Awareness, experiences, and beliefs related to ultra-processed foods among young people in Cebu, Philippines

Abstract

Ultra-processed food (UPF) intake is rising in low- and middle-income countries, where non-communicable diseases are now the leading contributor to disease burden. The purpose of this study was to assess awareness and knowledge of UPFs, factors that influence consumption of UPFs, and beliefs about the relationship between UPF intake and health among young people (18-20 years old) in a metropolitan area of the Philippines, a lower middle-income country. We conducted eight focus group discussions across four strata defined by gender and urban-rural neighborhood designation. We applied deductive and inductive codes to transcripts and organized codes into themes. Sixty participants were included in the study. Although most were unfamiliar with the concept of UPFs, participants demonstrated an intuitive understanding of the meaning of the term. Vendors in or around schools were commonly reported as a source of UPFs, though most participants reported consuming UPFs at home as well. Factors that were reported as having influence over participants’ UPF intake included taste, convenience, cost, influence from parents, peers, and others, and health knowledge and status. Participants expressed various beliefs about the link between overconsumption of UPFs and risk of multiple health outcomes, including diabetes, hypertension, and kidney disease. Some males, but not females, believed that some UPFs were neutral or beneficial with respect to health. Commonly cited sources of information about UPFs and their link to health included parents, schools, and social media. This study provides important insights into the factors that drive UPF consumption among young people in a lower middle-income country and should inform efforts to reduce UPF intake among young people in this and similar settings.

1. Introduction

Ultra-processed foods (UPFs) are ready-to-consume foods and beverages that are industrially manufactured and contain few, if any, whole foods (Monteiro et al., 2019; Monteiro et al., 2018). In the past decade, there has been a growing body of evidence implicating high-UPF diets in the development and progression of diet-related, non-communicable diseases. In a randomized crossover trial, a diet high in UPFs increased weight and adiposity compared to a diet without UPFs (Hall et al., 2019), and two recent umbrella reviews concluded that the evidence supporting the positive associations of UPF intake with all-cause mortality, cardiovascular disease incidence and mortality, common mental health disorders, type 2 diabetes, and overweight and obesity was suggestive or convincing (Dai et al., 2024; Lane et al., 2024). The availability of UPFs in low- and middle-income countries (LMICs) around the world has increased steadily since the late 20^th century, including in LMICs of Southeast Asia (Baker & Friel, 2016; Huse et al., 2022), where approximately one in every five adults experiences overweight or obesity (Popkin, Corvalan, & Grummer-Strawn, 2020). Because Asian populations are, on average, more susceptible to non-communicable diseases at lower levels of adiposity (Lear, James, Ko, & Kumanyika, 2010; Ramachandran, Wan Ma, & Snehalatha, 2010), the growing prevalence of overweight and obesity in Southeast Asia may portend an increase in the region’s burden of non-communicable disease.

In the Philippines, an archipelagic, lower-middle-income country of Southeast Asia, the prevalence of overweight and obesity was 37% among adults 20 years and older in 2019, considerably higher than the regional prevalence of overweight and obesity and more than double the national prevalence estimated in 1993 (17%). A similar trend has been observed among Filipino adolescents (10-19 years); in 2019, 11% of Filipino adolescents experienced overweight and obesity, up from 5% in 2003 (Department of Science and Technology Food and Nutrition Research Institute, 2022).

The globalization of the food supply in the Philippines and, consequently, of the diets of the Filipino people accelerated during the American occupation and colonization of the archipelago following the signing of the 1898 Treaty of Paris, which marked the end of the Spanish-American War. Efforts by the colonizers to “Americanize” the Filipino diet and the introduction of American food products into the national food supply were billed as attempts to improve nutritional status and life expectancy among Filipinos (Orquiza, 2020). An indirect effect of this strategy may have been to denigrate Filipino foodways (Orquiza, 2020), which may have resulted in a preference for the American convenience foods introduced in the Philippines later in the 20^th century, such as SPAM (Matejowsky, 2007). In this way, the actions of colonizers at the turn of the 20^th century may have fueled the rise in sales of UPFs that began in the Philippines in the mid-20^th century and continues today (Baker & Friel, 2016).

