Countries have tried different labelling formats, but warning labels have emerged as the most effective in guiding consumers to make healthy food choices. Here’s what India needs to do
Countries are working to find ways to nudge consumers into healthy food choices and to contain the growing crisis of obesity and diet-related non-communicable diseases (NCDs) such as diabetes, hypertension and heart ailments.
It is a crisis that increasingly impacts children and also exacerbates novel coronavirus disease (COVID-19) symptoms. Front-of-pack (FoP) labelling is definitely an effective tool in this effort.
While there are several formats being used across the world, voluntarily by the industry or enforced by governments, experiments and usage suggest that interpretive ‘warning’ labels are better than the other formats.
They warn about the specific nutrient that is present in excess amount in a product and provide binary information — if the product has a warning label for salt, it has excess salt.
The information is then conveyed using tools such as colours, shapes and graphics. They do not leave consumers confused with a glut of information, text and numbers to process and thus informs the unlettered and those not familiar with the language.
At least seven countries have adopted warning labels in the past five years. These include Chile, Peru, Mexico, Israel and Uruguay.
Brazil and Columbia have announced to implement the label in 2022, with Canada likely to enforce by December 2022 and Argentina, South Africa and the UK considering it.
Marcela Reyes, from Institute of Nutrition and Food Technology, University of Chile, Santiago, Chile, tells Down To Earth that warning labels “have better performance than any other type of labels in visualisation, understanding and healthier food purchase behaviour”.
Chile’s warning label, for instance, is a black-and-white octagon with text saying ‘high in’ for nutrients that exceed thresholds.
The overall nutrition of the product can be assessed by number of octagons on the package — four octagons mean the product is high in all of sodium, sugar, saturated fat and calories.
Since the labels came into force in 2016, nutrients cut‐offs have become increasingly stricter over a three‐year period. Studies show warning label along with other policy measures have helped reduce purchases of sugary drinks by 24 per cent.
Low- and middle-income mothers have shown profound changes in attitudes towards food purchases as they now understand the nutritional content of packaged foods.
Even children can read the labels and take an informed decision. This has also forced food companies to reduce the amount of sugar and sodium in foods and beverages.
Peru has a similar black-and-white octagon, with text ‘high in’ for nutrients. Apart from sugar, saturated fat and sodium, this label displays trans fat. These labels came into force in 2019, with nutrients cut‐offs becoming increasingly stricter 39 months after the approval.
Mexico, which had implemented Guideline Daily Amounts (GDA), switched to a black octagon on white background warning label in 2020. It uses ‘excess’ for specific nutrients instead of ‘high in’, which is frequently used while making health claims, such as ‘high’ protein.
Mexico implemented the law in 2020 with thresholds to become progressively stricter over five years. Uruguay also has black and white octagonal warning label for products that have ‘excess’ salt, sugar, fat and saturated fat against the prescribed thresholds.
These came into force in 2020 with the food industry given 18 months to adapt to the new regulations.
Israel has implemented a warning label that is even easier for consumers to understand. It is a circular red warning for products high in saturated fat, sugar or sodium along with interpretive images such as ‘salt-shaker’ for salt, ‘spoon’ for sugar, ‘butter and knife’ for fat.
The government implemented this keeping in mind the low literacy proficiency of the country. The law was approved in 2018 for implementation in 2020. A second stage, with stricter maximum thresholds, came into effect in January 2021.
Colombia has also announced a warning label, similar to Israel, for foods high in salt, saturated fats and added sugars in 2020 that will be implemented in 2022.
Instead of red, it has kept the colour black. Brazil’s approved ‘warning label’, to be implemented in 2022, is also a ‘high in’ symbol but in black rectangles with a magnifying glass for sodium, added sugar and saturated fat.
“The studies we conducted in Brazil clearly demonstrated the superiority of warning labels relative to other FoP options. These do seem to reduce the perceived healthfulness of products among both adults and children,” says Neha Khandpur, Department of Nutrition, School of Public Health, University of São Paulo.
Canada has also proposed a similar label with magnifying glass and ‘high in’ text for sugar, sodium and saturated fat. The label is in English and French for everyone in Canada to understand.
Warning labels better
When compared no other label system has shown the impact that is manifested among all population groups and across the education-level spectrum.
For instance, studies suggest that the GDA system is difficult and consumers did not use this system in making their food choices. Small wonder, Mexico replaced it with warning labels.
Even the ‘traffic lights’ format — once a big breakthrough in nutrition labelling — has been found to confuse consumers in cases where a product has both green and red colours.
A study in Mexico shows the meaning of the amber colour is not fully understood by the consumers. A Brazilian study says warning labels influence consumer perceptions of nutritional quality of a product to a greater extent than ‘traffic lights’ label.
Experience from Ecuador where ‘traffic lights’ labelling was rolled out in 2014 suggests that despite most consumers’ awareness and understanding of the label, the extent of changes in purchase behaviours is not as much as observed under Chile’s warning label — while 79 per cent of the participants reported to be aware of the label, only 21 per cent reported using it for their food purchases.
