Impact of color-coded and warning nutrition labelling schemes: A systematic review and network meta-analysis

Prioritizing population-based nutrition-related interventions to prevent and control hypertension in Iran: a multi-criteria decision-making approach

Background

Numerous nutrition-related policy options and strategies have been proposed to tackle hypertension and other risk factors of non-communicable diseases (NCDs). In this study, we developed a comparative analysis using a multi-criteria decision-making (MCDM) model for prioritizing population-based nutrition-related interventions to prevent and control hypertension in Iran.

Methods

We employed a combination of Delphi technique and Analytic Hierarchy Process (AHP) method as the methodological tool to prioritize decision alternatives using multiple criteria. The prominent assessment criteria and intervention strategies were derived using a literature review, focus group discussion (n = 11), and a 2-round modified Delphi technique with specialists and experts involved in different stages of health policy-making (round 1: n = 50, round 2: n = 46). Then, the AHP was used to determine the weightage of the selected interventions and develop the decision-making model. The sensitivity analysis was performed to test the stability of the priority ranking.

Results

Nine alternative interventions were included in the final ranking based on eight assessment criteria. According to the results, the most priority interventions to prevent and control hypertension included reformulation of food products to contain less salt and changing the target levels of salt in foods and meals, providing low-sodium salt substitutes, and reducing salt intake through the implementation of front-of-package labeling (FOPL). The results of the sensitivity analysis and a comparison analysis suggested that the assessment model performed in this study had an appropriate level of robustness in selecting the best option among the proposed alternatives.

Conclusion

MCDM techniques offer a potentially valuable approach to rationally structuring the problem, along with the opportunity to make explicit the judgments used as part of the decision-making model. The findings of this study provide a preliminary evidence base to guide future decisions and reforms aiming to improve appropriate population-based interventions for tackling hypertension and other risk factors of NCDs.

Salt-Related Knowledge, Attitudes, and Behaviors and Their Relationship with 24-Hour Urinary Sodium Excretion in Chinese Adults

Salt intake in China is very high, which increases the risk of hypertension and cardiovascular disease. This study aimed to assess the levels of salt-related knowledge, attitudes, and behaviors (KABs) and the factors that influence them and to explore the relationship between the scores of salt-related KAB and 24-h urinary sodium excretion. In 2018, we collected data from 5453 individuals aged 18-75 years from six provinces in China. A face-to-face survey was carried out, focusing on the KAB related to salt reduction. All participants were asked to collect one 24-h urine sample. Of the 5453 participants, 5352 completed urine collection. The mean score for overall KAB was 31.27 (SD = 9.18), which was composed of three elements: knowledge 4.80 (SD = 5.14), attitude 9.33 (SD = 3.93), and behavior 17.14 (SD = 4.43). The average 24-h urinary sodium excretion was 187.70 (SD = 77.48) mmol, which was equivalent to a urinary sodium excretion of 4.32 (SD = 1.78) g/d. We found that salt-related knowledge, attitude, behavior, and overall KAB scores were all inversely associated with 24-h urinary sodium excretion. For every one-point increase in the KAB score, the 24-h urinary sodium excretion decreased by 0.851 mmol (95% CI: -1.095, -0.602). We also found that location (rural/urban), sex, age, and education are associated with salt-related KAB scores. These results suggest that large-scale health education is needed to reduce salt intake in the Chinese population. In particular, efforts should be focused on reaching those who live in rural areas with low educational levels and older people.

Protocol for a novel sodium and blood pressure reduction intervention targeting online grocery shoppers with hypertension - the SaltSwitch Online Grocery Shopping randomized trial

BACKGROUND

High dietary sodium intake is a leading cause of hypertension. A major source of dietary sodium is salt added to processed food products available in retail food environments. The fast-growing online grocery shopping setting provides new opportunities for salt reduction interventions that support consumers in choosing healthier options.

METHODS

The SaltSwitch Online Grocery Shopping randomized controlled trial is investigating the feasibility, acceptability, and effectiveness of a novel intervention for lowering salt consumption and blood pressure amongst people with hypertension who shop for groceries online. The intervention is based on a bespoke web browser extension that interfaces with a major retailer's online store to highlight and interpret product sodium content and suggest similar but lower-sodium alternatives. The primary outcome of interest is change in mean systolic blood pressure between individuals randomized (1:1) to the intervention and control (usual online shopping) arms at 12 weeks. Secondary outcomes are diastolic blood pressure, spot urinary sodium and sodium:potassium ratio, sodium purchases, and dietary intake. Intervention implementation and lessons for future uptake will be assessed using a mixed methods process evaluation. Participants with hypertension who shop online for groceries and exhibit high sodium purchasing behavior are being recruited across Australia. A target sample size of 1,966 provides 80% power (2-sided alpha = 0.05) to detect a 2 mm Hg difference in systolic blood pressure between groups, assuming a 15 mm Hg standard deviation, after allowing for a 10% dropout rate.

