UPF papers expose health divide

“Our bar is the representative product for a system of feeding people that is really, really deadly.”

This is how Professor Chris Van Tulleken, the author and NHS doctor leading the charge against ultra-processed food (UPF), justified the sale of their ‘Killer’ protein bar to his co-collaborator, Joe Wicks, in a recently aired Channel 4 documentary. Around midway through the provocatively titled, ‘Joe Wicks: Licensed to Kill’, the health guru was having a wobble over the ethics of selling a bar that had been intentionally packed full of the kind of additives commonly used to create such snack bars, while remaining just the right side of legal limits. Reassured by Van Tulleken, Wicks set his reservations to one side and the Killer bar was made available for sale to the public.

Unsurprisingly, the response to the show was mixed, not least within the public health community. Some nutritionists on my social media feeds decried it as an attention-grabbing stunt that would add to the public’s fear and confusion over UPF. Others heaped praise on the duo for shining a light on how such foods are often marketed with a health halo, despite making us sick, and the perverse way in which they are currently regulated in the UK.

The polarity of views reflects a growing schism within the health and nutrition community over UPF, the risk it poses and how that risk should be confronted. Often with matters of policy, health experts and campaigners sit squarely on one side of a very clear divide, for example over advertising bans for unhealthy foods. Where UPF is concerned, things are far more nuanced – and the dialogue is becoming ever more heated.

The latest subject for debate is a three-paper series published in The Lancet that reviews the evidence over UPF and the association with multiple diet-related chronic diseases. It’s a weighty piece of work and much of the evidence put forward is compelling. 

The first paper reviews the link between growing UPF consumption and harm to human health. 

The second focuses on policies to halt and reverse the rise in UPF production, marketing and consumption. 

The third paper explores how multinational suppliers of UPF have used their power to deliberately restructure food systems in favour of their products and sets out a vision for how a public health response can be mobilised.

It is this third paper that is proving most contentious as it treads the thin line between evidence and polemic. The suggestion that the response to UPF needs to borrow from the playbook for tackling tobacco consumption is proving particularly problematic for some when the definition of UPF (based on the NOVA system) includes foods such as wholemeal bread, plant-based meat alternatives and baked beans.

Combating criticism

To-date, much of the criticism levelled against NOVA (a system developed by Brazilian nutrition professor, Carlos Monteiro, a co-author of the first paper) has centred around its grouping of foods based on the degree of processing rather than their nutrient profile. The Lancet papers go some way to tackling this criticism head on.

In a nutshell, the authors’ argument is that we have to start tackling dietary patterns rather than narrowly focusing on individual nutrients. For decades, the latter has formed the basis for UK Government obesity policy during which time the prevalence and cost of diet-related ill health has continued to soar. A central hypothesis of The Lancet papers is that the problem with UPF concerns its role in a global transition (that is more advanced in some countries than others) away from diets centred on whole foods towards those where UPF now contributes more than 50% of energy intake in countries like the UK and US. This pattern increases the risk of chronic disease and nutrient imbalances by fuelling overeating (since UPF is designed to be hyperpalatable), reducing intake of health-protective phytochemicals, and increasing intake of toxic compounds, endocrine disruptors and potentially harmful classes and mixtures of food additives such as emulsifiers and artificial sweeteners.

Within each category of food, the authors argue the composition and processing characteristics of ultra-processed versions make them inferior to their non-ultra-processed counterparts. Possible exceptions – such as ultra-processed plant-based burgers compared with processed meat burgers – “do not invalidate the general rule”, they say.

The plant-based meat alternatives market has been a notable casualty of the backlash against UPF despite evidence of the benefits – both to health and the environment – of replacing a certain level of animal protein in the diet. It’s no surprise therefore that it’s proved a lightning rod for debate. A recent research paper published in the Nature Link journal concluded that the widespread perception that “natural” or unprocessed foods are inherently healthier can lead to the rejection of plant-based alternatives in favour of animal products such as red meat or dairy. “This is concerning, as current evidence suggests that many of these animal foods are more strongly associated with adverse cardiometabolic outcomes and higher chronic disease risk and mortality,” the authors wrote.

A nod to nuance

Although many subsequent newspaper headlines have been designed to provoke shock (I’m looking at you Daily Mail), The Lancet papers do attempt to reflect the nuance of the debate. The authors suggest, for example, that exploring the health effects of UPF sub-groups based on their nutrient profile might be relevant for regulatory purposes particularly where UPFs dominate the food supply – as they do in the UK and US. They acknowledge that in some categories of foods, like bread products, non-UPF versions can be rare. Where this is the case, they suggest UPF sub-groups like packaged breads could initially be exempted from regulations that target their price and availability to avoid detrimentally affecting people on low incomes.

In other areas, the proposals are more strident. The authors recommend the use of warning labels on menus in fast food restaurants and added taxation on fast food products that are UPF. They also suggest regulating food at the corporate level in foodservice and retail settings by applying restrictions or penalties based on the proportion of total sales of UPF products.

Both of these proposals would likely garner a reasonable level of support among health campaigners. But it is in the discussion of corporate power and how it has shaped a UPF dominated food system where the link between the authors’ thesis and potential policy responses becomes harder to square.

‘Danone paradox’

We might term this the ‘Danone paradox’. The multinational manufacturing giant is named in the third paper among the eight largest transnational UPF manufacturers, collectively referred to as “the UPF industry”. These companies are characterised as the villains of the piece. Yet Danone is often held up by public health campaigners as the exemplar for how a food business can reposition itself to support better health and wellbeing. It was ranked number one on the latest Global Access to Nutrition Index, the Access to  Nutrition initiative’s assessment of how the world’s largest food and beverage manufacturers perform in improving access to nutritious foods.  More than 90% of Danone’s sales by volume are classified as non-HFSS, while the company has led industry calls for junk food to be taxed more rigorously and for mandatory health reporting.

If Danone is part of the problem then those leading the crusade against UPF risk making impossible asks of policy makers. The authors rightly highlight the success of policies in South American countries like Chile and Brazil in curbing demand for UPF, but Chile’s cigarette-style black warning labels only apply to HFSS products – a business such as Danone would be almost entirely unaffected.

That’s not to suggest the diagnosis is entirely wrong. The authors are surely right to highlight coordinated industry activities aimed at blocking regulation, and they make a strong case why the industry’s economic and political power in food systems should be disrupted and reduced. The vision to shift towards a “local food system with emphasis on local food producers, preserving cultural foods transitions and economic benefits for communities” is one many would subscribe to. And you will find little disagreement among anyone within the health community about the need to improve access to fresh and minimally processed foods.

Yet is the notion that we essentially need to burn down the edifice of the current food industry a step too far? Is it helpful that a public still getting to grips with the notion of harmful nutrients is now being told the majority of foods they consume are potentially as dangerous as cigarettes?

Wicks had his ethical wobble for a reason. These are questions to which there is no easy answer. But one thing seems certain – while the health community is divided, politicians have an excuse to keep looking the other way.

*A version of this article was first published by Footprint Media.