Nutritionists and physicians say they are treating rising cases of childhood obesity; now is the time to act
India’s food regulators have done little. Guidelines on front-of-pack labels to warn consumers of unhealthy levels of sugar, salt and fat in packaged food are in the making for seven years
NEW DELHI :
In the winter of 2018, a lab in Maryland, US, was the site of a remarkable experiment. Twenty adult volunteers in their early thirties, half of them women, were admitted to the National Institutes of Health’s Clinical Centre for a month. The participants, in a random order, were put on two vastly different diets on a rotating basis. They were offered either minimally processed food or ultra-processed food (UPF). UPFs are industrially manufactured from substances extracted from natural food such as fats, starches and sugar, added with chemical flavours and stabilizers. Examples are commonly available inexpensive items such as sweetened breakfast cereals, fries, burgers, potato chips, biscuits, instant noodles, chocolates and the like.
Both types of meals that the volunteers ate contained similar amounts of sugar, fat and calories. Throughout the study, participants exercised as average adults would, wore loose fitting clothes—to blind them to any weight gain—and were asked to eat as much or as little they desired.
The results were striking: on the ultra-processed diet, participants ate about 500 calories more per day than they did on the unprocessed diet. They also ate faster on the ultra-processed diet and gained about 0.9 kg on an average whereas they lost weight on the unprocessed diet (14 days on UPF diet followed by 14 days of non-UPF diet). The researchers led by Kevin D. Hall put up an interesting hypothesis: perhaps, the sensory properties of the ultra-processed foods—softer food that is easier to chew and swallow—led to a faster eating rate and delayed satiety signalling to the brain, which in turn led them to eat more. Remember that feeling of emptying a packet of chips and still yearning for more?
The randomized controlled trial was the first to demonstrate causality: that a diet rich in UPF makes people eat more and gain weight. Something that nutritionists have been saying for years while pinning the blame on ultra-processed diets for the global surge in non-communicable diseases such as diabetes and hypertension.
The passive modern consumer sitting down to a meal of pre-prepared or fast food confronts a platter covered with inert, anonymous substances that have been processed, dyed, breaded, sauced, gravied, ground, pulped, strained, blended, prettified and sanitized beyond resemblance to any part of any creature that ever lived, wrote agriculturalist, poet and writer Wendell Berry in an essay titled The Pleasures of Eating. “The food industrialists have persuaded millions of consumers to prefer food that is already prepared. They will grow, deliver and cook your food for you and just like your mother, beg you to eat it. That they do not yet offer to insert it, pre-chewed, into your mouth is only because they have found no profitable way to do so."
Published in 1990, Berry’s essay hit the shelves much before the world took notice of the dangers of processed food, let alone define UPF. Three decades later, nearly half of the calories consumed by an average American or a British citizen comes from ultra-processed food. And emerging economies like India are in a transitory phase playing catch up.
Data from the Euromonitor International shows that sales of UPF products in India nearly trebled between 2006 and 2019, from 4.1 gram (gm) to 11.2 gm per person per day. During this period, sales of carbonated and sweetened beverages grew by more than four times, from 4.4 millilitre (ml) to 18 ml per person per day. The most troubling number is this: one in ten school-going children were found to be pre-diabetic while one in twenty had hypertension, according to the Comprehensive National Nutrition Survey, conducted by the Union ministry of health and family welfare and the United Nations International Children’s Emergency Fund (UNICEF), released in 2019. The prevalence of pre-diabetic children in the 5-9 age group is worryingly high in states such as Gujarat (21%), Odisha (19%), Kerala (19%), Madhya Pradesh (17%) and Chhattisgarh (15%).
In the face of this emergency, India’s food regulators have done precious little. Guidelines on front-of-pack labels to warn consumers of unhealthy levels of sugar, salt and fat in packaged food are in the making for seven long years; further, India is yet to regulate promotion and marketing of ultra-processed junk food, even to children. Meanwhile, consumers are merrily buying sugar-loaded fruit juices thinking they are healthier than carbonated beverages. Some brands are even fortifying junk food with vitamins to make them appear healthy.
We have some distance to go to reach the UPF consumption levels in developed countries, so now is the time to act, said Harshpal Singh Sachdev, professor and senior consultant in clinical epidemiology at the Sitaram Bhartia Institute of Science and Research, New Delhi. “Even children who are considered to be undernourished by physical features like height and weight are showing signs of metabolic obesity which means they are at the risk of developing diabetes and hypertension later in life."
To add to this, nutritionists and physicians say they are treating rising cases of childhood obesity with associated symptoms like fatty liver, greying hair, obstructive sleep apnea, hip dislocations and polycystic ovaries (among young girls).
Dragging its feet
A recent study conducted for the Food Safety and Standards Authority of India (FSSAI) shows why India needs to act fast. The research by The Nutrition Alchemy published in December last year assessed nutritional properties of over 1,300 samples of packaged food to investigate how many of these exceeded recommended thresholds of sugar, salt and fat.
More than 95% of the products failed the test as they exceeded the threshold on at least one parameter. For flavoured milk, 73% of the samples exceeded the threshold for added sugar (5 gm per 100 ml) by 1.6 times. Ice-creams had more than twice the threshold for total sugar (12 gm per 100 ml). Chocolates contained 8 times the recommended thresholds for sugar and four times the threshold for fat (8 gm per 100 gm). Ready-to-eat savouries contained four times the threshold for fat and over three times the threshold for salt (250 mg per 100 gm). Crème biscuits had over six times the recommended levels for sugar and 2.4 times the threshold for fat. Fruit drinks were found to contain nearly double the recommended levels for sugar.
