Raging Non-Communicable Diseases In The Caribbean Have Sparked A War Between The Food Industry And Public Health

In the English-speaking Caribbean, one of the sub-regions of the world with the highest prevalence of non-communicable diseases (NCDs), public health organizations are locked in a tug-of-war with the food industry over proposed food-related legislation targeted at addressing the over-consumption of NCD-causing foods.

In summary: Diet-driven NCDs cause up to 83% of all deaths in the region. Front of package warning labels (FOPWL) have been proven to positively impact consumer behavior, nudging them towards more healthy options and encouraging industry to improve the nutritional profile of foods and drinks. The World Health Organization has recommended FOPWL as a key policy tool to reduce NCD prevalence worldwide. But due to competing interests, there has been no obvious way forward.

Here’s why.

Take Jamaica, for example— one of the largest markets in the Caribbean Community (CARICOM)— where the top 10 causes of death  are all non-communicable diseases; diet is the second highest behavioral risk factor, after tobacco, in driving death and disability. A 2020 study conducted by the University of Technology in Jamaica (UTech) on behalf of Jamaica’s Ministry of Health and Wellness revealed that 83% of confectionery, 71% of cooking oils, 56% of desserts and 50% of dairy products commonly consumed by Jamaicans contain trans fats above the recommended levels, while most of these foods contain more sodium than is recommended.

In other words— food is making people sick… and killing them.

“We have an NCD issue in Jamaica, with 80 percent of deaths linked to lifestyle,” confirms Jamaica’s Minister of Health and Wellness, Dr. Christopher Tufton. “While consumption is not the only issue, it is a big issue… And so that’s why we have to do things, things that we’re doing, but some of it is going to become contentious, because it means restricting, or further regulating how industry operates.”

Herein lies the problem.

Stakeholders on opposing ends of the debate vehemently disagree over how consumers should be informed about how healthy (or unhealthy) their food choices are.

Over the past few years, the main point of contention has been around the subject of front of package warning labels (FOPWL) and whether a black and white octagonal “HIGH IN” system should be used on Caribbean food packaging.

In 2018, the CARICOM Regional Organization for Standards and Quality (CROSQ) began a process of revising the (2010) CARICOM Regional Standard for Specification for labeling of pre-packaged foods to incorporate front-of-package labeling specifications. It presented its recommendations before National Mirror Committees consisting of food industry and public health stakeholders as part of a consultative process— and recommended the octagonal FOPWL system as the ideal standard for the region.

Under the proposed octagonal system, only foods that exceed thresholds set by the Pan American Health Organization (PAHO) Nutrient Profile System would be required to carry the label “high in sugar,” “high in salt,” or “high in fat.” This would essentially mean that the food industry would need to either reformulate those foods to avoid FOP warnings or rethink their packaging— which would come at a cost.

The octagonal system and its corresponding benchmarks have the power to truly upset the apple cart for the regional food industry. In fact, a pilot study conducted in Trinidad & Tobago found that, as per the thresholds set by PAHO, close to 90 per cent of food produced in the region would not fall within the acceptable limits of sugars, salts, and fats.

But the system in question also has the power to create a sizeable shift in consumer behavior and by extension, public health.

A 2020 meta-analysis of 14 experimental studies, reported in the Journal of Human Nutrition and Dietetics, found that out of all the main FOPWL systems currently in use, only “high in” warning labels resulted in a significant reduction in the calorie and sugar content of purchased products compared to no label.

A 2021 study, reported in Preventive Medicine Reports, which tested five different FOPWL in six countries (Australia, Canada, Chile, Mexico, the United Kingdom, and the United States) found that compared to a no-label control condition, the “high in” octagon warning label had the most significant impact on perceived healthfulness of a sugar-sweetened beverage in five out of the six countries.

Closer to home, a trial conducted by the Ministry of Health and Wellness of Jamaica, the University of Technology, Jamaica, and the Pan American Health Organization, between 2020 and 2021, also concluded that the octagonal-shaped system “is the best performing system to allow consumers to correctly, quickly, and easily identify products with unhealthy nutritional profiles.”

Studies that have used children, adolescents and middle and low income focus groups have overwhelmingly found the octagonal system to be the most impactful on consumer behavior.  

Sandra Husbands, Barbados’ Minister in Ministry of Foreign Affairs and Foreign Trade believes that while all interests must be heard, the implementation of front of package warning labels would serve national interests and thus, from a policy-perspective, it is not about if but how.

“Government has the responsibility to understand all of the different sides and where each side is coming from and be the voice of practicality,” she explains. “But at the same time to be firm… that if something is in the national interest… if all of us will benefit in the end, even though it may cause some intermittent pain on the journey… government can help to alleviate that pain… But sometimes there is no question about whether we take the journey or not. And this is one of those times.”

But what if the question of how is stalling the entire process?

On the public health side, stakeholders argue that the validity of CROSQ’s recommendations are substantiated by the successful implementation of the octagonal system in countries such as Mexico and Chile. and that the octagonal system has the potential to influence manufacturers to reformulate food items, as was the case in Chile, where the proportion of foods and beverages classified as “high in” sugar and/or sodium fell significantly in the three years following implementation. These research findings were published in PLOS Medicine in July 2020.

