Carlos Augusto Monteiro, the revolutionary

 versão em português

Translated by Christopher Peterson

Epidemiologist Carlos Augusto Monteiro raised a new scientific hypothesis that is so simple, so very simple, that it appears to have been there forever. Monteiro’s theory does not belong to profoundly abstract fields like those in pure mathematics; it is not in the realm of challenges that keep theoretical physicians awake at night, like reconciling general relativity with quantum mechanics. On the contrary. It is about humanity’s most mundane, important, primal, and intuitive act: eating. Despite all its simplicity, the hypothesis caused a cataclysm in the international community of public health experts – and irritated the hell out of food industry giants.

Monteiro heads the Center for Epidemiological Research in Nutrition and Health (Nupens), a group he created thirty years ago at the University of São Paulo (USP), Brazil. In 2010, he proposed a food classification system that would later be called NOVA – an ironic allusion to the nuclear explosion that happens in a star. The system recommended a total break with the way scientists were accustomed to studying food. Until then, foods were classified according to their nutritional content, and it didn’t matter how they were made. For example, the class of carbohydrate sources included any bread, cookie, or pasta, whether homemade or full of chemical additives. Sources of protein included all kinds of meat, from fresh cutlets to cold cuts stuffed full of industrialized dyes.

Obsessed with digging up, comparing, and interpreting public health indicators – which he does while squinting his blue eyes behind wire-rimmed eyeglasses –, the Brazilian physician decided to change the game. He suggested classifying foods according to the levels of physical, biological, and chemical processes they undergo before reaching people’s tables.

He began by creating three categories of foods. In the first, called in natura or “minimally processed”, he included foods that are consumed as they are removed from nature, such as fruits and vegetables, or those undergoing minimal processes, such as beans, which are bagged, wheat, which is turned into flour, or milk, which is pasteurized.

The second category features “processed culinary ingredients”. These are substances extracted from the foods themselves, or from nature, through physical processes such as pressing or centrifuging. This group is necessary to prepare recipes. The group includes such items as sugar, extracted from sugar cane, butter, made from milk, or olive oil, pressed from olives. When used in small amounts, Monteiro says, they serve traditional dietary habits, helping people congregate – and they don’t kill anybody.

The third class of foods is “processed”, foods that undergo industrial or simple household stages, relying on the addition of “processed culinary ingredients” such as fats, salt, or sugar. This category includes breads and artisanal cheeses, preserves, canned fruit, and jams and jellies. The class covers the entire legacy of methods improved since humanity began to mix some things to turn them into other things, in this case edible. In these, Monteiro discovered magical properties that still amaze many people, like watching the simple miracle of bread rising in the oven.

After publishing his first articles on the subject and receiving feedback from peers, Monteiro proceeded to improve his classification. He created the fourth and final group, that of ultra-processed foods. These are products derived from aggressive fractionation of natural (or in natura) foods that later go through successive processes and additions of substances used exclusively in industry. They end up turning into a hodgepodge of dyes, flavorings, emulsifiers, and thickeners developed in the laboratory to last longer and cost less, with intense flavor and preferably not satiating – for people to eat more and more. This list features sodas, fruit-flavored drinks, cookies and crackers, frozen lasagna and pizza, salty snacks in plastic bags, instant noodles, reconstituted meat products – and all that endless parade that appears on supermarket shelves, with labels so inscrutable for the lay consumer as hieroglyphs in an Egyptian tomb.

“They’re not food. They’re concoctions,” Monteiro quips.

 

The term “junk food” had already been used for decades to define foods with few nutrients and many calories, usually with addictive flavors. Grandmothers the world over had already warned their families about the risks of eating such garbage. There were already loads of academic studies showing the relationship between foods and beverages packed full of sugar or fat and the increased risk of developing cardiovascular and other diseases. Hence the simplicity of Monteiro’s hypothesis. He was the first scientist to use public health indicators to propose an organized food classification system. With this yardstick, it was easier to study eating. Later, with the creation of the term “ultra-processed”, he named something the food industry had been doing for decades and that people even realized, but until then in a diffuse, unorganized way.

The initial broad strokes for Monteiro’s hypothesis emerged in a commentary he launched in 2009 in the journal Public Health Nutrition, edited by The Nutrition Society and published by Cambridge University Press. In the paper, with the didactic title Nutrition and Health: The Issue Is Not Food nor Nutrients, so Much as Processing, the Brazilian physician contended that to scrutinize the relationship between quality of diet and chronic noncommunicable diseases, it was necessary to understand foods according to the extent and purpose of their processing. The following year, he launched the classification.

Moved by the rare opportunity to have a new topic to study, launched in the field by a well-founded hypothesis, scientists from all over the planet swarmed like flies to studies on ultra-processed foods. With time, research on the effects of this category of foods on various diseases flowed like loaves out of the oven. PubMed, the database on all literature produced in the field of biomedicine, showed the cascade effect of the scientific theory launched by Monteiro. In 2009, there was only one reference to the classification of foods by degree of processing. It was an article commenting on the new division proposed by Monteiro and his team at Nupens. Today, a search for the term “ultra-processed foods” yields 1,037 results, 286 of them for articles published this year alone. And more than two hundred indexed scientific studies used the new classification in some way.

Twelve years after its proposal, NOVA had already undergone six systematic reviews, that is, a kind of study that scours all the studies already performed on a theme and assesses the methodology they used and the quality of their results – thus, reviews are widely used in public policymaking. The latest, published in 2020 in the British Journal of Nutrition, showed a significant association between high levels of consumption of ultra-processed foods and heart diseases and other diseases related to diet, such as obesity and metabolic syndrome.

Monteiro became an international star. With five members of his team who also sign articles on the classification – Renata Levy, Maria Laura Louzada, Geoffrey Cannon, Jean-Claude Moubarac, and Euridice Steele –, Monteiro is among the 1% of scientists in the world most cited by their peers, according to a list produced by the British consulting firm Clarivate Analytics. In another ranking, prepared by the Public Library of Science (Plos), he is the fifth Brazilian scientist with the most citations in the international scientific literature. He ranks first in the fields of food and nutrition. One cannot tell whether these rankings necessarily reflect the planet’s most brilliant or prolific scientists because many of the researchers work in areas with less visibility than nutrition. But according to all the criteria, one can say that Monteiro has entered the scientific Olympia since NOVA.

