Pacific Island countries are facing a non-communicable disease (NCD) crisis, and unhealthy diets are the biggest contributors to the increasing rates of obesity, hypertension and diabetes(Reference Chand, Singh and Kumar1–3). NCD account for about 80 % of all deaths and 50 % of all premature mortality in the Pacific Islands(2,3) . In Fiji, where approximately 70 % of adult men and 75 % of adult women are overweight or obese(4), CVD account for one-third of all deaths and one-quarter of deaths is from diabetes(3). A key reason for high rates of NCD in Fiji is the transition away from traditional diets, which consisted mainly of fresh fruit, vegetables and fish(Reference Snowdon and Thow5) towards more readily available(6,7) and nutrient-poor processed, packaged foods that are high in Na, free sugars and saturated fat(Reference Charlton, Russell and Gorman8,Reference Thow, Heywood and Schultz9) .
The WHO recommends limiting foods high in Na, free sugars and saturated fat and ensuring that consumers can access and afford healthy food(10). Pacific Island leaders have been proactive in adopting a range of food policies and regulations to tackle unhealthy diets by addressing the increasing consumption of processed foods(11–Reference Webster, Pillay and Suku13). This includes taxes on sugar, regulations for Na levels in processed foods and programmes to improve food environments in specific settings such as schools and hospitals(Reference Reeve, Thow and Bell12,Reference Thow, Downs and Jan14) . In Fiji, the National Food and Nutrition Centre was established by the Government in 1982 to coordinate the multi-sectoral efforts needed to address the country’s diet-related disease burden including informing policies on food regulation.
Information provided on nutrition labels for processed, packaged food allows consumers to assess the nutritional quality of their food and make healthier food purchases. In Fiji, all food products sold are regulated through the Food Safety Act 2003 (15) and the Food Safety Regulations 2009 (16). Regulations around the labelling of processed, packaged food products require all pre-packaged food produced, processed, packed, distributed or imported to be labelled in English with the following required nutritional information per 100 g (or per 100 ml for liquids) for: energy, protein, fat and carbohydrate. In 2014, an amendment of the Food and Safety (Amendment) Regulations 2014 (17) was passed which stipulates mandatory reporting of additional nutrients including trans fatty acids, Na, total sugar, fat, saturated and unsaturated fats to be labelled per 100 g (or 100 ml for liquids). Officers authorised by the Government of Fiji are responsible for periodic monitoring of compliance with the labelling regulations, with fines and/or imprisonment incurred for noncompliance(16). However, to date, compliance with Fiji nutrient labelling regulations across the entire Fijian packaged food supply has not been assessed.
In 2010, the Minister for Health and Medical Services in Fiji convened a consultation with key stakeholders from the food industry, government and research groups who agreed on a coordinated strategy to reduce salt intake to 5 g/d by 2020. The Fiji Salt Action Challenge Strategy was endorsed by way of a Cabinet Submission in 2010, and the National Food and Nutrition Centre formed a secretariat to provide oversight and momentum. Na reduction has been highlighted as key to improving diet-related disease burden region-wide, and setting targets for Na levels in foods is a key component of effective salt (Na) reduction strategies(Reference Downs, Christoforou and Snowdon18–Reference He, Brown and Tan20). Based on the contribution of different processed foods to Na in the diet in the Pacific, the proposed maximum acceptable regional targets for Na levels in eight selected food categories were developed and agreed by representatives at the Pacific Islands NCD Forum in September 2013(Reference Downs, Christoforou and Snowdon18). These were adopted from the Pacific Island targets established the year prior and developed by the Food Taskforce Technical Advisory Group in 2014(21). The Na reformulation targets were modified to apply specifically to Fiji and finalised through a series of stakeholder and food industry consultations between 2012 and 2014. However, these targets remain voluntary and have not been formally ratified by the Government of Fiji.