DISCUSSION

This trial will provide evidence on an innovative intervention to potentially reduce salt intake and blood pressure in people with hypertension. The intervention caters to individual preferences by encouraging sustainable switches to similar but lower-salt products. If effective, the intervention will be readily scalable at low cost by interfacing with existing online retail environments.

Effects of Digitalized Front-of-Package Food Labels on Healthy Food-Related Behavior: A Systematic Review

Front-of-package (FOP) food labels may impact healthy food-related behavior. However, such labels may be presented using new technology and they may impact behavior differently than physical labels. This systematic review investigated the effects of physical and digitalized labels on healthy food-related behavior. This review used four search engines to collect articles that investigated the effects of food labels on the purchase, consumption, hypothetical choice, and self-reports of healthy foods. General findings, types of labels, or whether the articles used physical versus digitalized static, interactive, or technology-enabled labels were synthesized. The dependent variables were categorized according to whether they were under full, partial, or no control of the independent variables. The risk of bias was measured by the RoB 2 tool and adapted Joanna Briggs Institute Checklist. The search strategy identified 285 records and 30 articles were included. While digitalized static and physical labels did not differ in their effects on healthy food-related behavior, technology-enabled labels were more predictive of healthy food-related behavior than interactive labels.

Effect of different front-of-package food labels on healthfulness perception of ultraprocessed food and intention to purchase the products- A randomised controlled trial

This study aimed to evaluate the effect of different labels on participants: identifying products high in nutrients of concern; identifying unhealthy products, and intention to purchase unhealthy products. This blinded randomised controlled trial included a representative sample of South African households (n = 1951). Per household we selected a member primarily responsible for food purchases. Participants were randomised into the Warning Label (WL), Guideline Dietary Amounts (GDA) or Multiple Traffic Light (MTL) arms. Each participant answered questions in a no label condition (control) followed by same questions in the label condition (experiment). Complete data were collected and analysed for 1948 participants (WL = 33.7%, GDA = 32.1% and MTL = 34.2%). The probability of correctly identifying products high in nutrients of concern and identifying products as being unhealthy was higher with the WL compared to the GDA or MTL for most items. There was no difference in performance between the GDA and the MTL when considering all items together. A higher percentage of participants reported a lower intention to purchase an unhealthy product after exposure to the WL compared to MTL for 5 out of 6 products; 2 out of 6 products for the WL compared to GDA and 2 out of 6 products for GDA compared to MTL. Compared to the control condition, exposure to each of the labels resulted in better identification of nutrients of concerns, unhealthy products and a lower intention to purchase when considering all specific outcome items together. The WL showed a higher potential to enable South African consumers to identify products high in nutrients of concern, identify unhealthy products and discourage purchasing of unhealthy products.

Relationship between front-of-pack labeling and nutritional characteristics of food products: An attempt of an analytical approach

The adoption of supplementary nutrition information, i.e., front-of-pack labeling (FOPL), on pre-packed food products is advocated as a tool to improve the consumers' knowledge of the nutrient content or the nutritional quality of foods, but also to drive products reformulation by the food industry. Ultimately, FOPL should help people to select foods in order to compose an overall balanced diet, which is essential for health. However, the extent to which the different FOPL systems proposed in the European Union (EU) (interpretative or informative) are effectively able to convey the information useful to improve both food choices and dietary habits of the consumers is still under debate and needs to be analyzed in detail. The use of 3 FOPL schemes proposed within the EU (Nutri-Score, Keyhole and NutrInform Battery) to compare products available on the Italian market within different food categories, highlights some critical issues: (1) different FOPL provide to consumers different kinds of information; (2) systems based on similar theoretical approaches can provide conflicting information; (3) the algorithms on which interpretative FOPL are based can give the same summary information for products differing in nutrient composition, impact on the overall dietary balance and therefore on the health of people with different characteristics, physiological/pathological conditions, and nutritional requirements; (4) on the other hand, products with similar nutrient composition can obtain different interpretative FOPL; (5) informative systems are generally more complex and require greater both attention and knowledge from the consumer; (6) FOPL based on 100 g of product overlook the role of portion (and frequency of consumption) in determining the nutrient intake without informing on the contribution of a single food to the overall diet; (7) FOPL based on scoring systems could promote the reformulation of selected products, especially with a composition very close to the threshold limits; (8) for the portion-based informative FOPL systems, the incentive for reformulation could essentially involve the reduction of portion size. Finally, the importance of nutritional education interventions, which are required to encourage the use by consumers of informative FOPL systems, cannot be neglected to improve the quality of diets regardless of the FOPL used.

