Since prehistoric times, people have processed food to make it more palatable and safe. In the last 100 years, industrial techniques have become more prevalent in producing novel ultra-processed foods and drinks.
Evidence is mounting that ultra-processed food consumption is linked to an increased risk of noncommunicable diseases, creating a public health challenge.
Changes in global eating patterns
Globally, the consumption of ultra-processed food varies. In 2016, North America, Australasia, and Africa sold 271 kg of ultra-processed food per capita, while only 52 kilograms were sold in Africa.11 While sales fell or stagnated in regions with the highest consumption, Western Europe and North America, Australasia and Africa, sales of ultra-processed products increased in other regions from 2002-16, by a minimum of 20% in Latin America and the Caribbean to a maximum around 90% in South East Asia.11 Some studies in high-income countries report an inverse relationship between ultra
As the market for ultra-processed food becomes saturated in high-income countries, there are signs of a “problem shift” in lower-income countries. It has been estimated, for example, that Coca-Cola makes up to three-quarters of their global sales with ultra-processed beverages 17, invested over $1bn in each of China (PS0.8bn), Brazil (EUR0.9bn), Mexico, and Africa during the early 2010s.
Noncommunicable disease risk
There is increasing evidence that eating ultra-processed food is linked to obesity and noncommunicable disease. A longitudinal analysis of data collected from 2002-2016 found that ultra-processed food sales were positively correlated with men’s BMI, as well as ultra-processed drink sales. This finding is in line with a randomized controlled study comparing unrestricted ultra-processed and unprocessed eating patterns (matched in terms of total energy, macronutrients, sugar, salt, and fiber). Participants randomized to an ultra-processed meal consumed 508 more calories per day on average than those who ate.
Many prospective cohort studies also report associations between ultra-processed food consumption and noncommunicable disease outcomes. The consistent signals from different study designs, using different definitions for both exposure and outcome, strengthen the claim that increased consumption of ultra-processed food is associated with an increased risk of noncommunicable diseases.
These products tend to have higher energy density, free sugars, sodium, and saturated fats than less processed alternatives. These products are higher in energy density and free sugars and sodium than less-processed alternatives.
Factors encouraging overconsumption
Other factors may encourage overconsumption. Many consumers find ultra-processed food convenient. Shelf-stable products can reduce the need to shop frequently or refrigerate food.
The marketing of food can also influence the purchasing and consumption of foods, especially among children. 1 2 Because ultra-processed products tend to last longer than less-processed ones, there is a lower risk for waste on behalf of both manufacturers and retailers. They can afford to make small profits on each sale but must sell large volumes to generate revenue. This is why marketing is necessary. Marketing is also essential because of the increasing concentration of the global food market. A few brands are dominating the market.
Even though more research is required to determine the mechanisms by which ultra-processed food can harm health, public health actions could still be justified while this work continues.
Reliance on nutrition reformulation
The sliding scale design of South Africa’s health promotion levy, which taxes drinks based on their sugar concentration, has resulted in reduced sugar concentration in drinks. The sliding scale design for South Africa’s Health Promotion Levy, which taxes beverages based on sugar content, has led to a reduction in sugar concentration in drinks.
Some of these reformulation strategies could also serve a dual purpose by limiting the factors that drive the consumption of ultra-processed food. Chile’s restrictions on marketing foods that did not meet formulation targets reduced both children’s exposure and the marketing of such products 33.
Reformulation can also have perverse effects. For example, a focus on reducing unhealthy fats may lead to an increase in free sugars. Reformulations can also have perverse consequences. For example, a reduction in unhealthy fats could lead to a rise in free sugars. Modifying nutrient contents will not solve the problem if ultra-processing itself is harmful.
Reformulations based on nutrient-to-limit reflect a focus in dietary public policy that is more focused on nutrients than food and food practices. Suppose ultra-processing leads to overconsumption through non-biological mechanisms. In that case, intervening in those mechanisms may lead to greater improvements in global health than focusing on the biological harms caused by individual nutrients. International public health nutrition policies should not focus on how to make incremental changes to the nature of ultra-processed food. Still, they should promote access and affordability for affordable, convenient, and palatable minimally processed meals and foods.
