Ultra-processed foods and public health: Evidence of harm and of conflicts of interest in the food industry to evade regulation

Abstract

The global pandemic of diet-related disease is increasingly recognised as commerciogenic – driven by financial incentives in the food system which drive the marketing and consumption of harmful food, including ultra-processed food (UPF). Despite international consensus on the harms of UPF and the adoption of precautionary policies by organisations such as WHO, UNICEF and governments in Latin America, UK policy response remains compromised by widespread conflicts of interest. These conflicts exist across government agencies, regulatory bodies, academia and media institutions, many of which are directly or indirectly funded by the food industry. Drawing parallels with tobacco control, the paper concludes that eliminating these conflicts is essential to formulating effective public health policy. Without structural change and the exclusion of industry actors from policymaking, rates of diet-related disease will continue to rise.

Business as usual is not an option: The crisis of diet-related disease in the UK

The statistics on obesity are repeated so often in the press that we have become numb to them, and yet we have some of the worst rates in the European region. 10% of children are living with obesity by the age of 5, and by the age of 10 this has risen to 22%. In the past 30 years, rates of obesity among children aged 10–11 years increased by >700% and rates of severe obesity by >1,600%.¹ Obesity is a proxy for other diet-related disease, and in children it goes hand in hand with stunting. UK children at the age of 5 are around 9 cm shorter than their peers in northern and eastern Europe. Data from the Non-Communicable Diseases Risk Factor Collaboration make it clear that this is not due to genetic changes due to migration, but rather to environmental factors, mainly poor diet.² The burden of this crisis falls, predictably, on the most disadvantaged – the most deprived areas having a prevalence of obesity in school year 6 more than double that of the least deprived.¹

As well as being morally intolerable, this crisis is unaffordable. The 2021 National Food Strategy put the cost of obesity alone to the UK economy at around £58 billion³ and a 2024 analysis by the Food Farming and Countryside Commission put the food-related cost of chronic disease in the UK at £268 billion – similar to the entire government healthcare spend.⁴

The crisis is not caused by a failure of personal willpower⁵ nor inactivity.³ It is caused by a dietary pattern of industrially processed products which are energy dense, and typically contain excess saturated fat, salt and/or free sugars. These products are ubiquitous and persuasively marketed. They are designed and marketed to promote excess consumption and to displace traditional, whole and minimally processed foods.⁶ For many people they have addictive or quasi-addictive properties. These products are formally known as ultra-processed foods (UPF) and now make up 60% of our calorie intake on average in the UK.⁷

The new GLP-1 agonist drugs for treating obesity have been proposed as the solution to the obesity crisis⁸ – indeed the largest manufacturer, Novo Nordisk, is funding NHS weight loss programmes.⁹ These drugs are an important tool in the treatment of obesity, but they are expensive at over £1,000 per patient year.¹⁰ Treating all adults living with obesity would be roughly the same as the cost of diet-related disease to the health service. So they must never be confused with, nor distract from, strategies to prevent diet-related disease.

The definition and history of ultra-processed food

UPF is not a casual term like junk or fast food, but rather a formal scientific definition developed to test the hypothesis that the displacement of a traditional diet by industrially processed food was causing an epidemic of diet-related disease in Brazil.¹¹,¹² It is also known as Nova group 4, and is the fourth category in the Nova food classification system. The full definition is long, perhaps one of the longest category definitions in science, and it describes the wide variety of industrially processed food that has displaced traditional diets around the world.⁶ UPF are made from ‘formulations of ingredients, mostly of exclusive industrial use, made by a series of industrial processes, many requiring sophisticated equipment and technology’. A practical way to identify UPF is to check whether it contains at least one ingredient never or rarely used in kitchens.¹³

Other core components of the definition are the use of industrial chemical and mechanical manufacturing techniques, and the use of additives ‘whose function is to make the final product palatable or more appealing such as flavours, flavour enhancers, colours, emulsifiers, and sweeteners, thickeners, and anti-foaming, bulking, carbonating, foaming, gelling, and glazing agents’.

Importantly the definition includes the purpose of the processes and ingredients: ‘to create highly profitable, convenient, hyper-palatable products to displace freshly prepared dishes’.

