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In the current issue of the online Journal of the World Public Health Nutrition Association (of which I am a charter member), Carlos Monteiro, a professor at the University of São Paulo writes “The big issue is ultra-processing.”  Because his Commentary is so lengthy, I am taking the liberty of extracting pieces from it, not always in the order presented.

The most important factor now, when considering food, nutrition and public health, is not nutrients, and is not foods, so much as what is done to foodstuffs and the nutrients originally contained in them, before they are purchased and consumed. That is to say, the big issue is food processing – or, to be more precise, the nature, extent and purpose of processing, and what happens to food and to us as a result of processing.

Monteiro makes it clear that all foods and drinks are processed to some extent.  Fresh apples are washed and, sometimes, waxed.  Drinking water is filtered.  Instead, he distinguishes three types of processing, depending on their nature, extent, and purpose:

• Type 1: Unprocessed or minimally processed foods that do not change the nutritional properties of the food.
• Type 2: Processed culinary or food industry ingredients such as oils, fats, sugar and sweeteners, flours, starches, and salt.  These are depleted of nutrients and provide little beyond calories (except for salt, which has no calories).
• Type 3: Ultra-processed products that combine Type 2 ingredients (and, rarely, traces of Type 1).

The purpose of Type 3 ultra-processing is to create:

durable, accessible, convenient, attractive, ready-to-eat or ready-to-heat products. Such ultra-processed products are formulated to reduce microbial deterioration (‘long shelf life’), to be transportable for long distances, to be extremely palatable (‘high organoleptic quality’) and often to be habit-forming. Typically they are designed to be consumed anywhere – in fast-food establishments, at home in place of domestically prepared and cooked food, and while watching television, at a desk or elsewhere at work, in the street, and while driving.

Monteiro argues: “the rapid rise in consumption of ultra-processed food and drink products, especially since the 1980s, is the main dietary cause of the concurrent rapid rise in obesity and related diseases throughout the world.”

As evidence, he notes that ultra-processed products as a group are:

• Much more energy-dense than unprocessed and minimally processed foods and processed culinary ingredients taken together.
• [Contain] oils, solid fats, sugars, salt, flours, starches [that] make them excessive in total fat, saturated or trans-fats, sugar and sodium, and short of micronutrients and other bioactive compounds, and of dietary fiber.
• Relatively or even absolutely cheaper to manufacture, and sometimes – not always – relatively cheaper to buy.
• Often manufactured in increasingly supersized packages and portions at discounted prices with no loss to the manufacturer.
• Available in ‘convenience’ stores and other outlets often open late or even 24/7, and vended in machines placed in streets, gas stations, hospitals, schools and many other locations.
• The main business of transnational and big national catering chains, whose outlets are also often open until late at night, and whose products are designed to be consumed also in the street, while working or driving, or watching television.
• Promoted by lightly regulated or practically unregulated advertising that identifies fast and convenience food, soft drinks and other ultra-processed products as a necessary and integral part of the good life, and even, when the products are ‘fortified’ with micronutrients, as essential to the growth, health and well-being of children.

Overall, he says:

Their high energy density, hyper-palatability, their marketing in large and super-sizes, and aggressive and sophisticated advertising, all undermine the normal processes of appetite control, cause over-consumption, and therefore cause obesity, and diseases associated with obesity.

His groups the main points of his argument in three theses:

• Diets mainly made up from combinations of processed ingredients and unprocessed and minimally processed foods, are superior to diets including substantial amounts of ultra-processed products.
• Almost all types of ultra-processed product, including those advertised as ‘light’, ‘premium’, supplemented, ‘fortified’, or healthy in other ways, are intrinsically unhealthy.
• Significant improvement and maintenance of public health always requires the use of law. The swamping of food systems by ultra-processed products can be controlled and prevented only by statutory regulation.

Lest there be any confusion about the significance of this proposal for public health nutrition, an accompanying editorial (unsigned but assumed to be by Geoffrey Cannon) poses a serious challenge: “Nutrition science: time to start again.”

This editorial is about the significance of food processing, and in particular of ‘ultra-processed’ food and drink products. It is also about the nature, purpose, scope and value of nutrition science, which as conventionally taught and practiced, is now widely perceived to have run into the buffers or, to change metaphor, to have painted itself into a corner.

