The Healthy Caribbean Coalition and the undersigned leading Caribbean civil society actors stand firmly in support of the Final Draft CARICOM Regional Standard for Labelling of Foods – Pre-Packaged Foods – Specification (Revision) (FDCRS 05) which incorporates octagonal front-of-package warning label specifications on pre-packaged products. We strongly support the adoption of octagonal “High in” front-of-package warning labels (FOPWL) and the application of the PAHO Nutrient Profile model (PAHO NPM), as part of the regional labelling standard for pre-packaged foods, as a key policy tool of a comprehensive approach to regulate obesogenic environments and help combat obesity and the burden of non-communicable diseases (NCDs) in the Caribbean.
Support for FOPWL from Regional Public Health Institutions, other Key Regional Entities and CARICOM Leadership
The introduction of octagonal front-of-package warning labels through the FDCRS includes octagonal FOPWL and the PAHO NPM with the regulatory objective of allowing consumers to quickly, easily and correctly identify unhealthy foods. This approach is strongly endorsed by regional health authorities the Pan American Health Organization (PAHO) and the Caribbean Public Health Agency (CARPHA). The Organisation of Eastern Caribbean States (OECS), the UNICEF Eastern Caribbean office and Caribbean Association of Nutritionists and Dietitians (CANDi) have also recently expressed strong support for the measure.
NCDs and obesity present a challenge to the development of our region, threatening health and human security. This has been acknowledged by CARICOM Heads of State and Government who have made various commitments to combat the regional burden of NCDs throughout the years. Front-of-package Labelling is supported by strong regional mandates, including the 2007 Port of Spain Declaration, the CARPHA 6-Point Policy Package approved by Heads of Government, and the communiqués of the 37th and 39th Conference of Heads of State and Government. FOPWL is also harmonised with CARICOM’s priority of advancing a regional agenda on Food and Nutrition Security that builds economic resilience and encourages the production of and access to healthy foods.
NCDs and Unhealthy Diets and Ultra-processed Foods
As a society, we must reject the tremendous, unsustainable and unconscionable burden of obesity and NCDs in the Caribbean accentuated by the coronavirus pandemic which places those with obesity and NCDs at greater risk of suffering severe illness or dying from COVID-19. NCDs contribute to a significant percentage of death, disability and healthcare expenditure in the Caribbean. In 2016, NCDs were responsible for almost 80% of deaths with over one third of these occurring prematurely in individuals under the age of 70[i]. In 2019, high blood pressure, high blood sugar and overweight and obesity accounted for almost half of NCD deaths and an estimated 4.6 million disability-adjusted life years in the Caribbean[ii]. Rates of overweight and obesity in the Caribbean are staggering and among the highest in the world – approaching 65% among adults in some countries while 1 in 3 children in the region is overweight or obese[iii],[iv]. NCDs consume health budgets placing tremendous strain on under resourced health systems with an estimated over US 65 million dollars spent on conditions related to overweight and obesity in the Caribbean in 2019 alone[v].
Unhealthy diets, dominated by ultra-processed foods defined as multi-ingredient, industrially formulated mixtures containing little (if any) intact foods, are increasingly being recognised as the leading cause of NCD mortality . Caribbean communities are consuming far too many processed and ultra-processed foods and insufficient fresh fruits and vegetables. The region has seen a nutritional transition away from healthy produce towards unhealthy diets dominated by widely available, affordable and heavily marketed, processed and ultra-processed foods, which are high in critical nutrients of public health concern – sugars, sodium, trans and saturated fats and other additives[vii]. The overconsumption of ultra-processed foods, high in these critical nutrients, results in excess calorie intake and can lead to the development of obesity and NCDs, including some cancers[viii],[ix],[x],[xi].
In order to protect our greatest assets – our people – urgent action is needed to modify regional diets towards healthier foods. The WHO/PAHO and CARPHA recommend front-of-package warning labels as a key evidence-based policy measure to tackle obesity and NCDs. These are labels affixed to the front-of-packages of foods containing excess levels of sugars, sodium and fats. Strong scientific evidence has shown that FOPWL help consumers to quickly, easily and correctly identify unhealthy foods.
Evidence in Support of Octagonal Front-of-package Warning Labels
While there are various front-of-package labelling systems in effect globally, octagonal ‘high-in’ front-of-package warning labels, in the current FDCRS, are the best performing system for the intended regulatory objective of allowing consumers to correctly, quickly and easily identify products that contain excessive amounts of critical nutrients. In a recent randomized controlled trial conducted by the Ministry of Health and Wellness of Jamaica, the University of Technology, Jamaica, and the PAHO, consumers shown octagonal warning labels were 91% more likely to correctly identify products high in sugar, sodium and fats; 108% more likely correctly identify the least harmful option out of a selection of products; and 91% more likely to choose the least harmful (or none) of a selection of products, when compared to consumers shown the same products with other FOP labelling systems[xii]. This regional study adds to the growing body of global evidence that supports octagonal warning labels as the most effective FOP labelling system. A study led by the University of North Carolina and the University of Chile found a decrease in household volume of high-sweetened beverages purchases by 23.7% as a result of a comprehensive regulation including octagonal warnings which was introduced in 2016[xiii].