This research aimed to identify opportunities to improve the nutritional quality of the food supply in Fiji. Our objective was to conduct a cross-sectional survey of the packaged food supply in Fiji and quantify the nutritional composition of the main food categories using three criteria: adherence to national nutrition labelling regulations, levels of Na and total sugar in packaged food and compliance of packaged food products with proposed Na reformulation targets. The findings can be used to guide policy decisions related to reformulation activities, front-of-pack food labelling, import controls, sales taxes and subsidies for healthier products, which can help guide consumers towards healthier food choices.
Methods
This research encompassed a systematic survey of packaged foods for sale in five major supermarket chain stores in Suva, Fiji. Data were collected between November 2018 and January 2019.
Retail outlets surveyed
The stores were purposively selected to ensure that the majority of packaged products in Fiji were included. A total of seven supermarkets were approached and invited, two declined and the remaining five agreed to participate. Supermarkets with more than two branches were selected to ensure more than 70 % of the market was captured. Written permission to collect data was obtained from each store manager prior to commencement of data collection.
Packaged foods surveyed
Packaged food products for human consumption that were available for sale in each store during the period of data collection were surveyed. Where products were available in multiple stores, only one instance of the product was surveyed. During each product survey, data collection staff captured the barcode and photographed the front of the pack, nutrition label, manufacturer details, ingredients list and product weight for every packaged food item on every shelf in each store surveyed. This was done using a smartphone application developed by The George Institute for Global Health(Reference Dunford, Trevena and Goodsell22) and according to a protocol devised by an international collaborative project designed to document the nutritional composition of packaged foods globally(Reference Dunford, Webster and Metzler23). The images collected were transmitted to a data management centre in India for processing. Data were uploaded daily into a database which was quality-checked, and data were recollected where required.
Data extraction
The data management centre used an in-house technology system that enables the systematic, standardised and replicable collection and collation of data describing packaged foods and beverages. Images of food packaging are captured, stored and processed with key data extracted from food labels. The key variables used for the current analysis were the brand name, product name, manufacturer name, serving size and presence of nutritional information per 100 g (or per 100 ml for liquids) for energy, protein, carbohydrate, Na, total sugar, total fat, saturated fat and unsaturated fat. Where data were absent from food labels, it was recorded as missing. Different package sizes of the same product were recorded as duplicate items in the database, but each product was included only once in the primary analyses.
Categorisation of foods
Foods were categorised using the system developed by the Global Food Monitoring Group(Reference Dunford, Webster and Metzler23) into fifteen major food groups and fifty-eight selected sub-categories: (1) bread and bakery products; (2) cereal and grain products; (3) confectionery; (4) convenience foods; (5) dairy and dairy alternatives; (6) edible oils and oil emulsions; (7) eggs; (8) fish and fish products; (9) fruit and vegetables; (10) meat and meat products; (11) non-alcoholic beverages; (12) sauces and spreads; (13) snack foods; (14) sugars, honey and related products and (15) special foods. Excluded categories were alcoholic beverages, baking powders, chewing gum, cough lollies, eggs, herbs and spices, meal kits, plain teas and coffees, plain waters, sports/protein powders, sugar, sweeteners, vitamins and supplements, yeasts and gelatines since they do not contribute significantly to nutrient intake, nor are manufacturers required to display a Nutritional Information Panel for many of these products. The special foods category encompasses baby food and protein and diet bars. This left data for 4278 food products categorised under fourteen major categories and thirty-six sub-categories.
Manufactures
Manufacturer information for each product was recorded based on the manufacturer name listed on the pack and includes companies local to Fiji as well as multinational companies licenced to manufacture or sell products in Fiji. Overall, data for the top thirty-four manufacturers selling products in Fiji were reported with manufacturers chosen based on the number of products collected during the survey, representing 39 % of all products surveyed. Of these, seven were Fiji local manufacturers, identified using in-country expertise. The remaining manufacturers were classified as ‘other’, comprising manufacturers with smaller numbers of packaged foods and beverages under their portfolio.
