Pity the poor students as they head off to university, ready to survive until Christmas on instant noodles and breakfast cereal. The first doctor to raise the health alarm on ultra-processed foods believes it is time to put a tax on those noodles – and he even has ice-cream in his sights. Prof Carlos Augusto Monteiro says the strength of the evidence of the problems such food causes for “most body systems” leaves “no doubt” that governments need to act now. “Strong policies, as soon as possible” on ultra-processed foods (UPFs) are needed to reduce chronic diseases in countries across the globe, says Monteiro. If we wait another 10 years to act, “this will be a tragedy, because this has a cost”. His team at São Paulo University in Brazil came up with the Nova classification system for foods, first proposed in 2009 and now widely adopted. It groups them by their level of processing, ranging from category one – unprocessed or minimally processed foods, such as whole fruits and vegetables – to four: ultra-processed. You cannot say, ‘Well, I already ate fruits and vegetables today, I can [drink] three cans of Coke.’ No, you can’t Carlos Monteiro This category is made up of food products that have been industrially manufactured, often using artificial flavours, emulsifiers and colouring. They include soft drinks and packaged snacks, and tend to be extremely palatable and high in calories but relatively low in nutrients. Critics say UPF is an ill-defined category and existing health policies, such as those aimed at reducing sugar and salt consumption, are sufficient to deal with the potential threat. Monteiro accepts that some foods sit between “ultra-processed” and “processed”, posing a problem for regulators. “A whole bread that has emulsifiers, that has added fibre – it is ultra-processed, technically, by the definition, but clearly it is not the worst product,” he says. “I think the solution is: forget about the technical definition of ultra-processed foods and target all the food groups that are very likely ultra-processed,” says Monteiro. Products that are clearly UPF, he says, include reconstituted meat products, instant noodles and soft drinks. He adds: “If you take, for instance, ice-cream. Probably 99% of ice-cream in the UK market is ultra-processed. And maybe you have 1% which is not, which is probably very expensive. So then, if you tax all ice-creams? Beautiful.” The hard sell of ultra-processed foods in developing countries, and among poorer communities in particular, is causing a crisis of non-communicable diseases, say campaigners. Earlier this year, Monteiro addressed the International Congress on Obesity in São Paulo, where research was presented that showed rapidly escalating rates of obesity in the country. Brazil is on course for 68% of adults to be overweight or obese by 2030, up from 62% today. He called for multinational food companies that manufacture UPF to be treated like tobacco companies, required to display warnings on the front of their packaging and subject to taxes and public health campaigns. Monteiro says he has been surprised by the amount – and consistency – of evidence accumulated over the past five years. He recently counted 70 cohort studies following large groups of people over long periods to look at the impact of diet on their health, and says 62 found UPFs were linked to health problems. The studies are observational – they cannot prove beyond doubt that UPFs cause the health problems – but, Monteiro points out, it was the same kind of evidence that linked smoking and lung cancer. “It is really strong, and not just with obesity or diabetes, but cardiovascular diseases, mental diseases, kidney, liver, gastrointestinal diseases. So we are talking about an exposure [to UPF] which is harming most body systems.” He believes it is time for a global convention on ultra-processed foods, comparable to that imposed on the tobacco industry: an international treaty aimed at curbing demand and supply that prevents tobacco firms lobbying the UN and World Health Organization, and sponsoring scientific conferences. There are obvious differences, he says, between UPFs and tobacco, not least that the relationship between diet and health is more complex than that between smoking and disease. But, he says, both “increase the risk of many serious diseases” and are “produced by huge transnational corporations that have immense power”. National dietary guidelines should tell people to avoid UPFs as far as possible, Monteiro says, pointing to evidence shows that even a relatively high-quality diet can be derailed by an increase in such foods. “You lose the protection,” he argues. “This means you cannot say, ‘Well, I already ate fruits and vegetables today, I can [drink] three cans of Coke.’ No, you can’t.” Guideline changes should be followed by taxes and marketing restrictions, Monteiro adds. In Brazil, he has advised on tax reforms that will lead to zero or low taxes on minimally processed foods and high taxes on UPFs. He takes issue with the idea that some ultra-processing can make foods healthier, contending that reformulation too often means simply making food more palatable, so consumers buy and eat more. “UPFs are manufactured to displace non-ultra-processed foods, so they are novel products: novel breads, novel yoghurts, novel soups, novel pizzas that replace traditional pizzas, traditional yoghurt, traditional cheese, traditional bread etc.” They are made “extremely palatable, to really arrive to our brain very quickly and produce enormous pleasure”. Nobody’s is saying that ultra-processed food should be forbidden … we don’t forbid tobacco or alcohol While flavoured yoghurt (an example of UPF) is “better than a soft drink, of course – you’ve got some calcium, you’ve got some protein – what about if I compare the flavoured ultra-processed yoghurt with the plain yoghurt and fruit?” Moreira has little time for the argument that extra taxes hit the poorest the hardest, as UPFs tend to be cheaper. This can be combated by targeted policies and social support, he says. This might mean working to improve the supply of fresh fruits and vegetables in “food deserts” such as Brazil’s slums, he says. But it is “ridiculous” to use that as “a reason to not promote healthy food or healthy diets”. “Nobody’s is saying that ultra-processed food should be forbidden,” he says, adding: “We don’t forbid tobacco or alcohol.” Countries find themselves in one of two situations, he says. In western states such as the US, Britain, Australia and Canada, traditional food cultures have been “destroyed” and UPF already makes up the bulk of the populations’ energy intake (about 66% for adolescents in the UK), a figure he believes is stabilising. In others, particularly “low- and middle-income countries”, consumption of UPF is lower, but “increasing very fast”. In less wealthy countries, chronic diseases linked with UPF can mean decades of suffering for patients, and costs for healthcare “that simply are not affordable”, he says. For himself, eating UPF is “an exception”. On a recent trip to Europe, he could not find any chocolate in a supermarket without emulsifiers or flavours or colourants, he says, adding: “I bought what I found.”