Content uploaded by Phillip Baker
Author content
All content in this area was uploaded by Phillip Baker on Aug 06, 2020
Content may be subject to copyright.
1
Ultra-processed foods and the nutrition transition: global, regional and national trends, food
systems transformations and political economy drivers
Phillip Baker1,2, Priscila Machado1,2, Thiago Santos3, Katherine Sievert2, Kathryn Backholer4, Michalis
Hadjikakou5, Cherie Russell2, Oliver Huse4, Colin Bell4, Gyorgy Scrinis6, Anthony Worsley1,2, Sharon
Friel7, Mark Lawrence1,2
1. Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia
2. School of Exercise and Nutrition Science, Deakin University, Geelong, Australia
3. Federal University of Pelotas, Pelotas, Brazil
4. Global Obesity Centre, Deakin University, Geelong, Australia
5. School of Life and Environmental Sciences, Deakin University, Geelong, Australia
6. School of Agriculture and Food, University of Melbourne, Melbourne, Australia
7. School of Regulation and Global Governance, Australian National University, Canberra, Australia
Corresponding author details: Phillip Baker, Institute for Physical Activity and Nutrition, Deakin
University, Geelong, Australia; phil.baker@deakin.edu.au
Link to publication in Obesity Reviews: https://doi.org/10.1111/obr.13126
Key words: ultra-processed foods, sugar-sweetened beverages, palm oil, nutrition transition, food systems,
commercial determinants of health
Running title: Ultra-processed foods and the nutrition transition
Conflicts of interest: The authors declare no conflicts of interest.
Acknowledgements: Phillip Baker received income through an Alfred Deakin Postdoctoral Research
Fellowship provided by Deakin University.
Abstract
Understanding changes in global ultra-processed food (UPF) consumption and associated drivers is
essential, given mounting evidence linking these foods with adverse health outcomes. In this synthesis
review we take two steps. First, we quantify per capita volumes and trends in UPF sales, and ingredients
(sweeteners, fats, sodium, cosmetic additives) supplied by these foods, in countries classified by income
and region. Second, we review the literature on food systems and political economy factors that may explain
the observed changes. We find evidence for a substantial expansion in the types and quantities of UPFs
sold worldwide, representing a transition towards a more processed global diet, but with variations between
regions and countries. As countries grow richer, more UPFs and a wider variety of UPFs are sold. Sales
volumes are highest in Australasia, North America, Europe and Latin America, but are growing most
rapidly in Asia, the Middle East and Africa. These developments are closely linked with the industrialisation
of food systems, technological change and globalisation, including growth in the market and political
activities of transnational food corporations, and inadequate governance and policy responses. The scale of
dietary change underway, especially in highly-populated middle-income countries, raises serious concern
for global health.
2
Introduction
In this paper, our starting premise is that human diets have become more highly processed in recent decades,
with important consequences for global nutrition, public health and the environment. Although several
schemas for categorising foods according to their degree of processing have been proposed 1, the NOVA
system developed by Monteiro and colleagues has become the most widely used in research and policy 1-3.
This distinguishes between four categories of food: unprocessed and minimally processed foods as edible
parts of whole foods, modified without adding new substances to extend shelf-life, safety or palatability
(e.g. milled cereals, meats, eggs, milk, vegetables, nuts and seeds); processed culinary ingredients as
extracted substances, or substances collected from nature, for use in food preparation (e.g. vegetable oils,
vinegar, butter, sugar and salt); processed foods as combinations of culinary ingredients, unprocessed or
minimally processed foods (e.g. canned fish, cheese, artisanal breads, cured meats); and ultra-processed
foods as ready-to-consume and ready-to-heat formulations, made by combining substances derived from
foods with cosmetic additives, typically through a series of industrial processes (e.g. soft drinks,
confectionary, savoury snacks, many packaged breads and sweet biscuits) 4.
Foods in the first three NOVA categories have long been dietary staples. Basic food processing has played
an important role in human nutrition and evolution ever since the use of fire began between 1.5 and 2
million years ago 5-8. The conversion of foraged and cultivated foods into more palatable, safe, nutritious
and durable forms – through, for example, heating, cutting, grinding, drying, salting, fermenting and
smoking – enabled hunter-gatherers and pastoral groups to thrive across many ecological zones, and later
in the agrarian era (beginning ~12,000 years ago) the growth of cities and entire civilizations 5, 7, 8. This
continues today in the production of artisanal foods and in the preparation of a wide variety of traditional
and modern cuisines using combinations of culinary ingredients, unprocessed and minimally processed
foods 6, 8. The mass-production and global trade in non-perishable processed food commodities (e.g. sugar,
tea, coffee and cocoa) accelerated during the colonial and mercantile-industrial eras (circa. 1870s onwards),
alongside the invention of canning, refrigeration and steam-powered transport (e.g. meats, butter, canned
meats, vegetables and fruits) 8, 9.
More recently (circa. 1950s onwards), ultra-processed foods (UPFs) have become a significant, and in some
cases the main, source of dietary energy in high-income countries including the United States, Canada, the
United Kingdom and Australia 3, 4. Such foods have only became available on a truly global-scale during
the current era, characterised by the globalisation of food systems (i.e. post-1970s) 1. They now play a key
role in the ‘nutrition transition’ underway in low- and middle-income countries, involving a shift away from
traditional diets towards those linked with obesity and diet-related non-communicable diseases 10-14.
Because such countries, for example Brazil, China, Indonesia, India and South Africa are home to more
than two-thirds of the world’s population, the dietary changes that are occurring have massive implications
for global health 13, 14. These developments also affect nutrition equity within countries 15. In high-income
countries, UPF consumption is inversely associated with socioeconomic position 16-18, whereas the reverse
is observed in middle-income countries 19, 20. This indicates a ‘social transition’ in consumption from higher
to lower socioeconomic groups as country income increases, as found with obesity 21. Although the adverse
health outcomes associated with some forms of basic food processing are well known (e.g. removing rice
husks and resulting thiamin deficiency and beriberi in populations with staple white rice diets) 8, the adverse
outcomes associated with more intensive forms of food processing – and in particular ultra-processing –
have only recently come under scrutiny 1.
3
Evidence for the health implications of food processing is mounting 22. Population-based cross-sectional
and cohort studies applying the NOVA classification system in high and middle-income countries find that
a greater contribution of UPFs to total energy intake results in poorer dietary quality 23-28, and also higher
risks of all-cause mortality 18, 29-31, obesity 32-36, cardio-metabolic diseases 37-41, cancer 42, gastrointestinal
disorders 43, asthma 44, frailty 45, and depression 46, 47. Ecological studies and systematic reviews find that
regular consumption of certain types of UPFs is associated with adverse outcomes, including sugar
sweetened beverages with obesity and type-2 diabetes 48-53, fast food with poor diet quality and obesity 54,
55, processed meat with colorectal cancer 56. The level of processing per se as an independent risk factor,
comes from a randomised controlled trial finding that an ultra-processed diet relative to an unprocessed one
causes excessive calorie intake and weight gain 57, and three cohort studies showing an association between
UPF consumption and weight gain, obesity, type-2 diabetes or hypertension risk, which remained
significant after controlling for nutrient composition or overall diet quality 34, 37, 40.
Evidence on the mechanisms linking UPFs with adverse health outcomes is emerging 22. It includes poor
nutritional profile (e.g. as vectors for added sugars, sodium and trans-fats) and displacement of unprocessed
or minimally-processed foods and associated fibre and beneficial nutrients in the diet 58-61, higher glycaemic
load and reduced gut-brain satiety signalling resulting from alterations in the physical properties of foods
(e.g. degradation of the food matrix during processing) 62-65, contamination with carcinogens formed during
high-temperature cooking (e.g. carbohydrate-rich foods with acrylamide, and meats with hetero-cyclic
amines) 66, 67, links between certain industrial food additives or clusters of additives and gut microflora
dysbiosis, increased intestinal permeability and inflammation 68-70, and endocrine disruption from chemical
plasticizers (e.g. bisphenols, phthalates) used in food packaging 71-74. Certain properties of UPFs may also
promote overconsumption, including their convenience 75-77, hyper-palatability and quasi-addictiveness for
susceptible individuals 78, 79, and the use of sophisticated and intensive marketing practices, often targeting
children 80-82. High consumption of added sugars in early childhood is associated with inter alia increased
preferences for sweet food 83, and dental caries 84. Food processing uses significant environmental resources
in the form of energy, water and packaging materials, and generates much of the plastic waste stream
entering marine ecosystems 85-87.
Recent studies also demonstrate the links between the nutrition transition and food systems dynamics –
changes in the inputs, actors and activities relating to the production, processing, distribution, preparation,
consumption and disposal of food 13, 88. Nutrition transition studies show that alongside changes in factors
generally associated with economic development and food systems change – including income,
urbanisation, technology and labour markets – there is also a shift away from traditional diets to those
higher in animal-sourced foods, vegetable oils, refined carbohydrates and caloric sweeteners 11, 89, 90.
Comprehensive empirical studies also implicate increasing processed and ultra-processed food
consumption as a central feature of the nutrition transition 14, 91-94. A growing number of studies further
demonstrate the importance of the underlying technological and political economy drivers of food systems.
These include trade and investment liberalisation, the global expansion of transnational food and beverage
corporations and their market and political activities, alongside changes in food production, processing and
marketing technologies, and the failure of policies and regulations designed to protect and promote healthy
diets in these new contexts 90, 91, 95, 96. As markets for UPFs have stagnated in high-income countries, food
and beverage corporations headquartered in the advanced capitalist economies of the United States and
Europe, are vigorously pursuing new growth opportunities throughout the Global South 95-97.
4
Despite the importance for global nutrition and public health, few systematic analyses of global trends,
patterns and drivers of UPF markets exist. In this analysis, we build on earlier work 14, 98-100, but also draw
from a wider literature and more comprehensive data set to address several key questions. First, to what
extent has growth in UPF markets continued, accelerated or abated in recent decades globally, across
regions and countries, and in which product categories? Second, what are the contributions of UPFs as
‘vectors’ for ingredients linked with obesity and diet-related NCDs, including sweeteners, oils and fats,
sodium, and cosmetic additives? Third, have all regions and countries undergone a similar food processing
transition, or are there transitions with substantial differences between them? If there are differences among
otherwise similar countries, what food systems and political economy factors may explain the observed
trends and variations? Although defined as a ‘processed culinary ingredient’ by NOVA, we also include
vegetables oils in our analysis, given the importance of this category in the nutrition transition and as an
ingredient used in UPF manufacturing 101.
Methods
Given the complexity of the research topic and the diversity of quantitative and qualitative data sources
required to address the aim, we adopted a mixed methods synthesis review method 102, 103. This combined
a) a quantitative analysis of worldwide trends and patterns in the apparent consumption of UPFs, including
‘risk ingredients’ linked to various categories, using per capita market sales data; with, b) a qualitative semi-
structured review of relevant literature on the drivers of food systems change, including relevant political
economy factors, to understand the results found in (a). Although the UPF concept, as defined by NOVA,
includes both food and beverage categories, from hereon we differentiate between ultra-processed foods
(UPF) and ultra-processed beverages (UPB) for analytical purposes.
Countries: Data on UPF and UPB sales volumes were available for 80 countries. For comparability we
followed Vandevijvere et al. 99 by classifying these countries by World Bank income category and Global
Burden of Disease Study regions (Table S1). These included 38 high-income countries (HICs), 26 upper-
middle income countries (UMICs), and 16 lower-middle income countries (LMICs), making-up 47.5%,
32.5% and 20% of the total number of countries respectively. The eight regions used were Africa, Central
and East Asia, Central and Eastern Europe, Latin America and Caribbean, North Africa and Middle East,
North America and Australasia, South and Southeast Asia and Western Europe.
Data sources: Globally comparable, nationally representative longitudinal household expenditure or
individual food intake survey data for UPFs and UPBs was unavailable. This at least partly reflects
inadequate provision for these products in standard instruments for measuring dietary change in
transitioning countries 104. Consistent with similar analyses 14, 48, 100, we instead adopted country-level sales
volume data (kilograms sold through combined retail and food service channels) from the Euromonitor
Passport database for the years 2006-2019, with projections to 2024 105. Guided by the NOVA classification
system, three of us (PB, PM and TM) agreed on grouping these into the UPF and UPB categories provided
in Table 1. All non-UPF categories were excluded with the exception of vegetable oils, which we analysed
separately as an important standalone culinary ingredient, and as an ingredient used in UPF manufacturing.
We further grouped the vegetable oils and sauces, dressings and condiments categories together, because
these are typically used as ingredients in food preparation whereas other categories are typically consumed
as convenience foods.
5
Table 1. UPF and beverage product categories used in the analysis, as defined by Euromonitor
Product categories
Sub-categories
Total ultra-processed foods
Aggregation of all ultra-processed food categories
Baked goods
Dessert mixes, frozen baked goods, packaged cakes, packaged flat
bread, packaged leavened bread, packaged pastries
Breakfast cereals
Ready-to-eat cereals
Confectionery & sweet spreads
Chocolate spreads, confectionery, jams and preserves, nut and
seed based spreads
Dairy products & alternatives
Chilled and shelf stable desserts, chilled snacks, coffee whiteners,
flavoured condensed milk, flavoured fromage frais and quark,
flavoured yoghurt, margarine and spreads, processed cheese
Frozen processed potatoes
Frozen processed potatoes
Ice cream & frozen desserts
Frozen desserts, frozen yoghurt, impulse ice cream, take-home ice
cream
Instant noodles
Instant noodles
Meat substitutes
Meat substitutes
Processed meat & seafood
Shelf stable meat, shelf stable seafood
Ready meals
Chilled lunch kits, chilled pizza, chilled ready meals, dinner
mixes, dried ready meals, frozen pizza, frozen ready meals, shelf
stable ready meals
Sauces, dressings & condiments
Sauces, dressings and condiments
Savoury snacks
Other savoury snacks, popcorn, pretzels, salty snacks, savoury
biscuits soup
Sweet biscuits, snack bars & fruit
snacks
Processed fruit snacks, snack bars, sweet biscuits
Vegetable oils*
Corn oil, olive oil, palm oil, rapeseed oil, soy oil, sunflower oil,
other edible oil
Total ultra-processed beverages
Sub-categories
Carbonated soft drinks
Carbonates
Concentrates
Concentrates
Dairy products & alternatives
Drinking yoghurt, flavoured milk drinks, milk alternatives
Functional & flavoured water
Flavoured bottled water, functional bottled water
Juice drinks & nectars
Coconut and other plant waters, juice drinks (up to 24% juice),
nectars, reconstituted 100% juice
RTD tea, coffee & Asian speciality
drinks
Asian speciality drinks, ready-to-drink coffee, ready-to-drink tea
Sports & energy drinks
Energy drinks, sports drinks
*vegetable oil is classified as a culinary food ingredient under the NOVA food classification
Euromonitor collects sales data from trade associations, industry bodies, business press, company financial
reports, company filings, and official government statistics. People working within the food industry then
validate the estimates 105. The Euromonitor database has similar limitations to official government statistics
6
and is not a scholarly database 100. Sales data do not capture products sold through informal channels, or
wastage (i.e. the proportion of food sold but not consumed). From a nutritional standpoint the data has not
been validated, for example by comparison to expenditure or survey data. However, it has some advantages.
Unlike survey data it is not subject to recall bias and data is consistently reported across all countries over
time using standardised measures 100. The database also offers a disaggregated food and beverage
classification, which allows for reclassification into UPF and UPB categories.
To understand the role of UPFs and UPBs as ‘vectors’ for risk ingredients, we obtained volume (kg) data
for the ingredients listed in Table 2 for each of the categories listed in Table 1. We included ingredient
sources of added sugars, fat and sodium, as well as additives with cosmetic functions (e.g. artificial
sweeteners, colorants, flavourings, emulsifiers, thickeners, bulking and gelling agents) which are a
characteristic group of ingredients used in UPFs 106. Artificial sweeteners were included in a separate
category (low-calorie & non-caloric sweeteners). Euromonitor calculates this ingredients data as follows:
i) recipes for the leading 2-5 branded products within each category and a generic recipe for the remainder
of the market are sourced from patent literature, trade interviews and specialist knowledge; ii) ingredients
for the same leading 2-5 brands are sourced from nutrition information panels and for the remainder of the
market from the generic recipe. The percentage of each ingredient in the total branded and generic recipes
are then estimated; iv) these percentages are multiplied by sales volumes to generate total ingredients
volumes; iv) the data is then validated by industry experts at ingredient companies and brand manufacturers
105. Because assumptions are made regarding the recipes of leading and other brands, and also in relation to
the sales volumes of the associated product categories, this data should be interpreted with caution. Using
country population size estimates sourced from the World Bank’s World Development Indicators database
107, we converted the UPF and UPB category sales volumes, and the ingredients volumes supplied by these
categories, to kg per capita. This data was not adjusted for energy intake.
