Draft Guidelines for Regulating Food High in Fat, Sugar and Salt (HFSS) also popularly known as Junk Food

Working Group set up by the Expert Group set up as per the order dated September 4, 2013 of the Honorable High Court of Delhi

January 16, 2014

Contents

  1. Background
  2. Directions of the Honorable Court
  3. FSSAI draft guidelines: Review and analysis
  4. Balanced diet, junk food and non-communicable diseases
  5. Balanced diet and dietary needs of children
  6. HFSS food and the ingredients of concern
  7. HFSS food consumption in India
  8. HFSS food and the burden of non-communicable diseases
  9. HFSS food regulations
  10. Draft guidelines for regulating consumption of HFSS food among children

Annexure

  1. Details of HFSS food regulatory status across the world
  2. Nutrient Profiling Model of the United Kingdom and Scoring
  3. Model school canteen policy – Australia
  4. Minutes of Meeting of Working Group set up by the Expert Group held on January 8, 2013
  5. Guidelines on wholesome food and nutrition in school canteen submitted by Industry representatives on January 3, 2014

References

Working Group set up by the Expert Group set up as per the order dated September 4, 2013 of the Honorable High Court of Delhi on guidelines for making available quality and safe food in schools.

Members

  1. Dr Sunita Narain, Director General, Centre for Science and Environment, Delhi (Co-Chair)
  2. Dr Rekha Harish, Professor and HoD, Dept. of Paediatrics, Government Medical College, Jammu(Co-Chair)
  3. Dr Anju Seth, Professor, Dept. of Paediatrics, Lady Hardinge Medical College, Delhi
  4. Ms Anuja Aggarwal, Nutritionist, AIIMS, Delhi
  5. Dr K Damayanti, Scientist C, National Institute of Nutrition, Hyderabad
  6. Ms. Kumkum Marwah, Representative, Advisor Nutrition, Ministry of Health and Family Welfare
  7. Dr Umesh Kapil, Professor, Public Health Nutrition, AIIMS, Delhi

The representatives of industry associations and experts listed below, submitted on January 3, 2013 a document titled, Guidelines on Wholesome Food and Nutrition for School Canteen. This document was discussed at the meeting of the working group on January 8, 2013. The minutes of the meeting record the areas of agreement and outstanding issues where there was no consensus (Annexure 5). The current guidelines incorporate the issues where there was agreement. However, as there are outstanding issues where no agreement was possible, the document submitted by the representatives of industry associations and experts is given in Annexure 6.

  1. Mr. N Ramasubramanian, Retailers Association of India*
  2. Dr. P. S. M. Chandran, Retailers Association of India*
  3. Dr Mridul Salgame, Restaurant Association of India*
  4. Mr Sunil Adsule, National Restaurant Association of India**
  5. Mr Sanjay Khajuria, All India Food Processors’ Association**
  6. Dr S Jindal, All India Food Processors Association**

* New members of the Working Group as per the Expert Group Meeting of December 3, 2013

**New members of the Working Group as per the Expert Group Meeting of December 13, 2013

Meeting Details

Time: 2:00 PM to 5:00 PM

Place: CSE Office, India Habitat Centre, New Delhi

Meeting 1 / November 26, 2013
Meeting 2 / December 06, 2013
Meeting 3 / January 08, 2014

Section1: Background

1.1 Directions of the Honorable Court

Order dated September 4, 2013 of the Honorable High Court of Delhi; W.P. (C) 8568/2010: Uday Foundation for Congenital Defects and Rare Blood Groups Versus Union of India and Others

------The key concern expressed by the Court in the order dated September 4, 2013 is the ill effects of consuming ‘junk food’ as a 'dietary habit' by children. The Honorable Court says "Whereas nobody can question the interest of the society in itschildren eating wholesome and nutritious food and abjuring eating ‘junk food’, which may be consumed once in a while; to satisfy the tongue. Ordinarily, as a daily intake, wholesome and nutritious food should beconsumed by the children. The ill effects of eating ‘junk food’ in today’s environ [environment] has been documented by public health experts as also pediatricians’.

