Background

Noncommunicable diseases (NCDs) remain leading causes of mortality, morbidity and disability in the Caribbean. Three conditions, namely high blood pressure, high fasting blood sugar levels and overweight and obesity, are the main drivers of this disease burden in the region. This crisis is being further aggravated by the COVID-19 pandemic, as persons living with NCDs (PLWNCDs) face a greater risk of becoming severely ill or dying from COVID-19.

High blood pressure, high fasting blood sugar levels and overweight and obesity are closely linked to unhealthy diets, and an excessive intake of sugars, total fats, saturated fats, trans fats and sodium. In turn, the excessive intake of these “critical nutrients” of public health concern, is largely driven by the widespread availability, affordability and promotion of processed and ultra-processed food products with unhealthy nutritional profiles.

Front-of-Package Warning Labeling

Against this backdrop, an essential part of the solution requires the use of laws and regulations to reduce the demand for and offer of processed and ultra-processed products that contain excessive amounts of critical nutrients. Front-of-package warning labeling represents one of the key policy tools of a comprehensive strategy to regulate obesogenic environments. Scientific evidence shows that octagon-shaped front-of-package nutritional warnings indicating if a product is “HIGH IN” on or more critical nutrients, is the best performing system to allow consumers to correctly, quickly, and easily identify products with unhealthy nutritional profiles.

Moreover, this approach has been supported as a rights-compliant response in a recent Statement by the UN Rapporteur on the Right to Health, which highlighted States’ obligations to adopt regulatory measures aimed at tackling NCDs. As part of this approach, The PAHO nutrient profile model allows the identification of products that should contain warnings on the front of the containers for their excessive content of critical nutrients that can affect health.

FOPWL is a simple, practical and effective tool to inform the public about products that can harm health and help guide purchasing decisions

FREE SUGARS

≥10% of total energy from free sugars

TOTAL FATS

≥30% of total energy from total fat

SATURATED FATS

≥10% of total energy from saturated fat

TRANS FATS

≥1% of total energy from trans fat

SODIUM

≥1 mg of sodium per 1 kcal OR ≥300mg/100g of product OR ≥40mg/100 ml for drinks that provide no energy

Situation in the Caribbean

In the Caribbean, the CARICOM Regional Organisation for Standards and Quality (CROSQ) is leading, since 2018, the revision of the (2010) CARICOM Regional Standard for Specification for labelling of pre-packaged foods (CRS 5:2010) to incorporate front-of-package labeling specifications.

This process is supported by strong regional mandates and has involved extensive consultations through National Mirror Committees with all relevant stakeholders, including industry and commerce. The current CARICOM draft standard meets the highest level of scientific excellence, including the octagon-shaped warning system and a nutrient profile model based on WHO recommendations.

Frequently Asked Questions

Does the “stop” sign indicates a legal violation?

A sign per se does not imply a violation. When applied to traffic, for example, a stop sign simply means the driver must stop before proceeding. Hence, the existence of a stop sign does not mean or indicate a legal violation.
The purpose of nutrition warning systems is to inform consumers in a quick, correct, and easy way if a product contains excessive amounts of sugars, fats, and/or sodium. It does not forbid consumers from buying products; it helps them to quickly and easily make an informed decision.

Are education campaigns more effective consumer behavior change tools than nutritional warnings?

Any measure to modify public behavior should form part of a suite of complementary policies supported by a comprehensive public education program and nutritional labeling is no exception.
Education and information campaigns are indeed important. However, such measures are not alternatives or substitutes for FOPL or any other policy; they are complementary.
FOPL is an education tool in itself as it provides information that helps educate consumers about the content of food products.
Compared with media campaigns, FOPL is more cost-effective given the reach and large self-sustainability over time.
Furthermore, a campaign to inform the population about healthy meals, by itself, would not allow consumers to know in a quick and easy way which products are high in sugars, fats, and/or sodium. Rather, a FOPL that fits that purpose must be concomitantly in place.
The evidence is consistent in demonstrating that consumers employ little cognitive effort and time in deciding their purchases. A large and growing body of scientific evidence consistently shows that FOPL nutrition warning systems work best to quickly, easily, and correctly inform consumers when products contain excessive amounts of nutrients related to noncommunicable diseases and to improve purchase intention and decision.