There is evidence that this perceived food hierarchy, in which energy-dense foods, including convenience foods, are considered superior to traditional and staple foods, like rice, persists among Filipino consumers. A recent study using household expenditure survey data reported that, between 2006 and 2018, the share of Filipino households’ food budgets spent on rice and other cereals decreased, while expenditure on more nutrient-dense food products, particularly meat and dairy, increased, indicating a shift in dietary preferences away from staples (Bairagi, Zereyesus, Baruah, & Mohanty, 2022). This shift tended to follow a socioeconomic gradient, with households spending less on rice, the principal staple food in Filipino diets, and more on meat, fish, and dairy, as household income and educational attainment of the household head increased. Furthermore, as the age of a household head decreased, household expenditure on staple foods decreased, while expenditure on meat, fish, and dairy increased, suggesting that the dietary preferences of young people in the Philippines may be shifting away from staple foods and toward nutrient-dense foods (Bairagi et al., 2022), such as UPFs.

In settings around the world, the highest levels of UPF intake have been observed among young people (Martini, Godos, Bonaccio, Vitaglione, & Grosso, 2021), which may be the result of exposure to aggressive marketing of UPFs in childhood and adolescence (Kelly et al., 2019). The transition from adolescence to adulthood is a period during which dietary habits are formed (Neufeld et al., 2022; Winpenny et al., 2018), with implications for health across the life course (Jacobs et al., 2022). Consequently, reducing UPF intake during this period is a necessary step toward preventing overweight and obesity and reducing the burden of non-communicable diseases in the Philippines and elsewhere in Southeast Asia. Achieving this requires understanding current behaviors related to UPF intake among young people in this setting and identifying the factors that influence their UPF consumption.

To this end, the objectives of this study were to assess awareness and knowledge of UPFs, factors that influence consumption of UPFs, and beliefs about the health effects of UPFs among older adolescents and young adults in a diverse, metropolitan area of the Philippines.

2. Methods

2.1. Study setting and participants

In April and May 2023, participants were recruited from two rural and two urban barangays, an administrative unit akin to a neighborhood, in Metro Cebu, the second-largest metropolitan area in the Philippines. Trained research team members familiar with the barangays, with assistance from barangay officials who had given their approval of the study prior to its start, identified eligible individuals, contacted them in-person at their homes, and invited them to participate in the study. Barangay officials are knowledgeable about the composition of households in their barangays; these officials were, therefore, able to improve the efficiency of the study team’s recruitment efforts. Furthermore, it is a common courtesy in this setting to inform barangay officials of a study that is to be conducted in their jurisdiction.

Eligible participants were 18-20 years old and currently residing in the selected barangays. Only one eligible individual per household was invited to participate. There were no additional inclusion or exclusion criteria.

Focus group discussions (FGDs) were held in the barangay from which participants were recruited, typically in the barangay hall (i.e., local administrative building). At the time of recruitment, participants were informed of the purpose of the study and of the activities in which they would be expected to engage. On the day of the FGD, prior to beginning, participants provided written informed consent and agreed to be recorded.

Participants were reimbursed for any travel costs incurred and were offered light refreshments. Study protocols and instruments were approved by the Research Ethics Committee of the University of San Carlos (#2023-011) and the Institutional Review Board of the University of North Carolina at Chapel Hill (#23-092).

2.2. Data collection

Eight FGDs were conducted in May 2023. This number was determined to be sufficient for answering our study questions, based on the high specificity of aims, the narrow age range and limited geographic distribution of the eligible participants, and the use of an established theory to guide the discussion and analysis (Malterud, Siersma, & Guassora, 2016). All FGDs were stratified by gender and urban-rural neighborhood designation to facilitate examination of potential differences in knowledge, awareness, and beliefs about UPFs according to gender and urban-rural designation. A recent study of UPF intake during the transition from adolescence to early adulthood in Metro Cebu found that, as urbanicity increased, the proportion of total daily calories from UPFs also increased (Busse et al., 2024), while an examination of food expenditures of Filipino households from 2006 to 2018 highlighted gender differences in food purchasing patterns, with female-headed households tending to spend a greater proportion of their food budgets on fruits and vegetables and nutrient-dense foods, like meat and dairy, relative to male-headed households (Bairagi et al., 2022). Thus, two FGDs were conducted within each of the following strata: rural females, urban females, rural males, and urban males. Each FGD had 6-8 participants, was 45-60 minutes long, and was conducted in Cebuano, the local language. FGDs were recorded using a digital audio recorder, and a note-taker captured details that were not captured by the audio recorder, such as non-verbal cues and body language. The two FGD facilitators, one male and one female (M.E.D.), were experts in qualitative data collection and participated in a training seminar related to UPFs prior to the study. The facilitators were gender concordant with the FGD participants.