With reference to the term 'junk food', the Court clearly is referring to the food that is high in calories and low in nutrition. The Court recognizes that medical problems such as obesity, hypertension and diabetes in children are direct consequence of excessive consumption of junk food. Further, in order to prepare the draft guidelines, it directed Central Advisory Committee of FSSAI to consult experts in public health, particularly health of a child, adolescent and the youth; and those with expertise on junk food and its ill effects if consumed as a dietary habit. The order says “The FSSAI would be permitted to take the help of experts in the field of not only public health but even those who are concerned with the dietary habits of the adolescent and the youth as also those who have expertise in controlling child obesity, child hypertension, child diabetes etc. i.e. such medical problems which are faced by children today which are the direct consequences of excessive consumption of ‘junk food’ by the children.”

The Court notes the inadequacy of the draft guidelines submitted by Nielson India Pvt. Ltd. in addressing the prayers in the original petition. It directed that the guidelines submitted would at best be a take off point with reference to the data collected and analyzed. The order says that “The report submitted by Nielsen (India) Pvt. Ltd. would at best be a take off point with reference to the data collected and analyzed."

------Later, in the order dated 29 October, 2013, the Court once again clarified over the key concern of the original writ petition and said "We only need to highlight that our order dated September 04, 2013 brings out that the concern in the writ petition is not with hazardous food or with a standard of food safety envisaged by the Act. The concern is with a dietary habit and promotion of what is popularly known as junk food amongst school children"

1.2. FSSAI draft guidelines: Review and analysis

Draft Guidelines for Making Available Quality and Safe Food in Schools

Submitted to the Honorable High Court of Delhi

------

How the guidelines fail to address the original petition?

The draft guidelines for making available quality and safe food in schools, submitted by Neilson seem to be focused on meals provided by the government under nation-wide programmes such mid-day meal scheme of the Department of Education and Literacy, Ministry of Human Resource and Development. The essence of original petition on the other hand is about limiting the availability of unhealthy and unhygienic food products that are commercially sold to urban school children and regulating advertisements targeted to this vulnerable group of consumer, which has limited discretion. The prayers in the original petition are:

  1. To immediately ban junk food and carbonated drinks in all unaided and private schools and schools under Central and State government and local municipality in Delhi
  2. To initiate measures to discourage the availability of fast food, unhygienic food and foods with unhealthy ingredients within 500 yards of the schools in Delhi
  3. To further direct respondents to develop a comprehensive school canteen policy, which emphasizes healthy nutrition among school going children?
  4. To ban junk food and carbonated drinks advertisements in media as well as in the television through any means

The draft guidelines are clearly addressing other end of the nutrition problem in India. It is about providing appropriate nutrition to the under-nourished children, whereas the premise of the original petition is increasing health problems in children due to excess calories from junk food. Consequently, the geographic focus of the survey and subsequent guidelines seem inappropriate to address the prayers in the petition.

In terms of the public health objective, the guidelines are about reducing the incidence of diet related deficiency diseases such as iron deficiency anemia, vitamin A and iodine deficiency diseases in children. However, the directions sought by the petitioner are to prevent early onset of non-communicable diseases such as obesity, diabetes, blood pressure in children.

In terms of observations on specifics of the guidelines, with reference to the guidelines mentioned on quality and safety of the food, well laid out and time tested guidelines are already available under the Mid-Day Meal Scheme. These could be used if required. Moreover, FSSAI's Food Safety and Standards (Licensing and Registration of Food Businesses) Regulations, 2011 also cater to similar issues of General Hygiene and Sanitary Practices that are to be mandatorily followed by food business operators.

The guidelines also fail to appropriately classify unhealthy food in a section wherein the issue of unhealthy and unhygienic food in schools and nearby is addressed briefly. Also, there is no mention of suggestions on promotion of unhealthy foods and advertisements.

There is limited clarity on the design of the survey and how at its first place it was envisaged to address the original prayers in total or partly. What is known is that the study objectives set by FSSAI were in the knowledge of the Honorable High Court of Delhi. However, the Court in its order dated 04 September, 2013 has directed further consultation with experts and suggested considering the data and analyses of the submitted guidelines as a take off point at best.

