Freshly Prepared Meals and Not Ultra-Processed Foods

Monteiro CA, Cannon G, Moubarac J-C, Levy RB, Louzada MLC, Jaime PC. (2019) Cell Metab 30(1) 5-6. doi: 10.1016/j.cmet.2019.06.006. Epub 2019 Jun 20.

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Abstract:

We write as members of the team in Brazil that has originated, developed, and refined the NOVA food classification system (Monteiro et al., 2018).

NOVA is used globally by many independent teams and now by Hall et al., 2019 in their randomized controlled trial showing that diets high in ultra-processed foods cause rapid increases in dietary energy intake and body weight and fat.

We here make four points on the nature of ultra-processed foods, the apparent higher cost of meals made with non-ultra-processed foods, the reformulation of ultra-processed foods, and global implications.

The nature of ultra-processed foods.

A few of the current media responses to the trial, and some criticisms of NOVA, confuse processing with ultra-processing, implying or stating that NOVA is opposed to food processing as such (Institute of Food Technologists, 2019).

This is not correct. All four NOVA groups include processed food (Table S1). Moreover, many industrial processes are necessary or even beneficial for health. These include those used to turn raw foods into minimally processed foods (that together with unprocessed foods are NOVA group 1); those used to extract processed culinary ingredients (NOVA group 2) from group 1 foods; and many of those used to modify group 1 foods, such as in making traditional breads and cheeses (NOVA group 3) (Monteiro et al., 2018).

As stated by Hall et al., 2019, ultra-processed foods (NOVA group 4) are formulations mostly of low-cost industrial sources of dietary energy and nutrients, additives, and little if any whole food.

Altogether, they contain high amounts of sugar, salt, oils, and fats, and often use processes with no domestic equivalent such as high-temperature extrusion and molding.

But what makes them altogether different from the other NOVA groups is their use of substances derived from foods seldom if ever used in culinary preparation, such as protein isolates, hydrogenated oils, and modified starches. Or their use of flavors, colors, emulsifiers, and other cosmetic additives designed to mask their basic ingredients and to make the final product attractive to the senses (Monteiro et al., 2019). As shown by several population-based, cross-sectional, and cohort studies (Monteiro et al., 2018), and now confirmed for the first time by a short-term randomized controlled trial, diets high in ultra-processed foods are detrimental to health.

Obviously, food is needed for life and health, but there is no need to consume ultra-processed food (Moodie et al., 2013).

Cost.

Hall et al., 2019 quite rightly, in our view, created non-ultra-processed meals that were as attractive to consumers in the USA as ultra-processed meals. This is likely one of the reasons why the non-ultra-processed meals used in the trial cost about 40% more. But this is not always the case.

In Brazil, for example, where most people are still accustomed to eating freshly prepared meals, diets based on ultra-processed foods are on average more expensive (Moubarac et al., 2013).

In many countries, long-established diets based on staple plant foods with a variety of vegetables and fruits, and modest amounts of animal foods, are likely to cost roughly the same as or less than diets mainly made from ultra-processed foods.

Besides, full cost-accounting of diets should include the health insurance given by freshly prepared meals against obesity and debilitating diseases that are expensive to treat, such as diabetes.

Product reformulation.

In response to rapidly growing awareness by policy-makers in relevant UN agencies and in national governments of the harmful impact of ultra-processed foods, manufacturers are now proposing reformulation, so that some products may add dietary fiber and reduce sugar, fat, or salt (Scrinis and Monteiro, 2018).

The findings of Hall et al. showing that energy intake and body weight increases are not only driven by the unbalanced nutrient profile of ultra-processed foods mean that nutritional reformulation is not likely to make them healthy foods.

It now seems that several mechanisms may well link food ultra-processing to non-communicable diseases. For instance, both advanced glycation end products created by high-temperature extrusion and cosmetic additives such as emulsifiers and artificial sweeteners cause changes in the composition and metabolic behavior of the gut microbiota that lead to diverse forms of inflammatory-related disease (Zinöcker and Lindseth, 2018).

Global implications.

Ultra-processing is not new. For example, cola and other soft drinks, cookies, and confectionery have been manufactured and marketed for a long time. But these and many other such products did not start to overwhelm global food supplies until recently.

The issue now is the volume of ultra-processed food in food supplies and dietary patterns, which may have reached saturation point in the USA and other high-income countries, but which is still accelerating in the global South and displacing dietary patterns based on freshly prepared meals (Monteiro et al., 2013).

It is, we think, not by chance that NOVA was first developed in Brazil, a middle-income country, where, in common with many countries in Latin America, South and Southeast Asia, the Middle East, and Africa, phenomenal increases in sales of ultra-processed foods in the two last decades have been associated with simultaneous increases in population body mass index averages (Vandevijvere et al., 2019).

But in these countries of the global South, long-established cuisines and the custom of enjoying freshly prepared meals with the family or in other company still survive.

Such meals are made from NOVA food groups 1, 2, and 3, many grown, made, and sold by regional and local farmers, manufacturers, and retailers. They are part of national and regional identity, and are good for rural and urban economies.

National, regional, and local cultures based on freshly prepared meals need to be recognized, protected, preserved, and promoted by relevant UN agencies and professional bodies, and above all by national governments with statutory policies and programs.

FAB RESEARCH COMMENT:

This article is a commentary, written in response to other comments made following the recent publication of a groundbreaking study which showed that

a diet of ultra-processed foods led to significant overeating - by a massive 500 calories per day - and rapid weight weight gain - of almost a kilo in just 2 weeks - compared with a nutritionally-matched diet made up of whole or minimally processed foods
the ultra-processed diet also caused significant increases in biomarkers of the 'metabolic syndrome' that is firmly associacted with, and predicts, the development of Type 2 diabetes, obesity and cardiovascular disease.

Most importantly, that study was a randomised, double-blind, placebo-controlled trial - the 'gold standard' design for assessing cause-and-effect relationships - and it was rigorously designed and conducted to the highest scientific standards.

(Notably, it was conducted by expert researchers in nutrition and biochemisty, who were initially highly sceptical that the effects of any diet on appetite and behaviour, or health, could possibly be influenced purely by the type of processing used to manufacture the foods involved, rather than the overall nutritional composition or 'quality' of the diet).

Predictably enough, the striking findings from this trial attracted a wide variety of responses - including several very familiar arguments that are always put forward whenever suggestions are made that governments and public health authorities might take action to reduce the ever-increasing proportions of ultra-processed foods (UPF) in human diets, namely

criticisms of the nature and definition of UPF
the cost of UPF versus real foods
the possibility of reducing the harms of UPF via 'reformulations'
the global implications of the industrialisation - and de-industrialisation - of food production

The authors of this commentary - who first created the classification system distinguishing 'ultra-processed food' as a separate category - provide some clear and succint explanations that address each of those points.

For more details of the recent randomised controlled trial to which this commenary refers, see: