Food for thought

We should eat freshly cooked meals

Congratulations to the BMJ for publishing this series of papers on food and nutrition science and policy (1, 2), and thus maintaining its proud record of upholding public health. Congratulations too to BMJ editor-in-chief Fiona Godlee for stating that ‘The BMJ is a campaigning journal’ (3). Congratulations also to all those who have created 12 important papers with 46 authors and nearly 1,000 references.

The BMJ series states in its introductory editorial: ‘More articles are planned in the coming months’. This is good to know. The rest of this letter suggests some approaches for more papers. Our suggestions are guided by some general concerns. Here are two.

First. More than 90% of authors of the present series of articles are affiliated with academic centres in high-income countries, and of the leading authors of the scientific papers, all but one are from US or UK universities.

This is not just an issue of geographical balance. Many high-income countries, certainly including the US and UK, have food systems where indigenous, traditional or well- established dietary patterns based on fresh or minimally processed foods and freshly prepared meals have been largely displaced notably since the 1980s by all sorts of packaged snacks, carbonated soft drinks (soda), sweetened ‘fruit’ and ‘milk’ drinks, ‘cereal’ bars, pre-prepared pizza, ‘chicken’ ‘nuggets’, and many other types of ready-to-consume, ultra-processed food and drink products (4-8). This greatly concerns scholars and policy-makers within countries at all stages of economic development.

By contrast, many low- and middle-income countries, although bombarded by the ultra-processed food manufacturing industry, with sales of various of their products increasing by 2-10% a year (9), still maintain traditional food systems. Large sections of the population in these countries (10-12), as well as in some high-income countries such as France (5, 13), Italy (5), and South Korea (14), still acquire foods for preparation and cooking in the form of regular fresh meals as a central part of living well.

Surely, the nature and solutions of problems that have to be faced in these contrasting food systems are different. The BMJ editorial rightly says that ‘food is central to culture and identity’. Scholars from countries where diets are based on freshly prepared regular meals, often enjoyed in company, are naturally liable to see problems and solutions differently from scholars in countries dominated by ultra-processed products, confronted by the omnipresence of thousands of types of packaged products typically snacked or drunk alone. Thus in some countries an increase in sales of reformulated ‘diet’ sodas could be seen as a public health success, whereas in other countries it could represent further displacement of fresh foods and regular meals. Likewise, promotion of cooking skills among children and young adults might seem utopian in some countries, but is a natural and feasible priority in others.

In this respect, awareness of cooking and of regularly consumed meals in this BMJ series is low. Neither is much mentioned in any article. Neither is discussed, and some mentions are merely within tabular lists. There is s rightly extensive discussion of breastfeeding, but nothing on regular meals as the natural basis of everyday dietary patterns for populations throughout the rest of life.

Second, and related to the first concern, the terms ‘processing’ and ‘industry’ are generally used loosely in the series. Almost all food is processed in some way. Grains are dried and packaged or transformed into flours and pasta, milk is pasteurized, fresh meat is chilled or frozen, and so on. No population guidelines recommend consuming only fresh food, and consumers should never be given the impression that all processed food is unhealthy. Minimal processes such as drying, grinding, pasteurization, chilling, freezing, fermentation, and packaging are often necessary or beneficial.

What requires focus here is specific types and forms of food processing, particularly those where complex evolved food matrices are destroyed and replaced by formulations of cheap, long-duration ingredients, such as processed starches, sugars, hydrogenated fats, protein isolates, and synthetic micronutrients, with additives other than preservatives used to make the final product palatable, or hyper-palatable (15). What also requires focus are the transnational corporations that manufacture, distribute and sell ultra-processed products, whose businesses have grown exponentially since the 1980s, and whose often colossal sales and profits come from intrinsically unhealthy products that cannot be made healthy by reformulation (9, 16, 17). We have failed to find the term ‘transnational corporations’ in any of the BMJ series of papers.

We suggest that the BMJ follows this series on the science and politics of nutrition with a further co-ordinated series of papers involving more authors from regions and countries whose food systems expressed as freshly prepared regular meals still survive. Nutrition scientists should be joined in this work by scholars from other relevant disciplines, such as anthropologists, ecologists and economists.

These new papers could bear the following key words and phrases in mind, depending on the topic of papers:

Chronic non-communicable diseases, Malnutrition (all forms).
Dietary patterns: food- and meal-based, versus ultra-processed food based.
National dietary guidelines.
Quality of life, Well-being, Wellness
Meals, Cooking, Culture, Food processing.
Primary producers, Rural economies, Transnational corporations.
Globalisation, Equity, Human rights, Justice.
Food crises. Food prices. Food support.
Natural and physical resources, Environmental degradation, Quality of air, soil, water.