Statistical analysis
Analyses were conducted across all products and for individual food categories. There were three main sets of analyses: (i) the proportions of packaged foods compliant with Fiji nutrient labelling regulations for all nutrients (i.e. displaying energy, protein, carbohydrates, Na, total sugar, saturated fat, trans-fat, monounsaturated fat and polyunsaturated fat), as well as separate proportions for products complying with labelling across each of the required nutrients; (ii) the average levels of Na and total sugar in packaged foods for which data were available, with both mean and median reported to allow ease of cross comparison against future years of data and against the packaged food supply in similar regions and (iii) the proportion of packaged foods meeting maximum Na content targets for the thirty-nine food sub-categories for which the targets have been developed. Foods were defined as ‘known to meet’ the target if the label reported a Na content that was at or below the specified target.
All analyses were done using the statistical software package Stata/IC version 15.1 and figures generated in Microsoft Excel.
Results
Nutrition labelling
Of the 4278 products analysed, 602 (14·1 %) products were fully compliant with Fiji nutrient labelling regulations (Table 1). Na was labelled on 4083 (95·4 %) products, and total sugar labelled on 3955 (92·4 %) (Table 2). Protein, energy, saturated fat and carbohydrates were also labelled on the majority of products and across most of the food categories; however, trans-fat, monounsaturated fat and polyunsaturated fat were only labelled on a minority of products.
Proportion of 4278 packaged food products in 2018 meeting Fiji regulation for nutrition labelling, across categories
Proportion of 4278 packaged food products in 2018 meeting Fiji regulation for nutrition labelling and proportion labelled with energy, protein, carbohydrate, sodium, total sugar, saturated fat, trans-fat, monounsaturated fat and polyunsaturated fat, across categories
The majority of manufacturers did well on labelling Na and total sugar across their products. Of the thirty-four top manufacturers selected for analyses, twenty-one complied with Na labelling across their products and nineteen complied with total sugar labelling (Table 3). The manufacturer with the lowest compliance to both Na and sugar labelling was Carpenters Fiji PTE Limited (79·5 % and 74·4 %, respectively). PepsiCo had the highest proportion of products meeting Fiji nutrient labelling regulations (33 (64·7 %)).
Proportion of 4278 packaged food products in 2018 meeting Fiji regulation for nutrition labelling and proportion labelled with sodium and total sugar, across manufacturers
Sodium and total sugar content
There was significant variability across all categories and sub-categories for both Na and total sugar content (Table 4). Food categories with the highest mean Na content were ‘convenience foods’ (1699 mg/100 g) and ‘sauces, dressings, spreads and dips’ (1422 mg/100 g). Unsurprisingly, categories with the lowest mean Na content were ‘sugars, honey and related products’ (36 mg/100 g) and ‘non-alcoholic beverages’ (49 mg/100 g). There was significant variability across all categories and sub-categories.
Mean sodium and total sugar content of food products, surveyed in Fiji in 2018
* ‘< 1’ Na values refer to non-zero Na content for the lowest range to distinguish from actual zero values listed on pack.
Food categories with the highest mean total sugar content were ‘confectionery’ (52·6 g/100 g) and ‘sugars, honey and related products’ (44·2 g/100 g). Categories with the lowest mean total sugar content were ‘edible oils and oil emulsions’ (0·3 g/100 g) and ‘meat and meat products’ (0·7 g/100 g). The lowest range values for both nutrients demonstrated that there were multiple instances where a content of 0 for Na or total sugar was listed on the label.
Assessing against reformulation targets
Of the 1188 products with proposed Na reformulation targets, 707 (59·5 %) met the relevant target (Table 5). The highest compliance was observed for ‘bacon’ (100 %) and ‘sweet, filled biscuits’ (90·4 %), which had reformulation targets of 1210 mg/100 g and 450 mg/100 g, respectively. The categories of ‘canned meat’, ‘meat-free products’, ‘shrimps/prawns peeled cooked/crumbed’ and ‘squid/calamari’ did not have any products meeting Na reformulation targets.
Compliance of targeted food categories with voluntary Fijian sodium reformulation targets
* Plant-based products sold as meat substitutes.
