside towns and villages in Amazonia, shown in the picture

below. A company media release explains that this 'offers access to

Nutrition, Health and Wellness to the remote communities'. One of the

products on sale is the 'Bono' sweet biscuit. In Brazil it is advertised

with the slogan (as translated here): 'The biscuit full of filling. It's

hard to resist Bono. Take one taste and you'll surrender!'

These are some of the contexts of ultra-processed products. It would be

strange if, in the volume now manufactured and consumed, they were not a

leading cause of the current pandemic of obesity.

http://www.wphna.org/images/wn_blueboat.jpg

A personal note

http://www.wphna.org/images/10white.gif

Like many senior nutrition scientists, my formal qualifications are as a

medical doctor with a higher degree in nutrition. My professional career

also included training in the USA, and a period based at the World Health

Organization in Geneva. Unlike most senior nutrition scientists, I am a

national of a lower-income country - Brazil. For most of my professional

life I have worked at the University of São o. I divide my research work

between topics specifically relevant to my country, and those with higher

international relevance, notably focusing on the so-called linked

demographic, nutritional and epidemiological transitions in lower-income

countries, in collaboration with my long-standing US colleague

<http://www.wphna.org/members_profilesnov2010.asp#bp> Barry Popkin. (10-12).

In the last 30 years, as a research scientist and a public servant as a

consultant to the Brazilian government, I have had special access to the

excellent periodical national surveys on health and nutrition and on

household expenditures that are a feature of Brazilian descriptive

epidemiology. A large part of my work has been analysis of these surveys, in

order to track trends in population nutritional status and food and drink

consumption in Brazil, and to draw conclusions and make recommendations,

including to the authorities in the federal Ministry of Health in Brasília

(13-14).

The shift in disease patterns

When I was a young health professional working in Brazil, obesity, and the

chronic diseases linked with obesity, was mainly only of academic interest.

Far and away the most important public health issues until the 1970s in most

of Brazil, and until later in impoverished regions, were infectious

diseases, and 'classic' malnutrition - impoverished populations suffering

from inadequate and deficient diets, as they still do within many countries

in Asia and Africa.

The increase in overweight and obesity in Brazil since the first national

nutrition survey, in 1975, to the most recent one, conducted in 2009, has

been phenomenal. The combined prevalence of overweight and obesity more than

doubled among adults (from 23.6 to 49.1 per cent) and increased four times

among adolescents (from 4.2 to 16.8 per cent) and 5 to 9 year-old children

(from 6.0 to 25.5 per cent).

The shift in dietary patterns

Over these years, what my studies of household food patterns in Brazil have

showed, as seen in Figure 1, is decreases in staple or basic foods and also

in basic culinary ingredients purchased as such. In only 16 years, from 1987

to 2003, the consumption of rice and beans declined by 10 per cent (from

22.4 to 20.2 per cent of total calories), milk and eggs by 27 per cent (from

7.4 to 5.4 per cent), and fruit and vegetables by 20 per cent (from 3.6 to

3.0 per cent). In the same period, oils declined by 18 per cent (from 12.3

to 11.1 per cent), table sugar by 20 per cent (from 12.8 to 10.3 per cent),

and wheat and manioc flour by 26 per cent (from 4.9 to 3.6 per cent). As

also seen in Figure 1, in the same 16-year period, 'cereal products' such as

breads and biscuits increased by 21 per cent (from 12.6 to 15.2 per cent of

total calories), 'meat products' such as burgers and sausages and 'dairy

products' such as cheeses and sugared milk drinks increased by more than 100

per cent (from 1.9 to 3.9 per cent), and soft drinks and sweets increased

also by more than 100 per cent (from 2.4 to 4.9 per cent).

____________________________________________________________

Figure 1

Foods whose contribution to total dietary energy changed significantly from

1987 to 2003. Brazil

Figures derived from national household expenditure surveys

http://www.wphna.org/images/wn_nov2010chart1c.jpg

Source: reference 5.

____________________________________________________________

In terms of the conventional food groupings used for dietary recommendations

(see the 'food pyramid' later in this commentary) the shifts shown in the

figure are hardly consistent with the increase in obesity. True, consumption

of rice and beans and of fruit and vegetables dropped, and of soft drinks

and confectionery rose, which are the wrong directions according to

conventional recommendations. But the foods whose consumption share most

conspicuously declined, were those conventionally classed within the 'fats,

oils, sugar' food group. These are usually recommended to 'use sparingly'

(and positioned at the tip of food pyramids). Also, substantial increases

were seen in foods conventionally classed within the 'meat' group or the

'dairy' group, usually officially recommended in moderation (in the middle

of pyramids), and also in the 'bread and cereals' group, now usually

strongly recommended - 'eat more of these' (at the base of pyramids). So if

anything, judged conventionally, the main shifts in dietary patterns in

Brazil were in 'healthy' directions.

As time went on, together with my colleagues, I came to realise that what

breads and biscuits, soft drinks and sweets, burgers, sausages and cheeses,

and also ready meals have in common, together with very many other products

consumption of which is also rising all over the world, is that they are

ultra-processed. And so it is time to explain what this term means.

