Commentary

BMJ Glob Health: first published as 10.1136/bmjgh-2021-007240 on 21 December 2021. Downloaded from http://gh.bmj.com/ on March 26, 2024 by guest. Protected by copyright.
‘Warning: ultra-­processed’ — A call for
warnings on foods that aren’t really foods
Trish Cotter, Alexey Kotov, Shuo Wang, Nandita Murukutla

To cite: Cotter T, Kotov A, It's high time that consumers had the
Wang S, et al. ‘Warning: Summary box
opportunity to see ultra-­processed foods for
ultra-­processed’ — A call for
warnings on foods that aren’t
what they are: foods that are not real foods, ►► The health harms of ultra-­processed foods are well
really foods. BMJ Global Health containing nutrients but not real nutri- documented, but consumers are not informed or
2021;6:e007240. doi:10.1136/ tion, pervasively marketed by supranational warned about these risks.
bmjgh-2021-007240 companies offering choices that are not real ►► Government action and public education should
choices. Despite the robust evidence that articulate that diets high in ultra-­processed foods
Handling editor Seye Abimbola links ultra-­processed foods to serious health are harmful, and policies should aim to reduce that
consequences,1–4 our research indicates that harm.
Received 20 August 2021 ►► Introducing warnings as part of existing or new
Accepted 8 October 2021 the public does not fully understand this
front-­of-­package nutrient labels on food packages
group of products, and it suggests that they would specifically identify ultra-­processed foods and
might be in the dark about the urgent actions give consumers important information at the point
that could be taken to prevent its dire harms.5 of purchase.
Simply put, ultra-­processed foods are foods ►► Tobacco-­ style campaigns on the harms of ultra-­
that can’t be made in your home kitchen processed foods might help to avert the looming
because they have been chemically or physi- threat to consumers' health by quickly building their
cally transformed using industrial processes. awareness.
They are recognisable on the supermarket
shelf as packaged foods that are ready-­to-­eat,
industry invests many millions in formulating
contain more than five ingredients and have
and marketing them to be highly desirable.
a long shelf-­life.6 The industrial processing, as
While the term ‘ultra-­processed food’ has
well as the cocktail of additives, flavours, emul-
gained much attention in the academic and
sifiers and colours they contain to give flavour
nutrition community over the past 10 years,
and texture, make the final product hyper-­ many advocates have taken to describing
palatable or more appealing and potentially these as ‘products’, to indicate that they are
addictive, which in turn leads to poor dietary not ‘real’ foods but formulations of food
patterns.6–8 substances.11 Unfortunately, the public
With more than half the total calories remains largely unaware of the risks of
consumed in high-­income countries coming consuming them.
from ultra-­ processed foods and rapid What do consumers know about ultra-­
increases in low- and middle-­income coun- processed foods?
tries, these products are exposing billions of Surveys and qualitative focus groups in
people to a higher risk of type 2 diabetes, heart Colombia and Brazil have enabled us to
disease, stroke, depression and death.1 4 9 Your gather some insight into public percep-
grandparents wouldn’t have used or even tions of ultra-­processed foods (full details in
recognised them. In the half century or so Wang5). We found evidence that while people
© Author(s) (or their since ultra-­processed foods became available, are not familiar with the term ‘ultra-­processed
employer(s)) 2021. Re-­use diets high in those products have largely products,’ they recognise the group of prod-
permitted under CC BY-­NC. No
commercial re-­use. See rights
displaced traditional and healthier diets, and ucts as harmful. That said, these products are
and permissions. Published by ultra-­processed foods have been among the also associated with positive emotions, which
BMJ. most aggressively promoted and marketed might be the result of decades of persuasive
Vital Strategies, New York, New products in the world.10 In addition, their marketing by the food industry. For instance,
York, USA intensive marketing has led to rapidly growing a considerable number of people associate
Correspondence to
sales in low- and middle-­income countries.9 10 the products with satisfying cravings, being
Trish Cotter; Worldwide, palates (and brains) have been tasty and bringing joy. People associate
​tcotter@​vitalstrategies.​org trained to crave these foods while the food ultra-­
processed products with family, social

Cotter T, et al. BMJ Global Health 2021;6:e007240. doi:10.1136/bmjgh-2021-007240  1

