Sugar, Scandal, and Silence

Why affected countries refuse to speak out on Nestle’s recent controversy

This week’s piece differs from my usual research-focused articles, but is something I’ve been pondering lately. Like some of my more recent posts, this piece too speaks to the larger issue of how neocolonial institutions affect global health, using Pakistan as a case study.

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Public Eye investigation

On April 17, 2024, Swiss nonprofit Public Eye released a report alleging that Nestle baby food products sold in low- and middle-income countries contain high levels of added sugar. Bangladesh, India, and Pakistan were among those affected. Since then, regulatory authorities in Bangladesh and India have announced their own investigations relating to the issue. Pakistan, on the other hand, has been silent.

Following the release of the report, Nestle’s stock price dropped by 3 percent in India. In Pakistan, the stock price decreased by less than 1 percent, but largely recovered in the following days. This is despite the Public Eye investigation determining that 8 out of 9 of Nestle’s baby cereal products sold in Pakistan contain added sugar. On average, these products were found to include one sugar cube per serving, which is undeclared on packaging. Such omissions endanger long-term public health outlooks by promoting harmful nutritional practices in early life.

The Pakistani baby food/formula industry

In 2024, the Pakistani baby food market is expected to gross over $546 million, a quarter of these sales driven by baby cereals. Baby cereals are particularly popular in Pakistan, in part exemplified by a study in Lahore in which the majority of mothers agreed it was the most effective weaning food.

Although Nestle Pakistan advertises its baby cereal for children as young as 6 months, experts recommend that children under 24 months avoid added sugars altogether. Similarly, international guidelines advise that children’s daily added sugar intake be less than 10 percent. Nevertheless, one portion of baby cereal can exceed this limit in Pakistan. This is concerning as a high intake of added sugars is associated with rapid weight gain in infancy. As it stands, experts estimate that 40-50 percent of children in Pakistan are overweight or obese. The continued use of added sugars thus threatens to worsen this existing public health crisis.

Moreover, baby cereals must be prepared with clean water, which most households in Pakistan do not have access to. Aggressive marketing of such products can in turn lead to water-borne diseases and consequently malnutrition. Such concerns prompted worldwide boycotts against Nestle in the late 1970s. At the peak of this controversy, infant mortality increased by 27 percent in populations using unclean water in low- and middle-income countries following Nestle’s entrance in local infant formula markets.

Baby formula in Pakistan

Existing legislation

In 2002, Pakistan introduced legislation prohibiting companies manufacturing breastmilk substitutes from making contributions to health workers. Despite this, a 2013 survey reveals that at least 20 percent of healthcare practitioners have received gifts from such companies. This was most prevalent in Balochistan, where one-third of health workers reported receiving gifts. The same survey finds that more than a quarter of Pakistani mothers were advised to use a particular brand of infant formula, of which 88 percent were specifically recommended Nestle products.

Although international guidelines prohibit the promotion of infant foods containing high levels of sugars, national laws are less protective as a result of lobbying by the baby food industry. This is the case in Pakistan where infant food standards discourage the use of added sugars, but do not place any formal restrictions.

In 2018, the Punjab Food Authority introduced guidelines governing the distribution and promotion of infant formula in the province. Like the 2002 Ordinance, these regulations prohibit infant formula companies from promoting their products via healthcare providers. This policy also mandates that infant formula only be sold on prescription. In practice, however, these guidelines are largely unenforced. The Sindh Government passed similar legislation last year, the effects of which are yet to be seen.

Policy solutions

If the Pakistani government cannot control the distribution of baby food, then it should at least attempt to regulate its production. One study suggests that 65 percent of mothers that give infants such complementary foods do so due to perceptions of insufficient breast milk. As such, it will likely take years for Pakistan to wean off breast milk substitutes. In the interim, policymakers must regulate the use of added sugars in baby food. This does not seem like a big ask, given that leading infant formula products in Pakistan claim to have no added sugars.

More importantly, lawmakers must mandate more prominent disclaimers to ensure the safe use of these products. Although national legislation requires that these products include messages promoting breastfeeding, such statements are not prominent. Safe preparation instructions must similarly be made more apparent on packaging. Given low rates of literacy nationwide, companies should also be required to provide these safe use disclaimers verbally via television advertising campaigns. Such increased regulation will allow parents to make more informed choices about their children's nutrition, helping safeguard Pakistan’s public health prospects in the long-run.