What processing is

http://www.wphna.org/images/10white.gif

International expert committee reports are now beginning to acknowledge that

increased production and consumption of industrially processed foods and

drinks is an important cause of the current pandemics of obesity and related

chronic diseases (15-16). The 6th Report on the World Nutrition Situation,

published by the United Nations Standing Committee on Nutrition at the time

this commentary was being completed, on a global scale notes 'a shift away

from traditional diets towards a more globalized intake pattern that

involves increased quantities of processed foods, animal products, sugars,

fats, and (sometimes) alcohol' (17). This stress on food processing is new.

However, no United Nations or other authoritative report known to me,

includes a precise definition of what is meant by industrially processed

foods (in this commentary, drinks are included within the term 'foods').

Also, distinctions are only sketchily made between different types of

industrial food processing, and indeed different types of home preparation

and cooking. Further, biological mechanisms by which the consumption of

industrially processed foods could influence human health are usually

mentioned only briefly if at all. (Nor are they here: this is a topic for

another paper).

In addition, to the best of my knowledge, evidence presented on the

association between industrially processed foods and disease is restricted

to that from studies examining the role of just a few products such as

sugared drinks (in the case of obesity) and processed meats (in the case of

certain types of cancer) (15-16).

Discussion of processing as a factor in human health may be inhibited by

arguments put forward by the food manufacturing industry and its associated

organisations. For example, a recent document carefully states that 'Many

processed foods are just as nutritious or in some cases more nutritious than

fresh or home-cooked foods, depending on the manner which they are

processed' and correctly, that 'Nowadays, it is difficult to eat a diet

based on fresh, unprocessed foods', while going on to say rather more

tendentiously 'The major portion of our family's food needs comes from

processed food products that add variety to our diet and convenience to our

busy lives. Processed foods enable consumers to shop less frequently and to

stock a wide range of foods on which to base varied and nutritious meals'

(18).

So what to think? Clarity requires clear definitions of industrial food

processing, and clear distinctions between different types of processing. It

also requires a classification of foods according to the nature, extent, and

purpose of processing. Following, is what I with my colleagues propose.

What unprocessed food is

Food is any substance intended to be, or reasonably expected to be, ingested

by humans that provides nutrients needed to maintain life.

Unprocessed foods, also known as fresh foods, are defined here as parts of

plants (such as seeds, leaves, roots, fruits) or animals (such as muscles,

offals, milk, blood) and also fungi or algae, shortly after they have been

harvested, butchered or extracted, or after they have been gathered from

nature.

Most unprocessed foods have two important limitations. First, they are

highly perishable and cannot be stored for a long time. Second, they require

kitchen (culinary) preparation and cooking to be digestible, safe, and

palatable. These limitations are the main reasons for the development of

numerous techniques of industrial food processing.

What industrial food processing is

Industrial food processing is defined here as a series of industry-performed

operations by which unprocessed foods are converted into foodstuffs suitable

for storage and/or consumption, with less or no kitchen (culinary)

preparation and cooking. Figure 2 shows the position of industrial food

processing in food systems.

____________________________________________________________

Figure 2

Industrial processing within food systems

http://www.wphna.org/images/wn_nov2010chart2c.jpg

____________________________________________________________

The three types of processing

http://www.wphna.org/images/10white.gif

A classification of three types of food processing, and a corresponding

three groups of processed foods, the result of discussions that began in

2008, is now proposed. Also described elsewhere (6), these are now

summarised.

A classification with more or many more divisions could be made, and much of

the discussion I have shared with colleagues has been on this point.

Eventually, we all agreed that the simplest possible system, focusing on the

general purposes and nature of processing, was best. The classification does

not imply that what are defined here as 'ultra-processed' products are best

never consumed (while as already mentioned, some products in this group are

formulated to be habit-forming to the point of being 'softly addictive'). It

is safe to say that nobody has ever become sick as a result of consuming one

burger, unless it was infected with pathogenic microbes. The issue is one of

proportion.

Type 1 processing

The processes classified here as type 1 do not substantially change the

nutritional properties of the original unprocessed foods, and may improve

them, intrinsically or in effect. Such processes include and are not

confined to cleaning, removal of inedible fractions, grating, squeezing,

draining, flaking, drying, parboiling, bottling (without additions other

than water), chilling, freezing, fermentation (when the result is not

alcoholic), pasteurisation, vacuum and gas packing, and simple wrapping.

The purpose of type 1 food processing is to extend the duration of

unprocessed foods, to enable extended storage, and often to reduce the time

and effort involved in their culinary preparation. The results of type 1

food processing are minimally processed foods, classified below as group 1

foods, together with fresh, perishable, unprocessed foods. Meat and milk,

cereals (grains), pulses (legumes), nuts, and fruits, vegetables, roots and

tubers sold as such, are usually minimally processed in various ways.

Type 1 food processing is usually undertaken by the primary producer,

packing house, distributor or retailer, as well as by manufacturers, for

eventual sale to consumers.

Type 2 processing

The second group of processes extract and 'purify' specific substances from

unprocessed foods. There are many. They include pressing, crushing, milling,

refining, 'purifying', hydrogenation, hydrolysation, extrusion, and use of

enzymes and additives. Combinations of such processes are commonly used to

make manufactured products.

One purpose of type 2 food processing is to convert unprocessed foods into

culinary ingredients. These are used in preparation and cooking of

unprocessed or minimally processed foods in the home, or in catering outlets

such as restaurants, cafes and street markets where meals are made on site.