“Many people come and ask me, especially at international congresses, ‘It seems so obvious that this business of processing foods is an important thing, so why didn’t anyone talk about it or create a classification before? And how was this system created precisely in Brazil?’,” says the professor.

 

Great theories are not plucked out of thin air by a solitary category of especially enlightened men. In the book To the Finland Station, critique Edmund Wilson defined this process as the result of other ideas, other men, and all the practical implications from thoughts that are not expressed or are even unconscious, the implications of instincts beyond conscience.

For example, the creation of the term “ultra-processed” resulted from a thread that had already been identified by influential scientists dedicated to reflecting on food. Among them was Australian researcher Gyorgy Scrinis, author of Nutritionism: The Science and Politics of Dietary Advice, who had pointed to the ills of nutritional reductionism, which reduces foods to their components, divorces people from a complete and tranquil view of eating, and at the limit, turns meals into hell – one day everyone avoids eggs, the next day people panic at fats. There was also the famous view of American journalist Michael Pollan, who used books and TV series to denounce a food industry that infiltrates countries’ food traditions and corrodes people’s tableside pleasure.

It is also relevant that Monteiro works – and eats – in a country that can understand what natural foods are. “We still eat 80% of our meals cooked, while 20% of the calories we consume come from ultra-processed foods, because this industry got to Brazil later. But UPF consumption is increasing year by year. In countries of the North, these products arrived much earlier, and the food system is already dominated by them. In the United States, nearly 70% of all the calories people consume come from ultra-processed foods. To change this trend, they would need to close the country and create a new food system from scratch,” he says.

But when asked about his reasons for creating the classification, the doctor replies without batting an eye: “Independence! We have never accepted funding for our research projects from the food industry!”

 

Monteiro started shaping his worldview – certainly through the lens of the political left – while still in his early teens. Partly influenced by an uncle, a political activist, and partly by the example of his mother, “who didn’t even know what it meant to be a leftist, but who had social concerns and huge sensitivity,” he says. The grandson of Portuguese immigrants who opened a bar in São Paulo’s North Zone, the future professor started working at 13 years of age, when he was attending night classes in public schools. He soon joined the student movement, joining the Brazilian Socialist Youth, a branch of the Brazilian Socialist Party. He was taking his first steps in his formative political years when the military coup struck Brazil in1964. Three years later, Monteiro enrolled in the School of Medicine at the University of São Paulo and soon joined the student union. At home, his activism was hidden from his conservative Catholic father. Only his mother knew. “She was sort of my confident on this. I would go to the protests and only tell her, not my father. Later, when she saw what was happening – billy clubs cracking skulls, tear gas from the Army, and all that mess – she would just say, ‘Be careful, son …’,” he jokes.

Throughout the time he was studying medicine at the University of São Paulo, he was active in the student movement, even after the military government cracked down harder with Institutional Act 5. “Two students in my class were killed by the dictatorship. The police raided our student union, and we couldn’t do anything more.” By the time he enrolled in the fifth of six years in medical school – after several activist classmates had gone into exile or underground –, Monteiro had decided: he wanted to be a doctor to try to do something for the country.

During the first year of his residency, he took some pediatrics, which he liked, and then preventive medicine, because he was attracted by the idea of fighting inequality. He participated in the creation of a public health service in Pariquera-Açu, a town in the poverty-stricken Ribeira Valley in the state of São Paulo. There, he was exposed to a very different world from what he was used to seeing at the University Hospital, namely, dealing with the devastating effects of childhood malnutrition. “At the University Hospital, we were used to treating serious diseases. Nobody admitted a malnourished patient to the hospital. I didn’t know what malnutrition was,” he explains. Interested in studying the problem deeper, he was gripped by the idea of practicing community medicine.

While still doing his residency, he spent a month in Porto Nacional, in the Tocantins Valley, working in the Special Public Health Service (Sesp), a program created in 1942 in partnership with the U.S. government to take medical and health care to the Amazon Valley. He spent that time with a group of doctors who were living in the community and working in a mixed unit, with a hospital and outpatient clinic. They treated everything and a little more, all the time. They operated, cared for children and pregnant women, and performed x-rays and blood tests. He loved the experience. He was convinced it was what he wanted for his life. He decided to join a team of residents that was going to leave São Paulo and take this community medicine experience to Conceição do Araguaia in the state of Pará.

The local Dominican priest in Conceição do Araguaia even announced excitedly to the populace that the new health service had arrived. But there was a major hitch: the Araguaia Guerillas, a movement backed by the Communist Party of Brazil (PCdoB) and that was in full swing, aimed at spreading a socialist revolution starting from the fringes of the Amazon Region. “We had nothing to do with that movement, and I was even turned off by all that weird thing of the Maoists, with the personality cult. And in fact, I never even got any news about the guerrillas, it was a kind of hermetic thing,” he recalls. Even so, the young doctors were investigated by the SNI, the dictatorship’s secret police, and could not even start their community medicine project. They were forced to retreat, returning crestfallen to São Paulo. To make matters worse, when he returned to the School of Medicine at the University of São Paulo, Monteiro was warned by the head of the pediatrics department that some strange men had been hanging around the school, asking about him in no uncertain terms. They were from Operation Bandeirante (OBAN), created by the Army with the support of the São Paulo state government to identify and dismantle subversive groups. “He told me: lay low for a while, or you’re going to get arrested,” Monteiro says.

In 1975, at 27 years of age and on the verge of finishing his residency, the young doctor ended up accepting an invitation to work as a teaching assistant at the USP School of Public Health. He only agreed because he needed a job. He didn’t plan to become an academic, sitting behind a desk forever. But when he realized that he could also do fieldwork there, he started to get fascinated by the job. He began to enjoy the research when he saw his colleague Malaquias Batista Filho, a physician from the state of Paraiba who had worked with the Peasant Leagues, speaking excitedly about the studies he was doing for his PhD. “He would open the door to my room and start to talk about some hypothesis he was thinking about, or about some data he was analyzing. I would say, “Sit!” He’d reply, “No thanks, I have to going.” But he would spend as much as two hours talking. He taught me to like the hypothesis bit, of trying to investigate some alternative explanation for something,” he says. Monteiro was changing. He gave up the idea of community medicine and became an epidemiologist.

During a major portion of his university career, until the mid-1990s, Monteiro focused on studying childhood malnutrition. When he returned to the Ribeira Valley, he unraveled the problem little by little. He began to understand how to diagnose and measure a malnourished child, learned to structure a research project in the field, created a students’ group, and with a probabilistic sample in São Paulo, conducted one of the first series of studies in Brazil relating malnutrition to infant mortality, or environmental sanitation to diarrhea. In 2009, he analyzed the trends in childhood malnutrition and how they had dropped due to social policies during the Fernando Henrique Cardoso and Lula governments. Later, he completed the package with research on these outcomes as the result of Brazil’s re-democratization and the assembling of a social protection State. Since this decrease in childhood malnutrition in Brazil attracted global attention, it was the first study that projected him in the international scientific scenario.

 

It was precisely this man (whose brain was equipped with software with somewhat socializing ideas) that ended up in one of the fields of medicine with the hottest debates on conflict of interest. The Nupens team was making important strides in studies on childhood malnutrition and was conducting in-depth research on breastfeeding. “So, our group was approached several times by Nestlé, which wanted to fund our research,” he recalls. The professor would reply, wagging his finger: “No, no, and no.” In the attempt to explain how women were steadily abandoning breastfeeding, he fell onto what epidemiology calls commercial determinants of diseases. “And a major determinant of abandonment of breastfeeding, thus resulting in malnutrition, was the profit motive of industries that produce formulas to replace breastmilk!” he protests, outraged. That was where he drew a line in the sand: in his studies on public health, only public funds would be accepted. And all his research has been funded by public Brazilian agencies such as Fapesp, CNPq, and Finep. In the field of nutrition, where large and respected research centers in the world have ended up raising private funding, the professor became a dinosaur.

With the kind of free tongue that is only possible for people who are unobligated to play the game with sponsors, the professor tells several stories of scoldings he gave to industry. Once, João Grandino Rodas, then-president of the University of São Paulo, invited him to a conversation with a member of the board of Nestlé in Latin America. “I went. It was on the top floor of the office of the university president, all very fancy. Nestlé wanted to fund a nutrition laboratory at USP. I replied that I would not feel comfortable with the offer, because in the field I study in Brazil, I see the food industry as having a major responsibility for health problems. At the very least, I would be giving a green light to companies that systematically sabotage the public policies that could solve these problems.” The lunch ended quickly.

In 2011, with other senior researchers in nutrition – like Malaquias Batista Filho, now professor emeritus at the Federal University of Pernambuco, and Cesar Gomes Victora, professor emeritus at the Federal University of Pelotas –, Monteiro campaigned against the paper placemats on trays at McDonald’s. The material displayed that store’s menu, next to the title “Friends of Health”, authorized by the Ministry of Health. The group sent a nasty letter to then-Minister of Health Alexandre Padilha, complaining: “Needless to say, the goal of the advertising campaign by the McDonald’s chain is to equate the consumption of products it sells with healthy behaviors, to induce consumers to think that these products should or could be consumed regularly (‘everyday foods’), and to deny that they might be less healthy than traditional foods in the Brazilian diet. Even more obvious is that the inclusion of the Ministry of Health’s seal on the company’s advertising material legitimizes the campaign and greatly increases its efficacy.” In the end, the scientists poured cold water on the partnership, and the fast-food chain’s educational placemats were dumped in the trash.

 

The public health field in Brazil has more than a century of history, following in the trail blazed by Oswaldo Cruz and others. For decades and decades, Brazilian public followed a tradition of studies on infectious diseases such as malaria and tuberculosis. Nutritional epidemiology was incipient. There was a lack of in-depth studies on a major health problem in the country, that Josué de Castro had called the biological expression of sociological ills: hunger. Especially hunger in children, the large group that becomes malnourished quickly and in a process with no return. Children need varieties of nutrients to expand their muscle tissue, bones, and blood, and if they don’t get the nutrients, they don’t grow. If the nutrients are lacking, they die.

In São Paulo, Monteiro’s group began to study childhood malnutrition in the early 1980s. Soon after, in Pelotas, in the interior of Rio Grande do Sul, Cesar Gomes Victora’s team also entered the field, studying childhood health in general. The two researchers prepared the field, which had accumulated just a handful of clinical trials in nutrition and a few others in nutrition education. “It was a backward approach, the idea that poor people were ignorant, that they didn’t know anything about nutrients, and that it was necessary to teach them how to eat. So, there was that notion that proteins were the ‘bricks’, that fruits were the ‘mortar’ – and so on.” Monteiro’s group contended that people don’t need to know what proteins or carbohydrates are. What they do need is resources to purchase diversified foods– a natural habit for humans – and sanitation, so they don’t lose to diseases all the nutrients they have eaten.

Epidemiologists basically produce and collect data to process them exhaustively until they have a story to tell about the processes that lead great masses of humans to fall ill, and later to propose solutions. Since Monteiro found a desert of data when he entered the field, he began working with the Ministry of Health in the organization of nationwide surveys, the data that furnish information on the quality of people’s diet. The first major survey was conducted in 1989, a nationwide probabilistic sample survey on childhood nutrition. The professor’s team helped to create questionnaires and to define the right way to measure and weigh children. From then on, Nupens started to have material to work with.

