1. No category

Consensus Conference on Nutrition
Diet and food policies affecting cardiovascular disease globally
A joint conference of WHF and the Canadian Academy of Health Sciences
Hamilton, Canada, May 14-16, 2014
The global shift from foods and freshly prepared meals to ultraprocessed products: health impact and policy implications
Carlos A. Monteiro
[email protected]
Center for Epidemiological Studies in Health and Nutrition
University of Sao Paulo, Brazil
• Classifying foodstuffs according the extent and
purpose of food processing
• What is wrong with ultra-processed products
• The global shift from foods and freshly prepared
meals to ultra-processed products
• Implications for national and global public policies
NOVA: a food classification based on extent and purpose of industrial processing
Groups and sub-groups
Extent, and examples
Unprocessed foods
No industrial processing: raw milk, fruits, nuts
Minimally processed foods
No subtraction of edible parts: brown rice, pasteurized milk
Moderately processed foods
Edible parts subtracted: white rice, white wheat flour
Processed culinary ingredients
Substances extracted from foods or nature: oil, fat, sugar, salt
Processed
ready-to-consume products
Single, whole foods added of salt or sugar or other substances:
vegetables in brine, fruits in syrup, cheese, simple breads
Ultra-processed
ready-to-consume products
Formulations of ingredients extracted or derived from foods
and other organic sources, with little or no intact food:
sweet/savory snacks, soft drinks, confectionery, ‘energy’ bars,
buns, reconstituted meat products, instant noodles etc
NOVA: a food classification based on extent and purpose of industrial processing
Groups and sub-groups
Purpose
Unprocessed foods
-
Minimally processed foods
Increase duration of foods
Moderately processed foods
Increase duration of foods
Processed culinary ingredients
Converting foods into freshly prepared meals
Processed
ready-to-consume products
Increase duration and modify palatability of foods
Ultra-processed
ready-to-consume products
Creation of convenient, low cost, hyper-palatable products to
replace fresh foods and freshly prepared meals
Source: Moubarac et al Current Obesity Reports 2014 3: 256-273
Food processing to encourage consumption
of foods and freshly prepared meals
Unprocessed foods
Minimally processed foods
Moderately processed foods
Processed culinary ingredients
Processed ready-to-consume products
MULTI-FOOD FRESHLY
PREPARED MEALS
(mostly consumed in
regular times, at table, and
often in company)
Food processing to displace consumption
of foods and freshly prepared meals
Ultra-processed ready-to-consume products
SNACKS, DRINKS AND
`FAST MEALS`
(mostly consumed across
the day, on the go, and
often alone
Foods and products ranked by percentage of total energy intake
US population, all ages, NHANES 2009-2010
Foods
Culinary
ingredients
Processed
products
Ultra-processed
products
1
Meat 8%
Oils 1%
Cheese 4%
Pizza, sandwich, other fast meals 10%
2
Fruits 5%
Sugar 1%
Ham 1%
Breads 9%
3
Milk 5%
All other < 1%
All other 2%
Soft drinks, fruit and milk drinks 8%
4
Grains 3%
Sweet snacks, ice cream, desserts 6%
5
Potatoes 2%
Cakes, cookies, pies, pastries 5%
6
Eggs 1%
Salty snacks 4%
7
Pasta 1%
Sugared breakfast cereals 3%
8
Fish < 1%
Alcoholic drinks 3%
9
Legumes<1%
Sauces, dressings, gravies 3%
10
Veggies < 1%
Reconstituted meat/fish products 2%
All other 1%
All other 5%
All
30.1%
2.9%
7,1%
59.9%
Source: NHANES 2009-2010 and Martinez et al (manuscript in preparation as part of a PhD dissertation)
Foods and products ranked by percentage of total energy intake
Brazilian population ≥ 10 y, POF 2008-2009
Foods
Processed
products
Ultra-processed
products
1
Rice 12.7%
Salted meat 1.1%
Bread 9.4%
2
Beans 10.7%
Cheese 0.7%
Pizza, sandwich, other fast meals 4.6%
3
Red meat 9.5%
All other 0.1%
Soft drinks, fruit and milk drinks 4.2%
4
Fruits 7%
Cakes, cookies, pies 3%
5
Other cereals 6%
Sweet snacks, ice cream, desserts 2.2%
6
Milk 5.5%
Salty snacks 2%
7
Poultry 5.3%
Reconstituted meat products 1.7%
8
Roots and tubers 3.6%
Alcoholic drinks 0.6%
9
Coffee and tea 2.9%
All other 1.6%
10
Fish 1.7%
All other 5%
ALL
68.9%
1.9%
29.2%
Source: POF 2008-2009 and Louzada et al (manuscript in preparation as part of a PhD dissertation)
• Extent and purpose of food processing: the key issue
• What is wrong with ultra-processed products
• The global shift from foods and freshly prepared
meals to ultra-processed products
• Implications for national and global public policies
What is wrong with ultra-processed products?