Table 2. Ingredients categories used in the analysis
Category
Sub-category
Ingredients
Sweeteners
Caloric sweeteners
Monosaccharides (dextrose, glucose/corn syrup, fructose, high
fructose corn syrup, honey, invert sugar, glucose/fructose syrup,
fruit juice*), disaccharides (lactose, sucrose, brown sugar,
molasses, treacle, isomaltulose, maltose syrup), polysaccharides
(maltodextrin)
Low-calorie & non-
caloric sweeteners
Sugar alcohols (Sorbitol, isomalt, mannitol, maltitol, maltitol
syrup, lactitol, inositol, erythritol, xylitol), non-nutritive
sweeteners (Acesulfame k, aspartame, saccharin, stevia,
sucralose, cyclamate)
Fats
Vegetable fats (solid at
room temperature)
Hydrogenated vegetable fat, hydrogenated vegetable oil,
vegetable fat, cocoa butter
Vegetable oils (liquid
at room temperature)
Vegetable oils
Animal fats
Animal fat (e.g. beef tallow, pork lard), milk fat (e.g. butter)
Other fats
Long chain omega-3 fatty acids, short chain omega-3 fatty acids,
powdered fats, stanol/sterol esters, waxes, other fats and oils
7
Sodium
Sodium
Monosodium glutamate, potassium chloride, sodium acetate,
sodium chloride, disodium diphosphate, sodium bicarbonate,
sodium metabisulphite, sodium sulphite, sodium sulphate,
sodium triphosphate, sodium carbonate
Cosmetic
additives
Cosmetic additives
Colours, flavours, flavour enhancers, thickeners and other
structurants, emulsifiers, bulking and gelling agents
Notes: *calculated as 90g sugar / kg as the average sugar content per unit volume of apple and orange juice
Sweeteners were grouped into caloric (mono-, di- and poly-saccharide sugars), and low-calorie (sugar
alcohols) and non-caloric (non-nutritive) sweeteners 108. The inclusion of added caloric sweeteners is
important given the WHO recommendation to limit ‘free sugars’ intake to less than 10% of total energy
intake, and to less than 5% or ~25g/day for further health benefits 109. Fruit juice was included as an
important ingredient and source of added sugars in UPFs, calculated as 90g of sugar / kg as the average
sugar content per unit volume of apple and orange juice 110. We characterised fats by their source (vegetable
vs. animal) and state (solid vs. liquid at room temperature). The differentiation between solid vegetable fats
and liquid vegetable oils was justified given the higher industrial trans-fatty acid content of the former
category, and the association of partially-hydrogenated vegetable fats with cardiovascular risk 111. Sodium
included all sources of added dietary sodium. Cosmetic additives included ingredients added to disguise
undesirable sensory properties of the final product, or to provide sensory properties especially attractive to
sight, taste, smell and/ or touch 106.
Analysis: We first estimated per capita sales volumes of the UPF and UPB categories for each country, and
country income and region category for all available years. Next, we estimated per capita volumes of
sweeteners, fats, sodium and cosmetic additives supplied from these categories. Artificial sweeteners and
monosodium glutamate, despite being cosmetic additives, were included in the categories of low-calorie &
non-caloric sweeteners and sodium, respectively. Growth in UPF and UPB sales, and of ingredients, were
estimated by calculating the compounding annual growth rate (CAGR) for the period 2009-19, representing
the mean annual growth rate over a one decade period. The analyses and graphical outputs were generated
using R version 3.6.2 (Foundation for Statistical Computing).
Semi-structured literature search and review: Given the broad and multi-faceted nature of the topic, we
used a combination of structured and branching searches to source literature on UPFs and UPBs, the
nutrition transition and related food systems and political economy drivers. Scholarly databases (Medline,
Scopus, Google Scholar) were searched using the search string: ‘*processed food*’ AND ‘nutrition’. To
identify drivers, these terms were used in combination with key words derived from food systems
conceptual frameworks 112, 113. We further searched the websites of key international organisations for
relevant grey literature including the WHO, Food and Agricultural Organization, Global Panel on
Agriculture and Food Systems for Nutrition, Global Nutrition Report and the International Panel of Experts
on Sustainable Food Systems. We did not set any dates limits on the searches. We included studies in
English, published in peer-reviewed journals or scholarly books and reports. Study quality was appraised
by relevance to the aim of the review and whether it had clearly described aims, study design and
methodology including data sources, a coherent statement of findings and justifiable conclusions. All
documents were uploaded to the qualitative analysis software NVivo (QSR International) and coded using
the food system frameworks as an initial guide. This allowed for the identification and development of key
8
themes. Thematic results were then synthesised and interpreted in relation to the results of the quantitative
component of the analysis.
Results
As a first step we described trends and patterns in per capita sales of UPFs and beverages and by country,
income-level and region.
Global trends and patterns in ultra-processed food and beverage sales
Figure 1 and Figure 2 show changes in per capita UPF and beverage sales volumes by region. Figures S1
and S2 and Tables S2 and S3 provide category-specific data for country income categories and highly-
populated countries. All regions except Western Europe demonstrated strong UPF sales growth. Sales were
markedly higher in Australasia & North America and Western Europe than in other regions. UPB sales
growth was strong in all regions except Australasia & North America, Western Europe and Latin America
& Caribbean, where it was stagnant or declining. UPB sales were also markedly higher in Australasia &
North America, Western Europe and Latin America & Caribbean than in other regions.
Figure 1. Ultra-processed foods sales (kg) per capita by region, 2006-19 with projections to 2024
9
Figure 2. Ultra-processed beverage sales (litres) per capita by region, 2006-19 with projections to 2024
Total per capita UPF sales in HICs were 3.4- and 11.3-fold higher than in UMICs and LMICs, reaching
109.3, 32.3 and 9.7 kg/capita respectively in 2019. UPB sales were 2.4- and 8.9-fold higher reaching 161.6,
68.5 and 18.1 L/capita respectively. UPF sales were increasing across all country income groups, with
compounding annual growth rates (CAGR) of 0.4%, 2.8% and 4.4% respectively in HICs, UMICs and
LMICs during the 2009-19 period. UPB sales in HICs were 2.4- and 8.9-fold higher than in UMICs and
LMICs, at 161.6, 68.5 and 18.1 L/capita respectively. In HICs, UPB sales grew at a CAGR of 0.1%
compared with 2.2% and 6.6% in UMICs and LMICs respectively. Total UPB sales growth was projected
to stagnate in HICs, but continue strongly in UMICs and LMICs.
Figure 3 shows combined per capita UPF and beverage sales volumes versus the CAGR for each country,
differentiated by income level and population size. Figures S3 and S4 show this data for UPF and UPB
separately. There is wide variation between countries at the same income level. Among HICs, the United
States and Germany have remarkably high sales whereas South Korea and Singapore have comparatively
low sales. Among UMICs, Mexico stands out with high sales, largely attributable to UPB, whereas China
has comparatively low sales. South Africa stands out as an African country with high sales and growth in
UPFs, and even more so in UPBs. Several countries in Africa, South Asia and South East Asia had
remarkably high sales growth in both UPFs and beverages, including Cameroon, India and Vietnam,
although from a low per capita baseline.
10
Figure 3. Combined ultra-processed food and beverage sales (kg) per capita in 2019 vs. compounding
annual growth rate (%) for the 2009-19 period, for countries classified by income and population size
There were notable differences in the types and volumes of categories sold. A wider variety of UPF types
were sold in HICs, including higher volumes of animal-sourced foods (e.g. dairy foods, processed meat and
seafood), convenience foods (e.g. ready meals, snack foods and confectionary), and those requiring
refrigeration (e.g. frozen desserts, processed frozen potatoes, dairy foods). In HICs, the ready meals,
savoury snacks, sweet biscuits & fruits snacks, meat substitutes and instant noodles categories had the
strongest sales growth, which offset near zero or declining growth in all other categories. In UMICs and
LMICs nearly all categories had moderate to strong growth, although the baked goods, and sauces,
dressings and condiments categories were dominant by volume.
Carbonated beverages comprised the majority of UPB sales globally, with volumes growing in most
regions, except Australasia & North America, Western Europe and Latin America & Caribbean with small
declines or stagnant growth. In Africa carbonated beverages comprised the largest majority of beverage
sales. In several regions declines in carbonated beverages have been offset by significant growth in other
beverage categories. East & South East Asia, for example, showed remarkable growth in ready-to-drink
(RTD) coffee, tea & Asian speciality drinks; Australasia & North America, and Western Europe increases
in sports & energy drinks; and Latin America & Caribbean in juice drinks & nectars.
11
Although not an UPF, we also examined changes in vegetable oil sales, given the recognised importance
of this category in the nutrition transition, and as an ingredient and cooking medium for UPFs. Figure 4
shows changes in per capita vegetable oil sales volumes by region. Figure S5 shows the same data by
country income level. There were marked differences between the types and volumes sold. Sunflower oil
dominated sales in North Africa & the Middle East and in Central and Eastern Europe, soy oil in Latin
America & Caribbean, Australasia & North America and Central & East Asia, palm oil in South & South
East Asia, and olive oil in Western Europe. Palm oil is by far the highest volume oil type sold in LMICs.
Total vegetable oil sales in UMICs and LMICs exceeded those in HICs at 10.6, 8.7 and 7.8 kg/capita
respectively in 2019. Vegetable oil sales increased by just 0.6% CAGR in HICs but grew markedly at 4.1%
and 11.6% CAGR in UMICs and LMICs respectively during the 2009-19 period. The two food categories
mainly used in meal preparation – vegetable oils, and sauces, dressings and condiments together comprised
46% and 57% of total sales in UMICs and LMICs respectively, compared with 21% in HICs.
Figure 4. Vegetable oil sales (litres) per capita by region, 2006-19 with projections to 2024
Global trends and patterns in ingredients supplied from ultra-processed foods and beverages
In a second step, we determined volumes of ‘risk ingredients’ supplied from UPFs and beverages, including
sweeteners, fats, sodium and cosmetic additives.
Figure 5 shows changes in per capita volumes of sweeteners, fats, sodium, and cosmetic additives from
UPFs and beverages by region. Figure S8 shows these same volumes by country income. Tables S4 and S5
provide further ingredients sales volume and growth rate data by country income and region respectively.
12
Irrespective of country income level, caloric sweeteners comprised the dominant share of ingredients from
UPFs and nearly the entire share of ingredients from UPBs. Caloric sweeteners made up approximately two
thirds of all ingredients supplied from UPFs and beverages combined, with volumes of 25.8, 9.2 and 2.2
kg/capita in HICs, UMICs and LMICs respectively in 2019. Total caloric sweeteners declined in HICs with
a CAGR of -0.3% over the 2009-19 period, but increased by 1.6% and 3.9% in UMICs and LMICs
respectively. However, the decline in HICs was mainly attributable to a -1.2% CAGR in caloric sweeteners
from UPBs, while caloric sweeteners from UPFs increased by 0.4%. Caloric sweeteners from UPFs and
beverages increased in all regions, with the exception of small declines from UPBs in Australasia & North
America, Latin America & Caribbean and Western Europe. Total low calorie and non-caloric sweeteners
(LCNCS) volumes were 0.4, <0.1 and <0.1 kg/capita in HICs, UMICs and LMICs respectively in 2019,
and had CAGRs of 0.4%, 2.3% and 4.2% for the 2009-19 period. In HICs, UPFs were the primary source
of LCNCS at 0.4 kg/capita versus <0.1 kg from UPBs, although the latter category grew much more with
CAGRs of 0.2% and 4% respectively. Volumes of LCNCs supplied in Australasian & North America and
Western Europe were between 2- to 40-fold higher than in other regions.
Figure 5. Volumes of sweeteners, fats, sodium and cosmetic additives supplied (kg) per capita from ultra-
processed foods (top) and beverages (bottom) by region, 2006-19 with projections to 2023
Vegetables oils made up a large share of the ingredients supplied exclusively from UPFs, at 6.3, 1.5, and
0.5 kg/capita in HICs, UMICs and LMICs respectively in 2019, with CAGRs of 2.0%, 3.8% and 8.0%.
Vegetable oils from UPFs increased in all regions. Solid vegetable fats, which we used as a proxy for trans-
fats, were supplied almost exclusively from UPFs, and were markedly higher in HICs at 2.6 kg/capita
compared with 0.7 and 0.2 kg/capita in UMICs and LMICs respectively. Vegetable fat volumes declined
13
in all country income groups, with CAGRs of -2.3%, -0.8% and -1.3% in HICs, UMICs and LMICs
respectively. Vegetable fats declined in all regions except North Africa & the Middle East. Reductions were
most prominent in Australasia & North America, and Western Europe.
Sodium was supplied almost exclusively from UPF at 1.2, 1.1 and 0.3 kg/capita in HICs, UMICs and LMICs
respectively in 2019, and increased with CAGRs of 0.4%, 1.7% and 1.8%. Sodium volumes increased in
all regions. Australasia & North America, Central & East Asia and Western Europe had markedly higher
sodium volumes of 1.3, 1.4 and 0.9 kg/capita in 2019. The supply of cosmetic additives increased
everywhere, mostly from UPFs. Total cosmetic additives supplied from UPFs and UPBs combined was
3.3- and 11.5-fold higher in HICs than in UMICs and LMICs at 2.3, 0.7 and 0.2 kg/capita respectively.
Volumes were markedly higher in Australasia & North America and Western Europe than in other regions,
with volumes of 3.1 and 1.8 kg/capita respectively in 2019. Furthermore, cosmetic additives increased with
CAGRs of 0.7%, 2.9% and 4.8% in HICs, UMICs and LMICs, exceeding growth in total UPF and beverage
sales.
Food systems transformations linked with changing ultra-processed food and beverage markets
Our results so far indicate that UPFs and beverages are becoming more prominent in food supplies
everywhere, and suggest a convergence towards a more highly-processed global diet. However, there are
also important divergences in the volumes and types of products sold and ingredients supplied at regional
and country levels 14, 92. In the following sections our objective is to understand how contemporary
transformations in food systems might explain this convergent-divergent pattern. This considers food
supply chains, food environments and consumer behaviour as core food system elements, but also a range
of external food system drivers (social, economic, technological, institutional, and political) and knowledge
systems, policies and regulatory frameworks shaping those systems 112, 114. We adopt a combined food
systems and political economy approach acknowledging in particular the power of transnational food and
beverage corporations (TFBCs) – including producers, processors, manufacturers, fast food chains and
retailers – to shape food systems in ways that alter the availability, price, nutritional quality, desirability
and ultimately consumption of UPFs and beverages 95, 96, 100, 114, 115.
From the literature we identified strong incentives for TFBCs to expand transnationally, including market
saturation in their home countries, their large market capitalisations and profits (providing finance to grow),
global brand recognition, knowledge capital (intellectual property, organisational practices, manufacturing
and logistical technologies), and their capacity to adapt global brands to local cultures and regulatory
contexts 96, 116, 117. Since the establishment of the World Trade Organization in the mid-1990s, the number
and depth of trade and investment agreements has increased substantially. Many countries have also
unilaterally liberalized their economics, becoming more integrated into the global economy and
deregulating markets 118, 119. This has accelerated the globalisation of food systems by reducing barriers to
the movement of finance, technologies, production capacity, raw materials and final products across
borders, enabling TFBCs to more easily enter and drive consumption within emerging markets, and connect
these markets to global supply chains 91, 92, 118, 120. Through greater investments, more intensive marketing
and the introduction of new technologies and business practices, such companies have also spurred
competition and bolstered the development of domestic (or home-grown) UPF and beverage industries 91,
96.
14
Basic economic, demographic and socio-cultural drivers: At the most basic level TFBCs have pursued
growth opportunities in emerging markets in response to factors associated with economic development
that drive demand for UPFs and beverages. These include income growth, urbanisation, changing
workforce structures and demographics. Total UPF and beverage sales have increased rapidly in Central &
East Asia, North Africa & the Middle East and South & South East Asia, regions where per capita income
has grown rapidly in recent decades 14, 118. As economies grow consumer incomes rise, resulting in higher
household expenditure on food alongside a decline in the proportion of total expenditure on food relative
to non-food items. This tends to result in increased diversification of the diet and expenditure on more
expensive products including animal-sourced and highly-processed foods 88, 94, 100, 121, and purchasing of
non-food items that facilitate greater access and utilisation of these foods, including cars, microwave ovens,
and refrigerators 11, 122. Our results reflect this, showing higher volumes of a wider variety of UPFs and
beverages, and a greater share of animal-sourced foods at higher country incomes. This is also reflected in,
for example, the higher volumes of refrigerated products (e.g. ice-cream and frozen desserts) in HICs, and
less perishable ones in UMICs and LMICs (e.g. vegetable oils, baked goods, sauces).