Meanwhile, a curious thing happened. While combing through data, the researchers discovered that in 1975, at the height of the military dictatorship, the national census bureau, called the Brazilian Institute of Geography and Statistics (IBGE), had conducted a large-scale household budgets survey in partnership with the United Nations Organization for Food and Agriculture (FAO). Since the data were not favorable to the government, most of the results were scurried away under lock and key. Monteiro asked for help from then-director of the Brazilian National Institute of Food and Nutrition, Eduardo Kertész, who managed to retrieve the file with the data. The data arrived, stored in an enormous computer tape, and they were pure gold. They furnished a 14-year-old historical series of diet in Brazil. By comparison with the data collected in 1989, it was possible to show that undernutrition was decreasing in the country. But obesity was on the rise.

In 1995, Monteiro wrote the book Old and New Health Problems in Brazil: The Evolution of the Country and its Diseases. The book is a compilation of articles by various specialists invited by the professor to scrutinize indicators and show that old problems such as undernutrition, tuberculosis, leprosy, infant mortality, and measles were disappearing from the map because of public policies maintained for decades – such as the National Immunization Program –, and the improvement in people’s lives in the wake of Brazil’s modernization, economic growth, sanitation, and medical care. Even tobacco was included among these old problems, attesting to a brilliant public health victory. In São Paulo, for example, the smoking rate among men was once 70%; now it is 11%. Meanwhile, the fight against new health problems was a disaster, largely because they were associated precisely with increasing income. Children and adults were now glued to the screens, consuming foods that had not been produced before because there was no technology to make them, nor purchasing power to buy them. “They are diseases that do not depend on insufficient consumption, but on unhealthy consumption,” says Monteiro.

With the core idea that it is necessary to understand both problems, the new and the old, the book became a milestone in social epidemiology. It stated that if the old diseases had been fought with food, vaccines, and running water, the diseases now appearing on the horizon, such as diabetes, cardiovascular disease, and obesity, needed to be confronted with regulatory policies. “The market may solve undernutrition and infectious diseases because they depend greatly on inputs, on generating resources. But it’s not like that with chronic diseases, where you have multiple causes. The relationship to the economy is almost the opposite. While one improves as the economy grows, the other may even get worse,” he says. Old and New Health Problems won the Jabuti Prize for best book in Brazil in medicine and natural sciences – a trophy Monteiro keeps proudly on top of a brown cabinet in his office in the School of Public Health.

Due to his familiarity with Brazilian dietary indicators and the clues he investigated while organizing the book, Monteiro developed an interest in the country’s rising obesity. “What was happening with diet? Our group isn’t sociologists or science philosophers. It’s epidemiologists. So, we searched for data,” he tells. Some of the data were hidden in that IBGE survey from 1975. Designed by economists to calculate the cost of living, the study also played the role of a nutritional survey. Compared to the Family Budgets Survey (POF) of 2008-2009, which studied the diet of more than 30 thousand Brazilians 10 years or older, these numbers formed an exquisite design.

Brazilian families were purchasing less and less salt, sugar, oils, and fats, but obesity and chronic diseases were increasing. Monteiro decided to analyze the data on other foods. He looked at rice, beans, manioc, and potatoes. They were all decreasing because people were buying less. Next question: if Brazilians aren’t starving to death, what are they buying? The group of foods that was increasing appeared: cookies and crackers, instant noodles, frozen foods, sodas, sausages. In short, things that people didn’t need to cook. That’s why people were buying less oil, salt, and sugar, which are used to prepare recipes. “One kind of item is used to prepare the food. The other is replacing the food itself,” he says. Monteiro had his Eureka moment and arrived at the NOVA classification.

 

In science, it is not enough to have a good idea – you need to convince your peers that it makes sense. A new hypothesis produced in Brazil, outside the wealthiest and most internationally famous research centers, tends to require more work. But the NOVA classification relied on a rare impulse. The classification popped out of the oven and influenced a public policy that had global repercussions.

Patrícia Constante Jaime, native of the state of Goiás, graduated in nutrition in 1994. She is part of a generation of health professionals that earned their credentials in an environment with the embryo of the Unified Health System (SUS) and important debates such as the country’s Industrial Property Law. She did rural extension in Tocantins, when the state had just split off from Goiás, and she witnessed firsthand the birth of the family health strategy, the backbone of primary care in the Unified Health System. Right after graduation, she did her residency in hospital nutrition at the University Hospital and ended up pursuing an academic career at the University of São Paulo School of Public Health. Meanwhile, Monteiro was on leave from teaching classes to treat a cancer in his right leg, but his name was still hovering over the department. As a professor, he trained entire generations of public health professionals, now scattered all over Brazil, and who was able to extract from the data conclusions capable of taking nutritional epidemiology to a whole new level. He had also just launched the book Old and New Health Problems. The nutritionist Patricia didn’t know him – and she froze when she learned that he would be part of her PhD review panel. Keen on painstaking analysis of the data, the professor was famous for not leaving any loose ends.

Not only did everything work out in the review panel, but two weeks later the young nutritionist received a phone call from Monteiro. “I was working in a private college, and when my cellphone rang, I whispered to a friend: ‘It’s God that’s here speaking to me!’” Monteiro was inviting her to do her post-doc at Nupens. In 2003, she passed an admissions exam and became professor at the Department of Nutrition and researcher in the group. She had joined the field of public policy studies.

When the department was starting to rock with the creation of the NOVA classification, she was in the UK during her post-doc work at the London School of Hygiene and Tropical Medicine. She returned to Brazil in 2008, ready to implement her research line in the department. But in 2011, she was called to work in President Dilma Rousseff’s administration in Brasília. She took over as head of the Division of Food and Nutrition in the Ministry of Health, a fourth-echelon technical position in the bureaucracy. Brazilian public health was already on a roll by including the food agenda – and doors that had traditionally been jammed in the bureaucratic mazes were tending to open to the issue. Five years before, for example, Brazil had passed its Organic Law on Food and Nutritional Security. And the country’s Pluriannual Plan for 2012 to 2015 was the first of its kind to have a thematic program on food and nutritional security, drafted by representatives from various ministries. “I had come from the University of São Paulo, which was on a roll because of the new paradigm with the NOVA classification. So, Patricia the academic met Patricia the public administrator at that moment,” she recalls.

