The NOVA classification is a 'revolutionary approach' to the health issues posing a major public health threat to the UAE and the developed world
Ultra-processed foods: what are they and are you eating too many?
By now, most of us know the basic rules of nutrition. Avoid snacking, go easy on the fast food and sugary drinks, major on fruit and vegetables and balance your intake of proteins, carbohydrates and fats.
It all makes perfect sense, but it’s not an easy regime to follow, or to stick to. If only there were a single, simple, hard-and-fast rule that placed all foodstuffs into two camps – good and bad – and left us in no doubt about what to eat and what to avoid like the plague.
Well, now there is. It began in 2009 with a commentary published in the journal Public Health Nutrition that challenged orthodox nutritional beliefs and caused waves in the public health community by suggesting that “the issue is not food, nor nutrients, so much as processing”.
Now, after almost a decade of research analysing the eating habits of tens of thousands of people in over 20 countries, a team of Brazilian researchers claim they have amassed overwhelming evidence to support what they say should be the one 'golden rule' of health and nutrition: 'Avoid ultra-processed products'.
Professor Carlos Monteiro and colleagues in the department of nutrition at the University of Sao Paulo, Brazil, have developed what they call the NOVA system, which puts all foods into just four groups. Group one is “unprocessed or minimally processed foods”; group two is “processed culinary ingredients”; group three is “processed foods” and group four – to be avoided at all costs – is what they categorise as “ultra-processed food (UPF) and drink products”. These are "industrial formulations typically with five or more and usually many ingredients, often including those also used in processed foods, such as sugar, oils, fats, salt, anti-oxidants, stabilisers, and preservatives”.
There seems little doubt that the findings have widespread implications for the UAE, where increased affluence and a mall-based fast-food culture have combined with disastrous results. While life expectancy in the UAE is increasing, that improvement can be attributed not to lifestyle improvements, but to better, and more costly, healthcare – more people are living longer, but often with multiple health problems and death rates from lifestyle-linked factors are still the biggest killers.
A top-ten ranking of risk factors for death and disability is dominated by the consequences of bad diets. The number-one risk is high body mass index (BMI), incidence of which has increased by over 190 per cent since 2005. At number two is dietary risks (up 202 per cent), followed by high blood pressure (192 per cent) and high cholesterol (211 per cent).
The toll of the UAE lifestyle is spelled out in shocking statistics compiled by the US-based Institute for Health Metrics and Evaluation, a US$279 million programme funded by the Bill & Melinda Gates Foundation designed to measure the global burden of disease, country by country.
Not only is heart disease the number-one killer in the UAE, but between 2005 and 2016 the rate of deaths increased by a shocking 215 per cent. In the same period the proportion of deaths from diabetes rose even more – by 219 per cent. Diabetes is now the fifth largest killer, and rising.
Professor Monteiro says the NOVA classification system is nothing less than “a revolutionary approach” to the nutritional issues currently posing a major public health threat in the developed world – not least because it points the finger of blame not at greedy or lazy consumers but at the corporations feeding them so-called ultra-processed foods.
NOVA, he told The National, “allows a precise identification of the main driver of the pandemics of obesity and other chronic diet-related non communicable diseases, such as diabetes, cardiovascular disease and many types of cancer”. And that driver, he says, “is the transnational corporations that control the manufacture and marketing of ultra-processed food worldwide”.
Ultra-processed products, says the NOVA group, have certain “common attributes”, such as “hyper-palatability” – the idea that highly processed foods can be addictive – “sophisticated and attractive packaging, multi-media and other aggressive marketing to children and adolescents, health claims, high profitability, and branding and ownership by transnational corporations”. And, crucially, a “role in the pandemics of diet-related non-communicable diseases”.
The NOVA group’s most recent paper, published last month in the journal Public Health Nutrition, looked at the proportion of ultra-processed foods in diets in 19 European countries, by analysing national household budget and dietary surveys. Results varied widely. In Portugal, they found that only 10.2 per cent of daily calories came from such foods. The worst performing country was the UK, where they accounted for over 50 per cent of calories.
When they then looked at obesity rates in the 19 countries, they found “a significant positive association” between intake of ultra-processed foods and national prevalence of obesity. Again, with 24.5 per cent of the population obese, the UK was the worst performer, while Portugal was among the best.
Any doubt that these issues are especially problematic in the UAE is settled by a table comparing the rate of key causes of premature death across 10 countries, grouped together because of socio-demographic similarities. The incidence of deaths from heart disease and diabetes in the UAE is significantly higher than the average. For example, in 2016 heart disease claimed 3,727 lives per 100,000 population in the UAE, compared to a group average of 2,606.