The advice of the report was simple: regulate the industry to control and reduce fat, sugar, and salt content in pre-packaged food products. Importantly, the damning numbers from the report that showed that most ultra-processed packaged food exceeded recommended thresholds is perhaps why the food industry has been opposing front-of-pack warning labels. Which is why the FSSAI’s draft labelling and display regulations released in 2018 still remains a draft.
What is even more shocking is that, earlier this year, a working group of FSSAI relaxed the thresholds by a great extent that would have helped industrial food products escape warning labels. For instance, thresholds for sugar in chocolates was raised from 6 gm to 35 gm (per 100 gm serving) while for hard candies it was raised to a staggering 50 gm. For savouries such as potato chips, the threshold for salt was increased from 250 mg to 400 mg. However, following strong criticism, FSSAI decided to discard the thresholds proposed by the working group.
A scientific panel is now working on simplifying the number of food categories (currently there are 115 sub-categories for food and beverages) and the respective thresholds, Arun Singhal, chief executive officer, FSSAI, told Mint.
Meanwhile, the food safety regulator held several rounds of consultations with the industry and consumer groups earlier this year. At a meeting on 30 June, where participants from the industry outnumbered those from non-profits by a wide margin (27 to 8), the industry spoke in favour of monochrome guideline daily amount (GDA) labels while consumer groups wanted warning labels that are easier for consumers to understand. GDA labels show the total amount of energy and nutrients as a percentage of what a typical healthy adult should be eating daily, while warning labels simply flag which nutrients are high or in excess in packaged food. The industry also pushed for ‘positive nutrients’ on labels which was strongly opposed by consumer groups as the purpose of front-of-pack labels is to warn consumers of negative ingredients, and not persuade them to purchase instant food fortified with say, iron and vitamins. This writer reviewed a copy of the minutes of the meeting.
For now, FSSAI is awaiting results from a study on consumer response to different types of front-of-pack labels by the Indian Institute of Management, Ahmedabad, which is expected by January next year. This study, and the scientific panel’s recommendations on thresholds which is also expected by January means FSSAI is likely to place a draft on labelling regulations for public consultation by mid-2022. So, warning labels on packaged food are at least a year away.
Ironically, while food manufacturers have successfully stymied introduction of warning labels, they often sport labels like ‘real’, ‘natural’, ‘fresh’ as part of product and brand names. All this is okay as long as they carry a 3 millimetre (mm) disclaimer stating ‘this is only a brand name and does not represent its true nature.’ So, a fruit drink sporting a ‘real’ or ‘natural’ label, or even a bottle of mustard oil saying Kachhi Ghani (cold pressed) on label may be far from a what a consumer might think it to be!
We have been extremely slow in curbing consumption of ultra-processed food even though more than half of India’s children are at risk of developing heart diseases and diabetes later in life, said Arun Gupta, paediatrician and convenor, Nutrition Advocacy for Public Interest. “In addition to warning labels on food packets, India needs to urgently ban advertising, marketing and celebrity endorsement of UPF, especially to children. FSSAI should immediately begin this work and set a deadline for developing a regulation on marketing of ultra-processed food."
While India has been dragging its feet on warning labels, several countries acted swiftly to curb the dominance of UPF. Researchers at the University of Sao Paolo, Brazil, were the first to develop the NOVA food classification system graded by the levels of processing.
According to Carlos Monteiro who helped develop the NOVA system, the practical way to identify if a product is ultra-processed is to check if its list of ingredients contains at least one item that is rarely used in kitchens, or classes of additives whose function is to make the final product palatable or more appealing. Examples of these ingredients are soya protein isolates, fruit juice concentrates, high-fructose corn syrup and additives like flavour enhancers, emulsifiers and glazing agents.
In 2014, the Brazilian government in its national dietary guidelines asked consumers to stay off NOVA-4 graded UPF. This was followed by similar guidelines issued by Ecuador, Peru and Uruguay, all of which recommended freshly prepared meals and avoiding UPFs.
Several countries across the world have now mandated various types of front-of-pack labels such as health star rating (Australia, New Zealand), Nutri-score (France, Spain), and traffic light label (UK, South Korea, Iran).
However, nutrition researchers have praised the Chilean warning labels for being the most effective. The warning labels use colours and symbols that can easily transcend language and literacy barriers to depict which ingredients of concern (salt, sugar and fat) are high.
Following the implementation of warning labels in 2016, households purchasing highly sweetened fruit and dairy beverages fell by 43% and 29%, respectively, a study published in medical journal PLOS Medicine, based on data collected between 2015-17, stated. Warning labels were also found to be more effective than imposing a sugar tax.
“In their rise to power, food companies have wielded salt, sugar, and fat not just in pursuing profits through the cheapest means of production. Theirs has been a concerted effort to reach the primeval zones of our brain where we act by instinct rather than rationalization," writes Pulitzer Prize winning author Michael Moss in his new book titled Hooked: How processed food became addictive. “Measured in milliseconds, and the power to addict, nothing is faster than processed food in rousing the brain."
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