Uncovering the Effect of European Policy-Making Initiatives in Addressing Nutrition-Related Issues: A Systematic Literature Review and Bibliometric Analysis on Front-of-Pack Labels

The last decades have been marked by the introduction of front-of-pack labels (FoPL) as an institutional corrective action against obesity and nutrition-related illnesses. However, FoPL-related policy-making initiatives issued by the European Union evolved over time and led to a diversity of labels with different effects on consumers' decisions. As a result, the extant literature adapted to the regulative scenario over the years and investigated the effects of the labels, creating consensus on some topics while being fragmented on others. Similarly, policy-makers adapted some regulations to the evidence supported by the research. With the aim to systematize the overall structure and evolution of the literature on FoPL, investigate the presence of a consensus on specific topics through a co-citation analysis, and examine the evolution of the consensus and co-citation networks over the years and potential research gaps, we report the results of bibliometric and co-citation analyses and a systematic literature review involving 170 papers and a selection of 49 articles published in the last months, for a total of 219 articles, analysed according to three timespans (Period 1 (1989-2011); Period 2 (2012-2016) and Period 3 (2017-2022)). Our findings highlight the interplay of policy development and FoPL research, the presence of few self-reinforcing and well-established co-citation networks based on validated evidence in the literature and the presence of alternative emerging theories that offer different and valid perspectives overlooked by mainstream co-citation research networks.

Nutri-Score: Awareness, Perception and Self-Reported Impact on Food Choices among French Adolescents

To date, no studies have evaluated the appropriation of the front-of-pack Nutri-Score labeling among adolescents, although they are both consumers and buyers of food products. Therefore, the objectives of the present study were (1) to assess Nutri-Score awareness, perception and self-reported impact on food choices in French adolescents and (2) to identify the determinants associated with higher Nutri-Score awareness and self-reported impact on food choices. A web-based survey was conducted in November 2021 among 1201 adolescents. Multivariate logistic models were used to evaluate the relationships between individual factors and Nutri-Score awareness and self-reported impact on food choices. Almost all the adolescents reported to know the Nutri-Score (97.0%) and more than 9 out of 10 considered this logo easy to understand and easy to identify on food packages. Finally, 54% self-reported that the label had already impacted their food choices. Girls (2.28 (1.09−4.77), p = 0.028) and the 15−17-year-olds (3.12 (1.32−7.35), p = 0.0094) were more likely to be aware of the label compared with their respective counterparts (i.e., boys and the 11−14-year-olds). Regarding the impact of food choices, the use of the Nutri-Score by the parents was the most determinant criterion (7.74 (5.74−10.42), p < 0.0001). Thus, promotion campaigns should target both adolescents and parents.

Front-of-Package Labels on Unhealthy Packaged Foods in India: Evidence from a Randomized Field Experiment

Policies to require front-of-package labels (FOPLs) on packaged foods may help Indian consumers to better identify foods high in nutrients of concern, including sugar, saturated fat, and sodium, and discourage their consumption, which are outcomes that are critical for preventing rises in diet-related non-communicable disease. The objective was to test whether FOPLs helped Indian consumers identify “high-in” packaged foods and reduce intentions to purchase them. We conducted an in-person randomized experiment (n = 2869 adults between ages 18 and 60 years old) in six states of India in 2022. Participants were randomized to one of five FOPLs: a control label (barcode), warning label (octagon with “High in [nutrient]”), Health Star Rating (HSR), Guideline Daily Amount (GDA), or traffic light label. Participants then viewed a series of packaged foods high in sugar, saturated fat, or sodium with the assigned FOPL, and rated product perceptions and label reactions. Fewer than half of participants in the control group (39.1%) correctly identified all products high in nutrient(s) of concern. All FOPLs led to an increase in this outcome, with the biggest differences observed for the warning label (60.8%, p < 0.001), followed by the traffic light label (54.8%, p < 0.001), GDA (55.0%, p < 0.001), and HSR (45.0%, p < 0.01). While no FOPLs led to a reduction in intentions to purchase the packaged foods, the overall pattern of results suggested that warning labels are the most effective FOPL to help Indian consumers identify unhealthy foods.

Nutritional Quality of Pre-Packaged Foods in China under Various Nutrient Profile Models