 Nutrient profile of ultra-processed products compared to
foods plus culinary ingredients in national food baskets
 Nutrient profile of overall diets according to quintiles of
the dietary share of ultra-processed products
 Ultra-processed products and obesity and NCD outcomes
The share of ultra-processed products (% of energy)
in national food baskets (1991-2010)
% 70
60
50
40
33
35 36 36
41 41
39 40 40
46
43 45
50 50
55
53 54
58
28 28
25 27
30
19
20
13
* Estimated from national household food expenditure surveys for Brazil (HBS), Canada (FOODEX), Chile (EPF), Colombia
(ENIG), Peru (ENAPREF) Mexico (ENIGH), Uruguay (EGIH), and the Data Food Networking (DAFNE) for all European
countries, except UK (LCF).
UK 2008
CANADA 2001
GERMANY 1998
CHILE 2007
IRELAND 1999
BELGIUM 1999
FINLAND 1998
MALTA 2000
NORWAY 1998
SLOVAKIA 2003
AUSTRIA 1999
CROATIA 2004
MEXICO 2010
LATVIA 2004
URUGUAY 2006
SPAIN 1999
CYPRUS 2003
GREECE 2002
FRANCE 1991
ITALY 1996
PORTUGAL 2000
BRAZIL 2008
COLOMBIA 2006
0
PERU 2009
10
vs.
In all countries we have studied, when compared to foods
plus culinary ingredients, ultra-processed products have:





Higher energy density
More free sugar
More trans fats
Less protein, less fiber
Less vitamins and minerals in general

Sources: Monteiro et al Pub Health Nutr 2011; Moubarac et al Pub Health Nutr 2013
and work in progress for countries other than Brazil and Canada
ENERGY DENSITY (KCAL/G)
Country
Foods plus culinary
ingredients
Ultra-processed
products
CANADA 2001
1.3
2.8
BELGIUM 1999
1.6
3.0
AUSTRIA 1999
1.7
3.1
FINLAND 1998
1.4
2.7
SPAIN 1999
1.9
2.7
GERMANY 1998
1.6
2,9
FRANCE 1991
1.5
2.6
UK 2008
1.4
2.8
BRAZIL 2008-09
1.9
2.9
COLOMBIA 2007
1.8
2.7
1.3-1.9
2.6-3.1
ALL (range)
Estimated from national household food expenditure surveys for Brazil (HBS), Canada (FOODEX), Colombia (ENIG),
and the Data Food Networking (DAFNE) for all European countries, except UK (LCF).