In the 16 years since the definition ‘UPF’ was created, it has proved to be an extremely powerful research tool for hundreds of studies conducted by independent research groups worldwide.

UPF causes negative health outcomes

A PubMed search will return >30 meta-analyses or systematic reviews linking a dietary pattern high in UPF to multiple negative health outcomes. This evidence satisfies the Bradford Hill criteria, the most frequently cited framework for causal inference in epidemiologic studies, which comprises nine ‘aspects of causation’: strength of association, consistency, specificity, temporality, biological gradient, plausibility, coherence, experiment and analogy.

The associations are strong and consistent: cohort studies conducted by groups from different countries, across diverse populations and age groups all show the same thing.¹⁴

Temporality, that exposure precedes the development of disease, is established by multiple prospective cohort studies showing associations between UPF consumption and negative health outcomes¹⁵ including obesity,¹⁶ type 2 diabetes, cancer, cardiovascular disease, metabolic dysfunction-associated steatotic liver disease (MASLD),17, 18 dementia and all-cause mortality. Globally in countries where there has been a nutrition transition from whole and minimally processed diets to UPF, rates of diet-related disease have risen.

There is a dose–response relationship: the more UPF is consumed, the greater the risk, and these associations are entirely coherent with existing knowledge on poor dietary quality and evidence around whole, minimally processed foods which associated with better health outcomes.¹⁴

The hypothesis is plausible. Food made for the purpose of profit by large companies owned by institutional investors is likely to be made using ingredients and processes that save money and produce food that is extremely desirable, so that UPF seem to have addictive or quasi-addictive properties for some people. Their addictive potential is increased by marketing practices that encourage excess consumption including price promotions, brand names like ‘Krave’ and slogans like ‘I bet you can’t eat just one’, or ‘Once you pop you can’t stop’. This marketing is exclusive to UPF and is associated with significant increases in UPF intake and purchase requests.

Perhaps the strongest support for establishing causality comes from experimental studies, including two randomised controlled trials (RCTs) of UPF looking at weight gain as a primary outcome and hundreds of clinical and preclinical studies on harmful properties and additives unique to UPF including food texture (softness), energy density, additives including emulsifiers, non-nutritive sweeteners and plastics, among others.

Mechanisms

This experimental evidence provides insight into the many possible mechanisms by which UPF might cause negative health outcomes.

First, UPF has a poor nutrient profile – it is high in sugar, salt and fat and low in fibre. Much of the debate around UPF focuses on whether it is merely salty, fatty sugary food and whether the ‘processing’ makes any difference. While it is legitimate to ask if UPF is a way of describing food that we already know is harmful because of the nutrient profile, this invites a more important question: is ultra-processing what is driving the consumption of so much sugar, salt and fat?

The epidemiological and experimental evidence suggest that this is the case. Most cohort studies adjust for the nutritional content of the diet, and in almost all cases the association with the negative health outcomes remains unchanged in both significance and magnitude. In the two RCTs that looked at UPF and calorie consumption, the nutrient profile of two diets was fixed while only the degree of processing was varied. More obviously, while no one eats mixtures of pure salt, fat and sugar, we do eat vast quantities of UPF where the salt, fat and sugar are ‘ultra-processed’. The texture, flavour, price point, packaging, health claims, mouth-feel, and other aspects of each product is optimised to maximise profitability. Two of the largest food companies, Pepsi and Unilever, even funded neuroscience research using functional MRI in order to improve products.

Trying to disentangle the effect of fat, salt and sugar is to misunderstand the relationship between nutrients and processing. Using large quantities and particular ratios of fat, salt and sugar are some of the ways in which the food industry drives excess consumption and this is why the vast majority of UPF in the UK exceeds UK guideline amounts.

The ultra-processing combined with the poor nutrient profile results in a double jeopardy – each mouthful is high in salt, sugar and fat, but you also take more mouthfuls because of all the other processes and ingredients.

Regulation of harmful food globally

The evidence around UPF tells us the type of products (and corporations) that require more effective regulation. Many countries and institutions globally have used this evidence to guide policy.