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gatherings, children, ‘ease’ and even breakfast and phys-
ical activity. For public health efforts to be successful in
reducing harm, it is crucial that the term ‘ultra-­processed
products’ itself—and the need for their regulation—is
clearly and consistently understood.5
To date, much of the evidence, policy and public
messaging about unhealthy food has focused on specific Figure 1 Proposed warning label for ultra-­processed food
nutrients—saturated fats, sodium and sugar. Informing (Vital Strategies).
the public about the harms of ultra-­processed food will be
difficult as long as the term is poorly understood. Aside Another approach is to warn consumers on the packaging
from Brazil, where the level of food processing forms the itself. A number of countries have introduced or propose to
basis of the Brazil Dietary Guidelines,12 public exposure introduce front-­of-­package warning labels on unhealthy food
to the term is low but growing. Recent notable references as they look for policy levers to improve population nutri-
have appeared in global news media (BBC, Forbes, etc), tion status in an effort to reduce the unsustainable burden
in several Latin and Central American countries, and in of poor diets on individuals, governments and society. These
public education mass media campaigns in Colombia existing efforts warning about foods that are high in satu-
and Brazil. rated fat, salt and sugar could be further strengthened by
Much as marketers build a brand, the public health incorporating an ‘ultra-­processed’ warning label to signal
community needs to build meaning around the term an independent, additional measure of unhealthiness.
‘ultra-­processed’. The best brand names are evocative, Such a label would enhance consumers’ existing knowledge
but even a bland name can be infused with meaning by a about harmful single nutrients to a broader understanding
good marketing campaign. While we’ve seen food, alcohol of unhealthiness based on the level of food processing.
and tobacco companies shamelessly build positive brand Imagine a label on the front of a box of cookies, packet of
images around their harmful products, the public health cereal or bag of crisps that says: ‘Warning: this product is
community has been notoriously negligent of public ultra-­processed AND it is high in (saturated fat/salt/sugar)’
health messaging and branding. ‘Non-­ communicable (figure 1).
diseases’ is a case in point, a clunky, technical term that For those countries that have already adopted front-­of-­
defines an important category of diseases—cancer, heart package labels and for those that see the enormous public
disease, diabetes and more—by what they are not, and is health potential of nutrient warning labels, our proposal
little known outside public health circles. is not to ‘throw the baby out with the bathwater’ but to
Aspects of a comprehensive global response to the build on successes and consider incorporating ultra-­
proliferation of ultra-­ processed foods and beverages processing and strong public education campaigns into
can be learnt and adapted from other strong public future updates as an acknowledgement of the current
health efforts to deal with the equally devastating harms strength and growing breadth of evidence.
of dangerous products. Look no further than tobacco
control to see where the public health community has Acknowledgements The authors gratefully acknowledge Bloomberg
Philanthropies for their generous support, Rob Moodie for his review, Johnny
achieved huge policy wins and strong public under- Hsu and Rebecca Still for design, and Ally Davis and Karen Schmidt for editorial
standing of the consequences of consuming a dangerous support.
product. Much of this success is a result of using tried Contributors Conceptualisation: TC, NM and AK; formal analysis: SW and NM,
and tested marketing techniques coupled with a faithful writing – original draft: TC and NM, writing – review and editing: TC, AK, NM. All
adherence to the science of tobacco’s harms. authors have read and agreed to the published version of the paper.
If we are to stave off the devastation to our food Funding This work was supported by grants from Bloomberg Philanthropies.
system and our health, governments with the support However, Bloomberg Philanthropies was not involved in any aspect of the
evaluation studies or in the writing of this paper.
of the global public health community need to urgently
implement effective strategies that lead to decreasing Competing interests None declared.
consumption of these unhealthy products and enable Patient consent for publication Not applicable.
healthier choices. One such strategy would be to estab- Provenance and peer review Not commissioned; externally peer reviewed.
lish the image of ultra-­processed foods—those glossily Data availability statement There are no data in this work.
packaged, alluringly marketed, ready-­to-­eat, convenient Open access This is an open access article distributed in accordance with the
and tasty products—as the vector for obesity and a risk Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
factor for serious diseases alongside tobacco, alcohol permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
and other unhealthy commodities. It’s time to invest
properly cited, appropriate credit is given, any changes made indicated, and the
in establishing the negative brand identity that ultra-­ use is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
processed foods and beverages deserve. We could start
by taking lessons learnt from tobacco control to build
public awareness and campaigns that reveal the true REFERENCES
1 Pagliai G, Dinu M, Madarena MP, et al. Consumption of ultra-­
nature of these products and the looming threat to processed foods and health status: a systematic review and meta-­
consumers’ health. analysis. Br J Nutr 2021;125:308–18.

2 Cotter T, et al. BMJ Global Health 2021;6:e007240. doi:10.1136/bmjgh-2021-007240

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2 Baker P, Machado P, Santos T, et al. Ultra-­processed foods and 8 Gearhardt AN, Hebebrand J. The concept of "food addiction"
the nutrition transition: global, regional and national trends, food helps inform the understanding of overeating and obesity: debate
systems transformations and political economy drivers. Obes Rev consensus. Am J Clin Nutr 2021;113:274–6.
2020;21:e13126. 9 Moodie R, Bennett E, Kwong EJL, et al. Ultra-­processed profits:
3 Monteiro CA, Lawrence M, Millett C, et al. The need to reshape
the political economy of countering the global spread of ultra-­
global food processing: a call to the United Nations Food Systems
Summit. BMJ Glob Health 2021;6:e006885. processed foods - a synthesis review on the market and political
4 Popkin BM, Barquera S, Corvalan C, et al. Towards unified and practices of transnational food corporations and strategic public
impactful policies to reduce ultra-­processed food consumption and health responses. Int J Health Policy Manag 2021. doi:10.34172/
promote healthier eating. Lancet Diabetes Endocrinol 2021;9:462–70. ijhpm.2021.45. [Epub ahead of print: 24 May 2021].
5 Wang S. Public perceptions of ultra-­processed products: findings 10 Monteiro CA, Moubarac J-­C, Cannon G, et al. Ultra-­processed
from studies of adults in Brazil and Colombia. Vital Strategies 2021 products are becoming dominant in the global food system. Obes
https://www.​vitalstrategies.​org/​resources/​public-​perceptions-​of-​ Rev 2013;14(Suppl 2):21–8.
ultra-​processed-​products
11 Marti A. Ultra-­processed foods are not “real food” but really affect
6 Monteiro CA, Cannon G, Levy RB, et al. Ultra-­processed foods:
what they are and how to identify them. Public Health Nutr your health. Nutrients 2019;11:1902.
2019;22:936–41. 12 Monteiro CA, Cannon G, Moubarac J-­C, et al. Dietary guidelines
7 Scrinis G. Ultra-­processed foods and the corporate capture of to nourish humanity and the planet in the twenty-­first century. A
nutrition. BMJ, 2020: m4601. blueprint from Brazil. Public Health Nutr 2015;18:2311–22.

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