On 1 April 2016 the UN General Assembly proclaimed the Decade of Nutrition, to run from 2016 to 2025 as part of the UN Sustainable Development Goals initiative^{( 1 )}. It will be guided by the FAO, the WHO and other UN agencies, with support requested from civil society and the private sector. All concerned repeatedly emphasize that this work is crucial, because of the evident multiple worsening threats to food systems and supplies, and thus to food security, human health and welfare, the living and physical world and the biosphere. At the General Assembly meeting, FAO Director-General José Graziano da Silva stated: ‘This Resolution puts nutrition at the heart of sustainable development’.

Reasons to emphasize food processing

Special attention to food processing is now crucial in order to understand the connection between diet and public health. Here are five reasons that justify this statement. They explain why the NOVA classification has been developed and why it is necessary to identity the sources of ultra-processed products.

One. Conventional food classifications no longer work well. They usually group foods and foodstuffs in terms of their botanical origin or animal species and according to nutrients they contain. In this way they often group together foods that have different effects on health and disease. So ‘cereals and cereal products’ often group whole grains together with sugared ‘breakfast cereals’ and cookies (biscuits), and ‘meat and meat products’ often group fresh chicken together with ‘nuggets’. This sidelining of food processing has serious consquences, as shown below.

Two. Evidence on the relationship between food processing and health outcomes has been increasing steadily. An obvious example is industrial trans-fats, produced by the partial hydrogenation process in the manufacture of a vast number of fatty branded packaged products, including margarines, biscuits and other ‘long-life’ baked goods. Trans-fats are now known to be a cause of CVD⁽ Reference de Souza, Mente and Maroleanu ^{12 )}. Reports issued by UN agencies and other authoritative organizations^{( 13 , 14 )} list some processed foods and drinks as certainly or probably implicated in obesity and chronic diseases. These include energy-dense food products, fast foods, soft drinks, sugary drinks, refined starchy foods, processed meat and salt-preserved foods. But such reports apparently do not see any pattern, and stop short of examining processing as such. Both the US 2010 and the 2015–2020 Dietary Guidelines for Americans reports^{( 15 , 16 )} advise less consumption of common ingredients of processed foods such as sodium, added sugars, trans-fats, refined grains and processed meats. Yet these reports also do not examine processing as such, and the term ‘processing’ is not even included in their glossaries of terms. Also, concern about food additives is usually limited and confined to issues of contamination; much less attention is given to the use of cosmetic food additives (notably, flavours and colours) that are used in order to make combinations of cheap processed oils, refined sugars and starches palatable and attractive.

Three. Food systems and supplies are changing globally and are determining changes in food purchase and consumption. Specialist food retailers are being rapidly displaced by supermarkets whose central aisles are dominated by branded packaged products. Home cooking has decreased in favour of snacking on processed products, consumption of pre-prepared dishes, and the very rapid rise of franchised fast-food caterers selling processed meat products, French fries and sugared soft drinks. Branded products such as fatty, sugary or salty snack foods and sugared soft drinks are available in all sorts of retail outlets, often round the clock^{( 2 , 6 ,} Reference Monteiro, Cannon and Levy ^{17 )}.

Four. All these phenomena are being driven by transnational corporations. These corporations are identified in a 2012 PLoS Medicine series, and in 2014 by Margaret Chan, Director-General of the WHO, as ‘Big Food’⁽ Reference Stuckler and Nestle ^{18 , 19 )}. Since the 1980s they have taken advantage of the freedom to make foreign direct investments, an engine of economic growth, which, as reported by the Organisation for Economic Co-operation and Development, have risen from $US 61 million in 1985 to $US 1068000 million in 2000 – and to $US 1730000 million in 2015^{( 20 , 21 )}. This has dramatically changed food supplies in middle- and low-income countries, as shown elsewhere⁽ Reference Wilkinson ^{22 ,} Reference Hawkes ^{23 )}. The annual turnovers of a number of corporations exceed the gross national product of mid-range countries and, unlike many national governments, they can divert or invest billions of dollars in new technologies and markets⁽ Reference Monteiro and Cannon ^{24 )}. As stated in a 2000 report by the Global Policy Forum⁽ Reference Greer and Singh ^{25 )}:

Five, and related. It is now becoming increasingly well known that transnational food corporations have colossal resources to manufacture, market, promote and lobby for their packaged branded products. Their impact is most evident in the middle- and low-income countries they have penetrated since the 1980s, where they often plan ‘double-digit’ growth, meaning 10 % or more increase in annual sales⁽ Reference Monteiro and Cannon ^{24 )}. As pointed out in the September 2016 ‘Foresight’ report^{( 2 )}:

Taken all together, these and other factors, including the impact of ultra-processed food and drink products on social life, culture, employment and the environment, of which more below, show that in this 21st century it is necessary to pay special attention to food processing and to ultra-processed products (see Box 1).

Food processing as such is not the issue

So, what does ‘processing’ mean? Organizations that represent the interests of food and drink corporations^{( 26 , 27 )} or professional organizations⁽ Reference Eicher-Miller, Fulgoni and Keast ^{28 –} Reference Weaver, Dwyer and Fulgoni ^{30 )} that are supported by food product manufacturers⁽ Reference Simon ^{31 )} have published reports, brochures or papers between 2010 and 2014 on food processing. These use very broad characterizations, such as ‘food processing is any deliberate change made in a food from the time of origin to the time of consumption’^{( 26 )}, or ‘a variety of operations by which raw foodstuffs are made suitable for consumption, cooking, or storage’^{( 27 )}, or else ‘food processing is the alteration of foods from the state in which they are harvested or raised to better preserve them and feed consumers’⁽ Reference Weaver, Dwyer and Fulgoni ^{30 )}.

Additives are explained with statements such as^{( 27 )}:

It is also true in a broad sense that^{( 27 )}:

Practically all food is processed in some sense and in some way, including by ‘other procedures’ not mentioned above such as hydrogenation, hydrolysation and extrusion. Thus the term ‘processing’ (like the term ‘industry’) is very general and therefore not helpful. It is a mistake to make any judgement of food supplies or foods simply because they are ‘processed’. Further, attempts to distinguish between different types of processing by using undefined terms such as ‘highly’ or ‘heavily’ processed, or ‘fast’, ‘convenience’, ‘snack’ or ‘junk’ food, are also unhelpful.

Verdicts on food processing as such have little or no meaning. Food scientists and technologists and food manufacturers rightly emphasize the benefits of originally ancient and also relatively novel processes such as drying, non-alcoholic fermentation, chilling and freezing, pasteurization and vacuum-packing. But on the other hand – just to take two examples – evidence on the harm done by partial hydrogenation is now conclusive, and on sugaring (notably with soft drinks or ‘soda’) is very strong⁽ Reference de Souza, Mente and Maroleanu ^{12 – 14 )}.

It is possible to make sense of food processing and its effects on human health only when analysis and assessment are discriminating and precise, with terms defined and with types, uses and effects of processing identified and distinguished. Definitions need to be meaningful, detailed and objective, which is to say specific, coherent, clear, comprehensive and workable. This is part of the purpose of the NOVA food classification⁽ Reference Monteiro ^{4 , 5 ,} Reference Monteiro, Cannon and Moubarac ^{11 ,} Reference Monteiro, Levy and Claro ^{32 –} Reference Monteiro, Cannon and Levy ^{35 )}.

The NOVA classification

NOVA (which is not an acronym) groups foods according to the nature, extent and purpose of the industrial processing they undergo. Food processing as identified by NOVA involves physical, biological and chemical processes used after foods are separated from nature, and before being consumed or prepared as dishes and meals.

Foods may be consumed by themselves (such as fruits, nuts, milk); or as a main item or accompanying items of dishes and meals (such as grains, flours, vegetables, meat, eggs); or as food products used in making these dishes and meals (such as oils, butter, sugar, salt). Or, they may be food products ready to consume or heat (such as bread, cheese, ham; packaged snacks, soft drinks, pre-prepared frozen dishes). NOVA classifies all foods and food products into four groups. See the Appendix for detailed lists of foods and food products in each of the four groups.

