The BMJ, June 13, 2022
A new health rating for processed foods has led Indian public health experts to clash with a food industry seeing huge potential profits from a country naive in regulation in the sector.
India’s packaged and processed foods will soon have a health star rating (HSR) displayed on the front of packaging after the scheme was approved by the country’s food safety regulator. The front of pack labelling (FoPL) regulation, approved by the Food Safety and Standards Authority of India (FSSAI) under the central health ministry, will aim to start awarding stars a year from now, grading processed foods based on salt, sugar, and fat content, as well as other ingredients, to give an overall assessment of the product.
Companies will then be asked to display the HSR on packaging voluntarily, though th policy is likely to state that ratings will become mandatory from 2027. Currently, packaged food companies are only mandated to display back-of-pack nutritional information.
But India’s health and nutrition experts and consumer advocacy groups are collectively opposing the move. Over 22 organisations—including the Public Health Foundation of India, the Indian Academy of Paediatrics, and the Centre for Science and Environment—said in a position statement that what India needs to fight a growing epidemic of lifestyle diseases is mandatory warning labels on ultra-processed, packaged food. A system such as HSR will create a “health halo” around unhealthy products and confuse and mislead consumers, they said. As part of their campaign against the new regulation, representatives have written to Prime Minister Narendra Modi to intervene and rollback the decision to go with HSR.
Indian experts fear the star rating will be misused and dilute the purpose of FoPL an the right of consumers to make informed decisions about food. “Promoting a HSR is a devious attempt to present packaged food as healthy,” said K Srinath Reddy, president of the Public Health Foundation of India. “By adding a smattering of protective foods, and by not reducing salt and sugar, you are not in any way decreasing the addictive nature of the foods. It’s like using a silencer with a gun—it does not reduce the injury.”
Star ratings
HSRs have been criticised before. Australia and New Zealand adopted similar systems in 2014, but studies found that they had little positive impact on health.1 The voluntary nature of the system lowered the effectiveness “because labels were mostly placed on already healthy products.”1 Others found foods high in sugar were awarded 4 or more stars by adding “positive” ingredients such as protein or vitamins.
The food industry in India is valued at £35bn a year and this is expected to double in 5-10 years. As accessibility, affordability, and demand for processed foods rockets, malnutrition worsens; less than 10% of children in India have access to nutritiously diverse food, says Vandana Prasad, a community paediatrician and public health professional. “The penetration of these foods is very high in remote areas and it’s available cheaply, for as little as INR5-10 (£0.05-0.10) a packet. So, while we need other kinds of social protection measures, simple warning labels—such as a red sign for ‘unhealthy’—will work for the population that is not nutrition literate.”
Government data show that one in four Indians is obese.3 Non-communicable diseases comprise 60% of total deaths in India. “Moving forward with HSR is a retrograde step. A star rating may further enhance our rising consumption of processed foods because a star will give a positive connotation to unhealthy food products,” said Arun Gupta, convener, Nutrition Advocacy in Public Interest, citing alternative examples of warning labels4 successfully curbing junk food consumption in countries such as Chile and Israel.5
Survey criticised
FSSAI’s new policy has long been in the making. In 2013, a Delhi high court directed it to curb the sale of junk food and tighten regulations. After years of discussions on FoPL with representatives from the food industry, consumer groups, and the public health sector, in 2021 FSSAI decided to take the question to consumers, surveying over 20 000 participants from across the country on their preferences for nutrition labels.6
The authors of the survey report concluded that both HSR and warning labels are “highest in the pecking order” when it comes to ease of identification, understanding, reliability, and influence. Though under some parameters warning labels fared higher, the final recommendation states that Indian consumers prefer HSR labelling overall. FSSAI chief executive Arun Singhal says it was “the largest survey of its kind in the world.”
“Our scientific panel is looking into how star ratings will be awarded. But the general philosophy is that positive nutrients should never outweigh the effects of harmful ingredients,” he tells The BMJ. “The weightage has to be decided accordingly. Every regulation evolves and if we find there is a problem, we will correct it.” After a scientific panel reviews the HSR rating plan this month, the draft policy for how ratings will be awarded will be opened for public comment, before it is sent for final approval to the central government.
But health and nutrition experts have called the results of the survey biased and the methodology flawed. Antony Kollannur, a health consultant, points out that adolescents, who form a significant proportion of packaged food consumers, have been omitted from the survey. “A single randomised trial is not enough to formulate a policy. Can 20 000 Indians represent all buyers in India?”
Food industry influence
There is also growing dissonance over what public health campaigners and consumer forums see as the rising influence of the food industry over the food safety regulator. “Making the front of pack labelling voluntary (until 2027) and leaving it to the industry to change their behaviour on their own is going to be difficult. Policy making should remain insulated from industry,” said Reddy. George Cheriyan, director of consumer group CUTS International, which is a member of FSSAI and FoPL’s stakeholder group, told The BMJ that it appears industry “is dictating and deciding on behalf of the regulator, who is supposed to be independent.”
At stakeholder meetings, Cheriyan says he has seen a power imbalance, with more voices from industry, and public health and consumer voices drowned out. “The sense is that, with economic losses from the pandemic, we should not have policies which result in further damage to industry,” he says. Industry representatives did not respond to requests for a comment from The BMJ. Singhal says all stakeholders were consulted equally on the matter. But, finally, consumers decided. “How do you substitute the findings of an objective survey with the opinion and feelings of some consumer groups? That to my mind is not proper,” he tells The BMJ.
Even as FSSAI pushes the new regulation towards the finish line, health organisations and advocacy groups say they will continue to campaign against it and demand warning labels, while appealing to members of parliament and health ministry officials to reconsider. Prasad says, “India is fairly new to the space of regulations. It’s an enormous, naive market and consumer awareness is low, making it attractive for industry and a bigger battle for public health experts.”
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