The label has not significantly affected households’ carbonated soft drink-buying habits. Even in Chile, initially ‘traffic lights’ was proposed as the FoP labelling system but preliminary discussions showed it was difficult to understand.
‘Health Star Rating’ and ‘Nutri-score’ have also been found confusing. First, these provide ordinal rating from 0.5 to 5 or A to E, and not a clear indication of healthy or unhealthy.
Consumers do not understand whether a rating of 2.5 / 3 / 3.5 is healthy or not.
Such ratings may help consumers select products within a category — for example, within the chocolate category a consumer may choose to buy the one product with a rating of 2 over the one with a rating of 1.5, but it would not discourage them from eating a chocolate because of its high sugar or fat levels.
Second, consumers think of stars as being more related to the product quality rather than healthiness.
A review of the ‘Health Star Rating’ after four years of its implementation shows that consumers liked and used the ‘Health Star’ logo, but effects on purchasing were largely unknown.
Uruguay, which has implemented warning labels, also studied the labels in terms of capturing attention and altering perceived healthfulness and purchase intention. It found that the effect on consumer behaviour towards unhealthy product categories was notably pronounced for ‘warning labels’.
Delhi-based Centre for Science and Environment (CSE) has worked on labelling system for over a decade now. It was part of the committee that recommended FoP labelling in 2014 and has pushed for the much-needed change ever since.
It has also participated in the current Food Safety and Standards Authority of India (FSSAI)-led stakeholder consultations to bring to the attention not only the urgency but also the need for stringent and health-based standards.
Some of its recommendations have been accepted but a lot needs to be done. Here are a few recommendations to make India’s FoP labelling robust.
Design to warn
The FoP label must have a warning and be simple to read and act upon, as its purpose is to inform consumer about the unhealthy nutrients in junk foods. We cannot dilute the message by providing data on the label or confuse the consumer by including ‘positive nutrients’.
India definitely needs ‘warning labels’ on front-of-pack, but this must be a symbol-based label with no text and numbers. This is because:
(i) Junk foods have high levels of unhealthy nutrients. There is strong evidence that sugar, salt and fat in junk foods are addictive, like nicotine in tobacco. FoP ‘warning’ labels have helped reduce cigarette consumption. It is time we adopted the same for junk foods.
(ii) Warning labels are easy to notice and understand. They do not confuse consumers with mixed messages. Their distinct shape, colour and size make them noticeable in the otherwise cluttered and colourful packaging.
With one label for one nutrient, it becomes easier to know if a product is high in more than one nutrient. The label by Israel is better than those implemented in Chile and other Latin American countries as it is symbol-based with no numbers and limited text.
(iii) Warning labels are the global best practice now. After decades of evolution of FoP labels across the globe, it is now accepted that warning labels are the most effective in informing consumers about the unhealthy aspects of junk foods and in discouraging its consumption.
Some stakeholders say warning labels can create fatigue since most junk food is labelled and consumers get used to it. But this is not correct.
(iv) Warning labels are best suited for India as they do not include numbers unlike many other FoP labels. In fact, warning labels that are symbol-based, like that of Israel, can transcend the barriers of literacy and language in India.
(v) FSSAI has experience of successfully implementing symbol-based FoP labels. Its “green filled circle in green outlined square” logo to depict vegetarian food has been hugely successful in informing consumers.
In recent years, FSSAI also has made similar laws to depict fortification (+F logo) and organic food (a green-coloured tick for Jaivik Bharat logo).
(vi) It is important to note that the FoP label proposed in FSSAI’s 2018 and 2019 drafts is not appropriate. It has too many numbers and duplicates information at the back of the pack. It also confuses the consumer by giving ‘per serve’ based numbers and then ‘red’ colour codes based on 100 g or 100 ml.
It is largely a mix of ‘Traffic lights’ and GDA system, which are difficult to understand even by a scientifically inclined consumer. These will not help the consumer but the packaged food industry.
(vii) Summary indicators should also not be considered. They will shift the focus away from nutrients of concern and fail to inform consumers about the nutrients that are high or low.
They can also mislead in many ways. Words like ‘Health’ and ‘Star’ in a bad food can give a positive connotation. Score for ‘positive nutrients’ can be used to mask the negative impact of nutrients of concern.
A rating in the middle such as ‘C’ in the Nutri-score A-E or 2.5 stars in the Health Star rating from 0.5-5 can be subject to interpretation.
Summary indicators are only suited for comparison within a product category as against telling the consumer that a product has a specific nutrient in high quantity. Moreover, it cannot lead to consumer education and awareness for long-term change in food habits.
Play up nutrients that harm
FoP labels must include information on nutrients that make food injurious to health. This should be distinct from the details on the back-of-pack. FoP labels should aim to inform the consumer, while the back-of-pack label serves the purpose of scientific compliance and enforcement.
Factors that need to be considered while designing FOP label include the level of consumer awareness, larger message that shapes up overall dietary habits, evolving science, local context and effective space utilisation.