Amongst manufacturers with at least three products eligible for proposed Na reformulation targets, Food Processors (Fiji) had the highest proportion of products meeting the targets (n (%) = 7 (100 %)) (Fig. 1). None of the six Desai Brothers products, which were all in the sauces and spreads category, met the proposed Na targets.
Compliance of International and National manufacturers producing eligible products with voluntary Fijian sodium reformulation targets
Discussion
This research found that most packaged foods in Fiji do not comply with national nutrition labelling regulations, although labelling of Na and total sugar was present on almost all foods surveyed. Packaged foods in Fiji were found to have a high degree of variability in their Na and total sugar content across all food categories examined, creating an opportunity to drive consumers towards healthier choices within any given food category. The proposed voluntary Na reformulation targets are already being met by the majority of products surveyed, suggesting that more stringent targets are needed to improve the nutritional quality of packaged foods in Fiji.
Only 14·1 % of all packaged foods available for sale in Fiji met national nutrient labelling regulations, whereby manufacturers are required to list certain nutrients on their packaged food product labels. In accordance with the national regulations, most packaged foods surveyed labelled Na, total sugar, energy, protein, carbohydrates and saturated fats. However, the majority of products did not comply with the requirement to report trans, monounsaturated and polyunsaturated fats. Lack of capacity for ongoing monitoring and accountability means that labelling incompleteness of nutrients is likely to persist, as the last amendment to nutrient labelling was made in 2014 providing ample time for the industry to comply. For consumers to make fully informed choices about the healthiness of products to purchase, packaged foods need to display all relevant nutrition information. The Fijian government needs to establish ongoing monitoring of nutrient labelling in order to enforce and assess compliance with these regulations.
In addition to implementing nutrient labelling completeness, the Fijian government has also been considering introducing Front-of-Pack (FoP) Labelling, which informs consumer choice by summarising the nutritional quality of a food with a summary indicator or warning label indicating high levels of nutrients to limit. A growing body of evidence suggests that FoP labelling may aid consumer understanding of nutritional quality, encourage selection and purchase of healthier foods and promote reformulation by industry(Reference Shangguan, Afshin and Shulkin24,Reference Neal, Crino and Dunford25) . Implementation of a FoP label is feasible in Fiji given the presence of imported food products from Australia and New Zealand. Some of these imported products already carry FoP labels known as the Health Star Rating(26,27) . In 2019, the WHO Fiji commissioned research to further elucidate stakeholder perceptions of FoP label implementation, focusing on investigating challenges and potential benefits of the different approaches. However, the fact that nutrient labelling is so low in Fiji means that governments and researchers would have to rely on supplementary, proxy nutrient information using alternate data sources in order to verify and monitor industry compliance and accuracy of FoP labelling. Research has shown that when a voluntary label such as the Health Star Rating is implemented, industry chooses to only label healthier products(Reference Jones, Shahid and Neal28,Reference Shahid, Neal and Jones29) , defeating the purpose of a FoP label as a tool for consumers to assess the nutritional quality of their food purchases, and emphasising the need for mandatory implementation of such policy across all products. Key to the implementation of a FoP label would therefore be industry compliance to label all required nutrients in accordance with the Fijian regulations.
In this research, Na and total sugar content varied significantly both within and across food categories. High levels of Na were found in pre-packaged ready meals and sauces such as soya sauce, as well as in snack foods and meat products. Unsurprisingly, the highest levels of total sugar were found not only in confectionery but also in bread and bakery products such as cakes, muffins and pastries. These are all packaged, processed foods that are increasingly being consumed in Fiji as the traditional diet moves towards a more Western-style diet(Reference Thow, Heywood and Schultz9). However, the high degree of variability found between the Na and total sugar content of similar product categories presents an opportunity for directing consumers towards the low Na and sugar options that are available in the Fijian food supply. Even as diet transitions towards processed, packaged foods, nutrient labelling completeness or FoP labels can drive consumers towards healthier food choices in any given food category. The wide variability of Na and total sugar is also encouraging as it suggests room for reformulation towards healthier products within any given category or product discontinuation. Building on the baseline data that our research has provided, ongoing monitoring of nutritional content is key to monitoring policy interventions to improve the nutritional quality of packaged foods in Fiji.