The editorial argues that nutritionists’ focus on nutrients, rather than foods, has led to the assumption that if foods contain the same nutrients, they are the same—even though it is never possible to replicate the nutritional content of foods because too much about their chemical composition is still unknown.

This notion is an exquisite combination of stupidity and arrogance, or else of intelligence and cunning. For a start, similar results can only be of those chemical constituents that are at the time known, and actually measured.

These are important ideas, well worth consideration and debate.  I am struck by their relevance to the latest survey of soft drink availability in American elementary schools.  Despite the efforts of the Clinton Foundation and the voluntary actions of Coca-Cola and Pepsi-Cola, the availability of soft drinks to young school children increased from 49.% to 61% just in the year from 2006-07 to 2008-09.  Soft drinks, in Monteiro’s terms, are ultra-processed.  Doing something about them requires statutory regulation.

Consideration of the effects of ultra-processing might help us look at what we feed our kids in a more constructive way.  This is important work.

Addition: I should have mentioned that Monteiro’s approach is consistent with that of the people (including me) who worked with the Strategic Alliance in Oakland, CA to write Setting the Record Straight: Nutritionists and Health Professionals ” Define Healthful Food.

The Alliance is California’s network of food and activity advocates, we’ve developed a definition of healthy food that asserts that truly healthful food comes from a food system where food is produced, processed, transported, and marketed in ways that are environmentally sound, sustainable, and just.

If you agree with Setting the Record Straight, you can endorse it on the Strategic Alliance’s website.

The most thoughtful comments I’ve seen on the proposal to block food stamp recipients from buying sodas come from Andy Fisher’s post on Civil Eats.

Mr. Fisher is currently a Kellogg Food and Society Fellow with the Institute for Agriculture and Trade Policy in Minneapolis.  He is the Co-Founder/Executive Director of the Community Food Security Coalition (CFSC).

I have added the red-highlighted emphases:

Banning Soda for Food Stamps’ Recipients Raises Tough Questions

October 8th, 2010  By Andy Fisher

On Thursday, New York City Mayor Michael Bloomberg announced that he had asked the US Department of Agriculture to allow the city to exempt soda from the permitted list of items its 1.7 million food stamp recipients can purchase with their benefits. This ban would last for two years, enough time to assess its effects and determine whether the ban should be continued on a permanent basis. New York City food stamp recipients spend an estimated $75 million to $135 million of their $2.7 billion in food stamps annually on soda, according to AP.

Anti-hunger and public health advocates at odds over proposal

Public health advocates contend the obesity epidemic is costing the US hundreds of billions of dollars per year in increased health care costs, and sugar sweetened drinks are a major factor.   They correctly note that low income persons tend to have higher rates of diet related diseases than the general public: poor New Yorkers have twice the rate of adult-onset diabetes than compared to the wealthiest. Mayor Bloomberg noted, “Sugar-sweetened drinks are not worth the cost to our health, and government shouldn’t be promoting or subsidizing them.”

On the other hand, anti-hunger advocates argue that food stamp recipients should have the same freedom of choice at the supermarket checkout counter as any middle class person. Exercising that freedom is a matter of personal dignity that the poor all too often are not afforded. Restricting soda is the first step in a slippery slope toward further demeaning regulations on what food stamp recipients can buy.  They correctly point out that poor people often can’t afford produce, as nutritious foods tend to be more expensive per calorie than less healthy food.

The anti-hunger community is correct that historically, as a nation, we have treated the poor paternalistically. American social, educational and health policy is littered with countless examples of this failed approach. Regulating what food stamp recipients can and can’t buy with their benefits puts forth the message that they are not capable of making good decisions, and the government needs to set forth boundaries to protect them from their own poor choices. To the contrary, some studies have shown that food stamp recipients actually buy more nutritious food per dollar than non-food stamp recipients.

Anti-hunger advocates are also right that poor people typically can’t afford nutritious foods. Highly processed foods, such as ramen, fill up a belly more cheaply than broccoli and whole wheat pasta.  In our food system, high calorie foods with low nutritional value are cheaper than nutrient dense foods. For example, a 12 pack of 12 ounce cans of Coke (144 oz) at Kroger’s costs $2.79 on sale, while a half gallon (64 ounces) of Minute Maid orange juice (also a Coca Cola Inc. product) is $2.49. The bad choice is the cheap choice.