The other purpose of type 2 food processing is to convert unprocessed foods

into food industry ingredients used in the industrial development of

ultra-processed foods (see below)..

The results of type 2 food processing are therefore culinary or food

industry ingredients, as classified below. Examples are oils, fats, sugar

and sweeteners, flours and pastas (when made of flour and water), and

starches. Salt is a group 2 ingredient. Most end products of type 2 food

processing are depleted or devoid of nutrients and essentially provide

energy. They are not palatable by themselves apart from sugar (which however

is not commonly eaten neat), and are not consumed by themselves. Oils are

used in the cooking of cereals (grains), vegetables and pulses (legumes),

and meat, and are added to salads. Flours are made into pastry used as a

covering for meat or vegetable dishes or as a basis for cakes. Pastas are

the base for dishes that include vegetables, meat and other group 1 foods,

and also oil. Table sugar is used to prepare fruit- or milk-based desserts.

And so on.

This group also includes industrial ingredients usually not sold directly to

consumers, such as processed remnants of meat, high fructose corn syrup,

lactose, milk and soy proteins, gums, preservatives, and cosmetic and other

additives. In modern food systems, the processing of such ingredients is

mostly undertaken by specialist firms, for sale to food manufacturers.

Type 3 food processing

The third type of processing combines the already processed group 2

ingredients, such as oils, fats, sugars, salt, flours, starches, remnants of

meat, with some (often only a small or even minuscule amount) of unprocessed

or minimally processed group 1 foods. Sometimes no group 1 foods are

included, although they may be imitated. Specific processes include baking,

battering, frying, deep frying, curing, smoking, pickling, canning, use of

preservatives and cosmetic additives, addition of synthetic vitamins and

minerals, and sophisticated types of packaging.

The purpose of type 3 food processing is the creation of durable,

accessible, convenient, attractive, ready-to-eat or ready-to-heat products.

Such ultra-processed products are formulated to reduce microbial

deterioration ('long shelf life'), to be transportable for long distances,

to be extremely palatable ('high organoleptic quality') and often to be

habit-forming. Typically they are designed to be consumed anywhere - in

fast-food establishments, at home in place of domestically prepared and

cooked food, and while watching television, at a desk or elsewhere at work,

in the street, and while driving. This is why they are termed 'fast' or

'convenience' foods.

Ultra-processed products are themselves of two types. One includes soft

drinks, and ready-to-eat savoury or sweet snacks, or products liable to be

consumed as such. The other includes pre-prepared ready-to-heat products

designed to replace dishes and meals in the home or on site in catering

establishments. Their processing is undertaken by food manufacturers, or by

caterers such as those that supply burger and pizza outlets, or food

retailers such as bakeries.

From the public health point of view, ultra-processed foods are problematic

in two ways. First, their principal ingredients (oils, solid fats, sugars,

salt, flours, starches) make them excessive in total fat, saturated or

trans-fats, sugar and sodium, and short of micronutrients and other

bioactive compounds, and of dietary fibre. Taken together this increases the

risk of various serious diseases. Second, their high energy density,

hyper-palatability, their marketing in large and super-sizes, and aggressive

and sophisticated advertising, all undermine the normal processes of

appetite control, cause over-consumption, and therefore cause obesity, and

diseases associated with obesity.

Ultra-processed products are usually not consumed together with unprocessed

and minimally processed foods. They are designed to be ready-to-eat or

ready-to-heat, and are often consumed alone or in combination with other

ultra-processed products, such as savoury snacks with soft drinks, and bread

with burgers. Any accompanying fresh food, such as lettuce within a burger,

is usually little more than trimming or decoration, added to give an

illusion of wholesomeness.. For this reason it is right to isolate

ultra-processed products in dietary analyses and guidelines.

Figure 3 shows the position of the three types of food processes within food

systems.

____________________________________________________________

Figure 3

The three types of food processes within food systems

http://www.wphna.org/images/wn_nov2010chart3c.jpg

____________________________________________________________

The three food groups

http://www.wphna.org/images/10white.gif

Now for the three food groups that derive from the three types of process.

Table 1 repeats some of the information summarised above, included here for

convenience

____________________________________________________________

Table 1

Food classification based on the extent and purpose of industrial and other

processing

Food group

Extent, purpose of processing

Examples1

Group 1 foods

Unprocessed or minimally processed foods

No processing (as defined here), or mostly physical processes used to make

single whole foods more durable, accessible, convenient, palatable, or safe.

Specific processes include cleaning, removal of inedible fractions, grating,

squeezing, draining, flaking, drying, parboiling, bottling (without

additions other than water), chilling, freezing, fermentation (when the

result is not alcoholic), pasteurisation, vacuum and gas packing, and simple

wrapping.

Fresh, chilled, frozen, vacuum-packed fruits, vegetables, fungi, roots and

tubers; cereals (grains) in general; fresh, frozen and dried beans and other

pulses (legumes); dried fruits and 100% unsweetened fruit juices; unsalted

nuts and seeds; fresh, dried, chilled, frozen meats , poultry and fish;

fresh and pasteurised milk, fermented milk such as plain yoghurt; eggs; teas

, coffee, herb infusions, tap water, bottled spring water

Group 2 ingredients

Processed culinary or food industry ingredients

Extraction and purification of components of single whole foods in order to

produce ingredients used in the preparation and cooking of dishes and meals

made up from Group 1 foods in homes or on the spot in catering outlets, or

else in the formulation by manufacturers of Group 3 foods..