NOVA in use

The NOVA classification has now been applied worldwide. Uses so far include description of population dietary patterns, assessments of changes over time in the dietary share of ultra-processed products, and analyses of the association of this share with the nutrient profile of diets and with health outcomes.

In Brazil, NOVA has been used to assess: the socio-economic and demographic distribution of dietary patterns⁽ Reference Monteiro, Levy and Claro ^{36 ,} Reference Sparrenberger, Friedrich and Schiffner ^{37 )}; time changes in dietary patterns⁽ Reference Monteiro, Levy and Claro ^{36 ,} Reference Martins, Levy and Claro ^{38 )}; the impact of the dietary share of ultra-processed products on the dietary content of macronutrients⁽ Reference Louzada, Martins and Canella ^{39 –} Reference Bielemann, Santos Motta and Minten ^{41 )} and micronutrients⁽ Reference Louzada, Martins and Canella ^{42 )}; and the association of consumption of ultra-processed products with obesity⁽ Reference Canella, Levy and Martins ^{43 ,} Reference Louzada, Baraldi and Martinez Steele ^{44 )}, metabolic syndrome⁽ Reference Tavares, Fonseca and Garcia Rosa ^{45 )} and dyslipidaemias⁽ Reference Rauber, Campagnolo and Hoffman ^{46 )}. NOVA has also been used in Brazil to study the relationship between household food purchase patterns and relative prices of ultra-processed and all other food items⁽ Reference Moubarac, Claro and Baraldi ^{47 )}, as well as the influence of the food environment⁽ Reference Leite, Oliveira and Cremm ^{48 –} Reference Vedovato, Trude and Kharmats ^{50 )} and of food advertising⁽ Reference Mallarino, Gomez and Gonzalez-Zapata ^{51 )} on the consumption of ultra-processed products; and to evaluate the impact of a nutrition education intervention⁽ Reference Franco, Rosa and Luiz ^{52 )}.

In the USA, NOVA has been used to describe population dietary patterns and to assess the impact of ultra-processed products on the overall consumption of added sugar⁽ Reference Martinez Steele, Baraldi and Louzada ^{53 )}, on the dietary content of other critical macronutrients and micronutrients⁽ Reference Martinez Steele, Popkin and Swinburn ^{54 )}, and on urinary levels of phyto-oestrogens⁽ Reference Martinez Steele and Monteiro ^{55 )}. With some adaptation, it has been used also to evaluate the nutritional quality of packaged foods purchased by US households and to study differences in purchase according to race/ethnicity⁽ Reference Poti, Mendez and Ng ^{56 ,} Reference Poti, Mendez and Ng ^{57 )}. In Canada, it has been used to assess secular trends in national dietary patterns⁽ Reference Moubarac, Batal and Martins ^{58 )} and the impact of ultra-processed products on indicators of nutrient profile of diets⁽ Reference Moubarac, Martins and Claro ^{59 ,} Reference Moubarac, Batal and Louzada ^{60 )}. In the UK, NOVA has been used to describe population dietary patterns and to study the relationship between household food purchase patterns and relative prices of ultra-processed and all other food items⁽ Reference Moubarac, Claro and Baraldi ^{47 )}, and to estimate the potential for reduction of CVD by reducing consumption of ultra-processed products⁽ Reference Moreira, Baraldi and Moubarac ^{61 )}. In Australia, it has been used to assess dietary sodium intake and food sources of sodium⁽ Reference O’Halloran, Grimes and Lacy ^{62 )}, to study national time trends in aspects of food practices implicated in diet-related health risks⁽ Reference Venn, Banwell and Dixon ^{63 )}, and to build a tool to measure healthy and sustainable dietary behaviours⁽ Reference Harray, Boushey and Pollard ^{64 )}.