Whole food reformulation
Whole food reformulation, or the development of less processed substitutes, is an alternative to nutrient-specific reformulation. There are already alternatives to many ultra-processed food products (e.g., canned fruit in place of “leathers” and rolled whole grains instead of ultra-processed breakfast cereals). This shows that the idea is feasible. The importance of the food sector to the global economic system will make it important for agricultural and financial incentives that support the development of new products and maintain profits.
The affordability of whole food reformulations is a key concern. 28 At present, less-processed alternatives are more expensive than ultra-processed foods 35. Fiscal levers can be used to maintain affordability. Taxes and subsidies can increase the cost of ultra-processed foods and drinks and their ingredients. In the same way, increasing subsidies and decreasing taxes can reduce the price of less-processed alternatives and their ingredients. For example, many countries have implemented consumer-facing taxes on sugar-sweetened drinks. Recent systematic reviews found that they are associated with significant decreases in the consumption of taxed drinks and non-significant increases in untaxed beverages. 36 Altering the current tax and subsidy structures for food manufacturers and producers could further support whole foods reformulation. Subsidies on corn production, for example, in the US, are implicated in the widespread usage of high-fructose syrup in ultra-processed food.
From home to hand-prepared
In both countries, a greater emphasis on food prepared at home is a core strategy for achieving this goal. It may be better to focus on food that is “hand-prepared” irrespective of where it comes from.
There are many reasons why people do not prepare more food at home, including lack of time, inability to access affordable ingredients and adequate kitchen facilities, high costs of cooking fuel, and preferences for ultra-processed foods. There are many reasons people don’t prepare more food at their homes, such as lack of time, inability to afford ingredients, inadequate kitchen facilities and high cooking fuel costs.
Hand-prepared food is a good alternative to relying more on home cooking. This is food that is prepared by hand using less processed ingredients, but it is not always prepared at home. Not all hand-prepared food is nutritional 42 or made with less processed ingredients. Hand-prepared food must be priced similarly to ultra-processed food.
Increase consumption of food prepared by hand.
You can consider strategies at all levels: household, community, retail, and national. ( Table 2). Many of these strategies are aimed at increasing the availability of hand-made food. However, they can also increase the perceived value, which will drive demand.
Meal kits that include premeasured ingredients with illustrated recipe cards can help support the home preparation of food by reducing the time, energy, and motivation required to prepare and shop for meals. Recipe boxes are a relatively new dietary intervention. In Australia, boxes contain contents that can be improved for maximum healthfulness. However, they are prohibitively costly (AU$11.65; PS6.40; EUR7.20; $8 per portion).
Many people look to “quick and easy” recipes as a way to make up for the lack of time they have in their homes. It may be more efficient to increase the predictability of available time by imposing maximum working hours and having stable employment contracts and regular schedules. Other barriers to home cooking could be overcome by ensuring that there is better access to ingredients at affordable prices (through tax and subsidy policies), kitchen facilities and fuel (through building codes), and adequate kitchen facilities.
Various meal-sharing strategies are being proposed within communities to reduce the effort needed to prepare food by hand. Some of these include meal preparation in large groups at central facilities and sharing meals with neighbors.
Retailers can also provide more affordable and nutritious food. Street food vendors offer cheap, convenient food that is of low nutritional value. Recently, efforts have been made to improve the nutritional value of street food.
At the national level, policies on food procurement could be used to influence the food served by public sector establishments, such as schools and hospitals. 47 They could focus on favoring hand-prepared food over ultra-processed foods, although enforcing these may be difficult in some places.
Synergistic Actions
We have described several strategies to rebalance the availability, affordability, and consumption of ultra-processed food and alternatives that are less processed. They address both the biological and wider mechanisms of harm caused by ultra-processed food. The fact that they are not all novel shows how ultra-processed food does not present a unique threat to public health. The lens of ultra-processed food offers an opportunity to re-conceptualize the policy problem of inadequate nutrition in a manner that reinforces the need for structural strategies rather than simply continuing reformulation, educational, or motivational approaches. Researchers and policymakers may also be able to redefine the outcomes they are interested in. Likely, many structural interventions that have the potential to improve public health will affect the intake of a wide range of foods and nutrients. 48 One way to capture the broad effects of these interventions is to evaluate the impact on ultra-processed diet intake.