On the food industry side— where most foods meet at least one of the PAHO thresholds to be designated as “high in” salts, sugar or fats— there will be costs and inconveniences associated with implementing any FOPWL system.

Industry arguments against CROSQ’s recommendations have been multifaceted and in many cases, impassioned.

“I get really emotional about this subject,” says William Mahfood, Chairman of the Wisynco Group, a leading Jamaican food and beverage manufacturer and distributor.

“As regional manufacturers, we are in support of better informing consumers on the sugar, salt and fat content of foods,” he says.

“Where it becomes challenging is that we are a region of about thirty markets with small populations… When you think about Mexico with one single market of more than 100 million people— Mexican manufacturers have huge and long runs of production to justify implementation.”

But there would be no way of getting around the logistical inconvenience of updating packaging if the region was to implement any FOPWL system as a standard.

It would then come down to the question of which inconvenience or burden a country is more willing to entertain— the burden of disability and disease or the inconvenience and financial burden of altered packaging.

Several small to mid-sized Latin American markets such as Argentina, Chile, Uruguay, Venezuela and Peru have already implemented the octagonal system successfully.

In December 2021, Venezuela, with a population of just over 44 million passed a resolution mandating the octagonal system. Under the new resolution, food processors are being given 36 months to comply with food labeling regulations, allowing them enough time to wind down legacy systems.

But how will this impact trade?

The Caribbean Private Sector Organization (CPSO), which has served as the voice of industry for much of the debate has argued that “Any FOPWL should be ‘best fit’ for the realities faced by CARICOM Countries as ‘Net-Importers,’ and Small Exporters in a trading system dominated by larger hemispheric partners.” In this light, food industry stakeholders have expressed concerns that the lack of uniformity in global labeling systems could become a technical barrier to trade.

Industry representatives, including the President of the Jamaica Manufacturers and Exporters Association, Richard Pandohie, have suggested that the Caribbean should utilize an identical labeling system to its major trading partners.

“This new octagonal labeling standard is really only currently in a few markets in the whole world,” says Mahfood. “It’s so minimally accepted around the world as a standard that it makes it very, very onerous on economies like ours… If you think about the fact that around 70% of our food is imported and our markets are so small; no exporter is going to change their packaging just for us. This means that every food item that is imported into CARICOM would have to be either relabeled or stickered. It makes it very, very difficult and costly.”

But the Heart Foundation of Jamaica (HFJ) disagrees.

“In Jamaica, products are allowed to be relabeled at the port. So, if Jamaica already has a labeling standard with certain requirements that may be different from other countries, a product can just be stickered before it is allowed into the marketplace; there’s already precedent for that…” says Deborah Chen, Executive Director of the HFJ.

“And in the case of changing our labels, we have seen where labels are changed for export markets. For example, right now, if a company exports to Canada, the US and the UK, there could be three different types of labels that they need to use depending on the requirements of that country. These things are already being done to meet export requirements.”

Global research shows that there are no regionally harmonized, mandatory FOP labeling systems currently in existence. While systems such as the Nutri-Score System, the Health Star Rating System, the Facts Upfront System (used in the USA) and the Multiple Traffic Light System (used in the UK) among other systems, are being used on an ad hoc basis in specific countries. Both the UK system and the USA system are voluntary.

The most-commonly-used mandatory system in the world is the octagonal system.

As the debate rages on, CPSO has been engaging with Ministry Officials and Ministries of Trade and Foreign Affairs across Member States, the CARICOM Secretariat as well as National Mirror Committees with respect to the private sector position.

In May 2021, Head of the CPSO Secretariat, Dr. Patrick Antoine was given approval by the Council for Trade and Economic Development (COTED) of the Caribbean Community for “time and space” to implement a study that would “research the availability of harmonized food based dietary guidelines for each CARICOM Member State and make appropriate recommendations on the way forward” with respect to its position on the PAHO nutritional standards, which it says are inconsistent with Caribbean culinary realities and culture.

“A number of the assumptions made about the weightings of various foods and the way in which we combine foods could not simply be transferred from Latin America to the Caribbean,” says Dr. Antoine. “You have to look at the way in which we combine our foods, how we prepare our foods. You can’t just import other people’s research, and use it to formulate policies in our region, that are so far reaching, and then be surprised that the end of the day when we don’t achieve the results.”

The study, according to the CPSO, will be evaluating “FOPWL schemes in terms of consumer understanding, economic impact, sustainability, regional food security implications, and potential to incentivize innovation as well as re-formulation of consumer preferences and potential impacts to the regional industry of implementing the PAHO Nutrient Profile System and the octagonal FOPWL system.”

At the time that this article was published, the findings of the study had not yet been made publicly available.

Meanwhile, on the sidelines of the debate are largely oblivious consumers— the general public— as many as 83% of them (in the case of Barbados) who will eventually die from non-communicable diseases such as high blood pressure, diabetes and cancer— that is, if no effective interventions are put into place.

