FSSAI has no reason ‘to not have warning labels’ on packaged foods  

The prevalence of diabetes and other metabolic non-communicable diseases (NCD) in India is considerably higher than previously estimated, according to a  new study. 

These are diet-related NCDs and the finding is a stern reminder that there should be clear warnings on packaged foods. But the Indian journey of front-of-pack labelling so far is the one marked by delays and dilutions.

The report reminded me of the  Food Safety and Standards Authority of India (FSSAI)-led stakeholder consultations that I was part of from January-June 2021 and later in February 2022, during which I pushed for warning labels on packaged foods. 

As Chile had set a good example, it was often referred to. But I could sense that people feel we need not be very aggressive as the problem of diabetes and obesity as well as other NCDs is much higher there. 

But the findings from this study Metabolic non-communicable disease health report of India: The ICMR-INDIAB national cross-sectional study published June 7, 2023 in the journal The Lancet Diabetes and Endocrinology tell a different story. The analysts estimated that over 101.3 million people in India had diabetes in 2021. The prevalence rate was 11.4 per cent overall among the participants, with 16.4 per cent in urban individuals and 8.9 per cent in rural.

These rates are perhaps similar or even higher than Chile but the burden of disease is certainly many times higher, as the absolute number of just the diabetic patients is about five times the near 20 million population of Chile.  

These new estimates of diabetic people are also much higher than the often-quoted figures between 700-800 million until a few years ago, when India was infamously referred to as the ‘diabetes capital of the world’, with about 17 per cent of the global diabetes patients.

The diabetes crisis is poised to worsen as another over 136 million people were estimated to be pre-diabetic in 2021. The prevalence rate was higher than diabetes (over 15 per cent) but similar in urban and rural individuals. 

The study was conducted from 2008-2020 by several senior doctors / experts from India. They claimed this is the largest nationally representative population-based study on diabetes and metabolic NCDs undertaken in India covering all 28 states, two Union territories and the national capital territory of Delhi. 

A total of 113,043 individuals over 20 years of age participated in the study, of which 70 per cent (79, 506) were from rural areas and 30 per cent (33, 537) from urban areas. 

The mean age was 43 years and 46.5 per cent were males. About 4,000 individuals were studied from each state, out of which 2,800 were from rural areas and 1,200 from urban areas. 

“The prevalence of other cardiometabolic risk factors such as obesity, hypertension, and dyslipidaemia is uniformly high across the country, particularly in the urban areas,” the study also noted. Clearly, a look at the estimates of other indicators of cardiometabolic risk share a worrisome scenario. 

Although, it does not throw light on what percentage of total participants had at least one problem, but it looks like a significant proportion of the Indian adult population is suffering from metabolic NCDs or has a real risk. 

• For example, over 315.5 million had hypertension in 2021. Overall prevalence was 35.5 per cent. It was higher among urban individuals (40.7 per cent) than in rural individuals (33 per cent). This could mean that at least every third adult has hypertension in the country

• Over 254.2 million were estimated to have generalised obesity in 2021, which is measured as equal to or higher than a body mass index of 25 kilogram per square metre. Against the overall prevalence of 28.6 per cent, again, urban individuals had a much higher rate (39.6 per cent) than rural (23.1 per cent)

• Over 351.1 million had abdominal obesity (measured through waist circumference). The prevalence rate was very high — 39.5 per cent overall with 51.6 per cent in urban individuals and 33.5 per cent in rural. This means every other urban individual in the country is obese at the waist level and obesity levels are higher in rural areas too

• Dyslipidemia is the imbalance of lipids such as cholesterol, LDL cholesterol, triglycerides, and high-density lipoprotein (HDL). The overall prevalence rate for dyslipidemia was 81.2 per cent, which means four out of five individuals had one or the other problem.  The study estimates that over 231.3 million in 2021 had high cholesterol (hypercholesterolemia) and over 185.7 million had high low-density-lipoprotein cholesterol 

These numbers are scary. The scale of burden on individuals, households and the nation is unimaginable.  There are several factors causing NCDs and there are multiple ways to address those, but the question is are we doing enough to help prevent what is preventable? Can we get the diet part right, considering these are diet-related NCDs? 

I am referring to the way FSSAI has addressed the issue of regulating marketing of packaged foods over the last decade. These ultra-processed foods high in salt, sugars or fats are globally blamed for adding to the NCD burden. Countries which are serious in their efforts to control NCDs have taken strong action to regulate marketing of such packaged foods. Many have regulated advertisements in a strong way and many have mandatory front-of- pack labelling systems. Several have warning labels. 

But India’s policymaking for front-of-pack labelling has been about multiple committees, reports and draft regulations, which become weaker each time they are revised. The latest draft of September 2022 proposed a design and calculation mechanism (Indian Star Rating), which was based on a model (Health Star Rating) that was just voluntarily adopted in two countries (Australia and New Zealand) and rejected by many others.

It is a carefully crafted design that can help sell unhealthy food as good food. It will confuse and mislead consumers due to deliberate and unwarranted inclusion of nutrients other than salt, sugars and fats, which are unhealthy at high levels and the real cause of concern. Else, it will do more harm than good. 

Thankfully, the draft is not yet notified, primarily due to the pressure created by the civil society groups and the medical and nutrition fraternity over the last several months. But with the powerful food industry, the fate of it is still not clear. 

The new report clearly tells us that the problem is much more than what we thought — we need to do more to prevent worsening of the NCD crisis. Anything less than that is not in the interest of citizens. 

FSSAI should consider this as an opportunity to get this right. Consumers need to be warned about these unhealthy foods and therefore should consider mandating a symbol-based warning label that informs them about high levels of just the salt, sugars and fats in a simple and effective way. 

There is no reason now why FSSAI should not be doing this. They have a mandate towards safe food that protects the health of the consumer.  

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