Why do warning symbols focus on negative aspects of products?

The FOPL nutrition warning system is clear about its focus and purpose. The more purposes expected from a system, the less focused and less effective it will become in achieving its purpose or multiple purposes.
The purpose of nutrition warning systems is to help the population identify products that contain excessive amounts of critical nutrients such as sugars, total fats, saturated fats, trans fats, and sodium. These nutrients should be the basis of the FOPL. Merging or adding information about positive nutrients or attributes into the FOPL system would divert its purpose, dilute the effect, and increase consumer confusion.
FOPL systems that present positive nutrient or positive attributive information are not an appropriate vehicle to fit the purpose abovementioned (i.e., to help the population identify products that contain excessive amounts of critical nutrients) and to promote healthy diets, for several reasons.
- They may stimulate excessive consumption of processed and ultra-processed products that would not be recommended as part of a healthy diet because they add a health halo effect and the misperception that the product in question is healthy.
- They distract consumers from dietary recommendations that should be addressed by using other policy tools and vehicles of information, not the label of pre-packaged products;
- Claims such as “low in sodium” could generate an excessive consumption of ultra-processed products so labeled and subsequent excessive intake of sodium and/or other critical nutrients. This could be caused by the combination of hyperpalatability of such products and the stimuli of claims
- Studies have demonstrated that when consumers are rating the healthfulness of a product that has excessive amounts of sugars, fats, or sodium, adding the green color (perceived as a positive feature) to the FOPL system distorts their perception, making consumers believe that the product is healthier than it really is, or that it is recommended as part of a healthy diet when it is not.
Products carrying front-of-package nutrition warnings are typically ultra-processed food and drink products that apart from having excessive amounts of critical nutrients, are associated with lower intake of positive nutrients such as vitamins, minerals, protein, and fiber. Hence, while FOPL nutrition warning systems focus on excessive amounts of critical nutrients, consumers are more likely to increase consumption of positive nutrients as well as avoid excessive amounts of sugars, total fats, saturated fats, trans fats, and sodium as they improve their purchase decisions due to the nutrition warning label.

Is the traffic-light FOPL system more attractive and preferred by consumers? Does it do a better job at facilitating consumer choice and understanding?

Consumer preference is not a parameter that measures the performance of a FOPL system and helps identify the most effective one. Hence, studies or assertions that indicate a system is preferred by consumers do not help in identifying the system that best suits the intended public health purpose.
Evidence does not support the argument that traffic light systems leave more room for consumer choice and facilitate reading and understanding of the products’ nutritional components, when compared with nutrition warning systems. In fact, independent scientific evidence has demonstrated the opposite:
- The use of the traffic-light system has been proven to be less effective in informing consumers when products contain excessive amounts of sugars, fats, and/or sodium compared with use of the nutrition warning systemadopted in Chile, Mexico, Peru and Uruguay, and proposed for use in Brazil, Canada, and other countries.
- The traffic light system has been proven to be less effective in influencing consumer purchase intentions and decisions.This lower efficacy or lower performance has been explained by several scientific studies showing that:
  - consumers can get confused when exposed to traffic light labels that are simultaneously high, medium, and/or low on different nutrients
  - consumers struggle with and take more time identifying whether a food product carrying a traffic-light FOPL is excessive in a given nutrient
  - the green sign for some products may work as a stimulus for the purchase of products that may be green in sodium, but are red in sugar, which could result in an undesirable increased consumption of these products.
- Since the 1970’s, marketing and consumer research has demonstrated that consumers employ little time and cognitive effort in making a purchase decision, especially when it comes to repetitive purchases, which is the case for food and drink products. The traffic light system requires more cognitive effort and more time for consumers to process and decide, when compared with the nutrition warning system.
In addition to this evidence, it is also known that green-red color blindness is the most common form of color blindness, which means the measure would exclude part of the population from having the information.
The traffic light system has been adopted voluntarily also because companies realized they could increase the sales of non-recommended products.Sugary drink companies adopted it voluntarily as a marketing strategy to upscale their sales by featuring the green light for sodium and fats in their sugary products.
In order to protect consumers, FOPL systems that may be used as part of a marketing strategy to leverage the purchase of superfluous and unhealthy products should be avoided. For more details see PAHO’s Technical Brief for a summary of the purpose of FOPL and comparison of the performance of different systems.

