Access pdf of this letter here
Access pdf of the December Food System editorial here
Access pdf of the December Food System commentary here
Access pdf of the December trans fats commentary here

Sir: I heartily welcome the arrival of the 'fourth phase' in the theory and practice of nutrition. This has been launched by the epic 'The Food System. Processing. The big issue for disease, good health, well-being', published in World Nutrition last month, December 2012 (1).

The specific thesis within its general theory, that 'the principal dietary driver of pandemic overweight and obesity, and of related chronic non-communicable diseases, is what we identify as ultra-processed products', rings true to me. But I still find some ambiguity in the commentary as a whole – perhaps to be expected with such a quantum leap paradigm break, I guess. I will elaborate.

'Specifically, the big public health issue is ultra-processing', we are told. And further: 'The central issue that confronts everybody now, is the form in which foods and food products are produced and consumed'.

Yes, but not to lose perspective, what the commentary insinuates, but does not elaborate on, is what – and who – is behind this. In particular, what I feel is missing is how we in the public health professions can take on the colossal corporate opponents responsible for the products that drive the pandemic of overweight, obesity, and associated diseases. This, since obviously, what we are doing so far is not yet leading to policies and actions preventing and controlling the pandemic.

Are we able, or willing?

So, I have two questions: First, are we prepared to face the realities of what is happening and also what is likely to come? Second, are we even willing to do so? For if not, how can we continue to feel relevant in what we do?

As stated in the commentary, against us professionally is the fact that: 'food technology is not a significant part of the nutrition science curriculum'. But then, so is the political economy of nutrition!

The authors of the commentary also rightly say that 'the significance and impact in particular of ultra-processing on human health, can be seen only with a "big picture" vision, which identifies nutrition – or at least public health nutrition – as also a social, economic and environmental discipline'. Yes, but does this say enough?

To me, the crux of the commentary is its statement that 'These conclusions are not mechanical. They require common sense and considered judgment. Moreover, there are occasions in public life that are so urgent, important and critical, that action must be taken before all the evidence is in'. Exactly.

Since the protection of public health has over-riding importance, our profession needs to go far further than the invention of a new classification - as important as this may be for research purposes. It is disappointing to read that that the University of São Paulo team's work, at least so far, is taking two forms, which are as they say: 'First, we have created a new classification….Second, we are analysing national dietary surveys'. Surely, the team should go further and unrelentingly confront Big Food and Big Snack as well, isn't it? In this respect, the commentary on trans-fats on the same December issue of World Nutrition is much more explicit about identifying possible rational and effective policies and actions (2).

Information and education is not enough

If the outcome of this seminal commentary is nothing more than recommendations to consumers-as-individuals it will have failed. This would be utterly insufficient and misdirected, as is the whole 'health information and education' approach as such. We saw such a recommendation come from the New York UN high-level meeting on chronic non-communicable diseases. It is characteristically not individuals who are responsible for their states of ill-health and disease, but the forces that bear down on societies. There are not only risk takers, but also risk givers! The São Paulo team rightly points out that 'going beyond the prevention and the control of obesity and related chronic non-communicable diseases requires control and restriction of the products that, consumed in current quantity, cause these conditions' and go on to say 'in all countries, policies need to be designed to check and reduce the volume in particular of ultra-processed products in food systems and supplies'. Yes, but by whom, how and when?

Political action, the logical path the commentary implicitly calls for, is not emphasised in its conclusions – and yet now, The Food System project is being carried out in conjunction with our Association. Its authors say: 'We believe that interventions designed in the public interest, which at least initially may be opposed by commercial interests, will be, when properly presented, generally popular'. So, if the public opinion does or will back us, what are we waiting for?

References

1. Monteiro CA, Cannon G, Levy RB, Claro RM, Moubarac J-C. The Food System. Processing. The big issue for disease, good health, well-being. World Nutrition, December 2012, 3, 12, 527-569. Obtainable at www.wphna.org.
2. Kraak V, Colon-Ramos U, Monge-Rojas R. Legislation: Trans fats. Case for a global ban. [Commentary]. World Nutrition, December 2012, 3, 12, 570-591. Obtainable at www.wphna.org.