In Chile, NOVA has been used to describe population dietary patterns and to assess the impact of the consumption of ultra-processed products on the nutritional quality of diets⁽ Reference Crovetto, Uauy and Martins ^{65 ,} Reference Cediel, Reyes and Louzada ^{66 )}. It has been used in Mexico to describe population dietary patterns and determinants of consumption of ultra-processed food products⁽ Reference Marrón-Ponce, Sánchez-Pimienta and Louzada ^{67 )}. In Norway, it has been used to assess the participation of ultra-processed foods in national food sales⁽ Reference Solberg, Terragni and Granheim ^{68 )}; in New Zealand, to describe the nutrient profile of supermarket foods⁽ Reference Luiten, Steenhuis and Eyles ^{69 )}; and in Sweden to study time trends in consumption of ultra-processed products and in adult obesity⁽ Reference Juul and Hemmingsson ^{70 )}. In Spain, the association between the consumption of ultra-processed foods and the 9-year incidence of obesity and hypertension was tested in a cohort of middle-aged adults⁽ Reference Mendonça, Pimenta and Gea ^{71 ,} Reference Mendonça, Lopes and Pimenta ^{72 )}.

Studies on time trends in sales of ultra-processed products have covered seventy-nine middle- and high-income countries⁽ Reference Monteiro, Moubarac and Cannon ^{73 )} and fourteen countries in Asia⁽ Reference Baker, Kay and Walls ^{74 )}. A paper published in The Lancet in 2013⁽ Reference Moodie, Stuckler and Monteiro ^{9 )} compared strategies used by the manufacturers of tobacco, alcohol and ultra-processed products, with implications for prevention and control of non-communicable diseases. A PAHO report described socio-economic determinants of sales of selected ultra-processed products in fifteen Latin American countries and analysed the association between annual changes in sales of these products and annual changes in population mean BMI^{( 3 )}. A WHO report has used NOVA to assess and compare the impact of the dietary share of ultra-processed products on the excessive overall intake of free sugars in the USA, Canada, Brazil and Colombia^{( 75 )}.

Altogether, studies based on NOVA show exponential growth in consumption of ultra-processed products and confirm that they displace unprocessed or minimally processed foods and freshly prepared dishes and meals made from these foods together with processed culinary ingredients. For example, between 1998 and 2012, per head sales of sweet or savoury snacks and soft drinks increased by 50 % in upper-middle-income countries and by 100 and 300 %, respectively, in lower-middle-income countries⁽ Reference Monteiro, Moubarac and Cannon ^{73 )}. In Brazilian urban households, ultra-processed products represented 18·7 % of total energy of food baskets in 1988, increasing by 50 % to 29·6 % in 2009, while minimally processed foods declined from 44·0 to 38·9 % and processed culinary ingredients from 35·7 to 28·9 %⁽ Reference Martins, Levy and Claro ^{38 )}.

Studies based on NOVA also show that the consumption of ultra-processed products increases the overall energy density of diets and their content of saturated and trans-fats and free sugars, and decreases dietary fibre, phyto-oestrogens, magnesium, potassium, vitamin A, iron and zinc, among other key micronutrients. For instance, the average content of added sugars in the US diet is 19·5 % among the highest consumers of ultra-processed products (upper quintile) and 7·5 % among the lowest consumers (lower quintile)⁽ Reference Martinez Steele, Baraldi and Louzada ^{53 )}. In the Brazilian diet, the content of vitamin A, iron and zinc among the lowest consumers of ultra-processed products exceeds by 5, 15 and 25 %, respectively, the same content among the highest consumers⁽ Reference Louzada, Martins and Canella ^{42 )}.

Ecological studies and cross-sectional and cohort studies have documented a direct association between ultra-processed products and obesity^{( 3 ,} Reference Canella, Levy and Martins ^{43 ,} Reference Louzada, Baraldi and Martinez Steele ^{44 ,} Reference Juul and Hemmingsson ^{70 ,} Reference Mendonça, Pimenta and Gea ^{71 )}, hypertension⁽ Reference Mendonça, Lopes and Pimenta ^{72 )}, metabolic syndrome⁽ Reference Tavares, Fonseca and Garcia Rosa ^{45 )} and dyslipidaemias⁽ Reference Rauber, Campagnolo and Hoffman ^{46 )}.

NOVA has also been used to orient the nutrient profile model developed by the PAHO for the region of the Americas^{( 7 )}. The dietary share of ultra-processed products has been recommended by a leading international organization as a way to monitor the overall quality of national diets⁽ Reference Vandevijvere, Monteiro and Krebs-Smith ^{76 )}.