Professor Patricia Jaime suggested to Carlos Monteiro: “Couldn’t we propose an update on the Food Guide for the Brazilian Population?” But he didn’t pay much attention, as a traditional public health professional more inclined to identify with regulatory policies rather than engaging in nutrition education. “At first, he said, ‘Hey… telling people what they should eat … has no impact!’” Patrícia Jaime insisted, Monteiro finally gave in. He became the coordinator of the Food Guide, heading a team of fourteen, and had changed hats again.

According to a FAO survey, more than a hundred countries now have food guides. These are technical documents produced to encourage healthy eating practices and orient public policies that guarantee the population’s food security. The first guide of its kind in Brazil, called the Food Guide for the Brazilian Population: Promoting Healthy Eating, was published in 2006. It is a manual with technical language that already viewed eating as not merely an individual choice, but that still used the traditional approach, grouping foods according to their nutrient profile. It was a daring idea to make a food guide based on the NOVA classification – which was still hot out of the oven and had barely been reviewed by peers.

When Monteiro joined the project, bringing his team of hard-school epidemiologists, who were keen on cold reading of data, he initially raised a dust cloud of mistrust. Experts in nutritional security doubted that the Nupens scientists could handle incorporating food’s sociocultural aspects. Among collaborators and graduate students in nutrition, the group recruited anthropologists, sociologists, and researchers in international food policies. They held seminars and conferences and launched into a calendar baptized as the “food guide caravan”, where the technical area in the Ministry of Health visited the states, and at the state health departments or regional nutrition boards, they discussed the guide’s draft proposal and received suggestions. Patrícia Jaime gave interviews on TV. She appeared on morning programs, explaining the food guide’s importance and providing details on the NOVA classification.

When the draft was in its second version, it was submitted to a public consultation. From February to May 2014, any Brazilian could visit the Ministry of Health’s website and record opinions on all the document’s chapters. A total of 3,125 suggestions were received from 436 individuals or institutions. The food industry started to whine during this phase. The Final Report of the Public Consultation, a document that explains all the steps in producing the guide and the reasons for the team to accept or rule out suggestions, reports a certain atypical trend at one point: “Reading the report, one notes various repeated inputs, with identical paragraphs, but with different authors.” These were criticisms that the food industry uses to this day: that the NOVA classification is confusing because it includes foods and beverages that are too different from each other. “A public consultation is an instrument in the Brazilian regulatory agenda that usually receives extremely limited public input, but the consultation for the Food Guide went viral,” says Patrícia Jaime. “The food industry closed ranks to participate directly, but it also used professionals who pretended to speak for themselves while using copied texts.”

In late 2014, after two years of work and monthly follow-up meetings, the food guide coordinated by Monteiro was ready. It was edited in palatable text, with various recommendations and what it calls the “golden rule”: always prefer natural or minimally processed foods and culinary preparations over ultra-processed foods. The manual is an ode to traditional Brazilian cooking. Using data from the Family Budgets Survey, it produced a list of examples of healthy meals already consumed in Brazil. There were examples for breakfast, lunch, and dinner, shown with photos and captions. Rice and beans, the great national favorite and extremely nutritional, is the backbone for these recommendations. The manual also suggests reclaiming such habits as cooking home meals and sharing this knowledge with the family. It discusses the importance of eating meals in other people’s company. When it is necessary to eat out, it talks about the advantage of eating at self-service pay-by-weight restaurants, which offer a variety of foods, where people tend not to overeat, and where the prices aren’t too salty. There is nothing in the document that suggests neurotic calory-counting or preoccupation with specific nutrients. And there are no definitions of servings or daily amounts for a healthy diet.

But the guide skewers the change in eating patterns that have happened as ultra-processed foods have encroached on Brazilian supermarkets and pantries. “Due to their ingredients, ultra-processed foods – like cream-filled cookies, ‘packaged salty snacks’, sodas, and ‘instant noodles’ – are nutritionally unbalanced. Because of their formulas and appearance, they tend to be overeaten and to replace natural or minimally processed foods. The ways they are distributed, sold, and consumed affect culture, social life, and the environment unfavorably,” the document says. The manual also indicates actions within everyone’s reach: “You can also participate in the struggle for tax policies that make natural foods cheaper and ultra-processed foods more expensive.” And it clearly advises: “Avoid ultra-processed foods.”

Called “revolutionary”, the food guide drew praise from nutrition experts the world over. Some were surprised at an official document’s alignment with a recently launched scientific hypothesis, the NOVA classification. United Nations agencies that deal with food, health, and childhood, like FAO, WHO, and Unicef, pointed to the manual as an example to be followed. Ministries of health from such countries as France, Canada, Uruguay, Ecuador, and Peru used the Brazilian text as a reference when establishing their own policies and drafting their own food guides, all using the bombastic word: ultra-processed.

But the food industry giants were ticked. They used representative organizations to try to prevent the guide’s publication. The document’s official release was scheduled in Brasília during ExpoEpi, an event held by the health surveillance sector. Forty thousand copies had already been printed, ready to be distributed to primary healthcare units. The entire Nupens team had their airplane tickets. But two days before the launch, Patrícia Jaime was summoned to the office of then-Minister of Health, Arthur Chioro. “I was questioned whether it was really necessary to release the guide, if it was possible to reopen the review process, because Abia was bringing a lot of pressure to bear and complaining that it had been excluded from the debate,” she recalls.

Abia is the Brazilian Food Industry Association. It includes 37.2 thousand companies that jointly account for 80% of the industry’s production and employ 1.72 million people. “Since they were unsuccessful in blocking the guide in the technical division, they went straight to the Minister of Health. I had always told my superiors what we were doing, but now I had the opportunity to explain the process again in all its details. I told him how the process had been open and transparent, with a three-month public consultation as part of the ANVISA’s formal regulatory agenda, during which the food industry had the opportunity to voice its positions,” she says. “I said, from the perspective of the technical division and social oversight, the guide is ready and printed. I’m sure of the process I led. If the political decision is to reopen the consultation, my job position is at your disposal,” she adds.

