Background: Ultra-processed food (UPF) and Ultra-processed beverage (UPB) consumption is associated with higher risks of numerous non-communicable diseases (NCDs). Yet global consumption of these products is rising due to profound changes in production, processing, manufacturing, marketing, retail, and consumption practices, alongside the growth of the resources and political influence of Big Food. Whilst the sales of UPFs and UPBs in high-income countries (HICs) are stagnating, sales are rapidly expanding in more populous middle-income countries (MICs). In this paper, we adopt a political economy of food systems approach to understand how growth of Big Food in MICs drives the NCD pandemic. Methods: We conducted a mixed methods synthesis review. This involved quantitative data collection and development of descriptive statistics; a search for academic, market and grey literature on the expansion of UPF in MICs; and the development of themes, three illustrative case examples (South Africa, Colombia, and Indonesia), and synthesis of the enablers of successful campaigns in MICs into recommendations for public health campaigns. Results: We project that the combined sales volume of UPFs in MICs will reach equivalency with HICs by 2024, and the total sales volume of UPBs in MICs is already significantly higher than in HICs. Similarly, annual growth in UPF sales is higher in MICs compared to HICs. We also show how Big Food has entrenched its presence within MICs through establishing global production and hyper-local distribution networks, scaling up its marketing, challenging government policies and scientific expertise, and co-opting civil society. We argue that public health can counter the influence of Big Food by developing an expanded global network of driven and passionate people with diverse skillsets, and advocating for increased government leadership. Conclusion:The projected increase in sales of UPFs and UPBs in MICs raises major concerns about the global capacity to prevent and treat NCDs.

Objective: The World Health Organization (WHO) recommends that adults consume less than 5 grams of salt per day to reduce the risk of cardiovascular disease. This study aims to examine the average population daily salt intake in the 53 Member States of the WHO European Region. Design: A systematic review was conducted to examine the most up-to-date salt intake data for adults published between 2000 and 2022. Data were obtained from peer-reviewed and grey literature, WHO surveys and studies, as well as from national and global experts. Setting: The 53 Member States of the WHO European Region. Participants: People aged 12 years or more. Results: We identified 50 studies published between 2010-2021. Most countries in the WHO European Region (n = 52, 98%) reported salt intake above WHO recommended maximum levels. In almost all countries (n = 52, 98%), men consume more salt than women, ranging between 5.39 – 18.51g for men and 4.27 – 16.14g for women. Generally, Western and Northern European countries have the lowest average salt intake, whilst Eastern European and Central Asian countries have the highest average. 42% of the fifty-three countries (n = 22) measured salt intake using 24h urinary collections, considered the gold standard method. Conclusions: This study found that salt intakes in the WHO European Region are significantly above WHO recommended levels. Most Member States of the Region have conducted some form of population salt intake. However, methodologies to estimate salt intake are highly disparate and underestimations are very likely.

Participation of people from culturally and linguistically diverse (CALD) communities in public health research is often limited by challenges with recruitment, retention and second-language data collection. Consequently, people from CALD communities are at risk of their needs being marginalised in public health interventions. This paper presents intrinsic case analyses of two studies which were adapted to increase the cultural competence of research processes. Both cases were part of the Optimise study, a major mixed methods research study in Australia which provided evidence to inform the Victorian state government’s decision-making about COVID-19 public health measures. Case study 1 involved the core Optimise longitudinal cohort study and Case study 2 was the CARE Victorian representative survey, an Optimise sub-study. Both case studies engaged cultural advisors and bilingual staff to adjust the survey measures and research processes to suit target CALD communities. Reflexive processes provided insights into the strengths and weaknesses of the inclusive strategies. Selected survey results are provided, demonstrating variation across CALD communities and in comparison to participants who reported speaking English at home. While in most cases a gradient of disadvantage was evident for CALD communities, some patterns were unexpected. The case studies demonstrate the challenge and value of investing in culturally competent research processes to ensure research guiding policy captures a spectrum of experiences and perspectives.

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