Despite scientific evidence presented by the region’s health sector, pointing to the efficacy of octagonal front of package labeling, a protracted struggle between public health and the food industry has stalled progress in the fight against the region’s number one killer.
It is January 2024 and Caribbean students have just returned to school from their Christmas break. Behind the mask of smiling faces and academic enthusiasm is a bubble that has long since burst. In the region, up to 36% of young people between the ages of 5 and 19 is living with overweight or obesity.
Between 2000 and 2016, overweight (including obesity) among children and adolescents increased in every country and territory in the region, doubling in 20 countries and territories and tripling in 3. Obesity— a by-product of urbanization and obesogenic food environments— is the primary risk factor for the development of NCDs, the leading cause of death in the region.
NCDs, such as diabetes, heart disease, cancer, and hypertension have taken a severe toll on Caribbean economies and societies, accounting for up to 83% of fatalities each year— the highest rates in the Pan American Health Organization (PAHO)/ World Health Organization (WHO) Region of Americas. The Caribbean also exhibits the highest rates of morbidity associated with NCDs and holds the top position for premature NCD mortality within the Americas.
The top seven countries for NCDs in the Americas are Guyana, Haiti, Belize, Saint Vincent and the Grenadines, Trinidad and Tobago, Suriname, and Grenada— all members of the CARICOM region.
NCDs impose a strain on healthcare systems, impacting childhood educational outcomes, impeding productivity, hindering economic growth, and costing the region billions of dollars each year.
There is overwhelming scientific evidence supporting the causal link between the consumption of foods high in fats, salts, and sugars and the development of NCDs.
Front-of-package warning labels (FOPWL) have emerged as a primary means of combating the region's growing NCD epidemic. More specifically, the black-and-white Octagonal Warning Label (OWL) standard— recommended by PAHO, The Caribbean Public Health Agency (CARPHA) and the UN Special Rapporteur on the Right to Health— signaling foods and beverages that are “high in” sodium/salt, sugar, fats, saturated fats, and trans fats is regarded by the scientific and public health communities to be the best standard for the region.
Globally, there are currently seven countries that have adopted “high in” octagonal warning labels. These are Mexico, Peru, Chile, Argentina, Uraguay, Colombia and Venezuela.
The OWL standard is the most popular standard in the Americas and the most popular mandatory standard in the world.
In 2020, a meta-analysis of 14 experimental studies in the Journal of Human Nutrition and Dietetics found that only front-of-pack warning labels using "high in" labels significantly reduced calorie and sugar content in purchased products, compared to products with no label. A 2021 study in Preventive Medicine Reports, conducted in six countries, revealed that the "high in" octagonal warning label had the most significant impact on the perceived healthfulness of sugar-sweetened beverages in five out of six countries, when compared to a beverage with no label.
Barbados Minister of Health, Senator Jerome Walcott, says that the OWL has the potential to decrease NCD-related deaths by up to 16% and save the government of Barbados approximately $732 million US dollars annually in mortality costs.
Since July 2023, the 15 CARICOM member states through their local Standards Bureaus, have been called to vote on whether to adopt OWL as part of the revision of a standard aimed at promoting healthier food choices— the Final Draft CARICOM Regional Standard for Specification for labeling of pre-packaged foods (FDCRS 5).
This is the second time the Standard has gone out for regional vote, the first instance being in 2021 when it did not pass.
To progress, the standard requires backing from a 75% majority of CARICOM member states. Should the 75% threshold be met, the black and white octagonal standard of cautionary labels will appear on both domestically produced and imported pre-packed and packaged foods available to consumers and will identify which packaged foods are “high in” sugars, sodium and fats, as per the PAHO Nutrient Profile Model.
The PAHO Nutrient Profile Model focuses on the proportion of calories in a food item that are derived from essential nutrients such as sugar, fat, and sodium and enables standardized comparisons across various consumer groups, food categories, and countries, making it relevant to all geographic contexts— including the Caribbean.