The dietary share of ultra-processed products
(% of total energy - quintiles)
and the quality of the overall diet
in the U.S. and Brazil
Dietary share (% of energy) of foods and products
US population, all ages, NHANES 2009-2010
Culinary
ingredients: 4.9%
Processed
products: 8.9%
Processed
products: 4.0%
FOODS
50.5%
(Unprocessed,
minimally or
moderately
processed)
ULTRAPROCESSED
PRODUCTS
35.5%
Lower quintile of
ultra-processed products
Culinary
ingredients: 1.2%
FOODS
12.2%
ULTRAPROCESSED
PRODUCTS
82.6%
Upper quintile of
ultra-processed products
Source: NHANES 2009-2010 and Martinez et al (manuscript in preparation as part of a PhD dissertation)
Dietary share (% of energy) of foods and products
Brazilian population ≥ 10 y, POF 2008-2009
Processed
products: 3.5%
FOODS
90.7%
(Unprocessed,
minimally or
moderately
processed)
Processed
products: 0.4%
ULTRAPROCESSED
PRODUCTS
8.9%
Lower quintile of
ultra-processed products
Source: POF 2008-2009
FOODS
44.5%
ULTRAPROCESSED
PRODUCTS
52.1%
Upper quintile of
ultra-processed products
Dietary fiber according to national quintiles of the
dietary share of ultra-processed products
Fiber
(g/1,000 kcal)
---BRAZIL POF 2008-09
---US NHANES 2009-10
15
Q1
13
11
Q1
9
Q5
7
Q5
5
0
20
40
60
80
Ultra-processed products (% of total energy)
100
SOURCES: Louzada ML et al, Martinez E et al (manuscripts in preparation as part of PhD theses)
Protein according to national quintiles of the
dietary share of ultra-processed products
Protein
(% of energy)
20
---BRAZIL POF 2008-09
---US NHANES 2009-10
Q1
Q1
18
16
14
Q5
Q5
12
10
0
20
40
60
80
Ultra-processed products (% of total energy)
100
SOURCES: Louzada ML et al, Martinez E et al (manuscripts in preparation as part of PhD theses)
Total fat according to national quintiles of the
dietary share of ultra-processed products
Total fat
---BRAZIL POF 2008-09
---USA NHANES 2009-10
(% of energy)
40
Q5
35
Q1
30
Q5
25
Q1
20
0
20
40
60
80
Ultra-processed products (% of total energy)
100
SOURCES: Louzada ML et al, Martinez E et al (manuscripts in preparation as part of PhD theses
Saturated fat according to national quintiles of the
dietary share of ultra-processed products
Sat fat
---BRAZIL POF 2008-09
---USA NHANES 2009-10
(% of energy)
14
Q5
12
Q1
Q5
10
Q1
8
6
0
20
40
60
80
Ultra-processed products (% of total energy)
100
SOURCES: Louzada ML et al, Martinez E et al (manuscripts in preparation as part of PhD theses
Dietary energy density according to national quintiles of the
dietary share of ultra-processed products
Energy density
(g/kcal)
Q5
2.5
---BRAZIL POF 2008-09
Q5
2
---USA NHANES 2009-10
Q1
1.5
Q1
1
0
20
40
60
80
Ultra-processed products (% of total energy)
100
SOURCES: Louzada ML et al, Martinez E et al (manuscripts in preparation as part of PhD theses
Added sugars according to national quintiles of the
dietary share of ultra-processed products
Added sugars
(% of energy)
20
Q5
Q5
---BRAZIL POF 2008-09
15
---USA NHANES 2009-10
Q1
10
Q1
5
0
20
40
60
80
Ultra-processed products (% of total energy)
100
SOURCES: Louzada ML et al, Martinez E et al (manuscripts in preparation as part of PhD theses
Non-nutrient attributes of ultra-processed products
which disturb the regulation of energy balance and
make them be often overconsumed
 Hyper-palatability (all products)
 Habituation/addiction (some products)
 Super size servings (many products)
 Inducement of mindless eating (all products)
Ultra-processed products are made to be overconsumed:
sugar, salt, fat, caffeine, sodium monoglutamate,
texture, flavors, colors, packaging …
Non-nutrient attributes of ultra-processed products
which disturb the regulation of energy balance and
make them be often overconsumed
 Hyper-palatability (all products)
 Habituation/addiction (some products)
 Super size servings (many products)
 Inducement of mindless eating (all products)
Aggressive marketing
The marketing of ultra-processed products
typically promotes compulsive overeating
New brand of ultra-processed products in Brazil
It is one after the other!
The name says it all:
‘Non-stop is simply irresistible’.