And given the consultative public policy approach, which is driven in principle by a consensus between industry and public health, the deadlock in deliberations has essentially driven any potential progress to a screeching halt.

In order for the CROSQ draft standard to be passed as a regional standard, eleven (or 75%) of fifteen countries must submit a position in support of it. To date, six countries have voted on behalf and three have voted against it.

Countries that have supported the CROSQ draft standard are Antigua & Barbuda, Barbados, Bahamas, Dominica, Saint Lucia and Suriname, while Belize, Haiti, Saint Vincent and the Grenadines, Saint Kitts and Nevis, Trinidad and Tobago and Montserrat have abstained from voting. Countries that have rejected CROSQ’s recommendations are Grenada, Guyana and the most controversial of all— Jamaica.

In Jamaica, on March 30^th, the National Mirror Committee achieved a majority vote in support of the CROSQ recommendations. But on June 4^th, in an industry-driven flip flop that continues to be shrouded in secrecy, the Mirror Committee was asked to do a re-vote which resulted in an overturn of the original position due to a change in vote on the part of several industry representatives.

“The Ministry of Health was outvoted because their colleagues, including government agencies voted against them,” says Deborah Chen of the HFJ, who also sits on the Mirror Committee. Chen says that she was never advised that there would be a re-vote but simply that there would be a Zoom meeting to which she was invited on the day that the re-vote was held.

“The front of pack label policy is a public health initiative, under the auspices of the Ministry of Health and Wellness; this is not a trade issue,” she says. “This is a very bad precedent for Jamaica because which other public health policy are we going to allow the Minister of Industry, Investment and Commerce to make? Tobacco? COVID? It’s a major problem for this country. In principle.”

When asked to respond, Minister Tufton would neither confirm nor deny suggestions that his ministry was forced to take the back seat in public health decision-making.

“The fact that there was a consultative approach, which is normally the case, would require [industry] involvement, but also the involvement of the consumer groups, a few other groups, the Standards Agency [Bureau of Standards Jamaica] … Some of these groups fall within the realm of the ministry that manages industry and investment activities… I don’t think it’s unusual that you would have contending views and, in some instances, even conflicting positions around matters that involve industry and public health. It’s the case for sugary drinks, it’s the case for tobacco, alcohol and so on. What we ultimately must subject ourselves to is the decision of cabinet and that decision has been made public and spoken about.”

In the absence of FOPWL, some countries, including St. Lucia and St. Kitts & Nevis committed to work towards the target of a 30 per cent reduction in mean population intake of salt/ sodium under the Global Action Plan for the Prevention and Control of NCDs 2013–2020, and in recent years, countries such as Barbados and Dominica have implemented taxes on sugary beverages.

But the absence of a uniform regionally recognized and mandated system to provide in-the-moment guidance on the levels of salt, sugar and saturated fats in foods has meant that consumers are largely dis-empowered in the management of their own health.

In the mean time, dietary risk factors associated with Caribbean diets continue to increase— driven by shifts towards high calorie and salty, sugary and fatty foods, larger portion sizes, increased consumption of fast food and ultra-processed “convenience” foods, combined with a lower intake of fruit, vegetables, and high-fiber foods. Studies show that more than 85% of adults in CARICOM Member States do not meet recommended levels of fruit and vegetable intake.

World Health Organization Global Burden of Disease data (2017) confirms that the most significant underlying risk factor fueling the NCD crisis, as defined by a cluster of dietary risks, is poor diet.

Barbados, as an example, with a population of just under 300,000, experienced 2170 deaths due to non-communicable diseases in 2019, primarily due to ischemic heart disease, stroke and diabetes. Dietary risks were found to be the top behavioral risk factor driving the most death and disability— a 28.2% increase over 2009.

“You have a generation now, that thinks that the national dish is macaroni pie and chicken. Both very greasy, very salty, and the macaroni pie, not so good for you,” says Minister Husbands of dietary habits in Barbados.

Caught in the middle of the battle between public health and industry are those with the power to drive policy-related change— politicians— but in many countries, competing interests among stakeholders and even ministries have stalled much needed progress.

“The main challenge, in getting to this destination, is the competing interests,” says Minister Husbands. “So, in my mind, the priority is the issue of poor-health that has been plaguing our countries… There is a tremendous cost associated with NCDs. And with the COVID-19 pandemic, it has been made worse, because all our people with NCDs are at greater risk of dying or being severely impacted by COVID… And so, our entire country is at risk.”

While policymakers throughout the region are undoubtedly invested in addressing the NCD crisis, many “governments’ compromising kumbayas,” according to one stakeholder, have essentially deferred any definitive change for the foreseeable future.

And as decisions hang, people die— not just from non-communicable diseases, but also from COVID-19 which has severe and potentially fatal implications for those with non-communicable diseases. Based on current trends, the Caribbean will not be able to meet the Sustainable Development Goals target of 30% reduction in premature mortality from NCDs by 2030.

“Ultimately, we as government, we must serve the greater good. And the greater good, I think, is a healthier society,” says Minister Tufton. “We have to work on getting everyone aligned to that vision.”