Public health advocates are hopeful, but not confident that this most recent vote will turn in their favor, lamenting that the adoption process was and continues to be marred by industry interferences, leading to ongoing delays and dissent among CARICOM member states.
In 2021, Grenada, Guyana, and Jamaica opposed the Final Standard (FDCRS 5), which resulted in the vote falling short of the required 75% majority. (Six countries supported, while another six abstained.)
Notably, the crucial dissenting vote stemmed from a contentious and unexplained shift in position by Jamaica— following an emergency behind-the-scenes meeting— less than 3 months after the committee had already approved FDCRS 5.
Concerns raised by major food and beverage producers in Jamaica, Guyana and Trinidad and Tobago (which abstained from voting in 2021) have cast a strong light on industry's resistance to the octagonal warning label— despite scientific evidence to prove its efficacy.
Maisha Hutton, Executive Director of the Healthy Caribbean Coalition (HCC), a coalition of civil society organizations dedicated to NCD prevention and control, argues that policy interference from economic actors has posed a significant barrier to the development and implementation of FOPWL and other preventative policy measures aimed at mitigating the NCD epidemic.
She says that there are elements of the private sector that are exploiting what she refers to as a “weak process,” “grave system flaws” and “weakness in governance infrastructure” to their benefit.
According to Hutton, “This has allowed the private sector, in some instances, to dominate voting at the national mirror committee level, because there are absent or weak and undocumented requirements around membership balance, means of consultation and voting protocols in many of the countries.”
The incongruence between the public health sector's mandate and the influence of industry representatives in public health policymaking has raised questions about the prioritization of health in the region.
The Loud Voice of The Food Industry
The Caribbean Private Sector Organization (CPSO), an Associate Institution of CARICOM, with a mandate of “advancing Private Sector priorities in the Caribbean Community” is the dominant voice of the regional food and beverage sector.
The CPSO features on its 12-member executive, the heads of 9 regional business entities with major interests in the Caribbean food sector—among them the leading supermarket chain in five Caribbean territories, the leading independent brewer of the Caribbean, multiple distributors representing thousands of brands and products including Coca-Cola, Sprite, Welch’s, Minute Maid, Hawaiian Punch, General Mills, Unilever, Nestle, Kellogg’s, Lipton, Charles Chocolates, I can’t Believe It’s Not Butter among others, as well as other regional powerhouses in the areas of food retail, food manufacturing, agribusiness, catering, meat processing, bakery operations, rum distilling, fish and shrimp processing, general trading and packaging.
CPSO has openly criticized the octagonal approach and is advocating for a heterogeneous FOPL model that integrates various global standards.
According to Dr. Patrick Antoine, Chief Executive Officer and Technical Director of the CPSO, the octagonal approach could pose a threat for both trade and manufacturing among the region’s small island net food importing countries.
"We believe that given the gargantuan nature of what this would mean for trade requires us to be very, very cautious, lest these unintended consequences essentially, you know, emerge,” says Dr. Antoine. “The unintended consequences I refer to is—mass reformulation."
The proposed hybrid approach— which is not linked to the PAHO Nutrient Profile Model— has emerged as the favored approach of many members of the food and beverage industry. Many among them express apprehensions about the potential necessity to reformulate products or label them as "high in" unhealthy nutrients should they not meet the defined "healthy" parameters.
In 2021, the CPSO received approval by the Council for Trade and Economic Development (COTED) to launch its own study, “The CARICOM Impact Assessment (CIA) study on front-of-package Nutritional Labelling,” to inform the FOPL vote.
Public Health advocates vehemently opposed the launch of the study, arguing that there was a clear conflict of interest.
The CPSO study, which went ahead in 2022, was conducted by a St. Lucia-based management systems consulting firm, owned and operated by the founder and prior managing director of a regional beverage manufacturer, and former Executive Director of the Saint Lucia Bureau of Standards, and Vice-Chair of the Saint Lucia’s National Export Council.
The study recommended that the UK Traffic Light scheme should be used in tandem with the US Facts Up Front System in a hybrid model.