Why not use FOPL systems combining GDA and traffic light colors or summary systems based on recommended portions?

Hybrid systems combining GDA and traffic light systems have the same limitations described in #4. In addition, the colored GDA does not include text that interprets the quantitative amounts of listed nutrients. For more details see PAHO’s Technical Brief for a summary of the purpose of FOPL and comparison of the performance of different systems.
In addition, FOPL systems that provide overall or summary nutrient scores do not allow consumers to clearly and quickly identify products that contain excessive amounts of critical nutrients (i.e., nutrients associated with the most burdensome diseases), such as sugars, total fats, saturated fats, trans fats, and sodium. For more details see PAHO’s Technical Brief for a summary of the purpose of FOPL and comparison of performance of different systems.

Does Codex Alimentarius prevent countries from developing their own FOPL systems?

Countries are sovereign and have a right to take necessary and non-discriminatory actions to protect public health and guarantee their populations’ food and nutrition security. This includes going beyond Codex guidance, such as where implementation would be ineffective or inappropriate for achieving the government’s health objective.
Discussions and development of any Codex texts are based on and informed by the experiences of countries and regions. Therefore, Codex seeks country experiences in implementing policies to inform the development of relevant Codex texts. This means that Codex expects member states to take action. By establishing and adopting their FOPL standards, Codex member states will also contribute to informing global Codex discussions and work development.

Is there a need for additional research on the use of FOPL nutrition warning systems?

In order to reduce the risk for diet-related noncommunicable diseases, the purpose of the FOPL system should be to inform people in a quick and easy way about which products contain excessive amounts of critical nutrients, i.e., sugars, total fats, saturated fats, trans fats, and sodium.
People benefit from clear and simple guidance from front-of-package labeling that can help them identifying products containing excessive amounts of critical nutrients at the time of purchase. Based on available scientific evidence, the nutrition warning approach is the one that best fits this purpose. See items #3, #4, #5 and PAHO’s Technical Brief for a summary of the purpose of FOPL and comparison of performance of different systems.
All studies comparing the performance of FOPL systems aimed at informing consumers about the excessive amounts of critical nutrients associated with the greatest burden of diseases draw the same conclusion: FOPL nutritional warnings perform better than other systems in meeting that purpose. In addition, nutrition warning labels help consumers to quickly and easily identify products that contain excessive amounts of sugars, fats, and sodium, which are associated with noncommunicable diseases, the principal cause of ill-health and death in the country and in the Americas. See items #3, #4, #5 and PAHO’s Technical Brief for a summary of the purpose of FOPL and comparison of performance of different systems.
It becomes an ethical imperative to take action and adopt the FOPL nutrition warning system considering the volume and consistency of the evidence supporting this system as the one that best meets the purpose of informing people about products that are excessive in nutrients responsible for the highest morbidity and mortality in the Americas.
For more details, see items #3, #4, #5 and PAHO’s Technical Brief for a summary of the purpose of FOPL and comparison of performance of different systems.

Why should FOPL be mandatory?