Within countries, the above processes appears to play out in socially-stratified and dynamic ways, whereby
UPF consumption increases first among higher-income groups 19, 20, and then shifts to lower socioeconomic
groups as countries grow richer 16-18. This same pattern is observed with the ‘social transition’ in obesity
prevalence 21, 123. There are however, significant variations in UPF and beverage sales between countries at
the same level of per capita income. Income appears to be more strongly associated with UPF sales in
countries that are more economically integrated, and hence more highly penetrated by TFBCs 97, 100. Food
prices are also a key determinant of affordability and consumption. Price per calorie of different types of
ultra-processed and ready-to-eat foods vary markedly across country income brackets and regions, as do
prices relative to unprocessed foods 124, 125. In 2011, for example, vegetable oils and sugar were relatively
cheap almost everywhere; soft drinks relatively inexpensive in HICs and very cheap in North America and
Australasia, moderately so in UMICs, and expensive in LMICs; and, potato chips very inexpensive in HICs,
moderately so in UMICs and LMICs, and inexpensive in India, China and elsewhere in East Asia 124.
Urbanisation is also a key driver. This facilitates greater physical proximity to more diverse and cheaper
foods, including UPFs and beverages, exposure to commercial marketing and ready-to-eat foods, and
occupations less conducive to home food preparation 126-128. This may partly explain differences in sales
and growth rates between the highly urbanised regions of Western Europe, Australasia & North America
and rapidly urbanising Asia, North Africa & the Middle-East, Latin America and Africa. However, with
the increased penetration of UPF and beverage supply chains into rural areas, the importance of urbanisation
may be diminishing 94, 129. In 2010, Reardon et al., for example, found highly-processed foods comprised
between 13% and 22% of total food expenditure in rural households of four low- and middle-income Asian
countries, comparable to (although still lower than) urban households with between 17.7% and 36.7% 94.
Another key factor is the growing number of women participating in formal work and the associated shift
to dual worker households, without an equitable re-distribution of household work between women and
men. In the United States this has meant an approximate halving of the time woman spend preparing food
and a small increase for men 130. This increases the time opportunity cost of sourcing and preparing food,
and consequently the demand for semi-prepared and ready-to-heat convenience foods, and for food eaten
outside of the home 88, 126, 131. This may explain the higher proportions of convenient ready meals and snack
foods in the HICs of Australasia & North America, and Western Europe relative to the higher proportions
categories used in meal preparation, such as vegetable oils, sauces, dressings and condiments sold in UMICs
15
and LMICs. Such demand may also closely link with a culinary skills transition involving significant
changes in the patterns and kind of skills required, and the time spent procuring, preparing and consuming
food 132-134. This can involve the adoption of ‘technological skills’ required to prepare convenience foods,
as in using a microwave oven, opening cereal boxes or assembling processed ingredients (e.g. sandwhiches)
132. Population age structure is another key demographic factor. The younger populations of middle-income
countries may be more likely than their elders to forego traditional foods for newer ones 12.
Supply chain transformations: Growing but highly variable worldwide UPF and beverage sales are not
driven by changing demand alone. Changes in global, regional and national supply chains are also
important, involving the actors and processes that take products from the production of raw ingredients
through to manufacturing, marketing, retail and consumption.
This begins with market consolidation, technological change and growth in the production, processing and
trade in basic agricultural commodities and additives used as ingredients in manufacturing 92, 113, 118. A small
number of corporations control this sector. These include the four so-called 'ABCD’ agribusinesses Archer
Daniels Midland (USA), Bunge (USA), Cargill (USA) and Louis Dreyfus (France), who together controlled
an estimated 70-90% of global grain trade by the mid-2000s 113, 135. Others include Dow Dupont (US),
Associated British Foods (UK), Royal DSM (Netherlands), Bunge (US), China National Cereals, Oils and
Foodstuffs (China) and Wilmar (Singapore), and a number of specialised ingredients suppliers spanning
the food, pharmaceutical and nutraceutical sectors 135, 136. As shown in Figure 6, world production of the
four major processed vegetable oil crops expanded 19-fold from 7.5 to 144.8 million tonnes between 1961
and 2014, mainly from government-supported expansion of palm oil production in Indonesia and Malaysia,
soybean oil in China, US, Brazil and Argentina, and canola/rapeseed in Canada and China 92, 118, 137. Palm
oil is now the world’s most significant vegetable oil 138, with food manufacturing using ~70 per cent of
production, and half of all packaged and processed foods containing this oil or its derivatives 135.
World raw sugar production expanded 3.3-fold from 53.2 to 176.9 million tonnes over the same period,
mainly from sugar cane in Brazil, India and China, and beet sugar in the European Union and United States.
In the United States, the production of high-fructose corn syrup (HFCS) also increased, with a subsequent
10-fold rise in consumption between 1970 and 1990 to represent >40% and ~100% of caloric sweeteners
added to foods and beverages respectively 139. In 1994, tariff reductions mandated under the North
American Free Trade Agreement then led to increasing volumes of HFCS in the food supplies of Mexico
and Canada 140, 141. Relative to rice, wheat production has also increased given its use in producing noodles,
baked goods and similar products, for example in Asia and West Africa 127, 142. Increased production of oil
and cereal crops has also provided cheap inputs for expanded livestock production, and hence the supply
of meat and other animal sourced foods used in manufacturing 143.
16
Figure 6. World production of raw sugar and major vegetable oil crops, 1961-2013
Notes: Data from FAOSTAT
In the food manufacturing sector, companies have utilised these low-cost and readily-available ingredients
to develop diverse product portfolios, often using variations of the same ingredients for multiple branded
products in the same market 113. In 2019, ten companies controlled 47.5% of the market share of the world’s
top-100 food manufacturers, with sales ranging from US$61.5 to US$17.6 billion 105. These included Nestle
(Switzerland), PepsiCo (US), Coca Cola (US), Mondelez (US), Danone (France), Kraft Heinz (US),
Unilever (UK/Netherlands), Mars (US), Kelloggs (US) and Ferrero (Italy) 113. However, when considering
the market in its entirety, the top-ten controlled just 14.7% of world market share in 2019 105, indicating the
importance of small- and medium-sized companies in this sector 144. Market concentration is, however,
much higher at the product category level, including beverages, snack foods and biscuits. For example,
Coca Cola and PepsiCo alone controlled 19.3 and 8.3% of the world’s beverage market in 2018, with 37
and 19 brands respectively. The carbonated beverages category is even more concentrated, with these two
companies controlling 45.6% and 17.5% of world market share 105.
Many of these manufacturers have been at the vanguard of economic globalisation 96. However, they have
expanded with renewed vigour from the 1980s onwards. This is evident in the rapid growth in foreign direct
investment in this sector throughout the Global South, with manufacturers establishing new (often ‘mega’)
manufacturing plants and distribution centres through ‘greenfield investments’ 91, 118, 119. This has led to the
establishment of vast manufacturing capabilities serving domestic and regional markets. For example,
Nestle reported having 403 factories spanning 84 countries in 2019, with 16 in Brazil, 13 in Mexico and 31
in the Greater China Region 145. Growth has also been achieved through the acquisition of domestic
17
competitors. For example, in 1993 Coca Cola became the market leader in India by acquiring the domestic
Parle Products company and its cola brand Thums Up, and in 1999 became the market leader in Peru by
acquiring the Lindley Corporation and its Inca Kola brand 118, 119. Some countries have seen the emergence
of large domestic companies prior to transnational market entry, for example IndoFoods in Indonesia, and
in China the state-owned China National Cereals, Oils and Foodstuffs 96, 142. Japan’s market is dominated
by domestic manufacturers, with foreign companies having limited market share 96, 146.
New production and processing technologies have increased production efficiencies, lengthened shelf-life,
enabled long-distance transportability, and enhanced the hedonistic properties of UPFs. This includes the
development of new varieties of high-yielding oilseed crops and processing techniques (e.g. extraction,
refining and hydrogenation) that have enabled the development of novel ingredients and reduced the costs
of baking and frying fats, margarines and cooking oils 147. New processing techniques of automation,
extrusion and frozen dough production, and additives such as new yeast varieties, enzymes and emulsifiers
have enabled the mass production of breads, noodles and other baked goods 88, 148. Other manufacturing
techniques and technologies have included high temperature processing, extraction, fractionation and
hydrogenation 149. New packaging technologies have enabled entirely new product categories, for example
microwaveable popcorn 150. Manufacturers have invested heavily in their technological capabilities to
enhance the organoleptic properties of their products including structure, mouth feel, taste, aroma and
flavour. Fortification, functionalisation and reformulation techniques have been used to alter the nutritional
properties of products151. They have also adapted (or ‘glocalised’) global brands and menu offerings to meet
local tastes, cultural preferences and regulatory environments 149, 152. This is enabled through the
establishment of food and nutrition science research capabilities, coordinated on a global scale. Nestle, for
example, has "the world’s largest private nutrition research capability" spanning a Research Centre for basic
research, seven research and development centres, and nine product technology centres, with nutritional
expertise in every market 153.
Developments in the retail sector have also contributed in important ways to growing and diversifying UPF
and beverage markets, especially the growth of modern food retail throughout the Global South. This sector
is highly concentrated (and moderately to strongly oligopolistic) in many countries, often dominated by
transnational grocery retailers including Walmart (US), Aldi (Germany), Carrefour (France), Tesco (UK)
and 7-Eleven (Japan), or other regional and national players 96, 113, 154. Figure 7 presents data on processed
food distribution channels by country income level. Distribution occurs predominately through ‘modern
grocery retailers’ in HICs (supermarkets, hypermarkets and convenience stores), in LMICs through
‘traditional grocery retailers’ (mostly small, independent, owner-operated stores and wet markets), and in
UMICs through a mix of modern and traditional channels. Modern grocery retailers originated in the US
and other HICs in the mid-1950s, with several companies achieving considerable market power in some
countries. Supermarkets then spread into South America, East Asia (excluding China) and South Africa in
the 1990s, followed by Mexico, Central America and most of South-East Asia in the mid- to late-1990s,
and then China, India and Vietnam in the early 2000s 155, 156. This expansion has closely followed the timing
of countries accession to the World Trade Organization and its General Agreement on Trade in Services,
which has liberalised foreign investment in the food retail sector 92, 122. Within countries, supermarkets tend
to spread from major cities to intermediate and smaller localities, reflecting an initial targeting of wealthier
middle-class consumer segments before targeting poorer urban and rural segments 157, 158.
18
Figure 7. Processed food distribution (calculated as % of total retail value) by modern vs. traditional retail
channels by country income, 2001-2014
Notes: Data from Euromonitor Passport
In contrast to traditional grocery retailers, supermarkets shape UPF and beverage sales in a powerful way
by facilitating market segmentation through the development of new products, or the re-development of
existing ones, to target consumer groups differentiated by income, age, gender, geography and lifestyle-
status. Supermarkets also provide a platform for facilitating market segmentation by stocking a wide variety
of foods and accepting the risk of introducing new foods, as well as regularly updating their stock in
response to demand. Because consumer purchasing behaviour shapes their procurement activities,
supermarkets also send market signals to manufacturers about what and what not to produce 154. This may
explain the greater variety of UPFs and beverages sold in HICs relative to UMIC and LMICs, because as
this analysis has demonstrated, a greater proportion of such foods are distributed through supermarket
channels in the former.
Supermarkets act predominantly as new distribution channels for durable processed foods in the early stages
of market growth, before offering a wider variety including fresh foods (and out-competing traditional wet
markets) in later stages 12, 157, 159, 160. As a result, supermarket distribution shares in categories such as grains,
noodles and dairy products have increased more rapidly than fresh food categories 161. This reflects not only
the greater economies of scale in sourcing processed foods 159, 162, but also because ‘cultures of
consumption’ change over time, from the daily purchasing of fresh foods in traditional markets to less
frequent purchasing from modern retailers and refrigerator storage 163, 164. Supermarkets often use price
discounting, prominent large displays at the end of aisles, and place snack food lines close to cash registers
19
to stimulate impulsive purchasing 165, 166. By leveraging their market power to negotiate large-scale
acquisition contracts, supermarket chains can drive down sourcing costs to supply customers with prices
well below those charged by traditional retailers 166, 167. For example, a Brazilian study found that the share
of UPFs as a proportion of total food purchased was 25% higher at supermarkets, and supermarket prices
were 37% lower for these products, compared with other food retail stores 165.
In the absence of modern retail formats in emerging markets, UPF and beverage manufacturers have also
developed novel strategies to target poorer and rural consumers. In China and India, for example, companies
have offered smaller package sizes and affordable pricing points more appealing to low-income and rural
consumers 168, 169. Others have developed ‘last mile’ strategies to reach the ‘base’ of the consumer pyramid.
In Mexico, for example, Coca Cola developed an extensive distribution network of tiendas (small stores),
providing free incentives such as refrigerators and point-of-sale advertising materials in return for
exclusivity agreements 92. In Brazil, Nestle has used ‘floating supermarkets’ to sell more than 300 products
to small towns throughout the Amazon basin, and through its door-to-door’ salesforce reaches more than
250,000 households with more than 800 products every fortnight 95, 170.
In LMICs and UMICs, the consumer food service sector tends to be dominated by thousands of small,
independent restaurants or street food operators, often selling local dishes at very low prices, and operating
entirely in the informal sector 96, 127. However, growth in transnational fast food chains has been rapid,
presenting more outlets for UPF and beverage distribution 88, 127. Five ‘fast food’ corporations have led this
transnational expansion: Seven & I Holdings (Japan/South Korea; 7-Eleven), Yum! Brands (US; KFC,
Pizza Hut, Taco Bell), McDonalds (US), Doctor’s Associates (US; Subway) and Starbucks (US). In China
alone, the number of fast food chain outlets expanded 6.4-fold from 25,984 in 2004 to 167,560 in 2018,
beginning in major cities before spreading to smaller cities and towns. Yum! Brands has been at the
forefront of this expansion, given the preference of Chinese consumers for chicken over beef 96. Franchising
has been a key growth strategy, allowing firms to acquire local knowledge about consumer preferences and
business practices, and to ‘glocalise’ their menu offerings. For example, McDonalds has offered vegetarian
options in India, rice porridge with chicken and pork in Thailand, and rice-based wraps, bowls and ‘bubble
tea’ in China 96. Local restaurants and street food vendors may often develop similar products, mimicking
the fast food brands 127. The rapid uptake of online food delivery platforms such as Uber Eats in many
countries has provided a new distribution channel, reducing the time-cost of sourcing fast food for
consumption at work or home 171, 172.
Growing but highly variable UPF and beverage markets also reflects more intensive food marketing
practices, enabled by the globalisation of marketing agencies and new media technologies 92. Food
companies and the marketing agencies that work for them, have used increasingly sophisticated techniques
to reach consumers segmented by age, income, location, lifestyle and cultural preferences. Extensive mass
media advertising targeting children and adolescents via television, film and media franchising has been
reported in many countries 152. The globalisation of digital technologies including social media, mobile
phones, gaming platforms and others, has enabled new ways to reach younger audiences, including
gamification, peer-to-peer and user-generated messaging, cross-device tracking, in-store surveillance and
prompting, and demographic- and location based targeting 88, 173, 174. These technologies are harnessed in
powerful ways by using ‘Big Data’ processing and analytics platforms to collate, analyse and use data,
including the profiling and predictive targeting of individual consumers 173. Sophisticated packaged-based
marketing techniques are also used to promote purchasing. This includes making health and nutritional
claims to imbue products with ‘health halos’, and packaging designs (e.g. shapes, cues and sizes) that skew
20
perceptions of quantity and increase preferences for supersized portions and packages 175. Some have
suggested that the net effect of these changes is the increased desirability of ultra-processed relative to
unprocessed and minimally processed foods 176, 177, the decline of traditional food cultures (e.g. commensal
eating) and a shift towards those more conducive to UPF and beverage consumption (e.g. snacking) 95, 178,
179.
Policy, regulatory and political economy drivers: Finally, growing but variable worldwide UPF and
beverage markets also reflect differences in the strength of policy and regulatory frameworks targeting
unhealthy diets, and the power of different actors and interests to enable or hinder action.
