Professor Carlos Monteiro recognised with prestigious William Philip T James Award

The William Philip T James Award recognises outstanding contributions to the management, prevention, surveillance of obesity.

The award which celebrates an individuals’ overall achievements in the field of obesity first began in 2020, and has been awarded to a number of remarkable healthcare professionals and researchers in the last four years. The award honours many who have spent decades working on and challenging the obesity epidemic.

This year in Sao Paulo, Brazil during the International Congress on Obesity 2024, the award was given to Professor Carlos Monteiro, an epidemiologist and Professor of Nutrition and Public Health at the University of Sao Paulo. A pioneer in the concept of ultra-processed food and the NOVA food classification system, Prof Monteiro has been a force in food and nutrition policies and population health.

We are pleased to share his speech in his own words, detailing his achievements and celebration of receiving this prestigious award, and what it means to him.

Obesity, its contexts and causes, and ultra-processing

It was not by chance that the concept of ultra-processed food, and the Nova food classification system of which it is a part, sometimes said to have revolutionised thinking on nutrition and health, originated in the global South, within Latin America, and in Brazil. Here and now I aim to show why.

First though, to commemorate Philip James, whose first official report on obesity was published in the UK in 1976. I first met Phil in 1998 at the International Congress on Obesity in Paris, and then a few times in the WHO headquarters at Geneva in activities related to the 2004 WHO Global Strategy on Diet, Physical Activity and Health. In April 2012 I got to know him better. This was at the World Public Health Nutrition Association (WPHNA) conference in Rio, with its guiding brief of ‘knowledge/ policy/action’, attended by 2,000 mostly young people, with speakers invited from all over the world. Phil had been asked to moderate a debate between Walter Willett and me on the then new concept of ultra-processed food, which I advocated. Phil challenged us both.

The obesity pandemic

As in other low- and middle-income countries, obesity in Brazil was considered for long time a problem only among wealthy people and assumed to be caused by personal greed. Infectious diseases and undernutrition were the greatest public health problems. But obesity rates started to rise fast in the last quarter of the twentieth century, as documented in a series of papers published by our group at the University of São Paulo (USP). Rates, around 5 per cent in 1975, doubled in 1989, tripled in 2009, and are now 25 per cent – still lower than in the UK and USA, but the numbers and the steep rise were clearly alarming.  

So what to do? In most of the twentieth century the development and practice of what has been termed ‘orthodox modern nutrition science’, has taken place in the USA and the UK, and broadly assumed to apply worldwide. Nutrition has been defined essentially as a biochemical discipline, and analyses and responses to diet-related diseases were largely medical or quasi-medical. This thinking originated in the discoveries made in the mid-nineteenth century in Germany by Justus von Liebig, and progressed in the early twentieth century by the discovery of vitamins and their significance, and then in mid-century by the powerful US epidemiologist Ancel Keys’s judgements on dietary causes of heart disease. Obesity was identified as a consequence of excess dietary energy intake caused by diets high in fat and, later on, by diets high in sugar. Expert reports neglected or ignored food processing – what is done to foods by industry. Policies were mainly directed to individuals, personally or in groups, in the form of advice to reduce fat or sugar intake. The costs of obesity and the value of its treatments were and are now, increasingly high.

The culture and politics of Brazil have also shaped policy and practice concerning nutrition. In Brazil, individualism, originated in the USA and spread to other ‘Anglo-Saxon’ countries, is an alien concept. As a republic, Brazil was founded according to the positivist thinking of the French philosopher Auguste Comte, who saw sociology, the study of society, as the master science. This view was harmonious with the Catholicism of most white Brazilians and its tenet of salvation through collective works rather than individual faith, and also with the tribal nature of originally African and of indigenous Brazilian populations. The Brazilian scholar Paulo Freire developed the concept of conscientização (collective consciousness) as a way to climb out of deprivation. Darcy Ribeiro, federal Minister of Education in the early 1960s, identified Brazil as ‘a new civilization’, owing little to Angl0-Saxon culture. Whether or not consciously borne in mind by Brazilian public health professionals in their work, such influences are ‘in our blood’.

More recently, following the 1988 national Constitution issued by the Federal Supreme Court that consolidated Brazil as a democracy, the National Council for Food and Nutrition Security (CONSEA) was set up as an equal collaboration of government officials and civil society organizations, originally housed in the Presidential offices, to combat all forms of malnutrition and, as such, a shield against commercial or political interference. In 2015 a government document stated: ‘Food and Nutrition Security consists of realizing everyone's right to regular and permanent access to quality food, in sufficient quantity… based on nutritional practices that promote health, respect cultural diversity, and that are environmentally, culturally, economically and socially sustainable’.

So it is natural for Brazilian health professionals like myself not to isolate obesity. We take a holistic view, seeing it not merely as a condition of individuals, but as one form of global malnutrition. In itself it is a disorder that creates vulnerability to various diseases and disabilities. It is also a warning sign of damage done to the living and physical worlds, as well as to humanity. All this takes nutrition science out of a biochemical silo and makes it a multidisciplinary discipline.