Specific processes include pressing, crushing, milling, refining,

'purifying', hydrogenation, hydrolysation, extrusion, and use of enzymes and

additives.

Vegetable oils, margarine, butter, milk, cream, lard; sugar, sweeteners in

general; salt; starches, flours, 'raw' pastas and noodles. Food industry

ingredients usually not sold to consumers as such, including high fructose

corn syrup, lactose, milk and soy proteins, gums and similar products.

Group 3 products

Ultra-processed food products

Combination of already processed group 2 ingredients usually with some

unprocessed or minimally processed group 1 foods in order to create durable,

accessible, convenient, and palatable drinks or ready-to-eat or to-heat

products liable to be consumed as snacks or desserts or to replace home- or

restaurant-prepared dishes and meals..

Specific processes include baking, battering, frying, deep frying, curing,

smoking, pickling, canning, use of preservatives and cosmetic additives, the

addition of synthetic vitamins and minerals, and sophisticated types of

packaging.

Breads, biscuits (cookies), cakes and pastries; ice cream; jams (preserves);

fruits canned in syrup; chocolates, confectionery (candies), cereal bars,

breakfast cereals with added sugar; chips (French fries), crisps (chips),

sauces; savoury and sweet snack products; cheeses; sugared fruit and milk

drinks and sugared and 'no-cal' cola and other soft drinks; frozen pasta and

pizza dishes; pre-prepared meat, poultry, fish, vegetable and other 'recipe'

dishes; processed meat including chicken nuggets, hot dogs, sausages,

burgers, fish sticks; canned or dehydrated soups, stews and pot noodle;,

salted, pickled, smoked or cured meat and fish; vegetables bottled or canned

in brine, fish canned in oil; infant formulas, follow-on milks, baby food.

Taken from reference 6.

1 These listings do not include alcoholic drinks. The examples given are not

meant to be complete. Many others can be added, especially to Group 3, using

the general principles specified in the text and as indicated in the second

column.

____________________________________________________________

The so far irresistible rise of ultra-processed products

All over the world, unprocessed and minimally processed foods, and processed

culinary or food industry ingredients, have been, are being, and continue to

be, displaced by ultra-processed products.

Initial analysis of surveys conducted in high income countries indicates

this process may be more or less complete. In the USA, the five most

commonly consumed foods are 'regular' sugared soft drinks, cakes and

pastries, burgers, pizza, and potato chips. These are all ultra-processed

(19). In the UK, eight ultra-processed products, breads, cakes, pastries,

confectionery, biscuits, processed meats, cheeses, and soft drinks, together

supply 45.3 per cent of total household purchased calories (20).

In Brazil my colleagues and I have made more precise calculations based on

household expenditure surveys and the classifications used in this

commentary. Here, the percentage rose from 19.2 in 1987 to 28.0 in 2003 (5).

Preliminary analysis of the 2009 survey indicates that this trend is

continuing.

Calculations for the UK and Brazil are based on household expenditure

surveys. So they do not include food and drink products purchased for

consumption outside the home, which by their nature will more often be

ready-to-consume ultra-processed products.

The bulk of the current business of transnational and other big food and

drink manufacturing companies, and the principal source of their turnovers

and profits, are ultra-processed products. In this respect, while being

competitive with one another within product ranges, they all have the same

overall policy. To adapt a jingle once used by the leading cola drink

company, they want to teach the world to snack. This is the problem. There

is no immediate answer, but problems can be resolved only after they have

been identified.

Classification

http://www.wphna.org/images/10white.gif

No classification of foods and drinks, whatever its purpose, can be

clear-cut. Take the 'Food Pyramid' issued in many countries by government

departments as a guide to good nutrition. One is shown here, as Figure 4. It

derives from what is now a century-old classification of foods usually into

4 to 7 groups, broadly based on their relative content of chemical

constituents - in particular, of proteins, carbohydrates, fats, vitamins and

minerals.

The most obvious problem of this and any other food pyramid (or other

device, such as a 'rainbow' or 'plate') based on such classifications, is

that they include only a few of the food and drink products that people

actually purchase and consume. In this pyramid, soft drinks are not shown,

and nor are burgers, pizzas, or other ready-to-eat or -heat foods, dishes or

meals. The base of the pyramid, illustrating the recommendation to consume

more starchy foods ('complex carbohydrates') includes cakes, buns and

biscuits together with wholegrain bread, oatmeal and boiled rice. Overall,

this pyramid makes no explicit reference to food processing. At best, it is

not particularly useful.

____________________________________________________________

Figure 4

A 'food pyramid'

http://www.wphna.org/images/wn_nov2010chart4b.jpg

____________________________________________________________

The classification proposed in this commentary is also not clear-cut, in the

sense of being unarguable, and again it could not be. Overall, as already

mentioned, with my colleagues I decided to keep the classification simple.

We were tempted to make further distinctions and thus create more groups.

Usually the argument to do so was based on a feeling that distinctions

should be made between more or less healthy and unhealthy versions, or less

or more processed versions, of the same sort of food. Our decision was not

to do this, largely because we agreed that the crucial distinctions are to

do with the extent and purpose of processing, rather than its intensity.