Chioro not only maintained the food guide as it was, but decided to launch it in person, a week after originally scheduled. “It was simply wonderful. We released it at a meeting of the National Health Council, which is the most beautiful body in the Unified Health System (SUS), with three levels of governance, participation, and oversight – everything it represents is there. So, this was another level of public visibility,” says Professor Patricia. Heading the General Division of Food and Nutrition, Patrícia Jaime had regular conversations with then-president of Abia, Edmundo Klotz, because of the regulatory agenda on sodium in industrialized foods. “When he realized he couldn’t prevent the launch, he told me, ‘Gee, Patrícia, I thought we were friends!’ So, I replied, ‘Wow, Edmundo, we can’t be friends, right? We share some agendas, but others we don’t!’ I think he meant that I had betrayed his trust …”

Soon after the food guide’s launch, Patrícia Jaime recalls, there was some pushback from the National Congress. At the time, the agribusiness caucus tried to make changes to the wording, through conversations with the Ministry of Agriculture, Livestock, and Supply, which regulates meat and dairy products. The industry complained that the food guide was telling Brazilians not to consume dairy beverages – and that this was harming their industry. “We explained that it was exactly the opposite. The food guide values milk as part of the natural foods group and values butter as part of the group of culinary ingredients. What the document criticizes is Toddynho, the chocolate milk drink, ultra-processed dairy beverages,” she says. Blocked by the Ministry of Health, the complaint by agribusiness died out.

Although the Brazilian food guide is widely accepted by public experts, it still gets some sucker punches. In September 2020, at the height of the COVID-19 pandemic, a technical note by the Ministry of Agriculture was leaked on the internet, demanding the food guide’s revision. The note claimed that the guide was confusing and incoherent, one of the worst in the world, and based on pseudoscience. There was a big outcry. In just a few days, a petition against the Ministry of Agriculture’s technical note collected more than 50 thousand signatures. Next, a group of 33 scientists from such renowned international universities as Harvard, Johns Hopkins, Yale, and Cambridge published a letter defending the food guide and the way it had been drafted. The Ministry of Agriculture published a rebuttal claiming that their own note was the summary of documents backing internal debates, the purpose of which was to ask the Ministry of Health to revise the guide. Among other things, the technical note requested that other specialists be heard, including food engineers. “Food engineers are the only people who still oppose the food guide,” Monteiro says, “because research in their area is largely financed by the ultra-processed food industry.”

 

“I’m a food engineer, so who do I work for? For industry, of course! As if you, a journalist, don’t work for the press!” says Raul Amaral Rego, technical coordinator of the Technological Innovation Platform of the Food Technology Institute (Ital). The organization is an offshoot of the Agronomical Institute of Campinas (IAC), founded in 1887 by Dom Pedro II. Ital was created 59 years ago to work with the food and beverage industries. It also collaborates now with the packaging industry. Ital operates on a 25-acre plot that used to belong to the IAC and is one of six research institutes under the São Paulo State Department of Agricultura and Supply.

Researchers there are focused on peeling away at the NOVA classification with all their might. Having graduated in the first food engineering class created in the 1970s at the University of Campinas – and inclined to view the world from the industry’s perspective –, they think the food guide should be overhauled. In lectures, articles, and publicity materials, they launch critical volleys against the concept created by Monteiro. “When talking about ultra-processed foods generically, the idea makes great sense. But when you delve into the details, in day-to-day reality, where there are millions of people consuming thousands of completely different products in the country, there is no way to have consistency. All kinds of contradictions emerge. So, there’s no avoiding it, we (at Ital) need to take a stance,” says Amaral Rego.

He elaborates on the issue from his home in Vinhedo, in the interior of São Paulo state: “But the UPF concept gained traction. In my opinion, it can never withstand a more critical analysis, and it became an activist thing, with an ideological bias, with people that are making a living from it. Activism is fine, it makes no difference to me. The problem is when activism starts to undermine the country’s regulatory authority. That’s when it becomes a national problem. The additives used by industry have all been approved by Anvisa. Is that wrong?” he asks. He discusses his doubts from the market perspective: “Take the category of culinary ingredients, for example: the food guide says you can use sugar and salt at home, in moderate amounts. Sure, you need moderation in everything, in industrial products and in non-industrial products! So, what is industry supposed to do, if it’s an issue of eating habits? Brazilians love sweet things and will stop buying the products if you remove the sugar. Are you going to regulate all that?”

In the conversation, by videoconference in July, Luis Madi, director of Institutional Affairs at Ital, completes Amaral Rego’s reasoning: “I’ve seen explanations that ultra-processed foods are defined as products that have more than five ingredients that people don’t recognize on the labels. But take any food, and it’s going to have compounds with names that people don’t know. It’s confusing,” he claims. “Now, we criticize the NOVA classification, and they claim we have a conflict of interests. Almost all studies now require participation by private enterprise. Fapesp (the São Paulo State Research Support Foundation) encourages private participation, because they believe it’s beneficial. The whole world is adopting research funding together with the market, which is public-private partnership. We work by developing improvements for industry. That’s why in 2014, when this version of the food guide appeared, we thought, it’s time to show the importance of industrialized foods,” he says.

Under Amaral Rego’s coordination, Ital hosted a platform inside the website of the São Paulo State Department of Agriculture and Supply. The platform provides publications in PDF with details on nine categories of industrialized foods: bread, yogurt, juice, crackers and cookies, ice cream, pizza, hamburgers, pasta, and cakes. The publications select products from the main brands sold in São Paulo and show tables on their composition, nutritional value, origin, and safety.

It’s funny to imagine Carlos Monteiro reading all that material displayed on a state government website. The publication Industrialized Cookies and Crackers, Nutrition, and Indulgence in Food Culture, for example, reports that 61 crackers from 16 companies and 182 cookies from 25 companies were studied. “The data show that the marketed products are nourishing, healthy, and safe for consumption, comprising an important part of Brazilians’ diet, contrary to the myths that have been propagated about these industrialized foods,” says the report. For example, the site shows packages of vanilla, chocolate, and strawberry flavored cream-filled cookies.