As our findings so-far demonstrate, the drivers of UPF and beverage markets are multi-factorial and
dynamic, reflecting transformational changes in food systems underway. Therefore, an ecological approach
to policy intervention, targeting multiple components of food systems simultaneously, is needed to
drawdown consumption and minimise harm 112, 114, 180. Various frameworks exist for guiding such action
112, 180, 181, requiring a strong role for government intervention, including the use of law and regulation 182,
183. These include actions targeting food supplies (e.g. removing sugar subsidies, reformulation, public
procurement standards), food environments (e.g. restrictions on advertising and promotion, taxes and
import tariffs, food and menu labelling, school food standards), and behaviour change communication (e.g.
food-based dietary guidelines, mass-media campaigns, nutrition education in school curricula, counselling
in health care settings) 180, 182. It also requires cross-cutting actions. These include bottom-up civil society
mobilization, sustained top-down political commitment, establishing well-resourced and empowered multi-
sectoral governance structures, protections against conflicts of interest, and monitoring, accountability and
enforcement mechanisms 184-186.
However, worldwide policy responses are currently inadequate in both scope and strength 187-189. According
to the latest WHO monitoring reports, the large majority of reporting governments have implemented
education and counselling (75%) and media campaigns (61%) targeting lifestyle-behavioural change. Far
fewer have implemented more upstream actions targeting food supplies and food environments including,
among others, taxes on sugar-sweetened beverages (38%) and unhealthy foods (6%), front-of-pack
labelling schemes (25%; with just over half being mandatory), elimination of industrially produced trans-
fats (37%), portion-size controls (16%), and school food standards (43%) 190, 191. The majority of these
actions have been taken in HICs in Europe189, although UMICs with high obesity and diet-related NCD
burdens in Latin America and the Pacific Islands are world leaders 88, 192, 193. Weak worldwide policy
responses and the skew towards lifestyle-behavioural interventions, at least partly reflects the nature of food
regulatory paradigms in many countries. For example, ‘cutting red-tape’ agendas have emerged in many
high-income countries, with potential to impede new UPF regulations 194. Drawing from behavioural
economics, ‘nudge’ approaches to policy intervention, involving minor modifications to consumer
environments, have also come into vogue. This approach shows mixed results, small at best, for modifying
consumer choices 195, 196. However, it reinforces an individualised and reductionist approach to intervention,
focusing on the ‘immediate choice architecture’ of consumers, but fails to address the commercial
determinants of consumption we describe 197.
Policy actions in many countries are informed by reductionist approaches, including nutrient-profiling
models, to assess the healthiness of foods 198, 199. Such models have an important role to play. However, in
focussing on the amount of certain nutrients in foods, this approach does not address other harms associated
with food processing, or how foods fit within an overall healthy diet. It has led to an over-reliance on
21
‘nutrients-to-limit’ reformulation initiatives in some countries 200, 201, with potentially counter-productive
outcomes. This includes the replacement of certain highly processed ingredients with other such
ingredients, for example unhealthy fats with added sugars, or with additives for example added sugars with
artificial sweeteners, rather than with whole or minimally processed foods. Nutrient-centric approaches,
can also stimulate the production and promotion of UPFs. For example, between 2014 and 2019, the
Australian nutrient-based Health Star Rating (HSR) system approved between 73-77% of UPFs using the
system to display a ‘pass mark’ of 2.5 stars or more (out of a possible 5) on labels 202, 203. Food-based dietary
guidelines (FBDGs) adopted in most countries are a foundation for nutrition policy and guidance 199, 204.
Yet a large majority of FBDGs adopt a nutrient-centric approach, recommending to limit foods high in risk
nutrients or ‘energy-dense and nutrient-poor’ foods. The term ‘discretionary foods’ is also used, a framing
that implies consumer rather than producer responsibility 85. Only Brazil, Peru, Uruguay, Ecuador and
Canada have dietary guidelines that differentiate foods by the degree of processing, recommending to
favour unprocessed and minimally processed foods, limit processed foods, and avoid UPFs altogether 4, 85,
201.
Weak worldwide responses also reflects the power of the food industry to undermine political commitment
for action 205, 206. The food industry, including predominantly transnational food corporations and the peak
industry groups that represent them, have strongly resisted policy responses using standard 'playbook'
tactics 97, 205. These have included inter alia lobbying policy-makers, making political donations, framing
policy debates, adopting self-regulation to pre-empt and delay government action (policy substitution),
public relations campaigns portraying business as ‘part of the solution’, and partnerships with community
and sporting associations 151, 205, 207, 208. This has occurred at multiple-levels, often focusing in battleground
jurisdictions, as shown in the intensive lobbying, media campaigns and establishment of front groups to
resist the adoption of SSB taxes in US counties and throughout Latin America 209-211. At the international
level, Codex Alimentarius, the UN food standard-setting body, has faced intensive lobbying as it often
functions as the de-facto benchmark for food regulatory agencies in low and middle-income countries, as
well as the reference standard used in WTO trade disputes 212. Companies and industry groups have skewed
the production of knowledge and evidence informing policy and regulatory debates. This includes financing
academic research, sponsoring scientific organisations to produce favourable messaging (e.g. International
Life Sciences Institute), and producing in-house research that minimises the harms and supports the health
benefits of their products 213, 214.
More broadly, food industry power has been enhanced in the context of growing preferences for hybrid
governance arrangements, including public-private partnerships (PPPs), that expand corporate influence in
policy decision-making 97, 115, 151. At both national and international levels this includes a variety of PPP
types involving various combinations of government, industry and civil society actors, and activities
spanning food reformulation and fortification, consumer education, labelling, direct food provision and
research 215, 216. By procuring in-house nutritional expertise, food companies have expanded their capacity
to engage in these activities, and thereby influence food policy and regulation-setting processes 151. As a
result, PPPs involving food manufacturers have focused more on nutrient-based responses, such as
reformulation. This depoliticises food environments by deflecting attention away from the structural
determinants of unhealthy diets, including the wide availability and intensive marketing of UPFs 151. Trade
liberalisation further enhances food industry power by restricting the ‘policy space’ of governments through
limiting the scope of regulatory actions allowed under trade rules, and by imposing ‘regulatory chill’ or a
reluctance to adopt regulation through the fear of a trade dispute 118, 217. This chilling effect is enhanced
22
when HIC governments representing the interests of TFBCs (mainly the US and EU) have used WTO trade
dispute mechanisms to challenge food regulations adopted by other countries 118, 218. Furthermore, as
suppliers of jobs and tax revenue, the food industry has gained ‘productivist power’ through its importance
in national economies, and greater international capital mobility as trade liberalisation enables TFBCs to
punish or reward governments for their policy decisions by shifting or threatening to re-locate jobs and
investments 14, 92, 205.
Market concentration is another key mechanism enabling the food industry’s power across all sectors,
whereby increasing market share, and hence market power, is held by a declining number of firms 157, 219,
220. This increases the buying and selling power of corporations, allowing them to dictate terms of trade, set
prices, control consumer product offerings and cut costs 117, 219, 221. Market power reinforces political power
as accumulating financial resources and economic importance in national economies can be used for
political influence 113, 115. Mergers and acquisitions have become the main mechanism by which this
concentration occurs and through which corporations grow 157, 219. The home markets of the US and
European food and beverage corporations are now highly concentrated, especially in the processing and
retail sectors 146, 221-223. Markets are also concentrating regionally as in the Asia-Pacific and Latin America,
as well as globally 96, 146, 221. In the manufacturing sector, concentration is highest in ultra-processed
segments such as soft drinks, biscuits, and snack foods 224, 225.
Through establishing transnational networks of affiliated firms and contractual suppliers, this market power
can be coordinated across global value chains (GVC) incorporating multiple supply chain components
including research & development, production, processing, manufacturing and distribution 96, 113. This
enables the sourcing of raw ingredients, labour and other production inputs from wherever costs are lowest
and regulatory environments most favourable, distancing consumers and regulators from the harms
associated with production (e.g. deforestation associated with palm oil production) 116, 226. Financialisation
of the global economy, involving the emergence of a liberal financial regime characterised by rapid growth
in marketised securities and monetary exchange freedoms, has facilitated GVC integration. This enables
food and beverage corporations to use financial derivatives to offset risks associated with sourcing large
volumes of agricultural commodities from volatile global markets 116. Processes of transnationalisation and
market concentration is also closely linked with the financialisation of food systems. A small number of
private equity firms – mainly Blackrock, Vanguard, State Street, Capital Group and Fidelity – have
funnelled vast amounts of equity into publicly listed food and beverage corporations, providing them with
access to finance for accelerated growth on a global-scale 227.
Discussion
Our findings have important implications for global public health and policy responses targeting unhealthy
diets, obesity and diet-related NCDs.
First, UPF and beverage sales are growing in all regions and in the large majority of countries, but most
rapidly in UMICs and LMICs, although with wide variations in the volumes and types of products sold.
Given the well-established evidence linking UPFs with adverse health outcomes, and because growth is
most apparent in highly-populated regions and countries, the consequences for global health are likely to
be substantial. We also find important changes in the nature of the transition to diets higher in UPFs and
beverages. A wider variety of products are sold in richer countries. Cosmetic additives are supplied from
23
UPFs in markedly higher volumes in HICs, but are increasing almost everywhere, and have approximately
doubled in UMICs and LMICs. The vegetable oils, and sauces, dressings and condiments categories used
in food preparation, make up a greater share of total food sales in UMICs and LMICs relative to HICs.
Together, these results indicate a shift in the global diet towards higher consumption of UPFs and beverages,
and that populations purchase a wider variety of products, and more higher-value and convenience products,
as countries grow richer. Although UPFs appear to contribute more to the ‘sweetening’ of the global diet,
vegetable oil as a stand-alone product and as an ingredient used in UPFs has grown rapidly, especially in
the UMICs and LMICs of Central & East Asia, and South & South East Asia. This is consistent with
previous studies showing vegetable oils have contributed more than any other food category to the
expanding world’s calorie supply – the ‘fattening’ of the global diet 92. The rise of palm oil as a cooking oil
in many transitioning countries, and as an ingredient or medium used in UPF manufacturing, raises concern,
given the high-levels of ‘probable carcinogens’ (certain fatty acid esters and glycidol), generated during the
refining process 228.
Second, important changes are underway in the beverage sector. Declines in carbonated beverages in high-
income countries and certain regions have been offset by growth in sports, energy, ready-to-drink teas, and
juice drinks. This diversification may represent several dynamics underway in beverage markets. This
includes rising health consciousness among consumers, substitution effects resulting from policy actions
targeting sugar-sweetened beverages (SSBs) 188, and more intensive marketing of these categories as
beverage companies diversify product portfolios to offset declines in revenue from carbonated beverages.
Our results show that beverages contribute nearly as much caloric sweeteners as UPFs across all income
levels, suggesting the continuing importance of policy actions to reduce SSB consumption. This may be
particularly important in HIC and UMIC countries where SSBs are a relatively inexpensive source of
calories 124. The growth in energy drinks in particular presents an important challenge for food regulators,
given the intensive marketing of these products to youth and the harms associated with excessive
consumption 229.
Third, our findings on ingredients raise several policy challenges. Caloric sweeteners from beverages are
declining in HICs, suggesting that policy actions including SSB taxation, labelling and reformulation, are
having some effect 188. However, caloric sweetener volumes from UPFs have increased or barely changed
in HICs, indicating a need to broaden policy actions beyond SSBs. Furthermore, volumes of caloric
sweeteners from UPFs and beverages are growing rapidly in UMICs and LMICs. Policy actions to reduce
added sugars from UPFs and beverages therefore remain crucial, given the well-established adverse health
outcomes associated with high sugar intake 230, 231. Significant growth in cosmetic additives and non-caloric
and low-calorie sweeteners raises further questions for public health, given the emerging evidence on the
health effects of these ingredients. Hydrogenated vegetable fat, which was our proxy for industrial trans-
fat in this analysis, is steadily declining in all country income levels. This possibly reflects successful policy
actions to eliminate these fats from the food supply. Sodium levels are increasing nearly everywhere, and
are markedly higher in North America, East & South East Asia and Western Europe. The world’s highest
sodium levels, reported in Central & East Asia, may reflect the use of sodium-rich sauces, dressings and
condiments used in food preparation, given home-cooked foods are the main dietary source of sodium in
China 232.
Fourth, we have shown how changing global markets for UPF and beverages reflect transformations
underway in all food systems sectors, including those linked with the expansion and growing market and
political power of transnational food and beverage corporations. Variations in sales across countries are
24
likely to reflect differences in these food systems factors and dynamics, and supports the importance of
adopting a combined food systems and political economy approach to understanding global dietary change
114, 115. A recent review on the political economy of nutrition reported industry interference as the most
important barrier to achieving strong regulatory actions on unhealthy diets, obesity and diet-related NCDs
in HICs and UMICs 205. This emphasises the importance of further understanding, monitoring and acting
on the commercial determinants of health 97. A growing literature on this topic is emerging, including
monitoring food industry corporate political activity in multiple countries 233, 234. Scholars are also paying
increasing attention to the political economy of food systems, placing actors and their relations of power at
the centre of analysis 115, 235. This includes emerging research on the financialisation of food systems, and
the way new investment patterns by private equity firms and food corporations are transforming market and
political relations in their favour 116, 227.
Finally, reducing UPF and beverage consumption and associated harms, involves implementing synergistic
policy actions targeting multiple food system sectors. Several factors have enabled progress in some
jurisdictions, especially the accelerated adoption of SSB taxes. These include the mobilisation of broad-
based civil society coalitions, the strategic development and use of evidence, and concerted advocacy
during key policy windows, for example during fiscal reform 184, 193, 210. Expanding financial support for
mobilizing civil society coalitions and ‘social lobbying’, as provided by Bloomberg Philanthropies in
Mexico 210, presents an important opportunity for accelerating worldwide policy change. Some of the key
challenges to sustaining policy actions in the long-term include maintaining political commitment,
countering ongoing industry resistance, and ensuring adequate capacity to design, implement and monitor
policy actions 205, 207, 236. This highlights the importance of continuing technical guidance and country-level
support provided by WHO, FAO, UNICEF, the World Bank and others. Classifying foods and beverages
by the degree of processing (as in the NOVA classification) in dietary guidelines, and not just nutrient
content alone, can help policy-makers and the public to better identify foods associated with adverse health
outcomes 237. Such ‘food-based profiling’ is now guiding policy action. For example, the Brazilian
Government recently included limits on UPFs in new school food programme legislation 238. Developing
guidance on food-based profiling, in combination with existing nutrient profiling work, may present an
important new technical activity for WHO in particular. There are also potential strategies to develop less-
processed packaged foods (whole-food reformulation), and to promote the consumption of home- and hand-
prepared foods 201.
There are several limitations of our analysis. We have not reported actual consumption and have instead
used retail sales data. Our reliance on using Euromonitor sales and ingredients data reflects the absence of
these food types in nationally-comparable standardised dietary survey instruments, presenting an important
data gap for the global nutrition community. We have not considered trends or patterns in the social
stratification of UPF and UPB sales within countries. Although urban consumers tend to be more affluent
than rural, some studies reveal the urban poor purchase higher levels of UPFs 128. We have also reported
only formal UPF and UPB sales. This may therefore under-represent true volumes as it does not capture
sales via informal channels, which are more important in lower-income countries. We have not included
commercial breastmilk substitutes or complementary foods, which are typically also UPFs, although we
have reported on these elsewhere 98. We have considered the health impacts of UPFs, but have largely
ignored the environmental implications. Our understanding of the links between the degree of food
processing and environmental degradation (or benefit) is emerging, and presents an important topic of
investigation as evident in recent studies focused on greenhouse gas emissions 239, 240. Although the large
25
variety of UPF products on supermarkets shelves may be manufactured from a small number of primary
agricultural commodities, the links between these products and agricultural biodiversity has barely been
explored.
Conclusion
The findings of this review supports our initial premise that there has been a substantial expansion in the
types and quantities of ultra-processed foods and beverages available in the world’s food supply, occurring
first in high-income countries and increasingly in middle-income ones. This provides evidence that a
transition towards a more highly-processed global diet is not only underway, but also continuing apace. As
countries grow richer, their populations appear to purchase a wider variety of ultra-processed products, with
the share of foods used mainly in food preparation declining. There are however wide variations at regional
and country levels, suggesting that although there may be a singular global transition to a more highly-
processed diet, transitions are also playing out across regions and countries at different stages of economic
and social development. This at least partly reflects differences in the underlying drivers, core factors and
dynamics of food systems that influence food purchasing behaviours and dietary change. Causes for
concern include the failure to reduce caloric sweeteners from UPFs in HICs, the rising supply of caloric
sweeteners from both UPFs and beverages in UMICs and LMICs, and the rising supply of cosmetic
additives and low-calorie and non-caloric sweeteners nearly everywhere.