The Business Case for FOPWL
As a Caribbean community we all want our businesses to thrive and profit but not at the expense of employee and consumer health. Octagonal FOPWL is the best front-of-package label to tackle obesity and NCDs and what is good for health must be good for business. FOPWL not only encourages healthier purchases, but it is also a tool to catalyse industry reformulation contributing to healthier food environments as evidenced by research in Chile which found that the proportion of foods on supermarket shelves with any ‘high in’ label dropped from 51% to 44%[xiv]. Caribbean manufacturers are urged to view the introduction of FOPWL as an opportunity develop and expand healthy product offerings in order to meet the growing consumer demand for health-enhancing foods. In terms of broader cost implications of the measure, economic evaluations have shown that the introduction of FOPWL does not negatively impact aggregate employment or real wages[xv]. In this region, it is anticipated that the costs to the regional food and beverage sector will be limited to short-term, one-time investment related to changing the printing plates. This is not unusual as labels are changed very often for promotion and advertising purposes; and for those companies operating in or exporting to different countries, labels are often changed in order to meet different legislative requirements. In the long term FOPWL is likely to save governments money. In Mexico, where octagonal FOPWL were introduced in 2020, it has been projected that the octagonal warnings will reduce obesity by 14.7% after five years of implementation and save the country an estimated US$1.8 billion in obesity costs[xvi].
Warning labels on the front-of-packaged foods are permitted under the Article 2 of the Technical Barriers to Trade Agreement by the World Trade Organization because they represent a necessary public health measure, based on the best available independent evidence. The WTO emphasis on evidence underscores the importance of selecting a labelling system based on the best available scientific research free of conflicts of interest. Further FOPWL is non-discriminatory as it will apply to all operators, domestic and international. Moreover, once Caribbean companies meet the nutrition labelling standards of the importing country they will continue to be capable of trading their products.
Human Rights, Equity and FOPWL
FOPWL is a key policy tool in recognising citizens’ inherent right to health and nutritious foods. United Nations’ Special Rapporteur on the on the Right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Dainius Pūras, in a Statement endorsed by UN Special Rapporteur on the right to food, Michael Fakhri, highlights that FOPWL is a rights compliant response to addressing NCDs. Importantly the Statement notes States’ obligations under the right-to-health framework, including a requirement to adopt regulatory measures aimed at tackling NCDs, to regulate the activities of the food and beverage industry, and decisively counter undue influence of corporations on government decision-making; and goes further to emphasise that “front-of-package warning labelling should follow the best available evidence free from conflicts of interest.”
The Statement also highlights the vulnerability of children to obesity and NCDs and the need to ensure an appropriate regulatory environment where children are protected from the marketing and advertising of unhealthy commodities and that such commodities have clear labelling to allow parents and children to make informed decisions. The United Nations Convention of the Rights of the Child (CRC) recognises children’s right to the “the enjoyment of the highest attainable standard of health” which includes the prevention of malnutrition via the provision of adequate nutritious foods and clean drinking water (Article 24). Caribbean countries signatory to the CRC have an obligation to ensure that children are protected from unhealthy food environments that undermine their right to healthy food and adequate nutrition.
Octagonal FOPWL is also a great leveller ensuring diverse populations equitable access to basic interpretive information about the food they consume. The universally recognisable stop sign symbol places the power of informed decision-making into the hands of all consumers regardless of literacy level, age, socioeconomic background and native language thereby providing a tool to begin addressing some of pervasive disparities in diet-related obesity and NCD-disease burden afflicting our communities.
FOPWL as an Enabling Policy
FOPWL is also a foundational or enabling policy that allows governments to more easily introduce important complementary healthy food policies which will collectively transform food environments. Once unhealthy foods are easily identified it then becomes far simpler to regulate their sale and marketing in settings like schools and workplaces or implement fiscal policies which make healthy foods more affordable and accessible, particularly for vulnerable populations.
Support for the Regional Process
Voting to adopt the FDCRS is currently underway across Member States until May 31, 2021 through a transparent and accountable CARICOM-mandated regional process managed by the CARICOM Regional Organisation for Standards and Quality (CROSQ). The regional process initiated in 2018 has been among the most extensive and widely consultative standards processes to date with significant documented engagement across all sectors including the private sector, the public sector and civil society.
FOPWL is Game-Changer for the Caribbean
The HCC and undersigned organisations encourage all sectors of society to mobilise around this critical game-changing policy measure which has the potential to dramatically and positively reshape our regional food environment resulting in tremendous long-term benefits in reduced disease burden and cost savings. Octagonal front-of-package warning labels are the best evidence-based labelling system and Caribbean people and children of all backgrounds deserve nothing less than the best. Their health must be prioritised. Now more than ever, we need better labels to help us make better choices for better health.