Section 2: Balanced Diet, HFSSfood and Non-communicable diseases

2.1Balanced diet and dietary needs of children1

As per "Dietary Guidelines for Indians, 2011" by National Institute of Nutrition (NIN), a balanced diet is one which provides all nutrients in required amounts and proper proportions. It should provide around 50-60% of total calories from carbohydrates, preferably from complex carbohydrates, about 10-15% from proteins and 20-30% from both visible and invisible fat. In addition, it should provide other non-nutrients such as dietary fibre, antioxidants, which bestow positive health benefits.

The guidelines depict the importance of foods through a "Food Pyramid". Balanced diet is recommended through a blend of four basic food groups such as cereals, millets and pulses; vegetables and fruits; oils, fats and nuts; milk and animal foods. Notably, food items such as burgers, pizza, fries, chocolates, ice cream, jam etc are not considered the right choice to meet nutrient needs and must be eaten sparingly.

Figure 1: Food Pyramid by NIN
Source: Dietary Guidelines for Indians,NIN; Reproduction of the figure mentioned

The guidelines recommendpreferring traditional and home-made foods; avoiding replacing meals with snack foods; and limit consumption of sugar and processed foods which provide only (empty) calories. It further statesthat "processed foods being rich in fats, salt, sugar and preservatives may pose a health risk if consumed regularly".

It also recognizes children's special needs of growth, fighting infections, maturation, bone development and bodybuilding. Nutritionally adequate and balanced diet has an important role in appropriate body composition, body mass index and reduced risk of diet-related chronic diseases in later life.

2.2 ‘HFSS Food' and ingredients of concern

As per NIN “junk foods as those containing little or no proteins, vitamins or minerals but are rich in salt, sugar, fats and are high in energy (calories).”

Globally as well, the term junk food is popularly used to identify food items with little or no nutritional value but high in salt, sugar and fat.

Foods with similar attributes are termed as:

  • HFSS foods i.e. foods that are 'high in fat, salt and sugar' by WHO and several other countries
  • FMNV i.e. ‘foods of minimal nutritional value’ such as in the US
  • EDNPFC, i.e. ‘energy dense and nutrient poor foods for children’ such as in Republic of Korea
  • 'Energy dense' foods by certain associations and countries

Such foods are regarded as not conducive in maintaining health. Key characteristics include:

  • Imbalance of nutrients:Excess of nutrients such as fat, sugar and salt (sodium) that have negative impact on health, if consumed in high amount. In addition, proteins, vitamins, phytochemicals, minerals and dietary fibre with a positive impact on health could be absent orpresent in limited quantity.
  • Unfavorable nutrients and chemicals: Presence oftrans fats and preservatives and additives used in processed foods that are known to have negative impact on health

Ingredients of junk food are known to impact health in several ways. Excess consumption is linked to obesity. Numerous studies across the world have established strong linkage with non-communicable diseases (NCDs) such as diabetes, hypertension, heart disease and cancer.

Sugar: Sugar is empty calories with no beneficial effect and there is no safe level of its intake. High use of sugar, particularly fructose, is harmful as it is addictive and induces more consumption2. Studies have confirmed that fructose which is most commonly used in carbonated beverages has toxic effects on the liver that are similar to that of alcohol3.Studieshave established direct relationship of sugar with obesity, diabetes and metabolic syndrome4.

Salt: Salt is added for preservation and enhancing the taste of food. High salt content in diet is strongly associated with high blood pressure and related cardiovascular diseases5. Evidence suggests that high salt intake increases mass of left ventricle, stiffens and narrows arteries, including coronary and renal arteries. It increases the probability of stroke, severity of cardiac failure and tendency for platelets to aggregate6. As per WHO, cutting down on dietary salt intake to recommended 5 g per day has a major impact on reducing blood pressure and cardiovascular diseases.

Saturated Fatty Acid (SFA): SFAs are widely used in packaged foods including milk chocolate, cookies, crackers, and snack chips. When consumed in excess of the recommended (limit less than 10% of total calorie intake), SFAs are known to clog arteries and increase risk of heart attack and stroke.