The Nova classification is used by the World Health Organization (WHO) and United Nations Food and Agriculture Organisation (UNFAO) to monitor diet quality globally, and moderating UPFs is embodied in the FAO/WHO core principles of healthy diets. Reducing or avoiding consumption of UPF is recommended by UNICEF, the American Heart Association, and in many countries’ national dietary guidelines.

The definition was designed for research, not product-level regulation, and does not distinguish between different UPF products. The evidence describes the harm of a dietary pattern so, in South and Central America, many governments regulate the categories of processed and ultra-processed food products using thresholds for sugar, salt, saturated fat and energy density – the nutrient profile of the food. If thresholds are exceeded, foods are given clear black octagonal warning labels and food with these warning labels is then subject to further regulations. For example, if a food has a warning because of harmful levels of salt or sugar, it cannot simultaneously have a health claim or a cartoon character. These policies have shifted purchases away from UPF in many countries, and evaluations do not show negative economic side effects.19, 20, 21, 22, 23

Controversy and conflicts in the UK

Despite widespread acceptance of the risks of UPF globally, in the UK you could be forgiven for thinking that the subject was a matter of legitimate scientific controversy.

This is because of the extensive conflicts of interest between the UPF industry and many of the individuals and institutions who might regulate it. These include formal government regulators, as well as ‘de facto’ regulators who have no formal power but still inform policy and public opinion – charities, academic research departments, press offices, academic journals, healthcare professional associations and so on.

A series of articles which questioned the evidence around UPF came out of a press conference in October 2023. Of the five speakers, four had significant relationships with companies that make UPF. And the conference was held by the Science Media Centre (SMC), a press office that claims to be ‘completely independent in both our governance and funding’. A BMJ investigation revealed that the SMC was funded at the time by a food industry body, Food Drink Europe (members include Cargill, Coca-Cola, Danone and Mars), as well as Nestlé and Proctor & Gamble.

Many of the scientists used by the SMC and who are quoted in stories about UPF also work with the British Nutrition Foundation (BNF), a ‘public-facing charity’ which advises on nutrition policy and which is majority funded by UPF companies including Coca-Cola, Nestlé, Mondelēz, PepsiCo, Mars, Danone, Kerry and Cargill. In 2023 their healthy eating week was funded by Coca-Cola among others.

At government level there are at least five institutions, which inform food regulation directly or indirectly, with financial links to UPF companies.

UK Research and Innovation (UKRI) has called for a public dialogue about UPF. Six out of the 14 members of the oversight group have either declared conflicts of interest with UPF companies or are industry representatives.

The Scientific Advisory Committee on Nutrition, or SACN, advises the government on nutrition and related health matters and defines a healthy diet. Members of this committee have declared conflicts with the British Nutrition Foundation, the American Society for Nutrition (whose funders include Mars, Nestlé and Mondelēz), Cargill, the meat industry, the dairy industry, CBC Israel (they make and market Coca- Cola and Sprite), Tate & Lyle, Sainsbury’s and Danone, and Nestlé. Despite the UK having some of the worst statistics of any comparable country, SACN has not produced a report on childhood obesity.

The government Food Strategy Advisory Board (FSAB) has an industry-funded charity as part of the secretariat (The Institute for Grocery Distribution or IGD), and there are industry representatives from four transnational UPF corporations on the committee.

The main formal regulator of food in the UK is the Food Standards Agency. A 2023 analysis showed that not one of the bodies advising the Department for the Environment, Food & Rural Affairs (Defra) or the Food Standards Agency (FSA) was free from conflicts of interest with the food industry, and several members of the FSA Scientific Advisory Committee have declared interest with food companies including Danone, Avara Foods Ltd, J Sainsbury plc and Coles Australia. A former head of the FSA, John Krebs, is the scientific adviser to Marks & Spencer plc.

UK policymakers have partnered with industry for more than two decades. Industry consulted on the nutrient profile thresholds that have been used to describe ‘less healthy’ food in the UK and have been involved in every major policy decision since then.

A 2021 analysis identified 14 government strategies published from 1992 to 2020 containing 689 wide-ranging policies. The vast majority of policies (95%) were proposed in a way that would be unlikely to lead to implementation and relied on individuals to make behaviour changes rather than focusing on deterrence and conflicts of interest. Rates of obesity have grown year on year throughout this period.