Made into a manual, the classifications can be accompanied by text that

explains and emphasises differences in nutrient nature and quality, and type

and intensity of processing.

Box 4

Meat and bread

Most quizzical or critical comments on this thesis, as contained in papers

already published, or in conference presentations, have addressed items in

the classification of foods that seem unexpected or counter-intuitive. Two

examples are meat and bread. Should these and other foods or products give

rise to sub-classifications? There is a case to do so, and as indicated in

discussion of ultra-processed products, we thought about introducing type 3A

for ready-to-consume snacks and drinks, and type 3B for ready-to-heat meals

and dishes. We chose not to do this.

For different reasons, many people might want to make a sharp distinction

between meat from wild and free-ranging animals, and meat from industrially

produced animals. We discussed this. Industrially produced meat certainly

could be counted as ultra-processed. Strongly on balance, we felt however

that such meat is not 'manufactured' in the sense that sausages and burgers

are, and that the arguments for making it a type 3 product are largely

ethical and environmental, which was not part of our brief. Also, and

importantly, we are not saying that any item that is unhealthy should for

this reason be classed as type 3, or that all unprocessed or minimally

processed foods are healthy.

The classification that so far has led to most comment, is bread. At the

September 2010 Porto congress on public health nutrition

<http://www.wphna.org/members_profilesnov2010.asp#lsm> Lluis Serra-Majem, a

leading champion of the Mediterranean Diet, stated that bread has always

been a part of the healthy Mediterranean Diet. Indeed so it has, but this

commentary is not saying that it is only products devised by modern

industrial methods that are counted as ultra-processed. People have been

ultra- processing meat and fish by salting, pickling, and smoking for

thousands of years. Nor are I and my colleagues saying that ultra-processed

products should all be avoided. As already stated, the issue is partly one

of degree and proportion.

Rather as with meat, it is tempting to make a distinction between wholegrain

and other 'rough' or artisanal breads that are delicious consumed by

themselves or as a part of meals, as traditionally done in the Mediterranean

region, on the one hand, and on the other hand breads that are made from

degraded flour, pumped full of air, and that are disgusting unless used to

be covered with or to contain usually fatty or sugary foods. But all bread

by our and we suggest any rational definition is ultra-processed.

Distinctions for nutritional and other reasons between different types of

bread can be made in the text accompanying general classifications.

Three theses

http://www.wphna.org/images/10white.gif

Within the general thesis set out here, three proposals are made, in the

form of specific these that derive from the main thesis, and from the

investigations and observations set out here. They come from a public health

point of view. Some recommendations are also included.

Thesis 1

Diets mainly made up from combinations of processed ingredients and

unprocessed and minimally processed foods, are superior to diets including

substantial amounts of ultra-processed products.

Unprocessed and minimally processed foods, processed ingredients, and

ultra-processed products, all have advantages and disadvantages. To repeat,

it is not stated or implied here that the best diets consist predominantly

of unprocessed and minimally processed foods, nor that ultra-processed food

and drink products are best eliminated from diets.

One key aspect of the food classification used here, is that processed

ingredients are not palatable and with one exception (sugar) not edible by

themselves. Their purpose, in all methods of food preparation and cooking

developed until recently, has been to be used together with unprocessed and

minimally processed foods, in the making of the meals (including feasts),

dishes, foods, drinks and snacks that altogether make up international,

national and local cuisines. The main dietary element in most ingredients is

energy (calories), and typically the processes used to produce them leave

them with relatively few nutrients. This is of course significant, and they

can be over-used.

Processed ingredients are not the problem

Greasy and sugary cuisines, and feast foods eaten regularly rather than

occasionally, are liable to make their consumers fat. This said, in judging

the quality of diets it is not meaningful to isolate the nutrient profiles

of ingredients, because they are consumed together with unprocessed and

minimally processed foods, suitably prepared. The unit to assess is not the

ingredients, but the combination. Furthermore, the dishes that result are

commonly consumed as part of meals including fresh foods, such as salads and

fruits.

This is an important finding. It explicitly or implicitly contradicts most

dietary recommendations, which for half a century, and still now, pick out

ingredients in isolation. Thus, the 'food pyramid' above states, of fats and

oils, 'use sparingly', and other guidelines use the same phrase for sugars.

This implies that the issue is fats and oils as ingredients used by a family

member in home cooking, and usually it is not. It also implies that those

responsible are the home cooks, and this is rarely the case. The finger is

pointing in the wrong direction.

In sharp contrast, ultra-processed foods and drinks are designed to be

consumed by themselves. They may seem to be industrial versions of home

cooking - combinations of unprocessed and minimally processed foods with

processed ingredients. Industry publicity is often designed to give the

impression that mass manufacturing is really just kitchen preparation on a

bigger scale. But this is not so. Characteristically the amount of

unprocessed and minimally processed food included within ultra-processed

products is minimal. In this case it is appropriate to assess

ultra-processed products as a unit. Further, the high energy density and

other properties of various ultra-processed products, including

hyper-palatability and super-size servings, and provision of a lot of

calories in liquid form in the case of sugared soft drinks, sabotage human

(and animal) appetite regulation mechanisms and energy balance. Artificially

sweetened drinks stimulate cravings for sweetness, making people more likely

to eat sweet foods. Passive overconsumption and obesity is also driven by

the packaging and advertising of ultra-processed products.