On the other hand, public health groups are dead-on accurate that it is irresponsible public policy to be subsidizing with tax dollars the purchase of unhealthy products that will burden society with increased health care costs in the future.  As a nation, we’re subsidizing soda companies $4 billion annually through the food stamp program. In return, decades later, the public will be stiffed with the hospital bill for billions of dollars more for extra health care costs from these poor dietary choices.

Thorny issue raises questions

Why are anti-hunger advocates in the absurdly precarious position of protecting the right of poor people to drink soda? Do I have a right as an American to poison myself with “soft” drinks that can dissolve the rust off a car? Does it matter whether I use my own money or tax dollars?  Should freedom of choice apply to products of marginal utility if not harmful products?

Why does it cost Coca-Cola more to produce a half-gallon of orange juice than a half gallon of Coke? How do we reverse this situation, such that healthful products are more affordable and unhealthy products are more costly?

Are food stamps an income support program- or as the program’s new name indicates, a Supplemental Nutrition Assistance Program? If it is a “supplemental nutrition” program, then shouldn’t USDA define which products are nutritious based on Institute of Medicine standards, and limit purchases to these products? USDA does this with the Women Infants and Children (WIC) program, which is widely touted for saving billions in health care costs.

If food stamps are an income support program, and anti-hunger advocates want to maximize poor people’s freedom of choice, then why shouldn’t food stamps be distributed as cash rather than as a debit card good for food purchases? Doesn’t receiving cash maximize a person’s dignity as it bestows trust upon that person that he or she will make the right choice with their money?  Would food stamps not then become a welfare program, and be subject to the negative public perception of welfare?

The real story behind food stamps is that it is neither a nutrition program nor an income support program. It is a massive subsidy for the food retailers, grocery manufacturers, and industrial growers. That is why commodity groups, the Grocery Manufacturers of America and the Food Marketing Institute all line up behind the food stamp program every five years when the Farm Bill is being debated. They know the extra buying power food stamps provides to low income Americans will end up in their pockets.

In their noble effort to reduce human suffering and to improve the livelihood of the 41 million Americans on food stamps, anti-hunger advocates are caught in an ever-tightening bind. They frame food stamps as a nutrition program, because a nutrition program has more public support and more powerful allies in Congress than a welfare or income support program. Yet, burgeoning rates of chronic diseases and the growing presence of the public health community as a player in federal food and farm policy, translates into increased accountability for the nutritional impact of the food stamp program.

What boat are both camps missing?

There is one very important point neither the anti-hunger nor the public health advocates are making. Our tax dollars, especially the $80-90 billion spent annually on federal food programs, are a powerful force in shaping the food system. Food stamps, like school meals and WIC, should be the cornerstone of a food system that is grounded in principles of environmental sustainability, social justice, and health. Directed toward the small farm economy, community-oriented retailers, brokers, and processors, even a modest percentage of these funds could ignite a transformation of our food system.

Consider this. While nationally food stamp recipients are spending $4 BILLION per year on soda, in 2009, only $4 MILLION of food stamps were redeemed at farmers markets. This difference is shaped by the fact that USDA has not equipped farmers markets with free debit card terminals (which are needed to accept food stamp benefits), and prohibited federal nutrition education programs to promote farmers markets. Does this mean the Department of Agriculture values soft drinks one thousand times more than farmers markets?

Mayor Bloomberg has proposed only half the solution. USDA should grant him the waiver he requests if and only if New York City agrees to redirect the $75-$135 million that would have otherwise been spent on soda to programs that encourage food stamp recipients to purchase locally grown foods at farmers markets, community supported agriculture farms, and other community-oriented venues.

New York City is serious about trying to reduce rates of obesity and the expensive and debilitating conditions for which obesity raises risks.  Its latest move?  It is asking the USDA for a Food Stamp waiver for two years during which recipients would not be allowed to use their benefit cards to buy sodas.

I hardly know where to begin on this one.  I learned about this from the front page of this morning’s New York Times and from reading the accompanying op-ed by city Health Commissioner Tom Farley and New York State Health Commissioner Richard Daines.

This is an old, old idea that has been consistently rejected by USDA and by public health advocates for the poor.  It is based on the commonly held notion—never conclusively demonstrated by independent data—that recipients of Food Stamps (now called SNAP, the Supplemental Nutrition Assistance Program)–make worse food choices than everyone else.