Names of Supporting Organisations
Healthy Caribbean Coalition
Faculty of Law, Cave Hill Campus, University of the West Indies
RISE (St. Lucia) Inc.
Caribbean Policy Development Centre (CPDC)
American University of Antigua College of Medicine
Cayman Heart Fund
The University of the West Indies, Trinidad and Tobago
UWI, Trinidad and Tobago
FMS-UWI St. Augustine Campus, Trinidad and Tobago
Caribbean Centre for Health Systems Research and Development
Caribbean Association of Nutritionists and Dietitians (CANDi)
Caribbean Association of Pharmacists
Kidney Association of Belize
National Health Insurance, Belize
Barbados Cancer Society
Chest and Heart Association of Trinidad and Tobago
EarthMedic and EarthNurse Foundation for Planetary Health
Cancer Society of The Bahamas
Trinidad and Tobago Heart Foundation
Cancer Support Services, Barbados
Rotary District 7030, St. Lucia
Barbados Family Planning Association
Barbados Association of Endometriosis and Polycystic Ovarian Syndrome
Barbados Muslim Association
Barbados Rugby Football Union
The Barbados Diabetes Foundation
Barbados Association of Palliative Care
Faces of Cancer, St. Lucia
The Diabetes Association of Trinidad and Tobago
The Heart Foundation of Jamaica
Heart & Stroke Foundation of Barbados
Kiwanis Clubs of Barbados
Dominica Diabetes Association
Barbados Association of Medical Practitioners (BAMP)
Osorio’s Family Health Clinic, Belize
Edutherapy Limited, Trinidad and Tobago
Atlantic Insurance, Belize
Mind Health Connect, Belize
Antigua and Barbuda Diabetes Association
Barbados Boy Scouts Association
Belize Cancer Society
Saint Lucia Cancer Society
[i] PAHO/WHO, Noncommunicable Diseases in the Region of the Americas. Facts and Figures. Washington, D.C., United States of America, 2019.
[ii] The Institute of Health Metrics and Evaluation. Global Health Data Exchange.
[iv] HCC. Childhood Obesity Fact Sheets. 2019
[v] World Obesity Federation. Calculating the costs of the consequences of obesity. 2017.
[vi] Branca F, Lartey A, Oenema S, Aguayo V, Stordalen GA, Richardson R, et al. Transforming the food system to fight non-communicable diseases. BMJ. 2019;364:l296.
[vii] Monteiro CA, Cannon G, Levy RB et al. NOVA. The star shines bright. [Food classification. Public health] World Nutrition January-March 2016, 7, 1-3, 28-38
[viii] Nardocci M, Leclerc BS, Louzada ML, Monteiro CA, Batal M, Moubarac JC. Consumption of ultra-processed foods and obesity in Canada. Can J Public Health. 2019;110(1):4-14.
[ix] Fiolet T, Srour B, Sellem L, Kesse-Guyot E, Allès B, Méjean C, Deschasaux M, Fassier P, Latino-Martel P, Beslay M, Hercberg S, Lavalette C, Monteiro CA, Julia C, Touvier M. Consumption of ultra-processed foods and cancer risk: results from NutriNet-Santé prospective cohort. BMJ. 2018;360:k322.
[x] Hall KD, Ayuketah A, Brychta R, Cai H, Cassimatis T, Chen KY, Chung ST, Costa E, Courville A, Darcey V, Fletcher LA et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake. Cell Metabolism. 2019; 30, 1–11.
[xi] Srour B, Fezeu LK, Kesse-Guyot E, Alles B et al. Ultra-processed food intake and risk of cardiovascular disease: prospective cohort study (NutriNet-Santé). BMJ. 2019;365:| 1451.
[xii] Pan American Health Organization. Superior efficacy of Front-of-package Warning Labels In Jamaica. 2020.
[xiii] Taillie LS, Reyes M, Colchero, MA, Popkin B, Corvalán C. An evaluation of Chile’s Law of Food Labeling and Advertising on sugar-sweetened beverage purchases from 2015 to 2017: A before-and-after study. PLOS Medicine. 2020; 17(2): e1003015.
[xiv] Reyes M, Tailie LS, Popkin B, Kanter R, Vandevijvere S, Corvalán C. Changes in the amount of nutrient of packaged foods and beverages after the initial implementation of the Chilean Law of Food Labelling and Advertising: A nonexperimental prospective study. PLOS Medicine. 2020; 17(7):e1003220
[xv] Paraje G, Colchero A, Wlasiuk JM, Sota AM, Popkin BM. The effects of the Chilean food policy package on aggregate employment and real wages. Food Policy. 2021; 100
[xvi] Basto-Abreu A, Torres-Alvarez R, Reyes-Sánchez F, González-Morales R, Canto-Osorino R, Colchero, MA, et al. Predicting obesity reduction after implementing warning labels in Mexico: A modeling study. PLOS Medicine. 2020; 17(7): e1003221.