Trans Fatty Acid (TFA): TFAs are formed during the process of hydrogenation of vegetable oils (PHVOs) to make it semi solid that enables longer shelf life, better form and texture. Typically they are found to be high in bakery products and snacks that are deep-fried in PHVOs.TFAs are well known to have an adverse impact on blood lipid levels as they reduce the amount of good cholesterol (HDL) and increase bad cholesterol (LDL). Their consumption increases insulin resistance and promotes obesity. WHO recommends less than 1 percent of calories from TFAs.

Besides the above key ingredients of concern, Caffeineused in carbonated beverages and energy drinks is an addictive stimulant, which if consumed in excess can lead to impaired muscle and nerve functions, dehydration and a host of other disorders7. For children, caffeine consumption should not exceed 2.5mg/kg per day and for adolescents 100mg/day is the recommended limit.

2.3 Junk food and burden of NCDs in children

WHO reports that Non-Communicable Diseases are the leading cause of death worldwide:

  • Unhealthy diets, especially the excessive consumption of calories, salt, saturated fat and sugar cause at least 40% of all deaths from NCDs, and approximately one-quarter of all deaths globally
  • Over 80% of global deaths due to cardiovascular diseases and diabetes occur in low- and middle-income countries. NCDs also kill at a younger age in these countries, where 29% of NCD deaths occur among people under the age of 60, compared to 13% in high-income countries
  • In India, as of 2008, about 53% of all deaths were due to NCDs.The disease burden of NCDs is expected to reach to 57% by 2020 as compared to 29% in 19909

WHO says unhealthy diet is associated with three out of four major NCDs. It is known one of the modifiable risk factors:

Table 1: Modifiable risk factors - Unhealthy diet associated with three out of four major NCDs

Tobacco Use / Unhealthy diet / Physical inactivity / Harmful use of alcohol
Cardiovascular diseases / √ / √ / √ / √
Diabetes(Type2) / √ / √ / √ / √
Cancers / √ / √ / √ / √
Chronic Respiratory Diseases / √

Unhealthy diet leads to metabolic changes and conditions such as overweight, high blood pressure, raised blood glucose and cholesterol, which are among the leading causes of NCD deaths in India10

Childhood obesity

Childhood obesity is one of the most serious public health challenges of the 21st century. Overweight children are likely to become obese adults. As per WHO, about 44% of the diabetes burden and 23% of the CVD burden is attributable to overweight and obesity. Overweight children are more likely than non-overweight children to develop insulin resistance, hyperinsulinemia, diabetes and cardiovascular diseases at a younger age, which in turn are associated with a higher chance of premature death and disability11.

Studies have established the link between consumption of HFSS food and obesity. Numerous studies done among school children of Delhi, Amritsar, and Southern Indiashow that the prevalence of overweight/obesity is high and on the rise.Inurban post-pubertal children of Delhi it increased from 16% in 2002 to about 24% in 2006. It is high among the affluent class and children of private schools compared to low and middle-income groups12

Hypertension

In India, hypertension is the leading NCD risk and estimated to be attributable for over 10 per cent of all deaths13.Hypertension is strongly associated with high Body Mass Index (BMI) and salt intake. A cross sectional study14, published in Epidemiology in 2013, among 400 school children in Chennai found that the total prevalence of hypertension was 21.5%. Several other studies done in India suggest high prevalence of hypertension in overweight and obese children compared to normal weight children15.

As per WHO, the amount of dietary salt consumed is an important determinant of blood pressure levels and overall cardiovascular risk. World Heart Federation says that a universal reduction in dietary intake of about 3 gms of salt, would lead to a 50% reduction in the number of people needing treatment for hypertension. The same decrease would lead to a 22% drop in the number of deaths resulting from strokes and a 16% fall in the number of deaths from coronary heart disease16

Diabetes and pediatricmetabolic syndrome

Type 2 diabetes which is very common in adults is now increasingly being reported in children. The leading risk factor for kids is being overweight, often connected with an unhealthy diet and lack of physical activity.According to a study done by Dr Anoop Mishra et al on post pubertal Indian children, 67% males with high BMI were found to have insulin resistance while overall prevalence was about 22% in males and 36% in females17. As per the Diabetes Atlas 2006 published by the International Diabetes Federation, the number of people with diabetes in India is around 40.9 million and is expected to rise to 69.9 million by 2025 unless urgent preventive steps are taken18.