We used a brief questionnaire to collect participant sociodemographic information, including age, marital status, household composition, employment status, school enrollment status, educational attainment, and responsibilities related to household food procurement and preparation.

A semi-structured discussion guide (Supplemental Material) was used to facilitate discussion about: 1) participants’ awareness and understanding of UPFs, 2) settings in which they consumed UPFs, 3) perceived changes in their UPF intake since mid-adolescence, 4) factors that influenced their consumption of UPFs, and 5) their beliefs about the health effects of UPFs. The development of this discussion guide was guided by previous literature on factors that influence UPF intake and a theoretical framework of adolescent eating behavior that combines social cognitive and ecological theories. This framework, first proposed by Story et al. (Story, Neumark-Sztainer, & French, 2002), posits that adolescents’ eating behaviors are influenced by factors at the individual, interpersonal, community, and societal levels. Both the discussion guide and the questionnaire were developed in collaboration with qualitative research experts at the University of San Carlos in Cebu. Questions were drafted in English and translated into Cebuano. Prior to its deployment, the discussion guide was pilot tested with a group of six age-eligible individuals enrolled at the University of San Carlos to determine whether the questions were understood as intended. During the FGDs, the term “ultra-processed foods” was stated in English, as there is not an equivalent term in Cebuano. Because English is an official language of the Philippines and the language of instruction in schools, stating the term in English was determined to be the best approach by the Cebu-based research team members.

After asking participants about their familiarity with the term “ultra-processed food” and their awareness of the characteristics of UPFs, facilitators defined the term and noted several examples of UPFs available locally to ensure common understanding among participants for the remainder of the discussion.

2.3. Data analysis

Sample characteristics according to stratum were summarized using descriptive statistics in Stata 18 (StataCorp; Dallas, TX, USA).

Audio recordings were transcribed verbatim and translated into English. One author (M.E.D.) reviewed the translations for accuracy. The transcripts were analyzed thematically (Gibbs, 2007), guided by the theoretical framework of adolescent eating behavior described above. All transcripts were coded by two authors, one coding in English (K.R.B.) and the other in Cebuano (M.E.D.). The two analysts first drafted a preliminary codebook that included codes identified a priori (deductive codes), based on literature about influences on adolescent food choice and initial impressions from the transcripts. Each analyst applied these codes to the same transcript, selected at random. Then, the analysts worked collaboratively to revise the codebook, modifying the preliminary codes and adding new codes (inductive codes), as necessary. Next, they applied the codes from the revised codebook to two new transcripts, selected at random, modifying existing codes and adding additional codes, as necessary, to create a final codebook. Each analyst then worked independently to code all eight transcripts. At each stage, the analysts compared the codes applied to the text, identifying and resolving any differences. Because each transcript included text in both Cebuano and English, stacked one on top of the other throughout the transcript, the analysts were able to compare codes across the two languages.

The lead analyst (K.R.B.) organized the codes into themes and constructed matrices to compare across strata (Miles & Huberman, 1994). A separate matrix was constructed for each theme, with each column of the matrix corresponding to a code and each row corresponding to a stratum (e.g., urban female). The interior cells contained quotes exemplary of the corresponding code and originating from a participant belonging to the corresponding stratum. The second analyst (M.E.D.) reviewed the matrices for accuracy.

Transcripts were coded in Microsoft Word 2023 using the highlight and comment functions, and the codebook and matrices were assembled in Microsoft Excel 2023 (Microsoft Corporation, Redmond, WA, USA).

3. Results

3.1. Participant characteristics

Sixty participants were recruited for the study, including 31 females (15 from rural barangays and 16 from urban barangays) and 29 males (15 rural and 14 urban). Nearly half (45%) of participants were 18 years old, while 38% and 17% of participants were 19 and 20 years old, respectively. Most participants were single, living with their parents, and enrolled in high school or college (Table 1). Five participants (4 females and 1 male) were married or had live-in partners, and five (4 females and 1 male) had one or more children. For most participants, a parent was primarily responsible for obtaining and preparing household food.

Table 1.