The platform was launched in 2010 in partnership with the São Paulo State Federation of Industries (Fiesp), the São Paulo Association of Supermarkets (Apas), and Abia (number 1 enemy of the food guide) and is part of the study called Brazil Food Trends, 2020. In the introduction to the publication called Industrialized Breads: Nutrition and Practicality with Safety and Sustainability, Claudio Zanão, executive president of the Brazilian Association of Cookie, Pasta, Bread, and Cake Industries (Abimapi), writes the following: “Currently, the large amount of tips on food, among other fads propagated in the media by opinion-makers and influencers, exposes society to a hazard camouflaged as information.” And he concludes: “Industrialized breads are not only tasty and versatile; they have features that reinforce healthiness and good functioning of the body.” Zanão is an experienced food industry executive, having worked previously in multinationals like Coca-Cola, Danone, and Bunge.

Before wrapping up the conversation nearly two hours later, Rego Amaral concludes: “Nothing in studies on ultra-processed foods identifies what in fact caused a given disease. You have an association between the disease and thousands of products that are on sale in the market. It’s pushing the argument to claim similarity between things that are so different …”

 

Epidemiology is accustomed to seeing the emergence of chronic diseases through a complex chain of factors that unfold over years and years. Nutritional studies usually monitor people for long periods (i.e., cohort studies) and establish correlations with eating habits that increase the risk of developing such diseases. Thus, doubts persisted for several years about how to ultimately detect a direct causal relationship between the consumption of ultra-processed foods and diseases – and food industry professionals jumped on this gap, criticizing Monteiro’s classification.

However, the National Institute of Health (NIH), the largest biomedical research center in the world, maintained by the U.S. government, published a study on ultra-processed foods in 2019 that changed the game. It managed to move on from the field of correlations and enter the field of causality. The first controlled clinical trial on these products was conducted by Kevin Hall of the National Institute of Diabetes and Digestive and Kidneys Diseases, affiliated with the NIH. For four weeks, he followed 20 volunteers – 10 men and 10 women. They were kept in a clinic, as if hospitalized, wearing loose clothing and eating only what was furnished by the researchers. For two weeks, the volunteers only received ultra-processed foods. In the other two weeks, they only ate unprocessed or minimally processed meals.

The two diets were selected in minute detail to contain the exact same amounts of protein, fiber, and fat – and to maintain the same pleasant taste for the volunteers. The results were crystal clear. On the days they were submitted to the ultra-processed diet, the volunteers ingested an average of 508 more calories and gained an average of 900 grams in body weight. Their blood tests showed that the hormones responsible for hunger remained high. Meanwhile, with the unprocessed food diet, the volunteers lost an average of 900 grams in two weeks.

Called randomized controlled trials (RCTs), these studies are rare, among other reasons because they require people willing to participate in them, locked into some sterile and boring place for days or weeks. But they are considered the gold standard in science, because they can reveal cause-and-effect relations. Published in 2019 in Cell Metabolism, the study cleared up several important doubts. For example, it makes no difference if an ultra-processed product has the same nutrients as a natural product. Even when it does, the UPF makes people fatter.

The study had thunderous repercussions. It was covered by all the mainstream American and British media channels and was interpretated as the consecration of the NOVA classification. Especially because it dealt with obesity, the disease that led Monteiro to create his classification in the first place and that backed the first study by Nupens that put the new classification to the test.

In 2015, a year after the food guide was released, Professor Maria Laura da Costa Louzada investigated whether it was possible to draw a correlation between rising obesity in Brazil and ultra-processed diet. As a gaúcha (a native of Brazil’s southernmost state of Rio Grande do Sul) with buzz-cut hair and tattooed arms that give her a daring look, Louzada symbolizes a new generation that is fired up to carry forward with the work by Nupens. In 2025, Monteiro will turn 75 years of age, which is compulsory retirement age in Brazil. After cross-analyzing data from the Family Budgets Survey (POF 2008-2009) and spending six months in the Department of Epidemiology at Harvard, Louzada finished her doctoral thesis that put the nail in the coffin: yes, the results show the harms to health from replacing meals made of natural or minimally processed foods with ultra-processed foods – and support the recommendation that consumption of the latter should be avoided.

Studies like this, which later appeared in various other research centers in the world, represent a turning point in the way obesity has been treated for decades. Louzada explains this genesis: “For a long time, obesity was linked to a sort of personality trait, a weakness of gluttonous, lazy people who can’t resist temptations. A hypothesis emerged later, based on the premise that “a calorie is a calorie”. The obesity epidemic began to be explained by a mathematical calculation – what was important was to not eat more calories than you spend, regardless of the kind of food. But something was missing. Even considering the bigger supply of foods, at a certain moment in history, did the bodies of 20% of the population begin to get the equation wrong and gain weight? Still later came the idea that the cause of obesity lay in the increased production of insulin triggered by excessive carbohydrate intake, throwing a monkey wrench into the hypothalamus. And everybody started to go on diets, like the Atkins diet, where you only ate meat. This idea proved to be unsustainable. Then some scientists started to challenge these nutrient-centered hypotheses. Monteiro’s hypothesis, that the foods’ processing is a key element, changed everything. Because ultra-processing uses a bunch of chemically created substances and changes the foods’ matrix. And studies have already shown that this has effects on the body. But that’s not the whole story. Ultra-processed foods influence the way we eat, like in the car, in front of the computer, no longer at the table. And they influence the way we combine the foods that complete each other nutritionally: enter frozen lasagna instead of rice and beans. It’s a chain of influences, a bigger thing.”

An ultra-processed food, as the research shows, is a consummate villain. Even if you remove doses of sugar, fat, or sodium from it, it will always be ultra-processed, something that knocks the system out of whack, simply because it is no longer a food. But the researchers at Nupens realized that consumption of ultra-processed products is part of a broader thing, a big food culture that has alienated people from the healthy and pleasurable dining table.