A single intervention is unlikely to produce a significant change. Simultaneous action in several areas can have a multiplier effect. Changes in supply and demand, for example, cannot be considered separately. The supply side of modifications to what food consumers have access to financially (through fiscal intervention), cognitively (through changes to food marketing), or physically (through the changes to what food is displayed at supermarkets) will only be economically feasible if there is a demand-side change that leads consumers to place greater value on food prepared by hand. The economic impacts of changing demand on food producers will only be felt if early supply changes are made so that consumers get something different from demand.
The global presence of ultra-processed food companies highlights the need for coordinated actions not only within countries but also across borders. A successful action to reduce the sale of ultra-processed food in high-income nations may lead to an effort to create compensatory growth for poorer countries. Global policy actors, such as the World Health Organization, can support our comprehensive approach. The environment would be favorable if recommendations were made that supported, for instance, whole-food approaches to reformulation and consideration of community food facilities when designing urban areas, as well as protection of policy spaces for strong nutrition policies such as taxes and labeling.
The growing awareness of the harmful effects of ultra-processed food provides an opportunity to shift global dietary policy from a focus on individual nutrients and eating habits towards a focus on the larger social, economic, and commercial drivers that lead to the overproduction and consumption of certain types of foods over others. This should ensure that those who are most vulnerable or food insecure benefit from this approach. To take advantage of these opportunities, coordinated action will be needed at the local, national, and transnational levels.
Key messages
- Food and beverages that have been ultra-processed contain ingredients from industrial processes.
- Evidence is mounting that a higher consumption of ultra-processed food increases the risk of noncommunicable diseases.
- Public health efforts must focus on broader determinants of consumption rather than specific nutrients or individual behaviors.
- Structures are needed to improve access to affordable, convenient, and palatable minimally processed food and dishes.
- To reduce consumption, it is necessary to simultaneously change the supply and demand at the local, national, and transnational levels.
Footnotes
- Contributors and sources JA is the leader of publicly funded and charitable research into population-level influences on dietary public and interventions that have the potential to improve it. KH is the leader of a research-to-policy unit in public health that focuses on identifying “best buys” for improving health outcomes and setting priorities. J-CM has a background in anthropology and public health. He has contributed to the creation of the Nova System and applied it to monitor the consumption of ultra-processed foods in Canada and around the world and assess their impact on diet and human health. He is also interested in the commercial determinants of health and public policy to promote healthy and sustainable food systems. AMT is the leader of a research program on nutrition policy. She has published extensively on policy analyses and the political economy behind increasing nutrition consideration in food system policies. The article is based on the collective experience of the authors and their review of public domain material. JA led the drafting, and all authors participated in developing the arguments, reviewing the literature, making comments, and editing earlier drafts. All the authors approved the final version. JA is the guarantor.
- Competing Interests: We have read and understand the BMJ policy regarding declarations of interest. The following is a declaration: JA has been funded by the Centre for Diet and Activity Research. CEDAR is a UK Clinical Research Collaboration Public Health Research Centre of Excellence with funding from the British Heart Foundation (BHF), Cancer Research UK (CRUK), Economic and Social Research Council (ESRC), Medical Research Council (MRC), National Institute of Health Research(NIHR) and Wellcome Trust. JA was a member of panels advising governmental organizations and charities. KH is a Fellow of the Academy of Science of South Africa. He has served on several national health committees, task teams at ministerial levels, and as a member of various ecclesiastical task forces. J-CM was a key contributor to the development of the Nova system and worked as a consultant with the Food and Agriculture Organization of the United Nations and PAHO. He is a part of the WHO Nutrition Policy Sub-Group, Nutrition Guidance Advisory Group. This group is responsible for developing official policy guidelines on nutrition.