The advice given with 'food pyramids' is misleading. Since governments

usually approve official advice after consultations with food manufacturers,

and/or expert advisors who are executives of or consultants to food

manufacturers, this is perhaps not surprising. It would be more somewhat

more helpful if the 'pyramid' guidance was: 'Avoid manufactured products

containing substantial amounts of sugar and/or fat, especially saturated

fat, and avoid trans fats'. But this is complicated advice, and food labels

are bewildering. The really helpful advice is simple. 'If you consume

ultra-processed products, do so only occasionally'. The text can then

specify what this means, making distinctions between different types of

ultra-processed products. No, it does not mean 'Always avoid...', nor 'Never

consume....'.

It follows that as a rule, all adequate and varied traditional diets are

superior to any diets containing a substantial amount of industrialised

ultra-processed diets. A detailed set of recommendations can quantify such

judgements.

Thesis 2

Almost all types of ultra-processed product, including those advertised as

'light', 'premium', supplemented, 'fortified', or healthy in other ways, are

intrinsically unhealthy.

Once again, just to make very sure there is no misunderstanding, this does

not mean that occasional consumption of ultra-processed products of itself

is likely to be a significant cause of obesity or chronic diseases - always

allowing for the caution that so many such products are very skilfully

formulated, packaged and marketed to be habit-forming. By analogy, when

dietary guidelines say that fruit and vegetables are healthy, this does not

mean that an apple a decade will keep the doctor away, and when they say

that alcohol is unhealthy, this does not mean that a drink a week, or indeed

usually a couple of beers or a shared bottle of wine a weekend, is likely to

do any normal healthy person any harm.

The basic point here, is that ultra-processed products have all the

disadvantages of processed culinary ingredients, without their crucial

advantage of being combined with unprocessed and minimally processed foods.

With exceptions, ultra-processed products typically are confected from

processed ingredients with little and even sometimes practically no content

of unprocessed or minimally processed food. Manufacturers often take a lot

of trouble to give the opposite impression, in 'friendly' names of products,

references to herbs and 'nature-identical' ingredients, 'homely' or

'country' images used on packaging, 'warm' copywriting on the packaging and

in publicity material, link-ups with smiling famous chefs, and so on, and in

the product's presentation, which often includes the fresh item sprinkled on

top, or conspicuous in some other way. Don't be misled.

Transnational and other big food and drink manufacturers are now of course

sensitive to the fact that a great deal of disquiet is being expressed by

citizens, health professionals, and indeed governments, about the obesity

pandemic. The current president of the USA has given the impression that

left to himself he would impose a 'soda tax' on sweetened cola and other

soft drinks. Industry is united in promotion of spectator sport and personal

physical activity, the idea being that people who skip rope or do circuits

three times a week, or who play outdoors with their children at weekends,

can consume all the processed products they feel like, and get or stay lean.

It seems unlikely that anybody really wholly believes this.

Ultra-processed products are not good or better for you

Over the years, and increasingly in recent years, manufacturers have

responded in different ways. One way has been to divide their products into

'fun', 'better for you', and 'good for you', and such-like categories. 'Fun'

products are, as might be expected, ultra-processed items about which

nothing or almost nothing nutritionally good can be said - what are commonly

termed 'junk foods'. Techniques for advertising these are somewhat like

those once used to advertise cigarettes as essential accessories of the good

life - glamour, smiling, sharing, and in the case of soft drinks, convivial

young people partying.

The 'better for you' category includes products that are normally very

fatty, sugary or salty, that have been reformulated to be somewhat less so,

or to contain somewhat more dietary fibre. Such products may be promoted as

'lite', but are usually still 'heavy' - just rather less so. Rules are

agreed with regulatory authorities that allow the manufacturers to boast

about these changes in big lettering on the product labels. Cynics say that

these moves are similar to those in the 'low-tar' stage of cigarette

manufacture. A strong concern expressed particularly in the USA, is that in

the last 20 years or so, manufacturers have removed some fat from their

products, and thus have been able to advertise them as in effect 'better for

you' (or even 'good for you') while preserving their 'organoleptic quality'

(or 'yumminess' or 'more-ishness') by adding more sugar.

In one case, strong pressure has led to industry seeing the writing on the

wall. Trans-fatty acids are now being eliminated from many products. These

therefore become 'less bad for you', but this is not a phrase used by

manufacturers. Sometimes products boast about containing no noxious

substance, like trans-fats, or cholesterol, that previously never contained

such things.

The 'good for you' category includes three types of ultra-processed

products. One is product variants marketed as 'premium' - high quality or

luxury. These may also be marketed as being good for the producer. Chocolate

containing high proportions of cocoa, often stated to be fairly traded, is

an example. These are of course expensive. The second type is reformulated

to contain more unprocessed or minimally processed foods. Staying with

chocolate, brands containing whole nuts are an example, though chocolate

usually relies on marketing emphasising naughtiness but niceness, with coy

references to chocoholism .

'Good for you' ultra-processed products are now big business. Some have been

around for a long time. These notably include milk-based drinks and bases

for drinks for children, including young children, and breakfast cereals.

The claim is based on their being 'fortified' with synthetic vitamins or

minerals. This is now a very sophisticated business, as anybody can see by

looking at the nutrition information labels of ready-to-eat breakfast

cereals, including some sugary lead lines promoted vigorously as good for

children. The number, combination and dose of the added micronutrients is

usually negotiated between the manufacturer and regulatory authorities, with

reference to the findings of recognised international or national expert

advisory committees. This enables strong claims to be made.