We have also shown that these transitions are closely linked with the industrialisation of food systems ,
technological change and globalisation, including growth in the commercial and political practices of
transnational food and beverage corporations, and the power they have to shape food systems on a global
scale. Growing UPF and beverage markets are closely linked with the mass production of primary
agricultural commodities, and the conversion of these commodities into a diverse range of cheap ingredients
available for use in food manufacturing. In the current era of trade and investment liberalization, these
ingredients flow through globally integrated value chains and production networks of corporations, making
ultra-processed products available on a truly global scale. These food processing transitions are also closely
linked with transformative changes underway in food retailing, especially the growth of modern grocery
retailers, as well as the intensive use of sophisticated marketing techniques, including new digital
technologies.
Our results also suggest that these food processing transitions reflect variations in the strength of policy and
regulatory frameworks targeting unhealthy diets and the power of different actors and interests to help or
hinder policy action. Although there has been some recent progress, policy and regulatory actions in many
countries are weak, with a skew towards lifestyle-behavioural interventions targeting individuals rather than
more upstream ones targeting the commercial practices of the UPF industry. Substantial evidence now
shows this industry has impeded political commitment for strong regulatory action, and that this power has
been expanded by favourable governance arrangements, nutrient-based approaches to profiling the
healthiness of foods, and processes linked with trade and investment liberalisation, market concentration,
and the financialisation of food systems. This brings into question the role of the UPFindustry in current
governance arrangements and in shaping policy actions to attenuate unhealthy diets.
Overall, these findings suggest that adopting an approach that combines food systems and political economy
thinking is vital for understanding the determinants of global dietary change, and to informing future
26
nutrition policy actions. Given the rapidly emerging evidence on the adverse health outcomes associated
with diets high in UPFs, and the scale of change underway, the implications for global nutrition and public
health policy are crucial to consider.
References
1 Moubarac J-C, Parra DC, Cannon G, Monteiro CA. Food classification systems based on food
processing: significance and implications for policies and actions: a systematic literature review and
assessment. Curr Obes Report. 2014; 3: 256-72.
2 Monteiro CA, Cannon G, Moubarac JC, Levy RB, Louzada MLC, Jaime PC. Ultra-processing. An
odd 'appraisal'. Public Health Nutr. 2018; 21: 497-501.
3 Monteiro CA, Cannon G, Moubarac JC, Levy RB, Louzada MLC, Jaime PC. The UN Decade of
Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutr. 2018;
21: 5-17.
4 Monteiro CA, Cannon G, Lawrence M, da Costa Louzada ML, Machado PP. Ultra-processed foods,
diet quality, and health using the NOVA classification system. Rome: Food and Agricutlural Organization
of the United Nations 2019.
5 Cordain L, Eaton SB, Sebastian A, Mann N, Lindeberg S, Watkins BA, et al. Origins and evolution
of the Western diet: Health implications for the 21st century. Am J Clin Nutr. 2005; 81: 341-54.
6 Pollan M. Cooked: a natural history of transformation: Penguin 2014.
7 Ulijaszek SJ, Mann N, Elton S. Evolving human nutrition: implications for public health:
Cambridge University Press 2012.
8 Kiple KF, Ornelas KC. Cambridge world history of food. United Kingdom: Cambridge University
Press 2000.
9 McMichael P. A food regime genealogy. The Journal of Peasant Studies. 2009; 36: 139-69.
10 Monteiro CA, Levy RB, Claro RM, De Castro IRR, Cannon G. Increasing consumption of ultra-
processed foods and likely impact on human health: Evidence from Brazil. Public Health Nutrition. 2011;
14: 5-13.
11 Popkin BM. Global nutrition dynamics: the world is shifting rapidly toward a diet linked with
noncommunicable diseases. The American journal of clinical nutrition. 2006; 84: 289-98.
12 Popkin BM, Adair LS, Ng SW. Global nutrition transition: the pandemic of obesity in developing
countries. Nutrition Reviews. 2012; 70: 3-21.
13 Global Panel on Agriculture and Food Systems for Nutrition. Food systems and diets: Facing the
challenges of the 21st Century. London, UK 2016.
14 Baker P, Friel S. Processed foods and the nutrition transition: Evidence from Asia. Obesity Reviews.
2014; 15: 564-77.
15 Development Inititatives. 2020 Global Nutrition Report: Action on equity to end malnutrition.
Bristol, UK 2020.
16 Djupegot IL, Nenseth CB, Bere E, Bjørnarå HBT, Helland SH, Øverby NC, et al. The association
between time scarcity, sociodemographic correlates and consumption of ultra-processed foods among
parents in Norway: a cross-sectional study. BMC Public Health. 2017; 17: 447.
17 Moubarac J-C, Martins APB, Claro RM, Levy RB, Cannon G, Monteiro CA. Consumption of ultra-
processed foods and likely impact on human health. Evidence from Canada. Public health nutrition. 2013;
16: 2240-48.
18 Schnabel L, Kesse-Guyot E, Allès B, Touvier M, Srour B, Hercberg S, et al. Association Between
Ultraprocessed Food Consumption and Risk of Mortality Among Middle-aged Adults in France. JAMA
Intern Med. 2019.
27
19 Simões BdS, Barreto SM, Molina MdCB, Luft VC, Duncan BB, Schmidt MI, et al. Consumption
of ultra-processed foods and socioeconomic position: a cross-sectional analysis of the Brazilian
Longitudinal Study of Adult Health. Cadernos de saude publica. 2018; 34: e00019717.
20 Khandpur N, Cediel G, Obando DA, Jaime PC, Parra DC. Sociodemographic factors associated
with the consumption of ultra-processed foods in Colombia. Revista de saude publica. 2020; 54: 19.
21 Monteiro CA, Moura EC, Conde WL, Popkin BM. Socioeconomic status and obesity in adult
populations of developing countries: a review. Bulletin of the World Health Organization. 2004; 82: 940-
46.
22 Elizabeth L, Machado P, Zinocker M, Baker P, Lawrence M. Ultra-Processed Foods and Health
Outcomes: A Narrative Review. Nutrients. 2020; 12: 1955.
23 Louzada MLDC, Ricardo CZ, Steele EM, Levy RB, Cannon G, Monteiro CA. The share of ultra-
processed foods determines the overall nutritional quality of diets in Brazil. Public Health Nutr. 2018; 21:
94-102.
24 Cediel G, Reyes M, da Costa Louzada ML, Martinez Steele E, Monteiro CA, Corvalán C, et al.
Ultra-processed foods and added sugars in the Chilean diet (2010). Public Health Nutr. 2018; 21: 125-33.
25 Martínez Steele E, Popkin BM, Swinburn B, Monteiro CA. The share of ultra-processed foods and
the overall nutritional quality of diets in the US: evidence from a nationally representative cross-sectional
study. Popul Health Metr. 2017; 15: 6.
26 Rauber F, da Costa Louzada ML, Steele EM, Millett C, Monteiro CA, Levy RB. Ultra-Processed
Food Consumption and Chronic Non-Communicable Diseases-Related Dietary Nutrient Profile in the UK
(2008⁻2014). Nutrients. 2018; 10.
27 Moubarac JC, Batal M, Louzada ML, Martinez Steele E, Monteiro CA. Consumption of ultra-
processed foods predicts diet quality in Canada. Appetite. 2017; 108: 512-20.
28 Machado PP, Steele EM, Levy RB, Sui Z, Rangan A, Woods J, et al. Ultra-processed foods and
recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from
a nationally representative cross-sectional study. BMJ Open. 2019; 9: e029544.
29 Kim H HE, Rebholz CM. Ultra-processed food intake and mortality in the USA: results from the
Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994). . Public Health Nutr.
2019; 1-9.
30 Rico-Campà A M-GM, Alvarez-Alvarez I, et al. Association between consumption of ultra-
processed foods and all cause mortality: SUN prospective cohort study. . BMJ. 2019; 365:.
31 Blanco-Rojo R, Sandoval-Insausti H, Lopez-Garcia E, Graciani A, Ordovas JM, Banegas JR, et al.
Consumption of Ultra-Processed Foods and Mortality: A National Prospective Cohort in Spain. Mayo Clin
Proc. 2019; 94: 2178-88.
32 Juul F, Martinez-Steele E, Parekh N, Monteiro CA, Chang VW. Ultra-processed food consumption
and excess weight among US adults. Br J Nutr. 2018; 120: 90-100.
33 Louzada ML, Baraldi LG, Steele EM, Martins AP, Canella DS, Moubarac JC, et al. Consumption
of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015; 81: 9-15.
34 Mendonça RD, Pimenta AM, Gea A, de la Fuente-Arrillaga C, Martinez-Gonzalez MA, Lopes AC,
et al. Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra
Follow-Up (SUN) cohort study. Am J Clin Nutr. 2016; 104: 1433-40.
35 Nardocci M, Leclerc BS, Louzada ML, Monteiro CA, Batal M, Moubarac JC. Consumption of
ultra-processed foods and obesity in Canada. Can J Public Health. 2018.
36 Canhada SL, Luft VC, Giatti L, Duncan BB, Chor D, Fonseca M, et al. Ultra-processed foods,
incident overweight and obesity, and longitudinal changes in weight and waist circumference: the Brazilian
Longitudinal Study of Adult Health (ELSA-Brasil). Public Health Nutr. 2019: 1-11.
37 Mendonça RD, Lopes AC, Pimenta AM, Gea A, Martinez-Gonzalez MA, Bes-Rastrollo M. Ultra-
Processed Food Consumption and the Incidence of Hypertension in a Mediterranean Cohort: The
Seguimiento Universidad de Navarra Project. Am J Hypertens. 2017; 30: 358-66.
28
38 Rauber F, Campagnolo PD, Hoffman DJ, Vitolo MR. Consumption of ultra-processed food
products and its effects on children's lipid profiles: a longitudinal study. Nutr Metab Cardiovasc Dis. 2015;
25: 116-22.
39 Srour B, Fezeu LK, Kesse-Guyot E, Alles B, Mejean C, Andrianasolo RM, et al. Ultra-processed
food intake and risk of cardiovascular disease: prospective cohort study (NutriNet-Sante). BMJ. 2019; 365:
l1451.
40 Srour B, Fezeu LK, Kesse-Guyot E, Alles B, Debras C, Druesne-Pecollo N, et al. Ultraprocessed
Food Consumption and Risk of Type 2 Diabetes Among Participants of the NutriNet-Sante Prospective
Cohort. JAMA Intern Med. 2019.
41 Martínez Steele E, Juul F, Neri D, Rauber F, Monteiro CA. Dietary share of ultra-processed foods
and metabolic syndrome in the US adult population. Prev Med. 2019; 125: 40-48.
42 Fiolet T, Srour B, Sellem L, Kesse-Guyot E, Allès B, Méjean C, et al. Consumption of ultra-
processed foods and cancer risk: results from NutriNet-Santé prospective cohort. BMJ. 2018; 360: k322.
43 Schnabel L, Buscail C, Sabate JM, Bouchoucha M, Kesse-Guyot E, Allès B, et al. Association
Between Ultra-Processed Food Consumption and Functional Gastrointestinal Disorders: Results From the
French NutriNet-Santé Cohort. Am J Gastroenterol. 2018.
44 Melo B, Rezende L, Machado P, Gouveia N, Levy R. Associations of ultra-processed food and
drink products with asthma and wheezing among Brazilian adolescents. Pediatric allergy and immunology
: official publication of the European Society of Pediatric Allergy and Immunology. 2018.
45 Sandoval-Insausti H, Blanco-Rojo R, Graciani A, Lopez-Garcia E, Moreno-Franco B, Laclaustra
M, et al. Ultra-processed Food Consumption and Incident Frailty: A prospective Cohort Study of Older
Adults. J Gerontol A Biol Sci Med Sci. 2019.
46 Adjibade M, Julia C, Alles B, Touvier M, Lemogne C, Srour B, et al. Prospective association
between ultra-processed food consumption and incident depressive symptoms in the French NutriNet-Sante
cohort. BMC Med. 2019; 17: 78.
47 Gomez-Donoso C, Sanchez-Villegas A, Martinez-Gonzalez MA, Gea A, Mendonca RD,
Lahortiga-Ramos F, et al. Ultra-processed food consumption and the incidence of depression in a
Mediterranean cohort: the SUN Project. Eur J Nutr. 2019.
48 Basu S, McKee M, Galea G, Stuckler D. Relationship of Soft Drink Consumption to Global
Overweight, Obesity, and Diabetes: A Cross-National Analysis of 75 Countries. American Journal of
Public Health. 2013; March: e1-e7.
49 Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play
a role in the epidemic of obesity. Am J Clin Nutr. 2004; 79: 537-43.
50 Hu FB. Resolved: there is sufficient scientific evidence that decreasing sugar-sweetened beverage
consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev. 2013; 14: 606-
19.
51 Malik VS, Popkin BM, Bray GA, Després J-P, Hu FB. Sugar-sweetened beverages, obesity, type
2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010; 121: 1356-64.
52 Pereira MA, Kartashov AI, Ebbeling CB, Van Horn L, Slattery ML, Jacobs DR, et al. Fast-food
habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet. 2005;
365: 36-42.
53 Imamura F, O'Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, et al. Consumption of
sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2
diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ. 2015;
351: h3576.
54 Duffey KJ, Gordon-Larsen P, Steffen LM, Jacobs Jr DR, Popkin BM. Regular consumption from
fast food establishments relative to other restaurants is differentially associated with metabolic outcomes in
young adults. The Journal of nutrition. 2009; 139: 2113-18.
55 Smith KJ, McNaughton SA, Gall SL, Blizzard L, Dwyer T, Venn AJ. Takeaway food consumption
and its associations with diet quality and abdominal obesity: a cross-sectional study of young adults.
International Journal of Behavioral Nutrition and Physical Activity. 2009; 6: 29.
29
56 Chan DSM, Lau R, Aune D, Vieira R, Greenwood DC, Kampman E, et al. Red and Processed Meat
and Colorectal Cancer Incidence: Meta-Analysis of Prospective Studies. PLOS ONE. 2011; 6: e20456.
57 Hall KD AA, Brychta R, et al. . Ultra-Processed Diets Cause Excess Calorie Intake and Weight
Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake. . Cell Metab. 2019;
10.1016/j.cmet.2019.05.008. 31105044.
58 Luiten CM, Steenhuis IH, Eyles H, Ni Mhurchu C, Waterlander WE. Ultra-processed foods have
the worst nutrient profile, yet they are the most available packaged products in a sample of New Zealand
supermarkets. Public Health Nutr. 2016; 19: 530-8.
59 Ni Mhurchu C, Brown R, Jiang Y, Eyles H, Dunford E, Neal B. Nutrient profile of 23 596 packaged
supermarket foods and non-alcoholic beverages in Australia and New Zealand. Public Health Nutr. 2016;
19: 401-8.
60 Poti JM, Mendez MA, Ng SW, Popkin BM. Is the degree of food processing and convenience
linked with the nutritional quality of foods purchased by US households? American Journal of Clinical
Nutrition. 2015; 101: 1251-62.
61 Martínez Steele E, Monteiro CA. Association between dietary share of ultra-processed foods and
urinary concentrations of phytoestrogens in the US. Nutrients. 2017; 9: 209.
62 Fardet A. Minimally processed foods are more satiating and less hyperglycemic than ultra-
processed foods: a preliminary study with 98 ready-to-eat foods. Food Funct. 2016; 7: 2338-46.
63 Fardet A, Méjean C, Labouré H, Andreeva VA, Feron G. The degree of processing of foods which
are most widely consumed by the French elderly population is associated with satiety and glycemic
potentials and nutrient profiles. Food Funct. 2017; 8: 651-58.
64 de Graaf C, and Kok, F.J. . Slow food, fast food and the control of food intake. Nat Rev Endocrinol
2010; 6, .
65 Small DM, DiFeliceantonio AG. Processed foods and food reward. Science. 2019; 363: 346-47.
66 Authority EEFS. Panel on Contaminants in the Food Chain. Acrylamide in food. EFSA Journal:
2015.
67 Gibis M. Heterocyclic aromatic amines in cooked meat products: causes, formation, occurrence,
and risk assessment. Comprehensive Reviews in Food Science and Food Safety. 2016; 15: 269-302.