Soon, we found the explanation: people were replacing homemade meals based on minimally processed staple foods, such as rice and beans, with ready-to-consume food, drink, and snack products containing high amounts of fat, salt, and/or sugar. These products were made with little if any whole food using technological processes with no domestic equivalent, and flavors, colors, and other cosmetic additives. Examples were soft drinks, sweet and savory snacks, sugared breakfast cereals, instant soups and noodles, burgers and other reconstituted meat products. So we realized that to understand the obesity epidemic we had to go beyond shifts in nutrient intakes and examine the impact of industrialised food products on dietary patterns. We reported our findings initially in Brazilian journals.

In 2009 Public Health Nutrition, then a relatively new journal, had begun to publish regular commentaries and also letters, both designed to encourage discussion of hypotheses. PHN published a short commentary by me with the title ‘Nutrition and health. The issue is not food, nor nutrients, so much as processing’. The commentary proposed the hypothesis according to which what was driving the pandemic of obesity in Brazil and in most parts of the world, was not the unwise preference of individuals for fatty, salty and sugared foods, but the manufacture and aggressive marketing of ready-to-eat formulations of food substances and additives created by the industry to displace real foods and freshly-prepared meals and to maximize industry profits. We termed these products ‘ultra-processed foods’. Of course we did not suggest that all forms of processing are harmful: many are necessary, harmless or benign. We outlined a first version of the Nova classification system which categorised all foods according to the nature and purpose of their processing, so that once the system was finalized our hypothesis could be independently investigated.

It was also natural for us in Brazil to identify ultra-processed foods broadly, in their commercial context. A 2012 paper in PLoS Medicine was written in collaboration with my colleague Geoffrey Cannon, who in the UK had worked with Phil James for many years before coming to live and work in Brazil. This stated that they: ‘are typically branded, distributed internationally and globally, heavily advertised and marketed, and very profitable. Growth in their production and consumption has been spectacular in the last decades in both higher- and lower-income countries’. Of course we did not suggest that the food industry as a whole was responsible; rather, what was referred to in the title as ‘Big Food’ or, more precisely, transnational food corporations (TNCs) whose growth since the 1980s has been exponential, driven by ‘neoliberal’ deregulation. This has given TNCs global market penetration, a form of colonialism, with no responsibility for or interest in the health or welfare of the countries from which they take money. This alone explains the apparently inexorable rise in obesity throughout the world. The income of the largest food TNCs is equivalent to the gross domestic products of middle-size countries.

The Guia was supported by the United Nations Pan American Health Organization. Drafts were revised after two workshops and assessment by health professionals from all regions of Brazil. Comments were made by 436 individuals and organizations during three months of public consultation.

In a 15-page chapter it includes color photographs of four versions each of breakfasts, lunches, dinners and snacks, varied according to the foods chosen and by regional cultures, not artificially constructed but recognisable, adapted from those actually eaten by the Brazilian population whose diets were still based on unprocessed or minimally processed foods and freshly prepared meals.

Its four recommendations do not refer to nutrients or specify numbers. They are about foods, and meals preferably regular and enjoyed in company.

1. The first is: ‘Make natural or minimally processed foods the basis of your diet’. 
2. The second: ‘Use oils, fats, salt and sugar in small amounts for seasoning and cooking foods and to create culinary preparations’.
3. The third: ‘Limit the use of processed foods, consuming them in small amounts as ingredients in culinary preparations or as part of meals based on natural or minimally processed foods’.
4. The fourth: ‘Avoid ultra-processed foods’ The Guia ‘golden rule’ is: ‘Always prefer natural or minimally processed foods and freshly made dishes and meals to ultra-processed foods’. A section summarises some of the ways ultra-processed products damage human health, and also social life, culture and the environment.

A total of 60,000 copies were printed and distributed including to government offices, civil society organisations, and health professionals, centres and clinics throughout the country. It is written in a style that can readily be adapted in any country. English and Spanish translations were published in 2015.

Positive research on healthy diets as set out in the Guia is now needed, to find out if these, all over the world, are as protective of good health as is the Mediterranean Diet in the Mediterranean region. We at NUPENS are already moving in this direction.

Research of itself will not halt or reverse the obesity pandemic or all the other damage done by ultra-processed food products. Pandemic obesity signals a public health catastrophe as great as that caused by free-flowing sewage or tobacco. Evidence-based public actions including ultra-processed food taxation, marketing restrictions, and front-of-package warning labels are needed, on a grand scale. As well as public actions to make unprocessed or minimally processed foods and freshly-prepared meals available for all.

These will extend healthy life, relieve national economies, and support all the diverse industries that have always grown, made, supplied and sold good food, on which food security depends.

And transnational corporations? Phil James had a word of advice for them. Diversify.