Public Health Nutrition: 12(5), 729–731
Nutrition and health. The issue is not food, nor nutrients,
so much as processing
Orthodox teaching and practice on nutrition and health
almost always focuses on nutrients, or else on foods and
drinks. Thus, diets that are high in folate and in green
leafy vegetables are recommended, whereas diets high in
saturated fat and in full-fat milk and other dairy products
are not recommended. Food guides such as the US Food
Guide Pyramid are designed to encourage consumption
of healthier foods, by which is usually meant those
higher in vitamins, minerals and other nutrients seen as
What is generally overlooked in such approaches,
which currently dominate official and other authoritative
information and education programmes, and also food
and nutrition public health policies, is food processing.
It is now generally acknowledged that the current
pandemic of obesity and related chronic diseases has as
one of its important causes increased consumption of
convenience including pre-prepared foods(1,2). However,
the issue of food processing is largely ignored or mini-
mised in education and information about food, nutrition
and health, and also in public health policies.
A short commentary cannot be comprehensive, and a
general proposal such as that made here is bound to have
some problems and exceptions. Also, the social, cultural,
economic and environmental consequences of food
processing are not discussed here. Readers’ comments
and queries are invited.
Three groups of processed foods
Almost all food and drink is processed in some way, and
processed foods and drinks do not form a homogeneous
group. Of great importance for human health are differ-
ences resulting from the type, intensity and purpose of
food processing. There is of course nothing wrong with
the modification of fresh foods by processing as such.
This commentary is not suggesting a ‘back to nature’
approach. Much depends on the type and intensity of
processing. Official and other authoritative guides may
indicate that the less some foods (such as cereals and
cereal products) are processed the better, without giving
much guidance on what this means. It is proposed here to
divide processed foods and drinks into three groups
(from now on, ‘foods’ should be taken to refer to foods
Group 1 is of minimally processed foods. It is of whole
foods that have been submitted to some process that does
not substantially alter the nutritional properties of the
original foods which remain recognisable as such, while
aiming to preserve them and make them more accessible,
convenient, sometimes safer, and more palatable. Such
processes include cleaning, removal of inedible fractions,
portioning, refrigeration, freezing, pasteurisation, fer-
menting, pre-cooking, drying, skimming, bottling and
packaging. Fresh meat and milk, grains, pulses (legumes),
nuts, and fruits, vegetables, roots and tubers sold as
such, are usually minimally processed in various ways.
Data from national food balance sheets compiled by
the FAO from 1961 to 2003 (http://faostat.fao.org) do
not indicate uniform trends for these foods: global sup-
plies per capita of meat and vegetables have increased,
whereasthose of pulses
Group 2 is of substances extracted from whole foods.
These include oils, fats, flours, pastas, starches and
sugars. Mostly they are not consumed by themselves.
Traditionally they are ingredients used in the domestic
preparation and cooking of dishes mainly made up of
fresh and minimally processed foods. Thus, oil is used in
the cooking of grains, vegetables and pulses and is added
to salads; flour is made into pastry and 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; and table sugar is added
tofruit- or milk-based desserts. FAO data (http://faostat.fao.org)
show the global supplies per capita of sugar and sweet-
eners increased by almost 30% between 1961 and 2003,
whereas those of vegetable oils more than doubled.
Now the use of group 2 foods has been transformed.
They have become the raw material bases for the third
group, of ultra-processed foods. These are made up from
group 2 substances to which either no or relatively small
amounts of minimally processed foods from group 1 are
added, plus salt and other preservatives, and often also
cosmetic additives – flavours and colours. This group of
foods includes breads, cookies (biscuits), ice creams,
chocolates, confectionery (candies, sweets), breakfast
cereals, cereal bars, chips (crisps) and savoury and also
sweet snack products in general, and sugared and other
soft drinks. Meat products such as nuggets, hot dogs,
burgers and sausages made from processed or extruded
r The Author 2009
remnants of meat can also be classified as ultra-processed
Ultra-processed foods are basically confections of
group 2 ingredients, typically combined with sophisti-
cated use of additives, to make them edible, palatable,
and habit-forming. They have no real resemblance to
group 1 foods, although they may be shaped, labelled
and marketed so as to seem wholesome and ‘fresh’.