68 Zinöcker M, Lindseth I. The Western Diet–Microbiome-Host Interaction and Its Role in Metabolic
Disease. Nutrients. 2018; 10: 365.
69 Miclotte L VdWT. Food processing, gut microbiota and the globesity problem. Crit Rev Food Sci
Nutr. 2019; 1-14.
70 Chazelas E, Deschasaux M, Srour B, Kesse-Guyot E, Julia C, Allès B, et al. Food additives:
distribution and co-occurrence in 126,000 food products of the French market. Scientific reports. 2020; 10:
1-15.
71 Halden RU. Plastics and health risks. Annu Rev Public Health. 2010; 31: 179-94.
72 Thompson RC, Moore CJ, Vom Saal FS, Swan SH. Plastics, the environment and human health:
current consensus and future trends. Phil Trans R Soc B. 2009; 364: 2153-66.
73 Heindel JJ, Newbold, R., & Schug, T. T. . Endocrine disruptors and obesity. . Nat Rev Endocrinol.
2015; 11.
74 Buckley JP, Kim H, Wong E, Rebholz CM. Ultra-processed food consumption and exposure to
phthalates and bisphenols in the US National Health and Nutrition Examination Survey, 2013–2014.
Environment international. 2019; 131: 105057.
75 Alexy U, Sichert-Hellert W, Rode T, Kersting M. Convenience food in the diet of children and
adolescents: consumption and composition. Br J Nutr. 2008; 99: 345-51.
76 Peltner J, Thiele S. Convenience-based food purchase patterns: identification and associations with
dietary quality, sociodemographic factors and attitudes. Public Health Nutr. 2018; 21: 558-70.
77 Bellisle F. Meals and snacking, diet quality and energy balance. Physiol Behav. 2014; 134: 38-43.
78 Gordon EL, Ariel-Donges AH, Bauman V, Merlo LJ. What is the evidence for “food addiction?”
A systematic review. Nutrients. 2018; 10: 477.
30
79 Filgueiras AR, Pires de Almeida VB, Koch Nogueira PC, Alvares Domene SM, Eduardo da Silva
C, Sesso R, et al. Exploring the consumption of ultra-processed foods and its association with food
addiction in overweight children. Appetite. 2019; 135: 137-45.
80 Lobstein T, Dibb S. Evidence of a possible link between obesogenic food advertising and child
overweight. Obesity reviews. 2005; 6: 203-08.
81 Pulker CE, Scott JA, Pollard CM. Ultra-processed family foods in Australia: nutrition claims,
health claims and marketing techniques. Public health nutrition. 2018; 21: 38-48.
82 Mallarino C, Gómez LF, González-Zapata L, Cadena Y, Parra DC. Advertising of ultra-processed
foods and beverages: children as a vulnerable population. Revista de Saúde Pública. 2013; 47: 1006-10.
83 Bleich SN, Vercammen KA. The negative impact of sugar-sweetened beverages on children’s
health: an update of the literature. BMC obesity. 2018; 5: 6.
84 Moynihan P, Kelly S. Effect on caries of restricting sugars intake: systematic review to inform
WHO guidelines. Journal of dental research. 2014; 93: 8-18.
85 Hadjikakou M, Baker P. The untenable role of “junk food” in a healthy and sustainable food system.
In: Lawrence M, Friel S (eds.). Healthy and Sustainable Food Systems. Routledge: London 2019; 158-69.
86 Kroyer GT. Impact of food processing on the environment—an overview. LWT-Food Science and
Technology. 1995; 28: 547-52.
87 Koutsodendris A, Papatheodorou G, Kougiourouki O, Georgiadis M. Benthic marine litter in four
Gulfs in Greece, Eastern Mediterranean; abundance, composition and source identification. Estuarine,
Coastal and Shelf Science. 2008; 77: 501-12.
88 Popkin BM, Reardon T. Obesity and the food system transformation in Latin America. Obesity
Reviews. 2018; 19: 1028-64.
89 Popkin BM. Nutritional patterns and transitions. Population and development review. 1993: 138-
57.
90 Kearney J. Food consumption trends and drivers. Philosophical transactions of the royal society
B: biological sciences. 2010; 365: 2793-807.
91 Hawkes C. The role of foreign direct investment in the nutrition transition. Public Health Nutrition.
2005; 8: 357-65.
92 Hawkes C. Uneven dietary development: Linking the policies and processes of globalization with
the nutrition transition, obesity and diet-related chronic diseases. Globalization and Health. 2006; 2.
93 Monteiro CA, Moubarac JC, Cannon G, Ng SW, Popkin B. Ultra‐processed products are becoming
dominant in the global food system. Obesity reviews. 2013; 14: 21-28.
94 Reardon T, Tschirley D, Dolislager M, Snyder J, Hu C, White S. Urbanization, diet change, and
transformation of food supply chains in Asia. Michigan: Global Center for Food Systems Innovation. 2014.
95 Monteiro CA, Cannon G. The impact of transnational "big food" companies on the south: A view
from brazil. PLoS Medicine. 2012; 9.
96 Baker P, Friel S. Food systems transformations, ultra-processed food markets and the nutrition
transition in Asia. Globalization and Health. 2016; 12.
97 Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Thamarangsi T, et al. Profits and pandemics:
prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. The lancet.
2013; 381: 670-79.
98 Baker P, Smith J, Salmon L, Friel S, Kent G, Iellamo A, et al. Global trends and patterns of
commercial milk-based formula sales: is an unprecedented infant and young child feeding transition
underway? Public Health Nutrition. 2016; 19: 2540-50.
99 Vandevijvere S, Jaacks LM, Monteiro CA, Moubarac JC, Girling‐Butcher M, Lee AC, et al. Global
trends in ultraprocessed food and drink product sales and their association with adult body mass index
trajectories. Obesity Reviews. 2019; 20: 10-19.
100 Stuckler D, McKee M, Ebrahim S, Basu S. Manufacturing epidemics: the role of global producers
in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS
medicine. 2012; 9: e1001235.
31
101 Hawkes C, Friel S, Lobstein T, Lang T. Linking agricultural policies with obesity and
noncommunicable diseases: a new perspective for a globalising world. Food Policy. 2012; 37: 343-53.
102 Pluye P, Hong QN. Combining the power of stories and the power of numbers: mixed methods
research and mixed studies reviews. Annual review of public health. 2014; 35: 29-45.
103 Heyvaert M, Maes B, Onghena P. Mixed methods research synthesis: definition, framework, and
potential. Quality & Quantity. 2013; 47: 659-76.
104 Walls HL, Johnston D, Mazalale J, Chirwa EW. Why we are still failing to measure the nutrition
transition. BMJ global health. 2018; 3: e000657.
105 Euromonitor. Passport Global Market Information Database. London: Euromonitor International
2019.
106 Monteiro C, Cannon G, Levy R, Moubarac J, Louzada M, Rauber F. Ultra-processed foods: what
they are and how to identify them. Public Health Nutrition. 2019.
107 World Bank. World Development Indicators: Population Estimates and Projections. Washington,
D.C.: World Bank 2019.
108 Cummings J, Roberfroid M, Andersson H, Barth C, Ferro-Luzzi A, Ghoos Y, et al. A new look at
dietary carbohydrate: chemistry, physiology and health. European Journal of Clinical Nutrition. 1997; 51:
417.
109 WHO. Guideline: sugars intake for adults and children. Geneva: World Health Organization
(WHO) 2015.
110 Public Health England. McCance and Widdowson's composition of foods integrated dataset.
London 2019.
111 Mozaffarian D, Katan MB, Ascherio A, Stampfer MJ, Willett WC. Trans fatty acids and
cardiovascular disease. New Engl J Med. 2006; 354: 1601-13.
112 HLPE. Nutrition and food systems: A report by the High Level Panel of Experts on Food Security
and Nutrition of the Committee on World Food Security. Rome: Committee on World Food Security 2017.
113 IPES-Food. Too big to feed: Exploring the impacts of mega-mergers, consolidation and
concentration of power in the agri-food sector. London: International Panel of Experts on Sustainable Food
Systems 2017.
114 IPES-Food. The new science of sustainable food systems: overcoming barriers to food systems
reform. London: International Panel of Experts on Sustainable Food Systems 2015.
115 Baker P, Demaio A. The political economy of healthy and sustainable food systems. In: Lawrence
M, Friel S (eds.). Healthy and Sustainable Food Systems. Routledge 2019.
116 Clapp J. Financialization, distance and global food politics. Journal of Peasant Studies. 2014; 41:
797-814.
117 Fuchs D, Kalfagianni A. The causes and consequences of private food governance. bap. 2010; 12:
1469-3569.
118 Baker P, Kay A, Walls H. Trade and investment liberalization and Asia’s noncommunicable
disease epidemic: a synthesis of data and existing literature. Globalization and health. 2014; 10: 66.
119 Baker P, Friel S, Schram A, Labonte R. Trade and investment liberalization, food systems change
and highly processed food consumption: A natural experiment contrasting the soft-drink markets of Peru
and Bolivia. Globalization and Health. 2016; 12.
120 Thow AM, Hawkes C. The implications of trade liberalization for diet and health: a case study
from Central America. Globalization and health. 2009; 5: 5.
121 Grigg D. The changing geography of world food consumption in the second half of the twentieth
century. Geographical Journal. 1999: 1-11.
122 Reardon T, Timmer CP, Berdegue JA. The rapid rise of supermarkets in developing countries:
induced organizational, institutional, and technological change in agrifood systems. Journal of Agricultural
and Development Economics. 2004; 1: 168-83.
123 Monteiro CA, Conde WL, Popkin BM. Income-specific trends in obesity in Brazil: 1975–2003.
American journal of public health. 2007; 97: 1808-12.
32
124 Headey DD, Alderman HH. The relative caloric prices of healthy and unhealthy foods differ
systematically across income levels and continents. The Journal of nutrition. 2019; 149: 2020-33.
125 Moubarac J-C, Claro RM, Baraldi LG, Levy RB, Martins APB, Cannon G, et al. International
differences in cost and consumption of ready-to-consume food and drink products: United Kingdom and
Brazil, 2008–2009. Global public health. 2013; 8: 845-56.
126 Popkin BM. Global nutrition dynamics: the world is shifting rapidly toward a diet linked with
noncommunicable diseases. Am J Clin Nutr. 2006; 84: 289-98.
127 Pingali P. Westernization of Asian diets and the transformation of food systems: Implications for
research and policy. Food Policy. 2007; 32: 281-98.
128 Hawkes C, Harris J, Gillespie S. Changing diets: Urbanization and the nutrition transition. Global
Food Policy Report. International Food Policy Research Institute (IFPRI): Washington, DC 2017; 34-41.
129 Stuckler D, McKee M, Ebrahim S, Basu S. Manufacturing epidemics: the role of global producers
in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS
Med. 2012; 9: e1001235.
130 Smith LP, Ng SW, Popkin BM. Trends in US home food preparation and consumption: analysis of
national nutrition surveys and time use studies from 1965–1966 to 2007–2008. Nutrition journal. 2013; 12:
45.
131 Gehlhar M, Regmi A. Factors shaping global food markets. Washington, DC: US Department of
Agriculture 2005.
132 Lang T, Caraher M. Is there a culinary skills transition? Data and debate from the UK about changes
in cooking culture. Journal of the HEIA. 2001; 8: 2-14.
133 Warde A, Cheng S-L, Olsen W, Southerton D. Changes in the practice of eating: a comparative
analysis of time-use. Acta sociologica. 2007; 50: 363-85.
134 Brunner TA, Van der Horst K, Siegrist M. Convenience food products. Drivers for consumption.
Appetite. 2010; 55: 498-506.
135 Murphy S, Burch D, Clapp J. Cereal secrets: The world's largest grain traders and global
agriculture. Oxford: Oxfam 2012.
136 Global M&A Partners. Food Ingredients Sector. Dublin: Global M&A Partners 2018.
137 Briones R, Rakotoarisoa M. Investigating the structures of agricultural trade industry in developing
countries. FAO Commodity and Trade Policy Research Working Paper, 38. Rome: Food and Agricutlural
Organization of the United Nations 2013.
138 Fry J, Fitton C. The Importance of the Global Oils and Fats Supply and the Role that Palm Oil
Plays in Meeting the Demand for Oils and Fats Worldwide. Journal of the American College of Nutrition.
2010; 29: 245S-52S.
139 Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play
a role in the epidemic of obesity. The American Journal of Clinical Nutrition. 2004; 79: 537-43.
140 Barlow P, McKee M, Basu S, Stuckler D. Impact of the North American Free Trade Agreement on
high-fructose corn syrup supply in Canada: a natural experiment using synthetic control methods. CMAJ.
2017; 189: E881-E87.
141 Unar-Munguía M, Monterubio Flores E, Colchero MA. Apparent consumption of caloric
sweeteners increased after the implementation of NAFTA in Mexico. Food Policy. 2019; 84: 103-10.
142 Reardon T, Echeverria R, Berdegué J, Minten B, Liverpool-Tasie S, Tschirley D, et al. Rapid
transformation of food systems in developing regions: Highlighting the role of agricultural research &
innovations. Agricultural systems 2019; 172: 47-59.
143 Delgado C, Rosegrant M, Steinfeld H, Ehui S, Courbois C. Livestock to 2020: The next food
revolution. Outlook on Agriculture. 2001; 30: 27-29.
144 Alexander E, Yach D, Mensah GA. Major multinational food and beverage companies and informal
sector contributions to global food consumption: implications for nutrition policy. Globalization and health.
2011; 7: 26.
145 Nestle. Annual Review 2019. Vevey Nestlé S.A 2019.
33
146 Wilkinson J. The globalization of agribusiness and developing world food systems. Monthly
Review. 2009; 61.
147 Popkin B. Technology, transport, globalization and the nutrition transition food policy. Food
policy. 2006; 31: 554-69.
148 Kamel B, Stauffer C. Advances in Baking Technology. Amsterdam: Springer 1993.
149 Scrinis G. Nutritionism: The science and politics of dietary advice. New York: Columbia
University Press 2013.
150 Risch SJ. Food packaging history and innovations. Journal of Agricultural and Food Chemistry.
2009; 57: 8089-92.
151 Clapp J, Scrinis G. Big food, nutritionism, and corporate power. Globalizations. 2017; 14: 578-95.
152 Hawkes C. Marketing activities of global soft drink and fast food companies in emerging markets:
a review. Globalization, diets and noncommunicable diseases. World Health Organization: Geneva 2002;
1-78.
153 Green H. Global obesity: Nestlé initiatives in nutrition, health, and wellness. Nutrition reviews.
2006; 64: S62-S64.
154 Hawkes C. Dietary implications of supermarket development: A global perspective. Development
Policy Review. 2008; 26: 657-92.
155 Reardon T, Henson S, Gulati A. Links Between Supermarkets and Food Prices, Diet Diversity and
Food Safety in Developing Countries. In: Hawkes C, Blouin C, Henson S, Drager N, Dube L (eds.). Trade,
Food, Diet and Health: Perspectives and Policy Options. John Wiley & Sons Ltd: Chichester, West Sussex
2010; 111-30.
156 Reardon T, Hopkins R. The supermarket revolution in developing countries: Policies to address
emerging tensions among supermarkets, suppliers and traditional retailers. The European Journal of
Development Research. 2006; 18: 522-45.
157 Reardon T, Timmer C. Transformation of Markets for Agricultural Output in Developing Countries
Since 1950: How Has Thinking Changed? In: Evenson RE, Pingali P, Schultz TP (eds.). Volume 3:
Handbook of Agricultural Economics: Agricultural Development: Farmers, Farm Production and Farm
Markets. Elsevier: Burlington 2005.
158 Reardon T, Timmer CP, Minten B. Supermarket revolution in Asia and emerging development
strategies to include small farmers. Proceedings of the National Academy of Sciences. 2012; 109: 12332-
37.
159 Hawkes C. Uneven dietary development: linking the policies and processes of globalization with
the nutrition transition, obesity and diet-related chronic diseases. Globalisation and Health. 2006; 2: 4.
160 Reardon T, Berdegué J, Timmer CP. Supermarketization of the "Emerging Markets" of the Pacific
Rim: Development and Trade Implications. Journal of Food Distribution Research. 2005; 36.
161 Reardon T, Timmer C, Barrett C, Berdegue J. The rise of supermarkets in Africa, Asia and Latin
America. American Journal of Agricultural Economics. 2003; 85: 1140 - 46.
162 Hawkes C. The role of foreign direct investment in the nutrition transition. Public Health Nutrition.
2005; 8: 357–65.