To reduce NCD, Member States of WHO are being urged to reduce salt intake(Reference Charlton, Webster and Kowal30). Many countries are doing this by setting targets to reduce Na (salt) levels in processed foods(Reference He, Pombo-Rodrigues and MacGregor31). Compliance with proposed voluntary Na reformulation targets in Fiji varied, with large differences found between manufacturers and in some food categories. The fact that over half of the products surveyed met the proposed targets also suggests the need for revised, more stringent targets to achieve widespread Na reduction through reformulation(Reference Rosewarne, Huang and Farrand32). The breadth of the proposed targets is encouraging as food categories with the highest Na content have a proposed reformulation target in line with recommendations(Reference Downs, Christoforou and Snowdon18), with the exception of convenience foods. Increasing stringency in the reformulation targets would therefore require lowering the Na targets in categories where the majority of products are already meeting the proposed Na levels. Ongoing monitoring of Na content is essential if targets are to be met so that manufacturers can transparently be assessed for compliance, and the efficacy of a reformulation policy for the Fijian packaged food supply can be assessed over time(Reference Charlton, Webster and Kowal30).
A key strength of this research is the highly standardised approach to the collection, processing and evaluation of the data and the extensive range of products captured in line with global protocols(33). Additionally, this research has conducted the largest survey of packaged food products available for sale in Fiji to date, providing baseline data required to improve the nutritional quality of the Fijian food supply. The results, however, must be interpreted in view of some limitations. While the data are representative of what was on the shelves of the sampled stores during the survey period, they do not represent every food and beverage available in every store throughout the year. In addition, the data illustrate what is available for sale in stores but not what is purchased or consumed, meaning that this research cannot allude to the actual consumption of harmful nutrients and their direct effect on ill-health. That said, the manufacturers included are the major suppliers nationally, and it is likely that the products included in the study would comprise the majority of packaged food available in the country. In the absence of time- and resource-intensive food monitoring such as individual diet surveys or population purchase and consumption data, our survey provides a good indication of the range of packaged food products available in supermarkets. Last, we acknowledge that this study does not necessarily represent what people in Fiji eat daily; however, given evidence of the nutrition transition in Fiji, we hypothesise that assessing and improving the nutritional content of processed packaged foods in Fiji will have beneficial impacts on diets generally.
Conclusions
There is a great need for the Fijian government to urgently address the healthiness of the packaged food supply in Fiji as diets continue to shift towards more processed, ready-made foods and burgeoning rates of diet-related NCD pose an enormous threat to the economy and health care system in Fiji. There are key opportunities for driving consumers towards healthier food choices and improving the nutritional quality of packaged foods in Fiji by improving nutrient labelling, further enforcing reformulation targets and monitoring changes in food composition, as well as introducing mandatory FoP labels. With strong government support and open transparent monitoring to ensure industry compliance, these measures have the potential to curb the escalating burden of disease associated with poor diets in Fiji.
Acknowledgements
Acknowledgements: N/A. Financial Support: The data collection for this work was supported by a DFAT Food Innovation Grant. This project is further supported by an NHMRC Project Grant (no. 1169322) as part of the Global Alliance for Chronic Disease Program on scaling up interventions to reduce hypertension and diabetes. C.J. is supported by a National Heart Foundation Postdoctoral Fellowship (HF101945); J.W. is supported by a National Heart Foundation Career Development Fellowship (no. 1082924), and through an NHMRC Centre of Research Excellence on food policy interventions to reduce salt (no. 1117300). The funders had no role in the design, analysis or writing of this article. Conflict of interest: There are no conflicts of interest. Authorship: C.J. designed the study and supervised data collection and writing up of the manuscript. A.P. supervised data collection. M.S. carried out data analysis with input from C.J. J.W. and G.W. helped interpret the results. M.S. and G.W. co-wrote the first draft of this research paper. All authors reviewed drafts and agreed the final draft. Ethics of human subject participation: N/A.