The marketing of ultra-processed products
typically promotes compulsive overeating
`Nestlé Canada is thrilled to introduce Peelin’ Pops, a unique new frozen
treat that looks like a banana and tastes like one too! Bite the tip of the
bar, peel the “banana skin”, enjoy the creamy vanilla filling!`
`With something so fun and tasty, kids and adults alike will be entertained each
and every time, keeping them coming back for more.`
http://www.corporate.nestle.ca/en/media/pressreleases/...treat-kids-will-go-bananas-over
The fake banana also in Brazil
See Nestlé. The BenNaNa master plan World Nutrition May 2014, 5, 5, 436-445
Reformulated
ultra-processed
products can be
as obesogenic as
regular products
(or more if
advertised as
`healthy foods`)
Studies on the association between
the dietary share of ultra-processed products
and health outcomes
(work in progress)
Share of ultra-processed products in national food baskets
and obesity in 7 countries in the Americas (2001-2010)
40
Obesity in adults (%)
USA
y = 0.287x + 12.112
R² = 0.543
35
30
Mexico
Chile
Canada
25
Uruguay
Peru
20
Colombia
Brazil
15
10
5
0
0
10
20
30
40
50
60
70
Ultra-processed products (% of total energy)
Sources of data: National household food expenditure surveys and national health surveys
in the same year or period and NHANES for USA
NUPENS/USP
Obesity in adults (%)
Share of ultra-processed products in national food baskets
and obesity in 19 European countries (1991-2008)
30
y = 0.3514x + 1.0513
R² = 0.4141
25
UK
Germany
20
Hungary
Croatia
Norway
Lithuania
Greece Spain Latvia
Portugal
15
Ireland
Slovakia
Austria
Cyprus
10
Malta
Belgium
Finland
France
Italy
5
0
20
25
30
35
40
45
50
55
60
Ultra-processed products (% of total energy)
Sources of data: National household food expenditure surveys and national health surveys in the same year or period
Table 3. Predictive values for household obesity indicators1 according to the
availability of ultra-processed food products (UPP). Brazil, POF 2008-2009.
Canella D et al PLoS One 2014 Mar 25
Household daily
Household
Household
Household
per capita
mean BMI
prevalence of
prevalence of
availability of
(Z score)
overweight +
obesity (%)
UPP (quartiles)
1
obesity (%)
1st (220.0 kcal)
0.56
35.6
9.9
2nd (345.6 kcal)
0.66
38.7
12.0
3rd (422.0 kcal)
0.69
39.6
12.3
4th (564.3 kcal)
0.75
41.7
13.6
From a linear regression model adjusted for income, demographic variables, region and
setting, percentage of expenditure on eating out of home, and complementary calories; all
confounding variables set to the mean.
Adjusted1 odds ratio for being obese by the dietary share (% of energy) of
ultra-processed products in Brazilian (2008-9) and US adolescents (2007-08)
Quintiles of ultraprocessed products
1
Brazilian 10 y+
(n=33,613)
1
US 8-19 y
(n=669)
1
2
0.94
1.55
3
1.69
1.68
4
1.79
2.29
5
2.59
2.41
p for linear trend
< .05
0.14
Sources: Louzada et al for Brazil and Baraldi et al for US – manuscripts in preparation as part of PhD dissertations
1
In Brazil: adjusted for age, sex, family income, education, ethnicity, region and setting,
smoking status, physical activity and consumption of fruits, vegetables, read meat and alcohol.
In the US: adjusted for age, sex, family income, family head`s education, ethnicity, physical
activity and screen time.