The NOVA four food groups are also the basis for the four main recommendations of the current official national Brazilian dietary guidelines^{( 10 )}, recognized by the FAO^{( 6 )} as the first food-based dietary guidelines that take social, cultural, economic and other aspects of sustainability into account. The main recommendations of the national dietary guidelines of Uruguay, published in December 2016, are also based on the NOVA four food groups^{( 77 )}.

The main recommendations of the Brazilian guidelines are:

1. 1. Make natural or minimally processed foods, in great variety, mainly of plant origin, and preferably produced with agro-ecological methods, the basis of your diet.

2. 2. Use oils, fats, salt and sugar in small amounts for seasoning and cooking foods and to create culinary preparations.

3. 3. Limit the use of processed foods, consuming them in small amounts as ingredients in culinary preparations or as part of meals based on natural or minimally processed foods.

4. 4. Avoid ultra-processed products.

The trouble with ultra-processing

As stated, ultra-processed products are not modified foods, recognizable as such, but formulations of industrial sources of dietary energy and nutrients, particularly unhealthy types of fat, starches, free sugars and salt, plus additives including those designed to intensify sensory impact. They typically contain little or even no intact food.

The ingredients of ultra-processed products make them fatty, sugary or salty, often high in saturated fats or trans-fats, and depleted in dietary fibre and various micronutrients and other bioactive compounds. This is why, in several countries, as shown above, higher consumption of these products is associated with unhealthy dietary nutrient profiles and several diet-related non-communicable diseases.

When solid, because of their main ingredients and the lack of dietary fibre and water, the energy density of ultra-processed products ranges from fairly high (about 940–1150 kJ (225–275 kcal) per 100 g for baked products) to high (about 1460–1675 kJ (350–400 kcal) per 100 g for ‘energy’ bars) or very high (1675–2090 kJ (400–500 kcal) per 100 g for most biscuits and for chips (crisps))^{( 10 )}. When formulated as drinks, ultra-processed products are often sugared, and are usually depleted in or devoid of nutrients. These attributes make most ultra-processed products prone to cause inadvertent overconsumption of dietary energy, and thus overweight and obesity^{( 14 ,} Reference Prentice and Jebb ^{78 )}.

They also typically have high glycaemic loads⁽ Reference Fardet ^{79 )}. This makes them liable to disturb and even derange endogenous processes in the nervous system that signal satiety and control appetite, and thus increase the risk of obesity and diabetes^{( 13 )}.

Ultra-processed products are often formulated to be habit-forming, and are sometimes even quasi-addictive, which makes it hard to make healthy choices and to avoid overconsumption⁽ Reference Brownell and Gold ^{80 ,} Reference Gearhardt ^{81 )}.

Many ultra-processed products create a false impression of being healthy by, for example, the addition of dietary fibre and some micronutrients and the replacement of sugar by artificial sweeteners, or the reduction of sodium, enabling manufacturers to make health claims despite the product remaining unhealthy⁽ Reference La Fontaine, Crowe and Swinburn ^{82 ,} Reference Scrinis ^{83 )}. Vast sums of money are spent by the biggest corporations on advertising and promotion of regular or reformulated products, including cross-advertising between brands, to make them attractive, exciting and even glamorous, especially to children and young people⁽ Reference Chandon and Wansink ^{84 –} Reference Cairns, Angus and Hastings ^{86 )}. All these practices impede ability to make healthy choices.

Ultra-processed products now dominate the food supplies of various high-income countries. For instance, they made up 57·9 % of the US food supply in 2009–2010⁽ Reference Martinez Steele, Baraldi and Louzada ^{53 )} and 47·7 % of the total dietary energy intake in Canada in 2004⁽ Reference Moubarac, Batal and Louzada ^{60 )}. In middle-income countries, figures are lower, for instance 29·8 % in Mexico⁽ Reference Marrón-Ponce, Sánchez-Pimienta and Louzada ^{67 )}, 28·6 % in Chile⁽ Reference Cediel, Reyes and Louzada ^{66 )} and 21·5 % in Brazil⁽ Reference Louzada, Martins and Canella ^{39 )}; but, as shown by sales data in Latin American countries^{( 3 )}, they are rising rapidly. Estimates of the contribution of ultra-processed products to the total dietary energy intake in low-income countries are not yet available, but the highest proportional increase in sales of sweet and savoury snacks and sugary soft drinks is seen in lower-middle-income countries⁽ Reference Monteiro, Moubarac and Cannon ^{73 )}.