Geoffrey Cannon replies: This response is written in the holiday period, and my co-authors from the University of São Paulo are on the beach. So I write personally, while thinking that my colleagues will probably have much the same view as expressed here.

It is an enormous compliment and also a massive burden to suggest that one university-based team of researchers can or should come up with the answers in all areas, and also become militant activists. Reinforcements will be needed.

Yes, the commentary does indicate that the new classification of foods according to the nature, extent and purpose of food processing, is the most rational and relevant basis for policies and actions that really could prevent and control obesity and other chronic non-communicable diseases. It also points to the need for careful research, involving original analyses of national and other dietary surveys using the new classification. Here is a case where sustained meticulous research really does need to be done: without this the thesis, however compelling, lacks verification of the type that will convince policy-makers, who these days place special reliance on the results of sustained and consistent epidemiological investigations.

The causes are identified

Also, give us a break! In the commentary, the basic reason for the vast increase in ultra-processed products, and in obesity and associated diseases, is made clear. For instance: 'We are not critical of industry as a whole, nor of the food industry as a whole. We are however sharply critical of the transnational and other very large corporations whose profits depend on ultra-processed products and alcoholic drinks' Furthermore: 'We are also sharply critical of the still prevailing "free market" political and economic ideology espoused by international agencies and national governments, that has created monstrous corporations whose products, taken together, are demonstrably damaging to public health and also public goods'.

In addition, as two of the commentary's co-authors make clear in other papers (2-4) as well as in the World Nutrition commentary: 'The impact of the food and drink product corporations is obvious but often not currently blatant in high-income countries of the global North whose food supplies are already saturated and flooded with ultra-processed products. In the global South the impact is blatant. Big Food and Big Snack are aiming for and achieving "double-digit growth", meaning sales increasing by 10 per cent or more every year. In this way transnational corporations are rapidly displacing traditional and long established food systems and dietary patterns'. In addition to all this, the case is made for going beyond banning trans-fats, and instead, being more radical and prohibiting the hydrogenation process (5).

Reinforcements, please

All this sounds defensive. True, the commentaries cited here do not include a blueprint for the global political, economic and other reforms that are needed to transform food systems in ways that will benefit public health. So far what they and other commentaries and papers do, is to provide a foundation for movements to achieve such reforms. They identify the issue (ultra-processing), and the cause (transnational corporations or, to go deeper, a prevailing political and economic ideology that has created these monsters).

The 19th century writer and social reformer Elizabeth Gaskell said: 'Evils once recognised are half way towards their remedy'(6). But a group of researchers at one university, cannot by themselves supply the whole remedy. This is mainly the task of other actors, including leaders in government, the health professions, and public interest civil society organisations, now that the writing is on the wall.

References

1. Monteiro CA, Cannon G, Levy RB, Claro RM, Moubarac J-C . The Food System. Processing. The big issue for disease, good health, well-being. World Nutrition, December 2012, 3, 12, 527-569. Obtainable at www.wphna.org.
2. Monteiro CA, Gomes FS, Cannon G (2010) Can the food industry help tackle the growing burden of under-nutrition? The snack attack. American Journal of Public Health 100: 975-981.
3. Monteiro CA, Cannon G. The Food System. Ultra-processed products. Product reformulation will not improve public health. [Commentary]. World Nutrition, September 2012, 3, 9, 406-434. Obtainable at www.wphna.org
4. Monteiro CA, Cannon G. The impact of transnational 'Big Food' companies on the South: a view from Brazil. PLoS Medicine 9 (7): e1001252. doi:10.1371/ journal.pmed.1001252. Published 3 July 2012.
5. Monteiro C. The big issue is ultra-processing. The hydrogenation bomb. Commentary] World Nutrition, April 2011, 2, 4: 176-194. Obtainable at www.wphna.org.
6. Daly M. In: Introduction. Gaskell E. Mary Barton. London: Penguin Books, 1996.

Please cite as: Schuftan C, Cannon G. The Food System. What are we waiting for? World Nutrition January 2013, 4,1, XXX-XXX. Obtainable at www.wphna.org