Characteristics of 60 young people (18-20 years old), by strata of urban-rural designation and gender, Metro Cebu, Philippines, May 2023

	Rural		Urban
	Female n (%)	Male n (%)	Female n(%)	Male n(%)
n	15	15	16	14
Age
18 years	6 (40)	10 (67)	6 (38)	5 (36)
19 years	7 (47)	3 (20)	6 (38)	7 (50)
20 years	2 (13)	2 (13)	4 (25)	2 (14)
Married or living with partner	2 (13)	0 (0)	2 (13)	1 (7)
Has children	2 (13)	0 (0)	2 (13)	1 (7)
Living arrangement
With parents	10 (67)	14 (93)	14 (88)	12 (86)
With other family	4 (27)	1 (7)	0 (0)	1 (7)
With live-in partner	1 (7)	0 (0)	2 (13)	1 (7)
Enrolled in school
Yes, high school	9 (60)	13 (87)	6 (38)	5 (36)
Yes, college	2 (13)	1 (7)	5 (31)	3 (21)
No, some high school	2 (13)	0 (0)	1 (6)	3 (21)
No, vocational education	0 (0)	0 (0)	0 (0)	1 (7)
No, high school graduate	2 (13)	1 (7)	4 (25)	2 (14)
Person primarily responsible for buying household’s food
Self	0 (0)	0 (0)	2 (13)	0 (0)
Parent	10 (67)	14 (93)	12 (75)	10 (71)
Other relative	5 (33)	1 (7)	1 (6)	3 (21)
Live-in partner	0 (0)	0 (0)	1 (6)	1 (7)
Person primarily responsible for preparing household’s food
Self	3 (20)	1 (7)	2 (13)	0 (0)
Parent	9 (60)	11 (73)	11 (69)	10 (71)
Other relative	3 (20)	3 (20)	2 (13)	3 (21)
Live-in partner	0 (0)	0 (0)	1 (6)	1 (7)

3.2. Themes from FGDs

Six themes arose from the FGDs: 1) understanding of UPFs, 2) settings for UPF consumption, 3) perceived changes in UPF consumption since mid-adolescence, 4) factors that influence consumption of UPFs, 5) beliefs about the health effects of UPFs, 6) sources of information about the health effects of UPFs.

3.2.1. Theme 1: Understanding of UPFs

Nearly all participants stated that they had never heard the term “ultra-processed food.” When asked to describe what came to mind upon hearing the term, many participants proposed that UPFs were particular types of foods or beverages, including junk foods, fast foods, instant foods, processed meat, soft drinks, and alcoholic beverages.

“For me, those are instant foods.”

(Female, urban barangay)

“I think those are hotdogs, longanisa [local sausage], corned beef, and things like that.”

(Female, rural barangay)

“Like candies and junk foods.”

(Male, rural barangay)

When asked to describe what makes a food or beverage ultra-processed, most participants described its ease of preparation, packaging, durability, and freshness, or lack thereof, suggesting that UPFs took little time or effort to prepare, were typically sold in cans or plastic bags, had long shelf lives, and were cooked or otherwise ready-to-consume.

“It’s…food that is easy to eat, like a beef loaf. You just have to open the can, fry and eat it.”

(Female, rural barangay)

“The first thing that came into my mind from what I understand about the word ‘processed food’ is the food like hotdogs, items that are refrigerated – hotdogs, tocino [cured pork], lumpia [fried spring roll] – or items that are packed in plastic.”

(Male, urban barangay)

“Those are foods that can last for months.”

(Female, rural barangay)

“It’s not fresh.”

(Male, urban barangay)

Participants also proposed that UPFs were foods that can be easily digested.

“Something that can be easily processed by our body, just like ice cream and chocolates.”

(Male, rural barangay)

A few characteristics of UPFs were discussed within certain strata. Several female participants, but not males, noted that UPFs were characterized by their unique ingredients, such as preservatives and non-food additives.

“For me, those foods are easy to cook since they are full of preservatives.”

(Female, rural barangay)

“Foods that are in powder form, with added chemicals.”

(Female, urban barangay)

One male participant from a rural barangay suggested that UPFs were foods made by big companies (“Coke”), and some of the females from the rural barangays proposed that UPFs were foods that had undergone processing.

“Any food that is processed by a machine and you need to buy it outside [of the house].”

(Female, rural barangay)

3.2.2. Theme 2: Settings for UPF consumption

One commonly discussed setting for UPF consumption was schools, specifically secondary schools, as most participants were either current students or recent graduates of secondary school. Participants reported that many foods available in the school canteen, or cafeteria, were ultra-processed.

“During snack time, we get hungry because we already ate our packed lunches. So, we just buy biscuits or pretzels with my classmates, like the ones available in the canteen”

(Male, urban barangay)

Many participants also noted that UPFs were readily available from vendors close to their schools, and one female from a rural barangay also spoke of faculty selling UPFs to students. Most participants discussed eating UPFs with friends, often as entertainment, and they reported consuming UPFs at events or celebrations.