Thus, ultra-processed products have troublesome effects on global nutrition and health. The evidence so far indicates that the displacement of unprocessed or minimally processed foods and freshly prepared dishes and meals by ultra-processed food and drink products is driving the high and increasing global burden of obesity and other diet-related chronic non-communicable diseases^{( 87 )}. The evidence also indicates that this change in dietary patterns can worsen the still relevant burden of micronutrient deficiencies in low- and middle-income countries^{( 87 )}, notwithstanding the fortification of some ultra-processed products with some micronutrients.

Ultra-processed products and their makers are also causing social, cultural, economic, political, environmental and other problems. Much of what follows is obvious or common sense, and is much discussed in the literature. Some invites further research, which should not delay action to slow, stop and reverse the increases in production and consumption of ultra-processed products.

Social life in and out of the home is weakened by ultra-processed products. Because they are convenient, being formulated as ready-to-consume snacks and drinks and ready-to-heat items, they displace dishes and meals made at home. The shared experiences of acquiring, preparing, cooking and enjoying food together, part of our evolution as humans⁽ Reference Wrangham ^{88 ,} Reference Garner ^{89 )}, with all the knowledge this brings of the nature, meaning and value of food, become increasingly lost. Meal tables and all that goes with them are used less often, or even not at all. The kitchen becomes less used and the dining room, a special place for people who live in the same place to come together and share in one another’s lives, may disappear. Instead, people at home get into the habit of eating alone, at different times, inattentively, often when doing something else. Children and young people eat while using their computer or playing video games. Out of the house, ultra-processed products are consumed anywhere, any time, while working, walking or driving, or when using cell phones. These are generally isolated situations, concealed by advertisements and other marketing suggesting that ultra-processed products enhance social interaction⁽ Reference Monteiro, Cannon and Moubarac ^{11 ,} Reference Pollan ^{90 ,} Reference Schlosser ^{91 )}.

Culture, national and local, is also harmed by ultra-processed products. Transnational ultra-processed food and drink manufacturers, distributors and caterers are increasingly oligopolistic⁽ Reference Monteiro, Cannon and Levy ^{17 ,} Reference Stuckler and Nestle ^{18 ,} Reference Wilkinson ^{22 )}, and work in concert, as is evident from joint trade organizations set up to defend their shared interests⁽ Reference Monteiro and Cannon ^{24 )}. Supported by international free trade agreements⁽ Reference Hawkes ^{92 )}, they displace authentic established varied food systems and cultures, and generate uniform consumer habits. Their strategy in effect is to teach the world to snack⁽ Reference Monteiro, Gomes and Cannon ^{93 )}. Everywhere, food customs that are part of the identity of countries and regions, and food cultures based on shared meals, are being undermined by ultra-processed products, with their branding, promotion, packaging and labelling. The contents of any type of product – the soft drinks and burgers and many other ultra-processed products made by giant corporations – are much the same everywhere. The impression of variety is given by marketing campaigns with vast sums spent on them worldwide using multimedia, social media, the Internet and television, as well as all sorts of printed advertisements, which further invalidate what have been established dietary patterns, culinary knowledge and skills, and social cultures. This has an alienating effect on children and young people, who get the impression that the culture and nature of their own country and location, ethnicity and tradition are boring⁽ Reference Monteiro, Cannon and Moubarac ^{11 ,} Reference Story and French ^{94 , 95 )}.