FoP labels should have information on ‘total sugar’ and not ‘added sugar’. There is no analytical laboratory method to differentiate ‘added sugar’ from total sugar and quantify it.
‘Added sugar’ is anyway required at the back of the pack, in addition to ‘total sugar’. It is expected that ‘total sugar’, as agreed upon in the latest FSSAI meeting, is retained when the nutrients are finalised.
The threshold for ‘total sugar’ should be based on a daily upper limit of no more than 50 g. This was proposed by FSSAI in its 2018 draft, but in 2019 the limit was used for ‘added sugar’, which is actually a subset of ‘total sugar’.
The National Institute of Nutrition, Hyderabad, also suggests to cap ‘added sugar’ intake at 25-30 g. Most junk foods contain a much higher proportion of added sugar than intrinsic sugars.
Some only have added sugar. Increasing threshold for ‘total sugar’ will allow greater quota for added sugar, which are considered best reduced by medical experts for Indian population.
Moreover, the industry argument of higher thresholds for ‘total sugar’ (to the tune of 90 g) based on certain high-income countries, ignores that the average fruit intake in these countries is much higher, which gets factored in their calculations.
‘Salt’ should be labelled on the front of the pack instead of ‘sodium’, which is already required at the back. ‘Salt’ will help the consumer, whereas ‘sodium’ will help the industry.
Salt is better known than sodium. Moreover, the conversion is difficult. Getting to know how much salt is present, if, say, 900 mg of sodium is there in a food, requires scientific understanding and mathematical skill.
This is the reason public health messages of health agencies is given in terms of salt. FSSAI also mentions namak (salt), not sodium, in its Aaj se thoda kum, the Eat Right movement.
There are countries that do give ‘sodium’ on FoP labels but the decision is based on what is better known among citizens. In India, it is undoubtedly salt. The 2018 draft of FSSAI had also proposed ‘salt’ for FoP label.
‘Total fats’ should be mentioned on the FoP label. It can be done in addition to ‘saturated fats’, if not instead of them. The Indian consumer understands ‘total fats’ easily than ‘saturated fats’.
Selective labelling of saturated fats would give the impression that it is bad and other types of fats (poly-unsaturated and mono-unsaturated fats) are fine to consume.
Both cases may not be true, which is why the Indian dietary guidance on fats has been to have a mix of all types of fats.
Further, mentioning saturated fats on the FoP can demonise the foods that are high in saturated fats such as milk and milk-based products (curd, paneer, butter / ghee), which are an important part of diet for vegetarians and rural population.
Since saturated fats are linked to cardiovascular health, mentioning them will address the issues of only a limited set of predominantly adult population. Mentioning ‘total fats’ will be linked to obesity, which can further lead to diabetes, heart disease and other diet-related NCDs.
Highlighting ‘total fats’ will, therefore, influence dietary habits of a larger set of population. Mentioning only saturated fats can mean that total fats, even if high, would go unchecked.
Also, if saturated fats are high then the food industry can move to other types of fats and still have high total fats in its product. There are examples of countries that use saturated fats and total fats on the FoP label.
Many who label saturated fats likely consume it in higher quantities from animal meat. This is not likely to be the case with India. The need to not demonise saturated fat is implicit in WHO’s guiding principles for FoP, which suggests to include ‘total fats’.
The FSSAI draft of 2018 also mentioned displaying total fats.
Calories are likely to be known more than any other nutrient and should be part of the FoP label. They require minimum calculation, are easy to understand and help identify a product, which otherwise can bypass the FoP label for individual nutrients providing calories like sugar or fat but collectively providing high added-up calories.
Fix salt, sugar, fat
The thresholds for quantity of salt, sugar, fat in food have to be health-based and not designed for the convenience of industry.
The ultra-processed food industry is powerful and uses its substantial market share and influence to dilute the thresholds so that consumers can be nudged into consuming unhealthy products.
FSSAI in its 2018 draft had proposed thresholds that were appropriate and can be adopted. These are based on the WHO-South East Asia Region nutrient profiling model, aligned with the Indian dietary habits, population nutrient intake goals and according to the recommendations made by the Indian Council of Medical Research-National Institute of Nutrition, Hyderabad.
The 2,000 kilocalories (kcal) used as basis for setting thresholds is suitable for Indian adult population and the concept of three meals with 25 per cent daily calorie/nutrient contribution and two main snacks with 10-12 per cent contribution.
These standards have enough buffer as calorie requirement of three to nine-years-old children — a big consumer group of junk food companies — is much less than 2,000 kcal.
The thresholds are also based on higher value of the range, for example 30 per cent in the case of total fats (15-30 per cent range) and 10 per cent in the case of sugars (wherein 5 per cent is desirable).
The thresholds proposed by the working group must not be adopted. If new thresholds are based on fewer categories, those should be stringent and in line with the FSSAI draft of 2018 or the best practices from the world.
India needs to move ahead for protecting consumer health, particularly in times of COVID-19, when we have learnt that those with obesity and comorbities like hypertension and diabetes are more likely to get severely ill from the disease.
This was first published in the 16-30 September edition of Down To Earth Magazine
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