Other studies have shown that 30 per cent of people in the UAE suffer from heart disease, diabetes now affects one in five and over 30 per cent of children are obese. According to the Institute for Health Metrics and Evaluation, 66 per cent of men and 60 per cent of women in the UAE are medically overweight or obese.
Professor Monteiro told The National that he and his team developed the concept of ultra-processed foods after studying a series of Brazilian Household Food Budget surveys. Analysis revealed that while households were buying less table sugar, table salt and plant oils, “the nutrient profile of the whole food basket had more and more sugar, sodium and fat, particularly saturated and trans-fats”.
The answer to this apparent contradiction, they concluded, was that “households were buying more and more soft drinks, sweet or savoury snacks and shelf-stable or frozen ready meals, and these products had much more sugar, sodium, saturated and trans-fats than all other foods taken together”.
Unsurprisingly, the food industry isn’t wild about the NOVA classification system, which is being increasingly used in international research projects and has been recognised by influential organisations including the Food and Agriculture Organisation of the United Nations and the Pan-American Health Organisation.
“Processed food should not be demonised,” a spokesperson for the UK’s Food and Drink Federation told The National. “By working closely with our partners throughout the food-supply chain, we can use processing positively to ensure all sectors of society have access to safe, affordable food.”
The food and drink industry, she added, was “consumer-led and manufacturers respond to changing trends and demands around health and wellbeing”. In the past decade global food and drink manufacturers had “reformulated” many products, reducing sugar, salt, fat and calories, “and there is now a greater variety of healthier products available to shoppers than ever before”.
While the federation and its members “recognise that obesity is a complex issue”, it believes that “a whole-diet approach to tackling obesity, focusing on net calorie intake and not the role of individual nutrients or ingredients, is the correct way to tackle such an issue”.
It isn’t only the food industry that has reservations. A commentary in the American Journal of Clinical Nutrition in November claimed there was “no evidence” to support the NOVA view “that UPFs give rise to hyper-palatable foods associated with a quasi-addictive effect” and that data in the US and Europe “fail to uphold the assertion that UPFs, which dominate energy intake, give rise to dietary patterns that are low in micronutrients”. Furthermore, “to perpetuate the myth that the modern approach to food classification is both static and outdated is both untrue and irresponsible”.
Undeterred, Professor Monteiro and his team are eager to spread the word further afield. In addition to the 19 European countries studied, they have detected similar negative outcomes associated with excessive consumption of ultra-processed foods in the US, Canada, Colombia, Chile and Brazil. They are keen to test their theory in the Gulf because the UAE has some of the highest levels of obesity and diabetes in the world. “We would love to associate ourselves with scientists in the region to do this,” says Professor Monteiro.
The NOVA system, he says, offers governments a chance to fine-tune what are often confusing nutritional messages. “National governments should fulfil their duties of protecting public health, which in this case means to clearly inform the population in national dietary guidelines why they should avoid UPF, to tax and to restrict the marketing of UPF, particularly for children and adolescents, to create environments free of UPF, such as school canteens and health settings, and to exclude UPF purchase from public food procurement.
“Individual consumers so informed and supported by public policies,” he believes, “will tend to adopt a much healthier diet.”
Apart from the impact on the health of individuals, and even entire nations, the São Paulo group believes that “the impact of ultra-processed products on human health is … a world crisis, to be confronted, checked and reversed as part of the UN Sustainable Development Goals and its Decade of Nutrition”. Even more sinister, in a commentary published last year in the journal Public Health Nutrition they denounced “the ever-increasing production and consumption of ultra-processed food and drink products” as one of the human activities “disturbing natural planetary balance to an extent that may well become irreversible”.
Not everyone agrees ultra-processed foods are a no-go
Julie Jones Miller, a professor of food and nutrition at St Catherine University, Minnesota, who chaired a joint task-force organised by the US Academy of Nutrition and Dietetics that looked at the effect of processed foods, is sceptical about the Nova recommendations.
“Our studies showed that you can construct diets with processed and ultra-processed foods that are unhealthy and those that are healthful and workable,” she says. “It all depends on choice.”
Studies done for the taskforce, she says, “show that processed foods can be part of diets of children and adults and can promote nutrition”.
Nova, she says, “gives the impression that home-prepared meals are somehow more nutritious. They may taste better, have the added ‘love’, but they may or may not be any more nutritious if they contain the same items as a typical western diet, which is unbalanced, having too large portions, inadequate fruits and vegetables, too much meat and fat, too many calories, and too many indulgent foods with low nutritional value”.
“Dietary recommendations have long advocated that people should choose more fruits and vegetables, whole grains, and reduce intakes of sugar and salt. If you make a meal at home that does not meet the above advice, it will not be healthier than foods boughtin the marketplace.”