“When with friends, we eat together and share stories. We even buy junk foods to be entertained.”

(Male, rural barangay)

Participants in all four strata also described consuming UPFs in their homes.

“In the house, it is easy to consume junk foods.”

(Male, urban barangay)

“When I was younger, it was snacks at school. Now, it’s snacks at home.”

(Female, urban barangay)

In a few instances, participants noted the specific types of vendors from which they obtained UPFs, including sari-sari (small or convenience) stores and food delivery services.

3.2.3. Theme 3: Perceived changes in UPF consumption since mid-adolescence

When asked how their consumption of UPFs had changed since they were 14 or 15 years old, participants described consuming fewer, more, or the same amount; this heterogeneity was present across all strata.

Changes in food preferences or appetite were given as explanations for consuming both fewer and more UPFs since mid-adolescence.

“When I was 14 years old, I kept eating junk foods. However, now I don’t eat junk food as much anymore. Sometimes, I get tired of eating them.”

(Male, urban barangay)

“It’s worse now compared to when I was younger. I was a picky eater, but since I turned 16, I eat more.”

(Female, urban barangay)

Similarly, many participants attributed changes in their UPF consumption since mid-adolescence, whether increases or decreases, to changes in their income or allowance.

“When I was younger, I had no money to buy those foods, but now, I have earnings.”

(Male, urban barangay)

“We can no longer ask for much money from our parents.”

(Female, rural barangay)

Many participants reported that changes in their UPF intake since mid-adolescence, whether increases or decreases, were due to changes in their autonomy or responsibilities related to their diet-related decisions.

“[I eat] less [UPFs] now, since I tend to choose what food to eat.”

(Female, rural barangay)

“In my case, I think I eat more ultra-processed food than before because, previously, I didn’t like soft drinks and junk foods because my parents forbade me from eating them. Now that I’m bigger, they seem to let me do what I want to do because I’m old enough. So, I can now eat junk food and have a drink.”

(Male, rural barangay)

One explanation for consuming fewer UPFs since mid-adolescence was a change in health knowledge or health goals.

“I think it was worse when I was 14 because I was more addicted to junk foods before I went to high school. Now, I am more conscious of the decisions I make with the foods I eat.”

(Female, rural barangay)

Some males, but not females, also said that they consumed fewer UPFs as young adults because of changes in health status.

“When I was 14 and younger, I loved junk food, but now that I have high blood pressure, I’m no longer fond of junk food.”

(Male, urban barangay)

Some females, but not males, attributed increases in their UPF intake since mid-adolescence to changes in their home food environment.

“I can say that I was healthier before when I stayed with my grandmother. They took care of me, and they always fed me vegetables during breakfast, lunch, and dinner.”

(Female, rural barangay)

3.2.4. Theme 4: Factors that influence consumption of UPFs

Taste, convenience, and cost were discussed by participants across all strata as the primary influences on their UPF consumption.

“Even if it’s wrapped in a bag, as long as it’s delicious, we’ll still eat it.”

(Male, urban barangay)

“It’s when we have limited time to eat, we just eat [UPFs] for the sake of having a meal.”

(Female, rural barangay)

While the taste and convenience of UPFs were typically noted as influencing greater UPF consumption, cost was described as a deterrent to eating UPFs by some participants and as an enticement by others.

“I’ve noticed that it’s seldom [that I buy UPFs] now because I have to save [money].”

(Female, rural barangay)

“That’s what we can afford.”

(Male, urban barangay)

Participants also suggested that they often consumed UPFs to satisfy their cravings.

“…we seem to crave its taste, like your meal is incomplete without it.”

(Male, rural barangay)

Participants also talked about the influence of people around them, most notably their friends and their parents. While friends were described as influencing greater UPF intake, parents were described as discouraging intake.

“Sometimes, [my friends] would tempt me.”

(Female, urban barangay)

“It’s bad according to my mama. That’s why I don’t eat junk foods.”

(Male, urban barangay)

Some females, but not males, also discussed how older relatives, such as grandmothers, discouraged them from eating UPFs.

“[My grandmother] will just say, ‘You will get sick if you eat [UPFs].”

(Female, rural barangay)

Participants also suggested that health status or health knowledge prompted them to consume fewer UPFs.

“When we were younger, we had no idea about the effect, unlike now, when we are more aware that those foods are not good.”