More recently, soft drinks and waters are being marketed and promoted as

'fortified' and therefore healthy. One previously niche brand of water with

added vitamins was recently purchased by the leading cola drink manufacturer

for $US 4.1 billion. (Yes, billion). This product is promoted as an

essential part of the gear of any sparky young executive. Such products

obviously are not unhealthy, for those who can buy them, and are a better

choice than sugared soft drinks. They are unhealthy only inasmuch as they

reinforce the notion that anything eatable or drinkable that is 'fortified'

is therefore healthy.

With the reservations and exceptions mentioned here, all types of

ultra-processed products are unhealthy, whatever they say, and however

legitimised their claims are. As said, they undermine appetite regulation

and so drive overconsumption and thus obesity. 'Better for you' and usually

'good for you' versions remain high energy-dense, hyper-palatable, fast

foods. The marketing of 'premium' ultra-processed foods and drinks, which is

misleading, is becoming even more aggressive than the marketing of their

'regular' counterparts.

Thesis 3

Significant improvement and maintenance of public health always requires the

use of law. The swamping of food systems by ultra-processed products can be

controlled and prevented only by statutory regulation.

The pandemic of overweight and obesity, including among children and young

people, also greatly increases the risk of 'adult-onset' diabetes in early

life. We are in the midst of a vast global public health emergency. It is

parallel with, and in some ways linked with, the more familiar outrageous

emergency of undernutrition, food insecurity, and deficiency and related

infections.

At the root of both crises is the ideology that has prevailed in the most

powerful countries especially since the 1980s, and imposed by them on most

vulnerable countries. This is the doctrine of 'the sovereignty of the

market'. In practice this continues to mean releasing big businesses from

what their chief and other executives regard as regulatory burdens, so that

that they can engage in any currently legal policies and practices that will

maximise their market share and their profits, worldwide.

This might not always be troublesome. In the case of food it certainly is. A

relatively small number of transnational food and drink manufacturing

industries, with associated businesses, now dominate international and

global food systems. Their competitiveness within their own sectors

disguises the fact that they all have the same overall interest. They are

all predominately or mainly in the business of making and selling

ultra-processed branded and very heavily marketed products.

What this means, is that legislation is essential, to check and reverse the

worldwide increase in production and consumption of ultra-processed food

products. This point should not be controversial. In many areas of public

activity, enjoyment of and pleasure in life has been enhanced by regulations

that govern access to parks and wilderness areas, that zone land for

different uses, that make neighbourhoods and streets safer, and that protect

children and young people. Laws governing guns, drugs, dogs, and cars, are

now rarely disputed. Laws governing access to alcohol and that control

smoking have become rapidly accepted. The same needs to apply to

ultra-processed food and drink products, in the public interest, and perhaps

most of all vulnerable populations, including the poor, sick, and old, and

mothers and children.

A public health issue

At any population level, 'business as usual' will not control or reduce

overweight and obesity. This is a public health issue. All public health

challenges and opportunities require public support, public money, and

public resources, from the public authorities. This means that formally the

lead must come from government, and in the case of a global crisis at all

levels, from global to international to national to state and province, to

municipalities and communities.

On 1 May 2009 the delegates assembled at the World Federation of Public

Health Association, at its global meeting held every three years, agreed The

Istanbul Declaration (21) Its purpose is in part to remind the profession of

the duties and responsibilities of public health professionals worldwide.

Its preamble begins:

'Now is the time to make a new commitment to the health of populations. The

need for improvement and maintenance of public health must now be

recognised, advocated and achieved by all policy-makers and decision-takers.

Protection of public health is a first responsibility of governments at all

levels, especially including heads of state and prime ministers. This

implies renewed political will. It also implies a new understanding of

public health as the first public good, needing adequate and therefore

increased human, financial, and other material resources'

The final statement of the preamble includes: 'We are now living in a new

world, of unique challenge and also unique opportunity for those committed

to public health and for everybody. The challenges we now face are as great

as those that faced public health pioneers of the 19th and early 20th

centuries. Committed and sustained leadership is needed, including from

young people. Now is the time for all those who affect the lives of others,

working in government, industry, and in civil society, and as health care

workers, academics, community and faith-based leaders, and citizens, to

affirm the fundamental and elemental importance of public goods, including

public health, and to assert and practice the basic human values of

solidarity, sustainability, morality, justice, equity, fairness and

tolerance'.

With my colleagues, I agree that this and other similar statements made

recently should become the principles that govern and guide rational

policies and effective actions. They should mark the revival of public

health in the great tradition, which particularly since the 1980s has become

increasingly privatised.

The need for rational law

How can the change come? As with tobacco and alcohol, and indeed other big

public health issues, all the evidence shows that the lead has to come from

governments. But governments will not make the move for public health until

politicians and civil servants realise that it will be politically more

convenient to legislate in favour of public health, than to leave

transnational and other big food and drink manufacturers free to do whatever

they like within existing laws to maximise their market penetration and

profits. This will depend on sustained intense pressure from intelligent and

resourceful civil society organisations, supported by health professionals

and their organisations acting in the public interest.