Production and consumption of ultra-processed products also have troublesome economic consequences. Transnational and other big corporations using cheap ingredients for their products operate economies of scale and have huge reserves of money for investment and development. They may take over national and local businesses, including the makers, distributors and sellers of minimally processed foods⁽ Reference Monteiro and Cannon ^{24 ,} Reference Greer and Singh ^{25 )}. In order to join in the market and to compete, national and regional manufacturers increasingly produce their own variations of ultra-processed products. Demand for cheap oils, sugar, starches and other common ingredients of ultra-processed products creates crop monocultures in many countries in order to produce raw materials usually for export and not foods for direct human consumption. Judgements vary on the economic effects. Some national and local businesses and family farmers adapt and flourish, but livelihoods especially of the most impoverished vulnerable and impoverished communities can be made even more insecure^{( 96 –} Reference Black ^{98 )}. In high- and middle-income countries, the price of most ultra-processed food products has decreased relative to that of most minimally processed foods⁽ Reference Brown ^{99 )}. But varied freshly prepared meals made from minimally processed foods with processed culinary ingredients can readily be made to be cheaper than ultra-processed products⁽ Reference Moubarac, Claro and Baraldi ^{47 ,} Reference Monroe ^{100 –} Reference Claro, Maia and Costa ^{102 )}. Ultra-processed products also carry another cost: obesity and related chronic diseases such as diabetes are debilitating and impede ability to work, and their treatment, for those without health insurance or access to publicly funded health services, can mean financial catastrophe^{( 96 , 103 )}.

There are also political consequences. Ultra-processed products have made the fortunes of the transnational food and drink corporations, of which, as mentioned, the largest have annual turnovers the size of middle-ranked national economies⁽ Reference Monteiro and Cannon ^{24 ,} Reference Greer and Singh ^{25 )}. The deregulation that has enabled transnational corporations to grow exponentially, their ability to move into the countries that give them most scope and their freedom to act as they choose within the law, all give them more power and elected national governments less ability to act in the public interest⁽ Reference Moodie, Stuckler and Monteiro ^{9 , 19 ,} Reference Monteiro and Cannon ^{24 ,} Reference Greer and Singh ^{25 )}. Thus, it becomes difficult for governments, should they wish to do so, to enact fiscal and other statutory policies designed to make unprocessed and minimally processed foods more available and cheaper, and ultra-processed products less available and relatively or absolutely more expensive. WHO Director-General Margaret Chan has explained^{( 19 )}:

Production and consumption of ultra-processed products are also damaging the environment. For example in the USA, food packaging is about half of total packaging by weight and accounts for almost two-thirds of total packaging waste by volume^{( 104 )}. Bottles, containers, wrappings and other packaging of ultra-processed products create colossal amounts of garbage, some not biogradable, thrown away in the street and countryside, washed out of sewers, and disposed of in landfill sites. The manufacture and distribution of ultra-processed products and their ingredients often involve long international transport routes and therefore excessive use of non-renewable energy, which contributes to climate disruption^{( 105 )}. Intensive breeding of animals for human food is especially prodigal in its use of energy. Cattle bred for the burger trade require animal feed produced by monocultures such as of soyabeans and corn, and many other inputs including antibiotics, and in countries such as Brazil involve the destruction of great tracts of rainforest and savannah^{( 106 ,} Reference Spanne ^{107 )}. All this, in common with other forms of industrial agriculture, contributes to climate disruption, causes pollution, loss of biodiversity, and depletion, degradation and losses of water, soil, energy and other non-renewable natural resources.

Living in the Decade of Nutrition

The Anthropocene, generally agreed as beginning in the 1950s, is the epoch in which human activities are disturbing natural planetary balance to an extent that may well become irreversible. Concerted public policies and actions are needed very urgently, to make life on Earth sustainable⁽ Reference Rockstrom, Steffen and Noone ^{108 ,} Reference Crutzen and Schwägerl ^{109 )}.

Human activities that are thwarting sustainability include those leading to climate disruption; precipitate urbanization; the pollution, degradation and depletion of air, land, water and sources of energy; gross abuses and waste caused by mass production of animals; and food and nutrition insecurity⁽ Reference Carrington ^{110 )}.

We propose that the ever-increasing production and consumption of ultra-processed food and drink products should be identified as one of the human activities leading to the crises listed above. We also propose that the impact of ultra-processed products on human health is itself a world crisis, to be confronted, checked and reversed as part of the UN Sustainable Development Goals and its Decade of Nutrition.