(Female, urban barangay)

The limited availability of or access to alternatives to UPFs was discussed as a factor driving UPF consumption among some of the participants. This included restrictions on purchasing foods outside of school premises during school hours and limited availability of unspoiled fresh foods following natural disasters (e.g., typhoon).

There were several notable differences in the factors discussed across the four strata. Some males and females in urban, but not rural, barangays reported consuming UPFs in response to boredom or to add variety to their usual diets.

“Sometimes, you may want to eat something else when you always have vegetables.”

(Female, urban barangay).

Many female participants, but few males, noted that eating UPFs generated positive feelings or helped them to cope with stress.

“It’s a stress reliever, especially after school when you’re stressed out due to the academics.”

(Female, urban barangay)

Some females in rural barangays, specifically, reported that their consumption of UPFs was influenced by marketing on social media or television.

“I can always see it on TikTok, which is why I get influenced [to eat UPFs].”

(Female, rural barangay)

Several male participants discussed how the durability of UPFs made them well suited for carrying away from home (e.g., to school or work).

“…if you cook it in the morning, you can still eat it in the afternoon.”

(Male, rural barangay)

Most of the male participants also described eating more UPFs when drinking alcohol. While the pairing of UPFs with alcoholic beverages was discussed among females, it was not described as an important factor.

“Sometimes, when there is an occasion, like drinking sessions, junk foods are always there.”

(Male, urban barangay)

3.2.5. Theme 5: Beliefs about the health effects of UPFs

Most participants believed that certain non-communicable diseases, including diabetes, high blood pressure, and kidney disease, were caused by high intake of UPFs. Participants also believed that other health outcomes, like hyperacidity, urinary tract infections (UTI), and hepatitis, were linked to overconsumption of UPFs.

“I believe that soft drinks are ultra-processed food because they can really harm the body because they can cause diseases like diabetes.”

(Male, rural barangay)

“At my auntie’s, they can’t afford to buy fish all the time, so they eat ultra-processed foods, and her child had a UTI.”

(Female, rural barangay)

Frequently, participants attributed the adverse health effects of UPFs to their unique ingredients or nutrient composition.

“Some junk foods have plastics, which can be harmful to our stomachs.”

(Male, rural barangay)

“It seems like it has been made with preservatives, high amounts of salt, sugar, or sometimes even artificial sweeteners to prevent it from spoiling. So, that’s what’s harmful to our bodies…It’s not advisable to frequently consume processed food.”

(Male, urban barangay)

Many participants also expressed beliefs about shorter-term physical discomforts, like stomachaches, rashes, and nausea, resulting from UPF consumption.

There were differences in the beliefs expressed by males and females. Notably, several males, but not females, proposed that the effects of UPFs on health may be mixed and not strictly negative.

“Ultra-processed foods can include a variety of dishes, such as lumpia [fried spring roll] and ham…Therefore, I cannot generalize and say that all ultra-processed foods are detrimental to health. Each type of food has different effects on our bodies, and we cannot generalize or assume that they all have the same impact.”

(Male, urban barangay)

There were unique beliefs expressed among female participants as well. Several of the females from urban barangays attributed weight gain and obesity to overconsumption of UPFs, while a small number of females from one of the rural barangays suggested that consuming too many UPFs may reduce mental acuity.

3.2.6. Theme 6: Sources of information about the health effects of UPFs

Most participants reported that their parents and schools were the primary sources of information about foods classified as UPFs (e.g., junk foods, soft drinks, instant foods) and their link to health.

“My mother always told me that I can get sick from eating too much junk food.”

(Male, rural barangay)

“You also learn in school that those foods contain ingredients that are not healthy.”

(Male, urban barangay)

To a lesser extent, participants reported learning about the health effects of UPFs through the experiences of their friends or peers who had suffered an illness, and among females in rural barangays, specifically, older relatives, such as grandparents, were indicated as sources of information about UPFs.

“It’s usually my grandmother. She knows that I like to eat junk food, so will say, ‘You’re going to have a UTI again.’ And that’s painful.”

(Female, rural barangay)

Several forms of media were cited as important sources of information, including television programs, books, and, most prominently, social media. In all of the FGDs, participants discussed social media as a key source of information about the health effects of UPFs.

“Before, I was not aware, but I learned through social media. When you scroll about the effects of food, you will see what you should avoid.”

(Female, urban barangay)

Finally, a small number of participants reported that medical professionals had advised them or someone close to them to limit their consumption of foods classified as UPFs, such as soft drinks and junk foods.

“Several doctors have told me to avoid eating junk foods because, if I keep doing it, I’ll get sick.”