Public health measures that address important risks for the population should be mandatory, to ensure the protection of the entire population.
When the health of the population is at risk, rigorous and urgent public health measures need to be mandated and enforced to ensure the protection of the public’s health. Public health regulations should be not left to be adopted on a voluntary basis.
There is no evidence to support that a voluntary approach can meet the intended purpose of a FOPL system. On the contrary, evidence has shown that food industry compliance with voluntary FOPL is low especially in instances where labels will reflect poorly on the products. The food industry is unlikely to comply with any voluntary FOPL that highlights negative properties of products they manufacture and discourages their purchase by consumers. Evidence from countries that have adopted a voluntary approach shows that companies selectively avoid applying the labeling to products of their portfolio that contain excessive amounts of critical nutrients, or they simply choose to not voluntarily apply the FOPL system at all.
In response to the growing recognition of the effectiveness and demand for front-of-package labels, the food industry has been promoting a voluntary guideline for daily amounts (GDA) front-of-package label. However, a robust body of global independent evidence has shown that GDAs perform poorly on a number of dimensions compared with other existing FOPL systems, and that GDAs are the least impactful and least effective globally. For more details, see items #3, #4, #5 and PAHO’s Technical Brief for a summary of the purpose of FOPL and comparison of performance of different systems.

Does lower laboratory capacity to derive quantitative assessments of nutritional content impede the adoption or implementation of FOPL?

Commercial operators (i.e., manufacturers and importers) should not be allowed to mislead the consumer or promote fraudulent product content information. It is their responsibility to provide accurate information about the content of their food products. Nutrient content can be assessed using laboratory analysis and/or a stepwise nutrient analysis based on the composition of ingredients and on processes used to manufacture the product.
In addition, laboratory and/or stepwise nutrient analyses are only one of the components of the monitoring and accountability frameworks to be used by governments. Noncompliance can be captured by means of manufacturing plant inspections and labeling documentation review. Such existing mechanisms can continue to be used to verify compliance throughout the Americas.
Even wealthy countries do not undertake laboratory testing of all products. Stepwise nutrient analyses are commonly used to determine or estimate nutritional content based on the ingredients, and companies must provide a sworn declaration that the information on nutrient content or on other characteristics of the product required by the legislation is trustworthy. If a false claim is identified, sanctions are applied. False claims can be investigated by means of manufacturing plants inspections and food labels reviews and in very few specific cases by means of laboratory analysis.
After inspections of manufacturing plants, document verification, and review of food labels, countries may need to analyze the nutrient content of samples of products considered at high risk of noncompliance. Countries and subregions of the Americas do have access to sufficient laboratory capacity for the various methods of analysis required.

Will nutrition warning labels have significant cost implications?

The food and beverage sector has to comply with external export regulations and should also be prepared to comply with international/regional/domestic regulations.
The initial costs of labeling will be a one-time investment related to the changing of the printing plates that are needed to print the labels. Companies operating in or exporting to different countries already have to meet different legislative requirements. In addition, the initial costs for businesses are diluted throughout the period of implementation.
FOPL stickers can be used temporarily in cases where a significant amount of a product with a long expiration dates has already been manufactured. In such cases, when the product has already been labeled and is ready to be sold in the domestic market, manufacturers may add nutritional warning stickers in order to comply. New products will have the new label, printed using the new label printing plate with the nutritional warning embedded on the label/packaging.
An analysis commissioned by the United Kingdom’s Department for Environment, Food and Rural Affairs demonstrated that companies are constantly re-labeling their products and mandatory changes due to new legislation account for less that 14 percent or re-labeling on average. It has been demonstrated that even smaller companies are changing their labels very often for promotion and advertisement purposes. Some of the costs of investing in labels already being used for product promotion would simply be redirected to meet public health and regulatory requirements. Product packaging is generally updated and reprinted quite frequently.

How FOPL will impact the economy?

Nutrition warning labels are not expected to have a negative impact on the economy. On the contrary, FOPL opens an opportunity for many businesses to develop and expand the demand and offer of foods recommended as part of a healthy diet.
Against the background of the growing epidemic of obesity, associated noncommunicable diseases, morbidity and mortality, the cost savings from deaths averted or lives saved outweigh the costs associated with modification of product labels.
There is evidence indicating that companies are likely to shift to manufacturing healthier products as a result of changing consumer behavior and product demands. Ultimately, company financial performance would not be adversely affected, as the basis of business models shifts toward healthier options.
Even for regulations that are more restrictive than FOPL, such as taxation of unhealthy products, the evidence shows that employment is not reduced.