Unlike the ingredients included in group 2, ultra-pro-
cessed foods are typically not consumed with or as part of
minimally processed foods, dishes and meals. On the
contrary, they are designed to be ready-to-eat (sometimes
with addition of liquid such as milk) or ready-to-heat, and
are often consumed alone or in combination (such as
savoury snacks with soft drinks, bread with burgers).
Ultra-processed products are typically branded, dis-
tributed internationally and globally, heavily advertised
and marketed, and very profitable. Growth in their pro-
duction and consumption has been spectacular in the last
decades in both higher- and lower-income countries. For
instance, the share of biscuits and soft drinks in the total
calories purchased by Brazilian families increased by over
200% and 400%, respectively, between 1974 and 2003(3).
In the USA, adolescents doubled their consumption of
soft drinks between 1965 and 1996, whereas consumption
of milk dropped by nearly 50%(4).
Processed foods and human health
How foods affect health depends on a number of factors,
one of which is their relative importance within diets.
One important factor is food nutrient density (nutrient per
energy unit) and food energy density (energy per
volume). Commonly consumed foods with low nutrient
density (of protein or vitamins, for instance) or high
nutrient density (of saturated fat or sodium, for instance),
as well as with extreme energy densities, unbalance diets
and cause either nutritional deficiencies or chronic dis-
eases (for example, obesity, dyslipidaemias and hyper-
tension), or both.
Traditional diets wholly or mainly made up from
unprocessed and minimally processed foods (group 1)
usually have adequate nutrient and energy density when
they contain a varied combination of plant foods (grains,
vegetables, pulses, fruits, nuts), only moderate quantities
of animal foods, and little salt. Even when the refined
ingredients from group 2 become a substantial part of
these traditional diets their overall quality may be still
As already indicated, diets are never made up just from
the substances from group 2 (extracted and refined oils,
fats, flours, starches and sugar), without any additions.
These are ingredients rather than foods and as such, with
the exception of refined sugar, by themselves are not
palatable. Apart from some oils of plant origin they are
also grossly depleted or devoid of micronutrients. In
themselves, and also as the basis of ultra-processed foods
in diets containing almost no fresh foods, they are hardly
compatible with survival.
This explains the problem with modern diets that
contain a lot of the ultra-processed foods in group 3.
While these diets usually do contain some group 1 plant
foods and meat and milk, they usually keep several of the
unhealthy features of the group 2 ingredients they are
mostly based on: low nutrient density, little dietary fibre,
and excess simple carbohydrates, saturated fats, sodium,
and trans fatty acids. They are also energy-dense. What
makes snacks, drinks, dishes and meals mainly made up
from the ultra-processed foods in group 3 different from
traditional dishes and meals that also use group 2 ingre-
dients, is that they are inalterable; they come ready-to-eat
or -heat. Diets that include a lot of ultra-processed foods
are intrinsically nutritionally unbalanced and intrinsically
harmful to health.
‘Premium’ ultra-processed foods are not a solution
The term ‘premium’ is used by the food manufacturing
industry to refer to ultra-processed foods that, compared
with ‘regular’ products, contain less fat, or no trans fats,
or less sugar, less salt, more added micronutrients, or
sometimes more whole foods such as fruits and nuts.
Some of these modifications, such as absence of trans fats
and limitation in salt content, are of course positive.
Others are at best no worse, such as reduction in fat but
increase in sugar content. Others may be harmful, such as
the addition of synthetic vitamins and minerals into soft
drinks or high energy-dense snacks: such ‘fortification’
with micronutrients will not make these products healthy
foods, but consumers are induced to think they are.
The same concern applies to ‘light’ products whose
‘reduced’ density in sodium, sugar or fat is still far higher
than recommended levels, and also to artificially swee-
tened drinks that stimulate cravings for sweetness, mak-
ing people more likely to eat sweet foods. Increasing the
proportion of whole foods in some ‘premium’ ultra-pro-
cessed foods is positive, but such products are typically
expensive and affordable only for a few. Higher prices
(and higher profits) are a general characteristic of all
‘premium products’. With few exceptions, ‘premium’
ultra-processed products are also unhealthy in them-
Ultra-processed foods induce unhealthy dietary patterns
Both ‘regular’ and ‘premium’ ultra-processed foods are
‘fast’ food, designed to be portable, convenient and
accessible. They induce eating patterns such as ‘grazing’
and skipping main meals, eating when doing other things
such as watching television, driving a car or working, and
eating alone. Extremely convenient packaged products
such as caloric soft drinks have created diets in which a
substantial amount of energy comes in liquid form. Liquid
calories are not part of the regular diet of any mammal,
except for milk during infancy, a period of rapid increase
in weight(5). There is growing evidence that consumption
of large quantities of caloric soft drinks may fool the
biological mechanisms responsible for satiety responses,
and cause over-consumption of energy and thus over-
weight and obesity(6,7).