163 Reardon T, Hopkins R. The supermarket revolution in developing countries: Policies to address
emerging tensions among supermarkets, suppliers and traditional retailers. Europ J Devel Res. 2006; 18:
522-45.
164 Coe NM, Wrigley N. Host economy impacts of transnational retail: The research agenda. Journal
of Economic Geography. 2007; 7: 341-71.
165 Machado P, Claro R, Canella D, Sarti F, Levy R. Price and convenience: The influence of
supermarkets on consumption of ultra-processed foods and beverages in Brazil. Appetite. 2017; 116: 381-
8.
166 Stanton R. Food retailers and obesity. Current Obesity Reports. 2015; 4: 54-9.
167 Taillie L, Ng SW, Popkin BM. Global growth of "big box" stores and the potential impact on human
health and nutrition. Nutrition Reviews. 2016; 74: 83-97.
168 Euromonitor. Packaged Food in China: Euromonitor International 2013.
34
169 Euromonitor. Packaged Food in India: Euromonitor International 2013.
170 Barki E, Parente J. Challenges and opportunities of the last mile for the base of the pyramid: the
case of Brazil. Field Actions Science Reports. 2014: 1-4.
171 Maimaiti M, Zhao X, Jia M, Ru Y, Zhu S. How we eat determines what we become: opportunities
and challenges brought by food delivery industry in a changing world in China. European journal of clinical
nutrition. 2018; 72: 1282-86.
172 Bates S, Reeve B, Trevena H. A narrative review of online food delivery in Australia: challenges
and opportunities for public health nutrition policy. Public Health Nutrition. 2020: 1-11.
173 Montgomery K, Chester J, Nixon L, Levy L, Dorfman L. Big Data and the transformation of food
and beverage marketing: undermining efforts to reduce obesity? Critical Public Health. 2019; 29: 110-17.
174 Freeman B, Kelly B, Baur L, Chapman K, Chapman S, Gill T, et al. Digital junk: food and beverage
marketing on Facebook. American journal of public health. 2014; 104: e56-e64.
175 Chandon P. How package design and packaged-based marketing claims lead to overeating. Applied
Economic Perspectives and Policy. 2013; 35: 7-31.
176 Hawkes C. The role of foreign direct investment in the nutrition transition. Public Health Nutr.
2005; 8: 357-65.
177 Hawkes C. Uneven dietary development: linking the policies and processes of globalization with
the nutrition transition, obesity and diet-related chronic diseases. Global Health. 2006; 2: 4.
178 Lang T, Rayner G. Overcoming policy cacophony on obesity: An ecological public health
framework for policymakers. Obesity Reviews 2007.
179 Kennedy G, Nantel G, Shetty P. Globalization of food systems in developing countries: impact on
food security and nutrition. Rome: Food and Agricultural Organization of the United Nations 2004.
180 Hawkes C, Jewell J, Allen K. A food policy package for healthy diets and the prevention of obesity
and diet‐related non‐communicable diseases: the NOURISHING framework. Obesity reviews. 2013; 14:
159-68.
181 WHO. Global action plan for the prevention and control of NCDs 2013-2020. Geneva: World
Health Organization (WHO) 2013.
182 Magnusson R. Advancing the right to health: the vital role of law. Geneva: World Health
Organization 2017.
183 Swinburn BA. Obesity prevention: the role of policies, laws and regulations. Australia and New
Zealand health policy. 2008; 5.
184 Baker P, Brown AD, Wingrove K, Allender S, Walls H, Cullerton K, et al. Generating political
commitment for ending malnutrition in all its forms: A system dynamics approach for strengthening
nutrition actor networks. Obesity Reviews. 2019; 20: 30-44.
185 Gortmaker SL, Swinburn BA, Levy D, Carter R, Mabry PL, Finegood DT, et al. Changing the
future of obesity: science, policy, and action. The Lancet. 2011; 378: 838-47.
186 World Health Organization. Report of the commission on ending childhood obesity. Geneva 2016.
187 Roberto CA, Swinburn B, Hawkes C, Huang TT, Costa SA, Ashe M, et al. Patchy progress on
obesity prevention: emerging examples, entrenched barriers, and new thinking. The Lancet. 2015; 385:
2400-09.
188 Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: patterns, trends, and
policy responses. The Lancet Diabetes & Endocrinology. 2016; 4: 174-86.
189 Haddad LJ, Hawkes C, Achadi E, Ahuja A, Ag Bendech M, Bhatia K, et al. Global Nutrition Report
2015: Actions and accountability to advance nutrition and sustainable development: Intl Food Policy Res
Inst 2015.
190 World Health Organization. Global nutrition policy review 2016-2017. Geneva 2018.
191 World Health Organization. Assessing national capacity for the prevention and control of
noncommunicable diseases: report of the 2017 global survey. Geneva 2018.
192 Dodd R, Reeve E, Sparks E, George A, Vivili P, Tin STW, et al. The politics of food in the Pacific:
coherence and tension in regional policies on nutrition, the food environment and non-communicable
diseases. Public health nutrition. 2019: 1-13.
35
193 Pérez‐Escamilla R, Lutter C, Rabadan‐Diehl C, Rubinstein A, Calvillo A, Corvalán C, et al.
Prevention of childhood obesity and food policies in Latin America: from research to practice. Obesity
Reviews. 2017; 18: 28-38.
194 Crammond B, Van C, Allender S, Peeters A, Lawrence M, Sacks G, et al. The possibility of
regulating for obesity prevention–understanding regulation in the C ommonwealth G overnment. obesity
reviews. 2013; 14: 213-21.
195 Bucher T, Collins C, Rollo ME, McCaffrey TA, De Vlieger N, Van der Bend D, et al. Nudging
consumers towards healthier choices: a systematic review of positional influences on food choice. British
Journal of Nutrition. 2016; 115: 2252-63.
196 Wilson AL, Buckley E, Buckley JD, Bogomolova S. Nudging healthier food and beverage choices
through salience and priming. Evidence from a systematic review. Food Quality and Preference. 2016; 51:
47-64.
197 Smith M, Toprakkiran N. Behavioural insights, nudge and the choice environment in obesity
policy. Policy Studies. 2018.
198 Mozaffarian D, Rosenberg I, Uauy R. History of modern nutrition science—implications for
current research, dietary guidelines, and food policy. BMJ. 2018; 361: k2392.
199 Ridgway E, Baker P, Woods J, Lawrence M. Historical developments and paradigm shifts in Public
Health Nutrition Science, guidance and policy actions: a narrative review. Nutrients. 2019; 11: 531.
200 Scrinis G, Monteiro CA. Ultra-processed foods and the limits of product reformulation. Public
Health Nutrition. 2018; 21: 247-52.
201 Adams J, Hofman K, Moubarac J-C, Thow AM. Public health response to ultra-processed food and
drinks. BMJ. 2020; 369: m2391.
202 Dickie S, Woods JL, Lawrence M. Analysing the use of the Australian Health Star Rating system
by level of food processing. International Journal of Behavioral Nutrition and Physical Activity. 2018; 15:
1-9.
203 Dickie S, Woods JL, Baker P, Elizabeth L, Lawrence MA. Evaluating Nutrient-Based Indices
against Food- and Diet-Based Indices to Assess the Health Potential of Foods: How Does the Australian
Health Star Rating System Perform after Five Years? Nutrients. 2020; 12: 1463.
204 Monteiro CA, Cannon G, Moubarac J-C, Martins APB, Martins CA, Garzillo J, et al. Dietary
guidelines to nourish humanity and the planet in the twenty-first century. A blueprint from Brazil. Public
Health Nutrition. 2015; 18: 2311-22.
205 Baker P, Hawkes C, Wingrove K, Demaio AR, Parkhurst J, Thow AM, et al. What drives political
commitment for nutrition? A review and framework synthesis to inform the United Nations Decade of
Action on Nutrition. BMJ Global Health. 2018; 3: e000485.
206 Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, et al. The global syndemic
of obesity, undernutrition, and climate change: the Lancet Commission report. The Lancet. 2019; 393: 791-
846.
207 Cullerton K, Donnet T, Lee A, Gallegos D. Playing the policy game: a review of the barriers to and
enablers of nutrition policy change. Public health nutrition. 2016; 19: 2643-53.
208 Nestle M. Food politics: How the food industry influences nutrition and health. California: Univ of
California Press 2013.
209 Gostin LO, Roache SA. The untapped power of soda taxes: incentivizing consumers, generating
revenue, and altering corporate behavior. International Journal of Health Policy and Management. 2017;
6: 489-93.
210 James E, Lajous M, Reich MR. The politics of taxes for health: an analysis of the passage of the
sugar-sweetened beverage tax in Mexico. Health Systems & Reform. 2020; 6: e1669122.
211 Carriedo A, Koon A, Encarnación LM, Lee K, Smith R, Walls H. The Political Economy of Sugar-
Sweetened Beverages Taxation in Latin America: Lessons from Mexico, Chile and Colombia. 2020.
212 Thow AM, Jones A, Hawkes C, Ali I, Labonté R. Nutrition labelling is a trade policy issue: lessons
from an analysis of specific trade concerns at the World Trade Organization. Health promotion
international. 2017; 33: 561-71.
36
213 Nestle M. Unsavory truth: how food companies skew the science of what we eat. New York: Basic
Books 2018.
214 Steele S, Ruskin G, Stuckler D. Pushing partnerships: corporate influence on research and policy
via the International Life Sciences Institute. Public Health Nutrition. 2020: 1-9.
215 Kraak VI, Harrigan PB, Lawrence M, Harrison PJ, Jackson MA, Swinburn B. Balancing the
benefits and risks of public–private partnerships to address the global double burden of malnutrition. Public
Health Nutrition. 2012; 15: 503-17.
216 Hawkes C, Buse K. Public health sector and food industry interaction: it’s time to clarify the term
‘partnership’and be honest about underlying interests. The European Journal of Public Health. 2011; 21:
400-01.
217 Friel S, Gleeson D, Thow A-M, Labonte R, Stuckler D, Kay A, et al. A new generation of trade
policy: potential risks to diet-related health from the trans pacific partnership agreement. Globalization and
health. 2013; 9: 46.
218 Barlow P, Labonte R, McKee M, Stuckler D. Trade challenges at the World Trade Organization to
national noncommunicable disease prevention policies: A thematic document analysis of trade and health
policy space. PLoS medicine. 2018; 15: e1002590.
219 Hawkes C. The role of foreign direct investment in the nutrition transition. Public Health Nutr.
2005; 8: 357 - 65.
220 Chopra M. Globalization and Food: Implications for the Promotion of “Healthy” Diets.
Globalization, Diets and Noncommunicable Diseases. World Health Organization: Geneva 2002.
221 Lang T. Food Industrialisation and Food Power: Implications for Food Governance. Dev Policy
Rev. 2003; 21: 555-68.
222 Hawkes C. Dietary implications of supermarket development: a global perspective. Dev Policy Rev.
2008; 26: 657-92.
223 Chopra M, Darnton-Hill I. Tobacco and obesity epidemics: not so different after all? BMJ. 2004;
328: 1558-60.
224 Hawkes C. The influence of trade liberalization and global dietary change: The case of vegetable
oils, meat and highly processed foods. In: Hawkes C, Blouin C, Henson S, Drager N, Dube L (eds.). Trade,
Food, Diet and Health: Perspectives and Policy Options. John Wiley & Sons Ltd: Chichester, West Sussex
2010; 35-59.
225 Wei A, Cacho J. Competition among foreign and Chinese agro-food enterprises in the process of
globalization. Int Food Agribus Man. 2000; 2: 437-51.
226 Clapp J. Distant agricultural landscapes. Sustainability Science. 2015; 10: 305-16.
227 Clapp J. The rise of financial investment and common ownership in global agrifood firms. Review
of International Political Economy. 2019: 1-26.
228 Wallace H, Jan A, Barregård L, Bignami M, Ceccatelli S, Cottrill B, et al. Risks for human health
related to the presence of 3-and 2-monochloropropanediol (MCPD), and their fatty acid esters, and glycidyl
fatty acid esters in food. EFSA Journal. 2016.
229 Reissig CJ, Strain EC, Griffiths RR. Caffeinated energy drinks—a growing problem. Drug and
Alcohol Dependence. 2009; 99: 1-10.
230 Steele EM, Baraldi LG, da Costa Louzada ML, Moubarac J-C, Mozaffarian D, Monteiro CA. Ultra-
processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional
study. BMJ open. 2016; 6.
231 World Health Organization. Guideline: sugars intake for adults and children. Geneva 2015.
232 Tan M, He FJ, Wang C, MacGregor GA. Twenty‐Four‐Hour Urinary Sodium and Potassium
Excretion in China: A Systematic Review and Meta‐Analysis. Journal of the American Heart Association.
2019; 8: e012923.
233 Mialon M, Swinburn B, Sacks G. A proposed approach to systematically identify and monitor the
corporate political activity of the food industry with respect to public health using publicly available
information. Obesity reviews. 2015; 16: 519-30.
37
234 McKee M, Stuckler D. Revisiting the corporate and commercial determinants of health. American
journal of public health. 2018; 108: 1167-70.
235 Harris J, Molly A, Clément C, Nisbett N. The Political Economy of Food. Brighton: Institute of
Development Studies 2019.
236 Baker P, Jones A, Thow AM. Accelerating the Worldwide Adoption of Sugar-Sweetened Beverage
Taxes: Strengthening Commitment and Capacity: Comment on" The Untapped Power of Soda Taxes:
Incentivizing Consumers, Generating Revenue, and Altering Corporate Behavior". International journal of
health policy and management. 2018; 7: 474.
237 WHO. Preparation and use of food-based dietary guidelines: report of a joint FAO/WHO
consultation. Geneva: World Health Organization (WHO) 1998.
238 República Federativa do Brasil. RESOLUÇÃO Nº 6, DE 8 DE MAIO DE 2020: Dispõe sobre o
atendimento da alimentação escolar aos alunos da educação básica no âmbito do Programa Nacional de
Alimentação Escolar - PNAE. Brasilia: Órgão: Ministério da Educação/Fundo Nacional de
Desenvolvimento da Educação 2020.
239 Hadjikakou M. Trimming the excess: environmental impacts of discretionary food consumption in
Australia. Ecological Economics. 2017; 131: 119-28.
240 Hendrie G, Baird D, Ridoutt B, Hadjikakou M, Noakes M. Overconsumption of energy and
excessive discretionary food intake inflates dietary greenhouse gas emissions in Australia. Nutrients. 2016;
8: 690.