(Male, urban barangay)

4. Discussion

In this study in a diverse, metropolitan area of the Philippines, we examined awareness, experiences, and beliefs related to UPFs among older adolescents and young adults. The findings from this study offer insights about the drivers of UPF consumption during the transition from adolescence to adulthood in a geographically and economically diverse setting in an LMIC.

Although few of the young people in this sample had encountered the term “ultra-processed food,” they demonstrated an awareness of the characteristics of UPFs and knowledge of the foods and beverages belonging to this category, such as instant foods, soft drinks, and junk foods. Previous studies in LMICs of awareness of UPFs and of the ability of a general adult population to distinguish UPFs from non-UPFs have reported mixed results. While in one study, a national sample of Brazilian adults performed poorly in classifying foods according to their degree of processing (Monteiro, Nakano, Zandonadi, Botelho, & Araujo, 2022), in two other studies in Brazil, one conducted among adults in Dourado (Menegassi, de Morais Sato, Scagliusi, & Moubarac, 2019) and the other among mothers in Cruzeiro do Sul (de Morais Sato, Hatzlhoffer Lourenço, do Manco Machado, Augusto Cardoso, & Baeza Scagliusi, 2021), participants were generally adept at distinguishing UPFs from less-processed foods. Notably, the national dietary guidelines of Brazil explicitly discourage consumption of UPFs (Ministry of Health of Brazil, 2015), potentially raising awareness of these food products. In contrast, the Nutritional Guidelines for Filipinos, last revised in 2012, do not mention UPFs nor degree of food processing, though they do discourage consumption of fried foods and foods high in sugar, salt, and saturated fat (Food and Nutrition Research Institute Department of Science and Technology, 2015). Our findings suggest that, even in a setting where the term “ultra-processed food” is rarely, if ever, encountered and where UPFs are not explicitly addressed in national dietary guidelines, young people may intuitively understand the meaning of the term and be able to distinguish foods according to their degree of processing.

Evident from the FGDs was the widespread availability of UPFs in urban as well as rural neighborhoods, with UPFs described as a prominent feature of the home and school food environments in both settings. The frequent mention of schools as a setting where UPFs were purchased and consumed aligns with previous qualitative research about school food environments in the Philippines, which described an abundance of snacks and other highly-processed foods available from school canteens and nearby vendors (Reeve et al., 2018). The similarities in the reported availability of UPFs comparing urban and rural neighborhoods in this setting differs from the findings of two previous studies of dietary intake among a cohort of adolescents in Metro Cebu in the 1990s and 2000s, which found that diets became more obesogenic (i.e., more energy dense, higher in fat) as urbanization increased (Kelles & Adair, 2009) and that UPF intake tended to increase with increasing urbanization (Busse et al., 2024). However, in the past two decades, the food environment of the Philippines has undergone considerable changes, with UPFs becoming more widely available as transnational food and beverage corporations and supermarkets expanded (Baker & Friel, 2016; Huse et al., 2022).

The factors that influenced older adolescents’ and young adults’ consumption of UPFs in this setting aligned closely with the model of adolescent food choice developed by Story et al. (Story et al., 2002). Factors at the individual (taste, cost, convenience, health knowledge, cravings, coping), interpersonal (influence from peers, parents, older relatives), and community (school and household food environments) levels featured most prominently in the FGDs, while societal factors (marketing, media) were less commonly mentioned. A recent systematic review of qualitative studies of the drivers of adolescents’ food choices reported many of the same factors (Vidal, Rivera-Navarro, Gravina, Díez, & Franco, 2023), as did a recent qualitative study of factors influencing adolescents’ food choice across multiple LMICs (Neufeld et al., 2022). In those studies, taste, cost, and convenience were identified as key factors influencing adolescents’ food choices. Two influences on UPF consumption that were not identified in our analysis but that have been highlighted in previous research of drivers of food choice among adolescents in LMICs (Janha et al., 2021; Joshi-Reddy et al., 2021; Neufeld et al., 2022; Trübswasser et al., 2021) were food security and food safety. The absence of these as drivers of UPF intake in our study may reflect a higher socioeconomic position of participants in this sample relative to those in previous studies of food choice among adolescents in LMICs.