This was the first-ever study to conclude that the US Facts Up Front system— which provides numeric information on percent daily values for a variety of nutrients— is the best performing FOPL system in guiding consumers to make healthier food choices.
The CPSO recommendations were disseminated across the region, despite objections from the public health community surrounding the methods used. These would eclipse the results of a scientific study on Caribbean FOPWL, conducted in 2021, which concluded that the octagonal standard was the most suitable for the region. The results of the 2021 study were published in BMJ, an international peer reviewed medical journal.
Dr. Alafia Samuels, honorary professor at the Caribbean Institute for Health Research (CAIHR), University of the West Indies (UWI) and former Director of the George Alleyne Chronic Disease Research Centre at CAIHR would refer to the research methods employed in the CPSO study as ”fatally flawed.”
“The [CPSO] study compared front-of-package labels (FOPL) with front-of-package warning labels (FOPWL)— not apples with apples at all,” she said.
“The U.S. Facts Up Front FOPL model provides nutrient quantities but requires the consumer to ultimately use their own judgment to determine whether these nutrient quantities are harmful. This typically requires a consumer to be educated and informed. FOPWL, on the other hand, serves as a clear nutritional warning which is better suited to Caribbean populations— 85% of whom are not college educated. The CPSO study also featured responses from close to 90% college-educated respondents, which is not reflective of the Caribbean region.”
A joint-letter signed by senior leadership from the Healthy Caribbean Coalition (HCC), the Organization of Eastern Caribbean States (OECS) Commission, The Pan American Health Organization (PAHO), The Caribbean Public Health Agency (CARPHA), the United Nations Children's Fund (UNICEF) and the University of the West Indies (UWI) Law and Health Research Unit, stated that the CPSO study’s online survey “lacked built in quality control checks and balances” and had “no mechanism to control for data duplicates, and to validate that the responses were from the target population and countries.”
Public health advocates and scientists opposed the recommended hybrid FOPL approach— stating that it would create confusion among consumers, negate the harmonization objective of regional standards, and defeat the ultimate purpose of FOPL— which is to curb NCDs.
The Food and Beverage Industry And Health Policy Making
In the Caribbean, the interests of health-related food packaging standards rests with the public health sector, but not within its regulatory jurisdiction.
The Caribbean Community (CARICOM) Regional Organization for Standards and Quality (CROSQ) is tasked with developing regional standards, and reports to the CARICOM Council for Trade and Economic Development (COTED), comprising the Ministers of Trade from the CARICOM region, where industry interests may prevail.
Public health stakeholders have contended that as the FOPWL standard is being proposed to address a health issue, that they should have a more dominant voice in the direction of the standards process, but instead, industry interests are frequently the first to get in the door.
Concerns around the potential influence of the private sector in shaping health policies is evident in Barbados’ National Strategic Plan For The Prevention And Control Of Non-Communicable Diseases 2020-2025 (NSP-NCD 20-25) which identifies policy inertia and industry interference as risks. The plan prompts a call for high-level, evidence-based advocacy and involvement of key stakeholders to counter industry pressures and demand action.
The 3rd United Nations High-Level Meeting on NCDs in 2018 emphasized the need to engage with the private sector while managing conflicts of interest.
“While consumption is not the only issue, it is a big issue,” says Jamaica’s Minister of Health, Dr. Christopher Tufton. “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.”
Public health stakeholders have argued that policymaking has been confused due to the private sector taking over the policymaking process through the utilization of well-established playbook methods that have been used globally by both the food and beverage and tobacco industries.
“There are high-level, high-stakes meetings with policymakers and policy influencers being held behind closed doors, largely in the absence of institutional requirements to disclose the existence of such meetings, who attended and what is being said. Furthermore, because these meetings are largely ‘off the record’ there is often no public health voice ‘in the room.’ This process has highlighted the need for greater transparency and accountability in decision-making processes across the region,” says Hutton.
Economic considerations have been raised by industry representatives in opposition to the octagonal system. Arguments have been made surrounding potential price increases and added costs associated with labeling, with warnings that such measures would negatively impact the industry and consequently, consumers.