Is nutrition warning FOPL a barrier to free trade, and will it affect trade with partners?

Foreign trading partners typically have different labeling standards or elements of labeling that differ somehow. In this context, having a different national approach does not change the status quo. Products would still be able to be sold in more than one market by meeting the requirements of the markets in question.
The FOPL system should not be decided based on trade partner practices, partly because trade agreements preserve the right to regulate to protect health. The nutrition warning FOPL has been designed to meet a public health purpose to protect countries’ populations health and is based on evidence and recommendations from PAHO/WHO.
The nutrition warning approach was firstly adopted in Chile, and then in Peru, Israel, Uruguay, and Mexico. Brazil, Canada and other countries are considering a similar system because it meets the purpose of helping consumers to identify products that have excessive amounts of critical nutrients associated with noncommunicable diseases.
Mandatory labeling, including FOPL, is not a barrier to free trade. States have an obligation to protect public health.105 Obesity is a growing problem in the Region and together with hypertension and diabetes caused 44 percent of all deaths in the Americas in 2017. This same year, Americas’ nations lost 75.2 million years of healthy life due to high blood pressure, high fasting blood sugar levels (measured as fasting plasma glucose), and overweight/obesity.1 Also it has been widely documented that obesity not only harms health, but it reduces educational attainment, job productivity (by increasing absenteeism and presenteeism), and reduces the likelihood of actual employment.2,3,4 The nutrition warning FOPL approach is based on the best available independent evidence, and it has proven to provide quick and easy information that meets the purpose, which is to allow consumers to identify products with excessive amount of nutrients associated with the diet-related noncommunicable diseases and change their purchase decision into a healthier choice (see items #3, #4, #5). For this reason, nutrition warning FOPL is a necessary public health measure. It applies to all operators, domestic and international, and is thus non-discriminatory. All companies are capable of trading their products anywhere; they simply need to meet the nutrition warning FOPL standard adopted by the importing country as for any other labeling requirements, so there is no barrier to trade. In any case, countries are sovereign to take non-discriminatory and necessary actions to protect the public health.
Chile, Israel, Mexico, Peru, and Uruguay have adopted nutrition warning FOPL to inform the population about products containing excessive amounts of critical nutrients and this has not resulted in a legal challenge under a trade agreement. Those nutrition warning FOPL systems are evidence-based and do not discriminate based on the origin of products, placing the governments in a strong legal position.
Therefore, when standards and regulations adopting nutrition warning FOPL systems do not discriminate based on the origin of products; by meeting public health and consumer protection goals, they do not violate regional and international obligations under SICA, CARICOM, NAFTA, MERCOSUR, or World Trade Organization (WTO) law.104 The breadth of the right to regulate under trade agreements is also reflected in a recent decision of the WTO Appellate Body upholding tobacco plain packaging as consistent with WTO law. In subregional example, Ministries of Health of MERCOSUR have approved an agreement on guiding principles for front-of-package labeling that are supportive of and consistent with the purpose and evidence-based features of nutrition warning FOPL systems.
The United States Food and Drug Administration (FDA) or Codex Alimentarius are often mentioned as a reference for FOPL options. However, the FDA is not an international body, and neither Codex nor the FDA have guidelines for front-of-package labeling. Codex Alimentarius actually counts on countries to advance the use of front-of-package labeling to help inform consumers in a quicker and easier way, and to share their experiences and results, so that Codex can learn from these experiences. For more details see item #7.
The July 2020 “Statement by the UN Special Rapporteur on the right to health on the adoption of front-of-package warning labelling to tackle NCDs” recognized front-of-package warning labels as a key measure for States to tackle the burden of NCDs. The statement was endorsed by the Special Rapporteur on the right to food, and the Chair and Vice-Chairs of the Working Group on the issue of human rights and transnational corporations and other business enterprises. States are called on to take a number of actions to fulfil their obligations:
- “States are required to adopt regulatory measures aimed at tackling NCDs, such as front-of-package warning labelling on foods and beverages containing excessive amounts of critical nutrients.”
- “States should decisively counter undue influence of corporations on government decision-making by strengthening legal frameworks and safeguard the policies that protect the right to health, such as the front-of-package warning labelling, from commercial and other vested interests of the food and beverage industry.”
- “States cannot remain passive in the face of NCDs. They should adopt an integral approach to reduce the consumption of unhealthy food products through the use of a broader set of laws and regulations. Front-of-package warning labelling is a key measure for States to tackle the burden of NCDs.”