 

TV personality Rita Lobo is a kind of cooking-show Carlos Monteiro. “The cooking-show field is largely a supermarket shelf for advertisers of ultra-processed products. It’s hard to find anybody involved in cooking with a TV channel or show that isn’t related to the food industry,” she explains. Lobo refuses all such advertisers, even if the proposals come cloaked in gimmicks like requests for her to be the ambassador of products that are in the so-called “improvement phase”. “I’ve lost a lot of money as a result, you know, dear?” she jokes. On the social networks, she defines herself as a “defender of real food”. During Brazil’s cool season, while teaching recipes for soups, she aired a series called It’s Complicated, “to show how industrialized bouillon cubes are the gateway to hell: you start to lose your ability to season your own food, and you actually begin to enjoy that ultra-processed taste”. She has posted on her social networks “the 30-day challenge of excluding ultra-processed products from your life once and for all”. Creator of Panelinha (“Little Cookpot”), her company that has a website, YouTube channel, publishing house, and video production department, where she records her program Cozinha Prática (“Practical Cooking”), aired on the GNT channel – Lobo is now the lay public’s main source for the NOVA classification created by Monteiro.

Soon after the publication of the Good Guide for the Brazilian Population, Rita Lobo approached the Nupens team. The guide features a final chapter with a list of reading references dealing with the importance of reclaiming the pleasure and quality of home-cooked meals. While the food guide was being produced, the Nupens group wanted to recommend at least one book of recipes. With waves of childhood memories, Monteiro thought of the iconic Dona Benta: Comer Bem ^[1] . Because of the revisionism targeting characters created by Monteiro Lobato in the early 20^th century, Carlos Monteiro heard protests from some of his team members. “They said to me, ‘My God, how backward can you get! Dona Benta was a white woman who used to steal recipes from the black cook Tia Anastácia.’ There you are, I wasn’t expecting that kind of pushback,” he regrets.

Then somebody suggested the book Panelinha: Receitas que Funcionam (“The Little Cookpot: Recipes That Work”). “The title was Panelinha, which I thought sounded a little simplistic. But when I saw the book, I said the name may not be the best, but the ideas are great! How come I never saw it before?” he recalls. The book’s recommendation was included in the food guide, and the Panelinha team was flattered but not very surprised. “When they created the NOVA classification, they realized something trivial, but which was a revelation in the science world: if you need to exclude ultra-processed products to maintain a healthy diet, people need to cook! We’ve been teaching that for twenty years,” Rita Lobo says. This realization sealed an official partnership between Nupens and Panelinha, which does not involve exchange of funds and was signed via the University of São Paulo Office of the Assistant Dean for Culture and Extension, which deals with relations between the university and civil society.

The initial cooperation developed into close on-going contact. Lobo gives lectures at all the editions of the Brazilian Congress of Cardiology (“The cardiologists are kind of surprised when I show up!”), and she accompanies Monteiro and Patrícia Jaime to various events in the field. Besides, she bases all her own recipe content on the data she gathers from the Nupens database or that she discusses with the researchers. She edited a book called Comida de Bebê (Baby Food), with scientific consultancy from Nupens pediatricians and nutritionists. She launched a package called O que Tem na Geladeira (Whatever is in the Fridge), which includes a book, a YouTube series, and two hundred recipes on the website, after analyzing data from the Family Budgets Survey and noting that Brazilians don’t realize that the most important thing is not to exclude nutrients from the diet, but to include vegetables. Studying statistics from the Census Bureau (IBGE), she developed a guide to solve food issues for people that live alone, besides another, Cozinha a Quatro Mãos (Cooking with Four Hands), for couples.

Every year, the cooking celebrity accompanies Monteiro’s team to the National Meeting on Food and Nutrition of the public Unified Health System (SUS), to talk about healthy eating and the food guide. The idea is to encourage people to eat at home. In one of these meetings, a nutritionist was listening to her tips and laid it on the line: she didn’t know how to home-cook because the people she associated with had just risen socially, and with their new social status, buying a frozen lasagna and serving it at the table was a source of pride. Right then and there, Lobo decided to run a season on her program extolling rice-and-beans. At the height of the COVID-19 pandemic, with the crisis that put hunger back on the map of Brazil, she repeated the dose – and broke audience records running live shows to teach people, stuck at home, to prepare the consecrated Brazilian staple combo, with various side dishes, preferably inexpensive ones.

Granddaughter of a physician who founded the São Paulo School of Medicine, daughter of a mathematician and an anthropologist, sister of two professors (medicine and architecture), Rita Lobo feels at home in the academic world, as if she were in her own kitchen. She and Monteiro became friends quickly. Both of them cook meals with their families on weekends. “He’s obsessed. I know an obsessed person when I see one, because I am, too. But he’s the kind that can have multiple interests. He likes reading, music, traveling, and he’s recently taken up cooking. I don’t know how he finds the inner space for so much,” she says. The capacity for abstraction, she postulates, may be one of the explanations for his having transformed epidemiological data into such a broad scientific hypothesis as the NOVA classification.

Professor Monteiro has a full academic agenda. He belongs to committees in the World Health Organization (WHO), the Brazilian Academy of Sciences (“It’s cool, to show that the collective health field also produces science, not just public policy”), and international organizations such as the Swedish EAT, alongside celebrities like Jamie Oliver. He currently also coordinates NutriNet Brasil, a gigantic study that will enroll more than 103 thousand Brazilian volunteers for several years to detect dietary patterns and their associations with diseases.

But the old regulatory buff is now fascinated by science communication for lay people. In 2016, he and Rita Lobo recorded a course called Comida de Verdade (Real Food), a series of ten videos posted on the Panelinha channel on YouTube. Monteiro appears next to her, explaining how to identify an ultra-processed product, how to eat well while spending less, and how to enjoy a healthy meal while eating out. “I’ve changed a lot since the experience with the food guide, a kind of material that didn’t enjoy very positive status in public health until recently. I’ve come to value information,” he says. Then he returns to his old self. “I came to realize that in certain issues, it’s so difficult to make progress because there is strong opposition from vested economic interests. The only way to move forward is for society to join the struggle.”

 

^[1]Translator’s note: Dona Benta: Comer Bem is a recipe book published in 1940, co-authored by children’s writer Monteiro Lobato, 1882-1948, no relation to Carlos Monteiro