New York City, according to the Times account, has 1.7 million people who receive SNAP benefits.  The rationale for banning soda purchases?

City statistics released last month showed that nearly 40 percent of public-school children in kindergarten through eighth grade were overweight or obese, and that obesity rates were substantially higher in poor neighborhoods. City studies show that consumption of sugared beverages is consistently higher in those neighborhoods….Anticipating such criticism, Dr. Farley and Dr. Daines said that the food-stamp program already prohibited the use of benefits to buy cigarettes, beer, wine, liquor or prepared foods.

The op-ed points out:

Every year, tens of millions of federal dollars are spent on sweetened beverages in New York City through the food stamp program — far more than is spent on obesity prevention. This amounts to an enormous subsidy to the sweetened beverage industry.

I asked for data on soda purchases by New York City SNAP recipients, and was sent the city’s waiver request to USDA:

An estimated $75 to $135 million dollars of SNAP funds were spent on sweetened beverages in New York City (NYC) alone in 2009 [Based on Nielsen beverage market data for 2009, the prevalence of SNAP participants in NYC, and prior studies of SNAP purchasing behavior].   This use of federal funds to purchase a group of products that are leading contributors to the diabetes and obesity epidemics (and whose extensive consumption contradicts the USDA’s own recommended dietary guidelines) far outstrips current federal funding for prevention of these health problems.

I am, as readers of this blog well know, no fan of sodas.   If people want to do something about controlling body weight, the best place to begin is by cutting out sodas.  Soft drinks contain sugars and, therefore, calories, but nothing else.  As the Center for Science in the Public Interest has long maintained, sodas are liquid candy.   And I am on record as favoring soda taxes (see previous posts) as a strategy to discourage use, especially among young people.

But if I were in charge of Food Stamps, I would much prefer incentives: make the benefit worth twice as much when spent for fresh (or single-ingredient frozen) fruits and vegetables.

How far will the city get with this request?  I can’t wait to find out.  If you want to watch lobbying in action, keep an eye on this one, as I certainly will.

As for this proposal?

By analogy with cigarettes, taxes on sodas might discourage people—especially young people—from consuming sugary drinks.  This might help with weight issues.

According to a new analysis by USDA economists,

A tax-induced 20-percent price increase on caloric sweetened beverages could cause an average reduction of 37 calories per day, or 3.8 pounds of body weight over a year, for adults and an average of 43 calories per day, or 4.5 pounds over a year, for children. Given these reductions in calorie consumption, results show an estimated decline in adult overweight prevalence (66.9 to 62.4 percent) and obesity prevalence (33.4 to 30.4 percent), as well as the child at-risk-for-overweight prevalence (32.3 to 27.0 percent) and the overweight prevalence (16.6 to 13.7 percent).

Soft drink companies know this all too well.  Hence, intense industry lobbying.  In the case of New York State, the lobbying succeeded.  Soda taxes are history (for now).

New York Times 7-2-10

As the New York Times explains:

Final lobbyist filings are not yet in, but estimates of the amount spent…range from $2.5 million, by Mr. Finnegan’s count, to $5 million, by the beverage industry’s count. The American Beverage Association spent $9.4 million in the first four months of the year to oppose New York’s soda tax, according to a search of public lobbying records by the New York State Healthy Eating and Physical Activity Alliance. Most of the money was spent on advertising, media and strategy.

This is a setback, but probably temporary.  Sooner or later, soda taxes will come.  Bring on the research!

Addition, July 5: Harvard researchers have just published a paper in the American Journal of Public Health showing that raising the price of sodas in a hospital cafeteria does indeed discourage sales.

If you are wondering why the idea of soda taxes causes so much controversy, try this: research published in the Archives of Internal Medicine estimates that a $1.00 price increase on soda and pizza would reduce daily calorie consumption by nearly 200 per day and would help people lose weight.

Or, as USA Today puts it, an 18% increase in the price of soda would be associated with a weight loss of 5 pounds per year.

Corporations go to a lot of trouble to neutralize potential critics.   Recent examples: two co-optations (McDonald’s alliance with Weight Watchers and PepsiCo’s with the Yale School of Medicine) and one aggression (Disney’s forced expulsion of the Center for Commercial-Free Childhood from Harvard).

Co-optation is the winning over or neutralization of opponents by bringing them into the fold.  It works well.