A recent review of a vast array of sophisticated studies,
from neuro-imaging of the brain to elegant behavioural
human experiments, indicate that excess eating is largely
the result of automatic and uncontrollable responses to
unappreciated environmental cues such as food accessi-
bility and food advertisement. These studies contradict
the idea that eating and drinking behaviours are simply a
matter of conscious choice that can be educated(8).
Modern and sophisticated food marketing strategies are
concentrated on ultra-processed products such as soft
drinks, burgers and biscuits, not on minimally processed
foods like traditional staples such as grains and legumes,
or even on oil and sugar. The reason is well-known. Ultra-
processed foods and drinks are very profitable. Their
ingredients may cost the manufacturer a mere 5–10% of
the product’s retail price, and in the case of ‘premium’
products, even less.
From the point of view of human health, at present, the
most salient division of foods and drinks is in terms of
their type, degree and purpose of processing. Three main
divisions are specified. Given this, the best dietary advice
is to base diets on fresh and minimally processed foods,
and on dishes and meals made up from such foods with
the addition of refined ingredients extracted from whole
If the aim is to prevent disease and enhance well-being,
the best personal advice on ultra-processed products,
irrespective of their nutritional profiles, is to avoid them
or at least minimise their consumption. This approach
implies systematic revision of current official and
authoritative dietary guidelines and graphic guides to
food, nutrition and health.
It also implies a concerted approach to public policies.
There are no signs that leading food manufacturers are
prepared to withdraw many of their leading ultra-pro-
cessed products from sale, even those now aggressively
marketed at children, and they may say that their duty to
their shareholders prevents them from any such action. In
which case, the only rational approach for governments
and other authorities responsible for the protection of
public health will be fiscal and other formal policies
similar to those that make cigarettes and alcoholic drinks
more expensive and less accessible.
This commentary has benefited from pleasant and
stimulating discussions – and meals – I have had in the
last year or so with my colleagues Ine ˆs Castro, Renata
Bertazzi-Levy, Rafael Claro and Geoffrey Cannon. The
main ideas underlying the food classification proposed
here have been ‘cooked and seasoned’ with their
invaluable help. I also acknowledge and recommend the
work of Michael Pollan(9).
Carlos A. Monteiro
Professor, Department of Nutrition
Director, Center for Epidemiological Studies in Health
School of Public Health
University of Sao Paulo, Sao Paulo, Brazil
1.World Health Organization (2003) Diet, Nutrition and the
Prevention of Chronic Diseases. Report of a Joint WHO/FAO
Expert Consultation. WHO Technical Report Series no. 916.
World Cancer Research Fund/American Institute for Cancer
Research (2009) Policy and Action for Cancer Prevention.
Food, Nutrition, and Physical Activity: A Global Perspec-
tive. Washington, DC: AICR.
Levy-Costa RB, Sichieri R, Pontes NS & Monteiro CA (2005)
Household food availability in Brazil: distribution and
trends (1974–2003). Rev Saude Publica 39, 530–540.
Cavadini C, Siega-Riz AM & Popkin BM (2000) US
adolescent’s food intake trends from 1965–1996. Arch Dis
Child 83, 18–24.
De Graaf C (2006) Effects of snacks on energy intake: an
evolutionary perspective. Appetite 47, 18–23.
Mattes R (2006) Fluid calories and energy balance: the
good, the bad, and the uncertain. Physiol Behav 89, 66–70.
Ludwig DS, Peterson KE & Gortmaker SL (2001) Relation
between consumption of sugar-sweetened drinks and
childhood obesity: a prospective, observational analysis.
Lancet 357, 505–508.
Cohen DA (2008) Obesity and the built environment:
changes in environmental cues cause energy imbalances.
Int J Obes (Lond) 32, S137–S142.
Pollan M (2008) In Defense of Food: An Eater’s Manifesto.
New York: The Penguin Press.
Invited commentary 731