Regulatory systems can be flexible, and allow for varying basic

circumstances. In some high-income countries, the market may already be

saturated with ultra-processed food products. In low- and middle-income

countries, these products are still in the process of displacing traditional

food systems. This suggests different regulatory strategies.

A rationally and carefully regulated market, with its implication of a

'level playing field', is in the interests of industry. Any unregulated

'free-for-all' makes the more responsible companies the victims of their

most ruthless competitors. Also, the transnational and other big food and

drink manufacturers could do quite a lot themselves. Product reformulation

can have some benefits, even if this only slows down increases in the

prevalence of epidemic disease. Other initiatives genuinely in the interests

of public health can also be taken. With increasingly impatient colleagues

inside and outside the public health professions throughout the world, I

look forward to these.

Box 5

Two appeals

Here are two appeals. The first is addressed to researchers who, like me,

have

access to well-conducted national and other substantial surveys of food

consumption patterns over substantial periods of time The second appeal is

addressed to citizens.

To researchers

Information from relevant well-conducted surveys needs to be pooled and

newly analysed, in terms of the conceptual framework proposed here. In the

preliminary stages of this initiative, some aspects of the system of

classification set out here may be revisited and revised. This work needs to

be done in parallel with analysis of trends in obesity and chronic diseases,

allowing for agreed time-lags between consumption and the emergence of

clinically observable diseases.

My prediction is that the results will prove to be a more powerful basis for

rational policies and effective actions designed to control and prevent

obesity and chronic diseases, than any results which, as they are now, are

based on obsolescent classifications of food.

To citizens

Properly seen, nutrition as practised is a branch of public health. The

health of populations is crucial to the social, economic and other aspects

of the welfare of nations. The current pandemic of obesity is a great

warning sign that something has gone very wrong with the systems of

governance now being operated in the world.

The issue is comparable with and related to other global crises that are now

affecting us all, including those of finance, fuel, climate and natural

resources. This is not a time in history for 'business as usual'. Nor can

information and education campaigns, or charitable Initiatives sponsored by

governments, industry and foundations make a really significant difference.

What is needed is structural change. This can begin with groups of engaged

professionals and informed citizens coming together, and forming or

reforming energetic civil society organisations. Then legislators will

listen. I will support such an initiative. Who will make the move?

Conclusion

http://www.wphna.org/images/10white.gif

http://www.wphna.org/images/wn_fatkids.jpg

In this commentary, as stated above, I advance a thesis and make proposals

not directly derived from what is now regarded as the 'hard evidence' of

methodically sophisticated and statistically powerful randomised controlled

trials, meta-analysed and systematically reviewed. However, the relevant

evidence and types of evidence known to me are consistent with the analysis,

proposals and recommendations made here. It should be remembered that

pandemic overweight and obesity, including among children, as illustrated in

the picture here, is an emergency.

Much of what is stated in this commentary is circumstantial and inferential,

and so not normally counted as 'hard' evidence - or even, for those who only

admit results from trials, as information that can be counted as evidence.

This must be so, because the published results of trials still virtually all

derive from and depend on a conceptual framework of the science of nutrition

that was originally conceived in the early years of the last century. This

framework, using classifications of food largely derived from their relative

contribution of chemical constituents, is not particularly appropriate,

helpful, useful or even relevant in this century and the circumstances in

which we live now.

Until the 1980s obesity among children and young people was uncommon in any

country, although the population of the USA and a few other countries was

becoming notoriously fatter. Now, populations of obese children and young

people amount to the overwhelming public health crisis in high-income

countries.

But as is now well-known, obesity is not a crisis only in high-income

countries, and higher-income populations in other countries. Increasingly it

is overwhelming lower-income countries and, within them, impoverished

populations. The picture that ends this commentary, of a mother in her 30s

and her teenage daughter, in a provincial city in my country of Brazil,

illustrates the point. In Brazil a generation ago, obese young people were

rare. Not now.

In my judgement, the impact of ultra-processed products on food systems and

supplies and thus diets, is so blatant and obvious, that the heavy burden of

proof is on those who wish to claim that ultra-processing is harmless or

incidental to public health. Evidence to back such a claim would be credible

only if it came from studies undertaken by researchers who are directly and

indirectly free from any inappropriate influence, notably that of

transnational food and drink manufacturers whose profits currently depend on

the sale of ultra-processed products. I believe that such credible evidence

will not be forthcoming.

The main direct dietary reason for the rapid increase in overweight and

obesity throughout the world especially since the 1980s, which is now an

uncontrolled pandemic, has been, is, and continues to be, the

correspondingly rapid increase in production and consumption of

ultra-processed food and drink products. That is the thesis of this

commentary.

http://www.wphna.org/images/wn_fatteen.jpg

Alberto Machado

Medico Veterinário

Consultoria em Agroecologia

So A Pasto Agroecologia Ltda

soapasto@...

Veja e Consulte

Horta : <

Conheça,

<http://remineralize.org/joomla/index.php/International-Coordinators>

http://remineralize.org/joomla/index.php/International-Coordinators

" Todo mundo 'pensando' em deixar um planeta melhor para nossos filhos...

Quando é que 'pensarão' em deixar filhos melhores para o nosso planeta? "

" Não é o mais forte da espécie que sobrevive, nem o mais inteligente; é o

que melhor se adapta à mudança. " Darwin