How rigorous is the PAHO Nutrient Profile Model?

The PAHO Nutrient Profile Model is based on WHO recommendations and nutrient intake goals, developed with rigorous scientific review of the evidence.
The PAHO Nutrient Profile Model classifies products as having an excessive amount of critical nutrients when the proportion of such nutrients in the product surpasses the WHO recommended intake. The WHO population nutrient intake goals aim at guiding the daily dietary intake of nutrients to prevent noncommunicable diseases and other diet-related diseases.
The WHO population nutrient intake goals are expressed as a proportion of energy intake (e.g., free sugars should provide less than 10 percent of energy), and not as a proportion of a fixed number of calories per day. Given that different age groups have different energy requirements, the PAHO Nutrient Profile Model accounts for diets that are balanced for all age groups. When someone eats a product that is in excess of a nutrient according to the PAHO Nutrient Profile Model, he or she is increasing the proportion of the energy from that critical nutrient beyond the recommended intake goals. For example, when someone consumes a sugary drink that provides energy only in the form of sugars (i.e,. 100 percent of the energy is from sugars), by the end of the day the total energy intake from free sugars will be above the 10 percent, regardless the amount of product consumed or the age group consuming the product. The consumption of processed and ultra-processed products that exceed the PAHO Nutrient Profile Model criteria increases the proportion of energy from critical nutrients or the amount of sodium beyond the recommended intakes, unbalancing diets.
If products do not meet PAHO/WHO recommendations, it does not mean that the PAHO Nutrient Profile Model is too rigorous; it simply means that products exceed the recommended nutrient intake goals. Public health recommendations are based on evidence, health risks, and associated burden. If products contain excessive amounts of nutrients that are associated with the most burdensome diseases, consumers should have this information quickly and easily available when they are making their purchase decisions. If the recommendations were to be changed, based on market and not on science, consumers would be misled to believe they are purchasing a product that is healthier than it actually is.

Featured Publications

Front-of-package Labeling as a Policy Tool for the Prevention of NCDs in the Americas

This technical brief summarizes the evidence on the performance of FOPL systems in meeting this purpose and provides a list of frequently asked questions about the nutrition warning system.

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Pan American Health Organization Nutrient Profile Model

This Plan of Action mandates that PAHO provide evidence-based information for the development of fiscal and other types of policies and regulations to prevent the consumption of unhealthy foods, including front-of-package (FOP) labeling and Regional nutrition guidelines for school food environments.

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Superior Efficacy of Front-of-Package Warning Labels in Jamaica

This fact-sheet presents the results of the first study to take place in the Caribbean to examine the best performing front-of-package labeling (FOPL).

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Videos

Octagon High in Warning Labels the Best Way to Go for the Caribbean - Not the Magnifying Glass

Dr. David Hammond, Professor CIHR, PHAC Chair in the Applied Public Health School of Public Health & Health Systems, University of Waterloo, Canada presents the evidence that supports octagon high in front of package warning labels as the most effective food label to support consumers purchase of foods low in sugars, fats and salts - the nutrients associate with obesity and NCDs when consumed in excess.

The presentation is part of the webinar "Human Rights Approach to Front-of-Package-Labeling in the Caribbean", on November, 9th, 2020.