Let’s start with the new partnership between Weight Watchers and McDonald’s.  OK.  This is happening in New Zealand, not here, but it is still a good example.  McDonald’s New Zealand makes three meals that meet criteria for 6 Weight Watchers’ points.    Will Weight Watchers New Zealand suggest that its members cut down on fast food?  Not likely.

Next, Yale.  Yale Medical School proudly announces that PepsiCo has agreed to fund a new fellowship.  This fellowship, which creates a new position in the MD-PhD program, is for doctoral work in nutrition science.

Dr. Robert Alpern, dean and the Ensign Professor at Yale School of Medicine, says of this gift:

PepsiCo’s commitment to improving health through proper nutrition is of great importance to the well-being of people in this country and throughout the world. We are delighted that they are expanding their research in this area and that they have chosen Yale as a partner for this endeavor.

You can’t satirize something like this, but why am I guessing that recipients of this fellowship are unlikely to study the effects of food marketing on obesity or the effects of fructose on metabolism or to advise their overweight patients to cut down on soft drinks? (Thanks to Michele Simon who commented on it on her newly restored blog, Sunday, March 7).

And then there is yesterday’s ugly story in the New York Times about Disney’s retaliation against the Center for Commercial-Free Childhood which had successfully gotten the company to back off on its advertising for Baby Einstein videos.  By all reports, Disney pressured the Harvard unit that housed the Center to evict the Center under truly shameful circumstances.

The moral: if you want to do something to prevent childhood and adult obesity, you are working against the economic interests of corporations that profit from kids eating too much food or watching too much television.  And you must take great care to hold on to your independence.

Just in time for the Albany conference on soda taxes (see previous post), the Beverage Association has issued a report on the great progress it is making in reducing calories from sodas sold in schools.

In fact, the Beverage Association is doing a terrific job on reducing soft drink consumption.  Sales of sodas are down by impressive percentages, but so are sales of all drinks sold in school vending machines, as illustrated by this chart from today’s Wall Street Journal.

Source: Wall Street Journal, 3-8-10

This is good news.  The next steps to improve school food?  Here are a few of my favorites:

• Get the vending machines out of schools altogether, those for snacks as well as sodas.
• Get rid of “competitive” foods, those sold in competition with school meals.
• Put some restrictions on the frequency and quantity of foods brought in for birthdays and other celebrations.
• Institute universal school meals.

If kids don’t buy drinks from vending machines, the schools don’t need them, right?

Update March 9.  Thanks to Coca-Cola for sending a copy of the press release and the final progress report summary.

I’ve been collecting information about soda taxes.  If you think they are worth a try, as I do, and want to help get the New York bill (the Duane Bill) passed, plenty of background information and tools are available.

Tomorrow, March 8, The New York Academy of Medicine, the New York State Healthy Eating and Physical Activity Alliance, and the New York State Public Health Association invite you to a symposium:

TAKING ACTION AGAINST OBESITY:
A Sugar-Sweetened Beverage Tax for New York State
Monday, March 8 2010 from 2:00 pm to 3:30 pm
Blue Room, 2nd Floor, Capitol Building, Albany, NY

Speakers include NYS Health Commissioner Dr. Richard Daines, New York City Health Commissioner Dr. Tom Farley, and Dr. Kelly Brownell from the Yale Rudd Center for Food Policy. The event is free.  RSVP to tsanders@malkinross.com

Here’s more than you ever wanted to know about why these taxes are likely to do some good and are worth passing:

• Dr. Daines’ editorial supporting the bill.
• A handy Q and A on the taxes.
• Advertisements from the Alliance for a Healthier New York.
• Talking Points for writing letters.
• More talking points from the New York State Healthy Eating and Physical Activity Alliance.

Convinced?  Want to help?

• Sign the Statement of Support.
• Join Legislative Visits on Wednesday, March 17, in Albany. Contact agarcia@nyam.org to sign up.
• Send a letter to your representatives. Citizen’s Committee for Children has a produced a letter-generator for this purpose.
• Write a postcard using this prototype..

And just for fun, here is testimony from an official of PepsiCola opposing the taxes and a rebuttal from some group (sorry, I don’t know which).

Finally, the Los Angeles Times (February 21) had a terrific graph of the recent sharp increase in lobbying expenditures (in the rebuttal).  Given the mess in Albany, it will be interesting to see how all this goes.  Act now!