Maureen Holder, head of consumer advocacy group, Barbados Consumer Empowerment Network (BCEN), says that suggestions that food labeling costs would have to be passed on to consumers are “egregious and vexatious.”
“Some in the food industry may be hesitant or resist FOPL, to avoid any potential negative impact on sales,” she says. “But Front-of-package labelling is necessary for consumers, especially those suffering from diet-related illnesses, to make informed choices about the nutritional content of food products. It really comes down to a question of whether those in the food industry are willing to prioritize profit-making over the health and well-being of consumers.”
In Barbados, a major importer and distributor of brands such as Oreo, Toblerone, Cadbury, Ritz, Nabisco, Chips Ahoy, Quaker, Kool-Aid and Motts, warned that if the octagonal system is adopted, the cost of labeling would be passed on to consumers.
“If the products have to be over-stickered, there definitely will be an increase because you have to buy the labels; when the [goods] come in, you have to open up the cases, take all the products out, put the stickers on, put them back in the cases, seal up the cases again,” he said.
In Jamaica; a member of the CPSO executive and Chairman of the Wisynco Group, a leading Jamaican food and beverage manufacturer and distributor argued that the small populations of the Caribbean do not make FOPWL stickering economically viable, in the same way as it would in a large market such as Mexico.
But public-health advocates argue that the costs of labeling are minuscule when compared to the annual cost of NCDs to the region.
Dr. Didacus Jules, Director General of the Organization of Eastern Caribbean States, an intergovernmental organization representing the combined interests of seven Eastern Caribbean countries, has implored the food sector and governments to ensure that economic concerns do not overshadow health concerns, stressing that the public health benefits of the octagonal system far outweigh its costs.
“National health is more valuable than industry wealth,” says Dr. Jules. “The push for octagonal warning labels should be seen not as a problem by manufacturers but as a long-term opportunity to make their food products more health compliant.”
“With increasing public awareness globally and given the fact that NCDs are the number one killer in the Caribbean, regional manufacturers have a moral and social responsibility to offer healthier foods and not contribute to the problem. Moreover, pivoting to healthier products opens the door to the internationally lucrative ‘whole’ and healthy foods market for our agro-products. In short, while the cost of implementing octagonal warning labels is a valid concern for industries, it's crucial to balance these costs against the potential benefits in terms of improved public health and reduced long-term economic impact of NCDs.”
The Way Forward
The long five year FOPL battle between public health and the food industry has elicited strong responses from across the region.
“Those who are hesitant to get on board with science backed FOPWL recommendations are being short sighted with respect to their own commercial interests and the future of the region as a whole,” says Nathan Haddad, Founder and CEO of Peppatree, a line of authentic Jamaican seasonings and sauces for the do-it-yourself chef.
Haddad, who has been following the deliberations from his vantage point in Jamaica, believes that the proposed octagonal labeling standard provides a business opportunity for the Caribbean food sector.
“As the owner of a Caribbean food company that strives to provide its customers with the freshest and healthiest ingredients, I want my customers to have access to the most transparent information to help them make their food decisions,” he says.
The adoption of front-of-package warning labels in the Caribbean is crucial, foundational policy within a wider package of healthy food policies urgently needed for addressing the growing burden of non-communicable diseases and promoting public health.
“We have advanced evidence based on research, regarding the black octagonal labeling, and we have said that publicly; there is no secret there,” says Dr.
Christopher Tufton. “Clearly, the discussion involves more than just us, it involves industry. And they have carried their own perspective in terms of what they think is in their best interests.”
To overcome impediments to implementing the octagonal standard, it is essential for Caribbean nations to establish transparent decision-making processes that are free of industry pressures and rely on independent scientific assessments to guide policy decisions.
“Industries have historically adapted to public health regulations, such as warning labels, and often these adaptations can be done in a cost-effective manner,” says Dr. Didacus Jules.
The road ahead requires a collective commitment to health and a steadfast dedication to policies that prioritize people over profits.