While young people are often gaining autonomy over their food choices as they transition from adolescence to adulthood, it was evident from the FGDs that parents, and to a lesser extent other older relatives, continue to exert a great deal of influence over their children’s food choices, including their consumption of UPFs, even as they become young adults. This aligns with our recent study of UPF intake during the transition from adolescence to adulthood in Metro Cebu using data from the 1994-2005 waves of the Cebu Longitudinal Health and Nutrition Survey. In that study, we found that UPF intake in adolescence and early adulthood tended to increase as maternal UPF intake increased (Busse et al., 2024). This influence by parents is likely explained by their prominent role in household food preparation. Indeed, most participants in our sample reported that a parent was the person primarily responsible for household food procurement and preparation, making parents important partners in any future efforts to reduce UPF intake and improve diet quality of young people in the Philippines.

Our findings have important public health implications. With the availability of UPFs in LMICs expected to increase in the coming decade (Baker et al., 2020), efforts to curb UPF intake will become increasingly important for preventing non-communicable diseases in the Philippines and around the world. The period between adolescence and adulthood is important for establishing independence in diet-related decision-making (Neufeld et al., 2022; Winpenny et al., 2018). Therefore, efforts to reduce UPF intake during this period may result in improved diet quality not only in late adolescence and young adulthood, but across the life course.

Our findings indicate that older adolescents and young adults in Metro Cebu are well-equipped to identify UPFs and believe that overconsumption of UPFs is, in general, bad for long-term health. This suggests that educating young Filipinos about the potential adverse health effects of UPFs may be less pressing than other strategies to reduce UPF intake, like fiscal policy, marketing restrictions, or front-of-package warnings.

Considering the frequency with which participants in our study noted the availability and consumption of UPFs in school settings, one potential strategy may be to restrict the sale and marketing of UPFs in schools, as existing regulations related to the provision and availability of energy-dense, nutrient-poor foods in and around schools in the Philippines have been found to be ambiguous and poorly enforced and proposals for new restrictions have been vigorously opposed by food companies (Reeve et al., 2018).

Imposing taxes on specific categories of UPFs, like packaged junk foods and sugar-sweetened beverages, may be another promising strategy. Such policies have been shown to reduce intake of sugar-sweetened beverages (Colchero, Rivera-Dommarco, Popkin, & Ng, 2017) and non-essential, energy-dense foods (Hernandez, Batis, Rivera, & Colchero, 2019) in Mexico and of sugar-sweetened beverages in South Africa (Stacey et al., 2021). The number of countries that have implemented similar fiscal policies continues to grow each year, and in 2023, Colombia became the first country to target consumption of UPFs, specifically, via fiscal policy (Taylor, 2023). In the Philippines, there appears to be interest in such a policy among some federal legislators, as indicated by the introduction of an excise tax on junk foods and sugar-sweetened beverages in the legislature in 2023 (Cervantes, 2023), though the bill ultimately failed to pass. To guide officials and other stakeholders in their decision-making related to improving nutrition and health, evidence of the effectiveness of this and other policies for reducing UPF consumption among young people in the Philippines and in LMICs elsewhere is badly needed.

4.1. Limitations and strengths

Limitations of this study included those common to many studies using FGDs, namely that, at times, a small number of participants dominated the discussions. Relatedly, in some cases, the first few responses to a prompt may have influenced subsequent responses. However, the facilitators had considerable experience facilitating FGDs and were trained to draw out the unique ideas of all participants. Finally, nearly all participants in this sample had completed secondary school or were still in secondary school; thus, while these findings may be generalizable to young people in the Philippines, where secondary school completion rates (78%) are among the highest in Southeast Asia (UNESCO Institute for Statistics, 2018), they may be less generalizable to young people living in metropolitan areas in Southeast Asia that have lower rates of secondary school completion.

A key strength of this study was the stratification of FGDs by gender and urban-rural neighborhood designation, which allowed us to consider whether certain factors influencing UPF intake were unique to specific demographic groups. A second strength of this study was the double coding of each FGD transcript by the same two coders in both English and Cebuano. This approach ensured reliability in the coding of transcripts between coders.

4.2. Conclusions

In this study, we learned that older adolescents and young adults in Metro Cebu, Philippines were knowledgeable about the characteristics of UPFs and held beliefs about the adverse health effects of diets high in UPFs. We also learned that factors at the individual, interpersonal, community, and societal levels influenced young people’s UPF consumption. This study yields insights about the drivers of UPF intake during the transition to adulthood in an LMIC setting and can inform efforts to reduce UPF intake and improve diet quality among young people in the Philippines and in LMICs around the world.

Abbreviations:

LMICs

low- and middle-income countries

FGD

focus group discussion

UPF

ultra-processed food

Data Availability

De-identified data collected for this study will be made available upon reasonable request.