As a result of these conflicts we have incredibly light-touch regulation of food when it comes to health. Children are steeped in marketing and we have no mandatory warning labels on even the most harmful products. The voluntary traffic lights are applied using thresholds which are entirely divorced from internationally agreed norms including our own government Eatwell guidance. We apply a sugar levy to sugary soft drinks, but not to any other sugary products (including milkshakes and confectionery!).

We urgently need to make healthy food affordable and to start to regulate food more effectively, but this will not happen as long as industry are in the room.

Why industry can’t be partners in changing the system

UPF products, and the companies that make them, have much in common with cigarettes and cigarette companies. They are owned to varying degrees by large institutional investors who, understandably, prioritise returns over other concerns like public health and the environment. A 2023 paper analysis used financial data to show that the largest food companies spend revenue on share buybacks and dividend pay outs while institutional investors vote down public health proposals at board level.²⁴

Nestlé have as their strapline ‘Good food, good life’ even as they add KitKat cereal to a product portfolio, the majority of which has been reported as unhealthy.²⁵ (Fig. 1, Fig. 2, Fig. 3).

Fig. 1.

Ultra-processed foods (UPF) in the diets of infants and young children in the UK. Used with permission. Credit to © First Steps Nutrition Trust.

Fig. 2.

Front-of-package labels around the world – mandatory and voluntary. Used with permission. Credit to ©Global Food Research Programme at UNC-Chapel Hill.

Fig. 3.

French public health advice for feeding children. Copyright ©Santé Publique France.

Solutions

Currently, many UK families depend on UPF, so policies must increase the availability and affordability of healthy food while shifting demand away from UPF in ways that are equitable and increase consumer choice.

There is a long list of policy solutions that could do this including front-of-package warning labels, subsidies and taxation, restrictions on marketing, promotions and placement of unhealthy products, free school meals, change the school curriculum and Healthy Start vouchers to name just a few.

But we will not see effective implementation of any of these until we end conflicts of interest. In this sense, we must approach the regulation of UPF companies in the same way as we did tobacco and get industry out of the room. That doesn’t mean that there should be no consultation with industry, but they can’t sit, or pay people, on policy committees.

The 2023 analysis by City, University of London, and University of Sussex Business School made a simple assertion – ‘that all people with commercial conflicts of interest should no longer be allowed to participate in UK food policymaking’.

In line with this, the UNICEF policy is the simplest distillation of how all policymakers and regulators should interact with the food industry:

UNICEF will avoid all partnerships with ultra-processed food and beverage (UPF) industries. To preserve our thought and action leadership, align with our programming strategies, and maintain our credibility as a trusted advisor for public policy, normative guidance, and programme implementation for children, UNICEF will avoid all forms of financial and non-financial partnerships and collaborations with the UPF industry. This includes individual companies as well as associations, platforms, and front groups representing UPF industries and their interests.

I’ll conclude with the dietary advice from France, the nation with the lowest childhood obesity rate in Europe, which advises limiting UPF intake especially in children.

‘Pour varier les goûts et les textures, le fait maison a tout bon … Plus de goûts, plus de textures, plus de miam!’

Or

‘To vary tastes and textures, home-made food includes everything good … More tastes, more textures, more yum!’

CRediT authorship contribution statement

Christoffer van Tulleken: Writing – review & editing, Writing – original draft, Conceptualization.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Christoffer van Tulleken reports a relationship with the British Broadcasting Corporation (BBC) that includes: employment. He has published a book called Ultra Processed People about the food system and conflicts of interest for Penguin Random House – he was paid an advance and receives royalties.

He has produced and presented two BBC TV documentaries on the same subject and does broadcasting on health and food generally for the BBC – he has received fees from the BBC.

He has given evidence to the House of Lords Obesity Enquiry in the UK and spoken frequently to news media on this subject, including multiple appearances on podcasts.

He writes articles in the national press about food and health, for which he is paid fees.

He is well known publicly for his position that the current food environment in the UK is harmful. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.