The industrialised food systems of the US and UK have developed in a way that is not a global model. Nutrition scholars, clinicians and concerned citizens are increasingly aware that these are an important cause of crises that affect well-being, health and disease now and as projected more in future for future generations, including corrosion of established cultures, collapse of family and community life, loss of rural and urban livelihoods, species decline, degradation of ecosystems and of air, land and water, draining of non-renewable energy resources, and climate disruption.

We believe the approach proposed here will produce papers that will complement those already now published, and translated into public policies and programmes will further protect public health, national and local culture, rural and urban employment, rational food systems, the living world, the environment and the biosphere.

References

1. BMJ. Food for thought: The science and politics of nutrition https://drive.google.com/file/d/1LJub2yZKrY2bZ7W_UlVlIkW-k1dEiVyY/view
2. BMJ. Food for thought: The science and politics of nutrition. June 2018, ISSN 2057-0066. https://www.bmj.com/food-for-thought
3. Peplow M. No time for stodgy: Crusading editor aims to shake things up in science. Stat January 4, 2016. www.statnews.com/2016/01/04/bmj-editor-fiona-godlee/
4. Adams J, White M. Characterisation of UK diets according to degree of food processing and associations with socio-demographics and obesity: cross-sectional analysis of UK National Diet and Nutrition Survey (2008–12). International Journal of Behavioral Nutrition and Physical Activity 2015; 12:160. https://doi.org/10.1186/s12966-015-0317-y
5. Monteiro CA, Moubarac J-C, Levy R, Canella D, Louzada M, Cannon G. Household availability of ultra-processed foods and obesity in nineteen European countries. Public Health Nutrition 2017; 1-9. doi:10.1017/S1368980017001379 S
6. Juul F, Martinez-Steele E, Parekh N, Monteiro CA, Chang V (2018). Ultra-processed food consumption and excess weight among US adults. British Journal of Nutrition 2018; 1-11. doi:10.1017/S0007114518001046
7. Baraldi LG, Martinez, Steele E, Canella DS, Monteiro CA (2018). Consumption of ultra-processed foods and associated sociodemographic factors in the USA between 2007 and 2012: evidence from a nationally representative cross sectional study. BMJ Open 2018; e020574. doi:10.1136/bmjopen-2017-020574
8. 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, E587.
9. Monteiro CA, Moubarac J-C, Cannon G, Ng SW, Popkin B. Ultra-processed foods are becoming dominant in the global food system. Obes Rev 2013; 14:21-28. doi: 10.1111/obr.12107
10. Louzada M, Ricardo C, Steele E, Levy R, Cannon G, Monteiro CA. The share of ultra-processed foods determines the overall nutritional quality of diets in Brazil. Public Health Nutrition 2017; 1-9. doi:10.1017/S1368980017001434
11. Cediel G, Reyes M, Da Costa Louzada M, Martinez Steele E, Monteiro CA, Corvalán C, Uauy R. Ultra-processed foods and added sugars in the Chilean diet (2010). Public Health Nutrition 2017; 1-9. doi:10.1017/S1368980017001161
12. Marrón-Ponce J, Sánchez-Pimienta T, Louzada M, Batis C. Energy contribution of NOVA food groups and sociodemographic determinants of ultra-processed food consumption in the Mexican population. Public Health Nutrition 2017; 1-8. doi:10.1017/S1368980017002129
13. Julian C, Martinez L, Allès B, Touvier M, Hercberg S, Méjean C, Kesse-Guyot E. Contribution of ultra-processed foods in the diet of adults from the French NutriNet-Santé study. Public Health Nutrition 2017; 1-11. doi:10.1017/S1368980017001367
14. Kim S, Moon S, Popkin BM. The nutrition transition in South Korea. Am J Clin Nutr. 2000 Jan;71(1):44-53.
15. Monteiro CA, Cannon G, Moubarac J-C, Levy R, Louzada M, Jaime P. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutrition 2017; 1-13. doi:10.1017/S1368980017000234
16. Monteiro CA, Cannon G. The impact of transnational ‘Big Food’ companies on the South: A view from Brazil. PLoS Med 2012; 9(7): e1001252. https://doi.org/10.1371/journal.pmed.1001252
17. Moodie R, Stuckler D, Monteiro CA, Sharon N, Neal B, Thamarangsi T. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Non-communicable diseases series 4. The Lancet 12 February 2013. http://dx.doi.org/10.1016/ S0140-6736(12)62089-3