38
Table S1. Included countries categorised by World Bank income group and Global Burden of Disease Study Region
Income group
GNI per capita (US$, PPP)
Region
Country
High-income
>12,376
Australasia and North America
Australia
Australasia and North America
Canada
Australasia and North America
New Zealand
Australasia and North America
United States
Central and East Asia
Hong Kong
Central and East Asia
Japan
Central and East Asia
Singapore
Central and East Asia
South Korea
Central and East Asia
Taiwan
Central and Eastern Europe
Czech Republic
Central and Eastern Europe
Estonia
Central and Eastern Europe
Hungary
Central and Eastern Europe
Latvia
Central and Eastern Europe
Lithuania
Central and Eastern Europe
Poland
Central and Eastern Europe
Slovakia
Central and Eastern Europe
Slovenia
Latin America and Caribbean
Chile
Latin America and Caribbean
Uruguay
North Africa and the Middle East
Saudi Arabia
North Africa and the Middle East
United Arab Emirates
Western Europe
Austria
Western Europe
Belgium
Western Europe
Denmark
Western Europe
Finland
Western Europe
France
Western Europe
Germany
Western Europe
Greece
39
Western Europe
Ireland
Western Europe
Israel
Western Europe
Italy
Western Europe
Netherlands
Western Europe
Norway
Western Europe
Portugal
Western Europe
Spain
Western Europe
Sweden
Western Europe
Switzerland
Western Europe
UK
Upper middle-
income
3,996 – 12,375
Africa
South Africa
Central and East Asia
Azerbaijan
Central and East Asia
China
Central and East Asia
Kazakhstan
Central and Eastern Europe
Belarus
Central and Eastern Europe
Bosnia Herzegovina
Central and Eastern Europe
Bulgaria
Central and Eastern Europe
Croatia
Central and Eastern Europe
Macedonia
Central and Eastern Europe
Romania
Central and Eastern Europe
Russian Federation
Central and Eastern Europe
Serbia
Latin America and Caribbean
Argentina
Latin America and Caribbean
Brazil
Latin America and Caribbean
Colombia
Latin America and Caribbean
Costa Rica
Latin America and Caribbean
Dominican Republic
Latin America and Caribbean
Ecuador
Latin America and Caribbean
Mexico
Latin America and Caribbean
Peru
Latin America and Caribbean
Venezuela
40
North Africa and the Middle East
Algeria
North Africa and the Middle East
Iran
North Africa and the Middle East
Turkey
South and South East Asia
Malaysia
South and South East Asia
Thailand
Lower middle-
income
1,026 – 3,995
Africa
Cameroon
Africa
Kenya
Africa
Nigeria
Central and East Asia
Georgia
Central and East Asia
Uzbekistan
Central and Eastern Europe
Ukraine
Latin America and Caribbean
Bolivia
Latin America and Caribbean
Guatemala
North Africa and the Middle East
Egypt
North Africa and the Middle East
Morocco
North Africa and the Middle East
Tunisia
South and South East Asia
India
South and South East Asia
Indonesia
South and South East Asia
Pakistan
South and South East Asia
Philippines
South and South East Asia
Vietnam
41
Figure S1. Ultra-processed foods sales (kg) per capita by country income level, 2006-19 with projections to 2024
42
Figure S2. Ultra-processed beverage sales (litres) per capita by country income level, 2006-19 with projections to 2024
43
Figure S3. Ultra-processed food sales (kg) per capita in 2019 vs. compounding annual growth rate (%) for the 2009-19 period, for countries classified
by income level and population size
44
Figure S4. Ultra-processed beverage sales (kg) per capita in 2019 vs. compounding annual growth rate (%) for the 2009-19 period, for countries
classified by income level and population size
45
Figure S5. Vegetable oil sales (litres) per capita by country income level, 2006-19 with projections to 2024
46
Table S2. Ultra-processed food sales (kg) per capita by world, country-income and most highly populated countries in 2019, with 2009-19
compounding annual growth rate (%)
Income
category /
country
Baked
goods
Breakfas
t cereals
Confecti
onery &
sweet
spreads
Dairy
products
&
alternati
ves
Frozen
processe
d
potatoes
Ice
cream &
frozen
desserts
Instant
noodles
Meat
substitut
es
Processe
d meat
&
seafood
Ready
meals
Sauces,
dressing
s &
condime
nts
Savoury
snacks
Soup
Sweet
biscuits,
snack
bars &
fruit
snacks
Vegetabl
e oil
Total ultra-
processed
foods*
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
HICs
23.2
0.2
2.7
-0.6
9.0
0.2
13.2
-0.3
8.1
0.6
5.2
0.3
1.3
1.0
1.8
1.2
2.8
-0.2
9.3
1.4
16.9
0.5
8.1
1.7
2.8
-0.5
5.0
1.0
7.8
0.6
109.3
0.4
USA
26.3
0.5
4.4
-1.6
11.0
-0.3
13.0
-0.3
11.0
0.1
7.6
-0.5
0.9
0.4
0.7
11.5
2.7
-0.5
10.9
1.4
21.3
0.8
14.3
1.7
4.7
-1.4
6.2
1.5
9.1
1.7
135.0
0.4
Japan
16.7
0.3
0.5
7.9
3.6
0.0
4.4
-0.6
3.8
0.4
4.2
0.6
3.5
1.3
11.9
-0.4
1.7
0.9
15.9
1.8
24.5
-1.4
5.9
0.9
1.0
0.8
2.3
1.3
5.8
-0.8
100.0
0.1
Germany
54.4
-0.2
2.2
-0.3
15.9
-0.7
23.6
-0.8
5.0
0.8
7.1
1.0
0.1
2.9
0.2
18.9
5.0
-1.3
14.8
1.1
16.9
0.4
5.0
3.0
1.1
-1.3
4.5
0.1
6.5
1.4
155.9
0.0
UMICs
5.6
2.7
0.2
2.7
2.5
0.9
2.6
2.0
0.9
7.5
1.4
1.1
1.7
-0.6
1.6
4.7
1.1
0.3
1.2
3.3
9.2
4.6
2.1
3.2
0.1
1.4
2.1
2.3
10.6
4.1
32.3
2.8
China
2.4
6.1
0.0
7.5
1.6
0.7
0.7
7.9
0.6
11.6
1.5
0.4
2.5
-1.1
2.9
4.8
1.0
-0.1
1.2
4.1
11.6
5.6
1.7
4.6
0.0
3.2
0.7
2.3
10.0
6.7
28.2
3.8
Brazil
5.6
1.5
0.1
3.6
3.0
-0.2
7.8
1.4
2.3
11.2
1.5
0.7
0.6
0.5
0.0
0.0
0.7
-0.4
0.9
4.4
7.1
4.1
2.7
0.5
0.1
2.8
4.4
-0.1
11.9
0.5
36.8
1.9
Russia
26.1
1.6
0.8
3.1
8.3
0.7
5.2
-1.3
1.2
10.8
2.2
2.4
1.0
1.8
0.0
0.0
2.7
1.4
4.6
0.6
9.8
1.3
2.4
1.6
0.2
-1.6
7.0
4.1
10.5
2.4
71.5
1.5
LMICs
2.0
3.7
0.0
5.8
0.8
3.8
0.7
3.0
0.1
6.2
0.4
4.6
1.0
4.3
0.1
5.6
0.3
4.9
0.1
5.8
1.8
4.2
0.8
8.2
0.0
2.5
1.5
4.6
8.7
11.6
9.7
4.4
India
0.9
3.8
0.0
16.3
0.5
11.4
0.1
7.7
0.0
20.0
0.3
12.5
0.3
12.6
0.0
0.0
0.0
13.3
0.1
17.2
0.6
10.4
0.9
14.1
0.0
11.7
1.8
5.1
11.8
17.1
5.6
7.8
Pakistan
0.7
5.8
0.0
5.8
0.4
5.2
0.3
8.7
0.0
13.4
0.2
5.1
0.1
6.5
0.0
0.0
0.0
0.0
0.0
0.0
0.1
5.7
0.2
6.3
0.0
6.9
1.4
6.5
2.8
5.1
3.4
6.3
Indonesia
2.5
5.6
0.0
10.7
1.4
3.7
1.5
3.5
0.2
7.2
0.3
5.7
3.8
2.2
0.3
8.8
0.4
8.0
0.0
4.6
4.3
6.7
1.1
3.7
0.0
6.1
1.0
3.1
7.2
6.5
16.8
4.5
World
6.5
1.4
0.5
0.1
2.6
0.8
3.2
0.6
1.6
1.7
1.5
1.0
1.1
1.2
0.8
3.5
0.9
0.5
1.8
1.9
6.4
2.7
2.3
2.8
0.5
-0.4
2.1
2.4
8.1
5.5
31.9
1.6
Notes: *total ultra-processed food values do not include vegetable oils; HICs – high-income countries; UMICs – upper-middle income countries; LMICs – lower-
middle income countries
47
Table S3. Ultra-processed beverage sales (kg) per capita by world, country-income and most highly populated countries in 2019, with 2009-19
compounding annual growth rate (%)
Income
category /
country
Carbonated
soft drinks
Concentrates
Dairy
products &
alternatives
Functional &
Flavoured
Water
Juice drinks
& nectars
RTD tea,
coffee &
Asian
speciality
drinks
Sports &
energy
drinks
Total Total
UPB
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
kg
%
HICs
82.2
-0.8
1.2
0.7
9.0
2.8
8.4
3.9
24.0
-1.9
19.9
2.4
12.6
4.0
157.2
0.1
USA
144.9
-1.1
0.1
12.4
10.2
3.9
12.9
5.2
32.3
-2.3
19.9
4.7
25.8
4.5
246.0
0.0
Japan
31.0
0.0
0.4
3.3
10.4
2.2
4.2
0.1
16.4
0.0
81.5
1.2
13.7
0.6
157.6
0.8
Germany
95.2
0.2
0.5
2.2
5.7
1.2
15.6
0.8
29.9
-2.9
15.1
0.7
9.4
7.0
171.4
0.0
UMICs
32.1
0.5
0.4
1.7
10.4
5.3
2.2
5.3
10.5
1.7
7.8
4.0
3.1
10.5
66.5
2.2
China
7.6
0.2
0.0
0.2
13.5
6.1
1.0
9.0
7.3
0.8
11.8
3.5
2.8
14.0
44.0
3.5
Brazil
61.4
-1.3
1.1
-2.1
5.0
-0.7
1.7
0.2
9.7
4.5
0.8
5.8
1.0
4.9
80.7
-0.6
Russia
33.0
2.8
0.0
0.0
3.9
1.0
1.7
7.8
14.1
-2.4
3.0
2.2
3.7
15.4
59.5
1.6
LMICs
10.2
5.3
0.1
3.7
1.2
9.5
0.1
7.7
2.8
7.9
2.4
9.4
0.9
9.2
17.6
6.6
India
4.8
9.6
0.0
3.0
0.3
18.8
0.0
0.0
1.7
15.9
0.0
11.7
0.0
15.2
6.9
11.1
Pakistan
6.9
6.4
0.1
4.5
0.3
14.8
0.0
0.0
4.1
7.0
0.0
4.1
0.4
4.8
11.8
6.7
Indonesia
3.2
2.2
0.4
4.6
3.1
11.5
0.2
3.8
2.3
16.0
12.6
7.7
2.3
6.1
24.2
7.4
World
28.9
0.6
0.4
1.7
5.3
4.8
2.1
4.4
8.6
0.5
6.5
3.7
3.3
6.1
55.1
1.7
Notes: HICs – high-income countries; UMICs – upper-middle income countries; LMICs – lower-middle income countries
48
Figure S6. Volumes of sweeteners, fats, sodium and cosmetic additives supplied (kg) per capita from ultra-processed foods (top) and beverages
(bottom) by country income level, 2006-19 with projections to 2023
49
Table S4. Ingredients supplied (kg) per capita from ultra-processed foods and beverages (kg) by country income in 2019, with 2009-19 compounding
annual growth rate (%) in brackets
Income
category
Category
Caloric
sweeteners
Low-calorie &
non-caloric
sweeteners
Vegetable oils
Vegetable fats
Animal fats
Sodium
Cosmetic
additives
HICs
Foods
14.1 (0.4)
0.4 (0.2)
6.3 (2.0)
2.6 (-2.3)
1.1 (0.2)
1.2 (0.4)
1.8 (0.8)
Beverages
11.7 (-1.2)
<0.1 (4.0)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (2.5)
0.4 (0.7)
Total
25.8 (-0.3)
0.4 (0.4)
6.3 (2.0)
2.6 (-2.3)
1.1 (0.2)
1.2 (0.4)
2.3 (0.7)
UMICs
Foods
4.6 (2.5)
<0.1 (2.2)
1.5 (3.8)
0.7 (-0.8)
0.2 (2.8)
1.1 (1.7)
0.6 (2.8)
Beverages
4.6 (0.8)
<0.1 (3.7)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (3.7)
0.1 (3.3)
Total
9.2 (1.6)
<0.1 (2.3)
1.5 (3.8)
0.7 (-0.8)
0.2 (2.8)
1.1 (1.7)
0.7 (2.9)
LMICs
Foods
1.4 (4.6)
<0.1 (4.2)
0.5 (8.0)
0.2 (-1.3)
<0.1 (7.7)
0.3 (1.8)
0.2 (4.7)
Beverages
0.8 (2.8)
<0.1 (3.9)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (6.6)
<0.1 (5.6)
Total
2.2 (3.9)
<0.1 (4.2)
0.5 (8.0)
0.2 (-1.3)
<0.1 (7.7)
0.3 (1.8)
0.2 (4.8)
Notes: Other fats category excluded due to very low volumes (<0.1 in all income categories and regions); HICs – high-income countries; UMICs – upper-middle
income countries; LMICs – lower-middle income countries
50
Table S5. Ingredients volumes supplied (kg) per capita from ultra-processed foods and beverages (kg) by region in 2019, with 2009-19 compounding
annual growth rate (%) in brackets
Region
Category
Caloric
sweeteners
Low-calorie
& non-
caloric
sweeteners
Vegetable
oils
Vegetable
fats
Animal fats
Sodium
Cosmetic
additives
Africa
Foods
1.0 (2.4)
<0.1 (1.2)
0.8 (4.5)
0.5 (-0.5)
<0.1 (1.4)
0.6 (1.3)
0.3 (3.2)
Beverages
3.2 (5.1)
<0.1 (9.0)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (7.2)
<0.1 (6.1)
Total
4.3 (4.3)
<0.1 (2.2)
0.8 (4.5)
0.5 (-0.5)
<0.1 (1.4)
0.6 (1.3)
0.4 (3.7)
Australasia and
North America
Foods
18.9 (0.6)
0.5 (0.6)
8.9 (2.5)
2.9 (-3.6)
1.5 (-0.4)
1.3 (0.7)
2.4 (0.8)
Beverages
19.0 (-1.2)
<0.1 (5.9)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (3.0)
0.6 (0.1)
Total
38.0 (-0.4)
0.5 (0.9)
8.9 (2.5)
2.9 (-3.6)
1.5 (-0.4)
1.3 (0.7)
3.1 (0.7)
Central and East
Asia
Foods
4.7 (2.6)
<0.1 (1.1)
1.0 (3.6)
0.4 (-0.5)
0.3 (1.8)
1.4 (1.2)
0.7 (2.4)
Beverages
2.9 (1.2)
<0.1 (3.8)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (2.8)
0.1 (3.4)
Total
7.6 (2.0)
<0.1 (1.2)
1.0 (3.6)
0.4 (-0.5)
0.3 (1.8)
1.4 (1.3)
0.9 (2.5)
Central and Eastern
Europe
Foods
8.3 (0.8)
0.2 (1.7)
4.9 (1.3)
2.2 (-1.3)
0.4 (1.9)
0.6 (0.7)
1.0 (0.6)
Beverages
5.8 (0.1)
<0.1 (1.7)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
0.1 (1.9)
Total
14.1 (0.5)
0.2 (1.7)
4.9 (1.3)
2.2 (-1.3)
0.4 (1.9)
0.6 (0.7)
1.2 (0.7)
Latin America and
Caribbean
Foods
5.3 (1.1)
0.1 (0.8)
2.5 (4.1)
1.3 (-2.1)
0.2 (3.1)
0.4 (2.4)
0.6 (1.9)
Beverages
10.2 (-0.2)
<0.1 (2.5)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (4.6)
0.3 (1.4)
Total
15.4 (0.2)
0.1 (0.9)
2.5 (4.1)
1.3 (-2.1)
0.2 (3.1)
0.4 (2.4)
0.9 (1.8)
North Africa and the
Middle East
Foods
3.2 (3.3)
<0.1 (4.0)
1.2 (3.7)
0.8 (2.7)
0.2 (3.9)
0.2 (4.4)
0.3 (4.8)
Beverages
3.9 (1.1)
<0.1 (2.5)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (3.3)
<0.1 (2.5)
Total
7.1 (2.0)
<0.1 (4.0)
1.2 (3.7)
0.8 (2.7)
0.2 (3.9)
0.2 (4.4)
0.4 (4.2)
South and South East
Asia
Foods
1.3 (6.4)
<0.1 (5.0)
0.4 (14.3)
0.2 (-1.6)
<0.1 (9.9)
0.4 (2.0)
0.2 (6.1)
Beverages
0.7 (2.9)
<0.1 (5.2)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (6.7)
<0.1 (5.7)
Total
2.0 (5.0)
<0.1 (5.0)
0.4 (14.3)
0.2 (-1.6)
<0.1 (9.9)
0.4 (2.0)
0.2 (6.0)
Western Europe
Foods
13.9 (0.2)
0.3 (-0.1)
6.0 (1.2)
3.0 (-1.5)
1.0 (0.8)
0.9 (0.3)
1.5 (0.6)
Beverages
7.6 (-2.0)
<0.1 (2.3)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (33.4)
0.3 (1.6)
Total
21.5 (-0.7)
0.4 (0.1)
6.0 (1.2)
3.0 (-1.5)
1.0 (0.8)
0.9 (0.3)
1.8 (0.7)
51
World
Foods
4.4 (1.6)
0.1 (1.3)
1.7 (3.0)
0.8 (-1.7)
0.3 (1.5)
0.7 (1.4)
0.6 (2.0)
Beverages
4.2 (0.4)
<0.1 (4.0)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
<0.1 (4.0)
0.1 (2.2)
Total
8.5 (1.0)
0.1 (1.4)
1.7 (3.0)
0.8 (-1.7)
0.3 (1.5)
0.7 (1.4)
0.7 (2.0)
Notes: *Other fats category excluded due to very low volumes (<0.1 in all income categories and regions)