• Extent and purpose of food processing: the key issue
• What is wrong with ultra-processed products
• The global shift from foods and freshly prepared
meals to ultra-processed products
• Implications for national and global public policies
Changes from 1987 to 2009 in the caloric share of foods
and products purchased by Brazilian households
6
Δ % TOTAL KCAL
4
Sweet
Snacks
2
Sugared
Sausages drinks
Bread
0
-2
Rice
Beans
Manioc Milk
-4
-6
Oils, fats, and table sugar
Source: Adapted from Martins et al 2013 Rev Saude Pub 47:656-65
Fast
meals
Changes from 1987 to 2009 in the caloric share of foods
and products purchased by Brazilian households
6
Δ % TOTAL KCAL
4
2
Ultra-processed products
Foods
0
-2
-4
-6
Processed culinary ingredients
Source: Adapted from Martins et al 2013 Rev Saude Pub 47:656-65
Changes from 1939 to 2001 in the caloric share of foods
and products purchased by Canadian households
Sweet snacks
Soft drink and juices
Frozen dishes, pizzas
Margarine, sauces
Cheese
Salty snacks
Breakfast cereals
Sausages
Vegetables
Meat and chicken
Fruits
Milk
Wheat flour
Breads
Potatoes
Table sugar
Butter, cream
-20
-10
0
Moubarac et al. (2014) Can J Diet Pract Res. 75(1):15-21
10
20
Δ % TOTAL KCAL
Time changes in the dietary share (%) of ultra-processed
products in household food baskets in Canada and Brazil
% of total energy
60
Canada
50
43.7
40
54.9
■
~55
46.6
36.9
30
20
29.6
Brazil
26.1
24.4
21.0
18.7
10
0
1930 1940 1950 1960 1970 1980 1990 2000 2010
SOURCES: Martins et al 2013 Rev Saude Pub 47:656-65 and Moubarac et al. (2014) Can J Diet Pract Res. 75:15-21
Per capita retail sales of selected ultra-processed products
46 middle income countries: 1998-2012
Kg
Frozen products
Kg
Snacks
Soft drinks
L
8
8
80
6
6
60
4
4
40
2
2
20
0
0
0
▲ Upper-middle-income countries
■ Lower-middle-income countries.
Source: EUROMONITOR in: Monteiro, Moubarac, Cannon, Ng, and Popkin. Obes Rev 2013
Per capita retail sales of selected ultra-processed products
33 high income countries: 1998-2012
Frozen products
Snacks
Kg
L
Kg
40
40
140
30
30
130
20
20
120
10
10
110
0
0
100
Soft drinks
Source: EUROMONITOR in: Monteiro, Moubarac, Cannon, Ng, and Popkin. Obes Rev 2013
Annual per capita sales growth of selected ultra-processed
products regressed on per capita national income (1998-2012)
20
Snacks
15
15
-5
-5
Per capita GNI (US$)
-5
Per capita GNI (US$)
Per capita GNI (US$)
SOURCE: Monteiro, Moubarac, Cannon, Ng, and Popkin (2013). Ultra-processed products
are becoming dominant in the global food system. Obes Rev doi: 10.1111/obr.12107
50000
0
50000
40000
30000
20000
0
10000
0
50000
0
40000
0
30000
5
20000
5
10000
5
0
%
10
%
10
%
10
40000
% = -1,66 ln(GNI) + 19,23
R² = 0,41
% = -1,09 ln(GNI) + 12,51
R² = 0,34
% = -0,97 ln(GNI) + 10,20
R² = 0,39
30000
15
Soft drinks
20000
Frozen products
20
10000
20
• Extent and purpose of food processing: the key issue
• What is wrong with ultra-processed products
• The global shift from foods and freshly prepared
meals to ultra-processed products
• Implications for national and global public policies
Business as usual
(industry-driven product reformulation,
marketing self-regulation,
dietary guidelines which ignore food
processing)
Health-oriented fiscal policies,
government-driven marketing regulations,
food- and meal-based dietary guidelines,
Dietary Guidelines for the Brazilian Population
Issued by the Brazilian Federal Ministry of Health, Brasília DF
Draft. Has been for public consultation until 30 April 2014
http://www.saude.gov.br/consultapublica
THE FOOD
SYSTEM
The big issue for nutrition
Carlos Monteiro, Geoffrey Cannon
Renata Bertazzi Levy, Rafael Claro, Jean-Claude Moubarac
Ana Paula Martins, Maria Laura Louzada, Larissa Baraldi, Daniela Canella,
Diana Parra, Logan Mauney, Maluh Barciottte, Semiramis Domene
Centre for Epidemiological Studies in Health and Nutrition (NUPENS)
School of Public Health, University of Säo Paulo. Brazil