This study used various nutrient profile models (NPMs) to evaluate the nutritional quality of pre-packaged foods in China to inform future food policy development. Nutrition data for pre-packaged foods were collected through FoodSwitch China in 2017-2020. The analyses included 73,885 pre-packaged foods, including 8236 beverages and 65,649 foods. Processed foods (PFs) and ultra-processed foods (UPFs) accounted for 8222 (11.4%) and 47,003 (63.6%) of all products, respectively. Among the 55,425 PFs and UPFs, the overall proportion of products with an excessive quantity of at least one negative nutrient was 86.0% according to the Chilean NPM (2019), 83.3% for the Pan American Health Organization NPM (PAHO NPM), and 90.6% for the Western Pacific Region NPM for protecting children from food marketing (WPHO NPM), respectively. In all NPMs, 70.4% of PFs and UPFs were identified as containing an excessive quantity of at least one negative nutrient, with higher proportions of UPFs compared to PFs. Food groups exceeding nutrient thresholds in most NPMs included snack foods, meat and meat products, bread and bakery products, non-alcoholic beverages, confectionery, and convenience foods. In conclusion, PFs and UPFs accounted for three-fourths of pre-packaged foods in China, and the majority of PFs and UPFs exceeded the threshold for at least one negative nutrient under all three NPMs. Given the need to prevent obesity and other diet-related chronic diseases, efforts are warranted to improve the healthiness of foods in China through evidence-based food policy.

Comment on Muzzioli et al. Are Front-of-Pack Labels a Health Policy Tool? Nutrients 2022, 14, 771

As scientists working and publishing in the field of front-of-pack nutrition labelling (FOPNL) for many years, we have read with interest and concern the narrative review regarding their effectiveness by Muzzioli et al. [...].

Reply to Aguenaou et al. Comment on "Muzzioli et al. Are Front-of-Pack Labels a Health Policy Tool? Nutrients 2022, 14, 771"

As a team of scientists who believe that exchanging views is one of the prerequisites of the scientific method, we welcome the comments from Aguenaou H et al. [...].

Exploring ways to respond to rising obesity and diabetes in the Caribbean using a system dynamics model

Diabetes and obesity present a high and increasing burden of disease in the Caribbean that have failed to respond to prevention policies and interventions. These conditions are the result of a complex system of drivers and determinants that can make it difficult to predict the impact of interventions. In partnership with stakeholders, we developed a system dynamics simulation model to map the system driving diabetes and obesity prevalence in the Caribbean using Jamaica as a test case. The study aims to use the model to assess the magnitude changes necessary in physical activity and dietary intake to achieve global targets set by the WHO Global Action plan and to test scenarios for interventions to reduce the burden of diabetes and obesity. Continuing current trends in diet, physical activity, and demographics, the model predicts diabetes in Jamaican adults (20+ years) to rise from 12% in 2018 to 15.4% in 2030 and 20.9% by 2050. For obesity, it predicts prevalence to rise from 28.6% in 2018 to 32.1% by 2030 and 39.2% by 2050. The magnitude change necessary to achieve the global targets set by the World Health Organization is so great as to be unachievable. However, a combination of measures both upstream (including reducing the consumption of sugar sweetened beverages and ultra processed foods, increasing fruit and vegetable intake, and increasing moderate-to-vigorous activity) at the population level, and downstream (targeting people at high risk and with diabetes) can significantly reduce the future burden of diabetes and obesity in the region. No single intervention reduces the prevalence of these conditions as much as a combination of interventions. Thus, the findings of this model strongly support adopting a sustained and coordinated approach across various sectors to synergistically maximise the benefits of interventions.

News coverage of Mexico's front-of-package food label policy

Objectives

To examine news coverage of Mexico’s front-of-package food labelling policy.

Methods

We used Lexis Nexis to identify newspaper articles that mention the proposed law in four Mexican newspapers representing politically centre-left and centre-right perspectives. We coded for type and valence of arguments, sources and research evidence cited.

Results

We identified N=361 relevant articles. Coverage of the front-of-package food label policy was primarily news (vs editorial/opinion). While most were neutral in tone, left-leaning newspapers had slightly more positive overall coverage compared with right-leaning newspapers, indicated by publishing more stories in favour of the policy, fewer in opposition, more propolicy arguments and more frequent inclusion of perspectives by government officials and public health advocates. Despite some evidence of bias, there was a general lack of credible opposition to the policy and mention of opponents across newspapers.

Conclusions and policy implications

The relative absence of food and beverage industry stakeholders in news coverage of the food label policy is unexpected given their documented involvement in prior food policy debates. We discuss possible reasons for their conspicuous absence and lessons for public health advocates around the globe.

Analysis of Content, Social Networks, and Sentiment of Front-of-Pack Nutrition Labeling in the European Union on Twitter

In recent years, concerted political efforts have been made at the national and European Union (EU) level to promote the consumption of healthy foods. The European Commission (EC) expressed the need for a harmonized and mandatory front-of-pack nutrition labeling (FOPL) system at the EU level. The EC will adopt the proposal by the end of 2022. Our research work aims to understand the public discourse on FOPL in the EU via Twitter, by analyzing tweet content, sentiment, and mapping network characteristics. Tweet search and data collection were performed using the Twitter application programming interface (API), with no time or language restrictions. The content was coded with the QRS Nvivo software package and analyzed thematically. Automatic sentiment analysis was performed with QSR Nvivo, and network analysis was performed with Gephi 0.9.2. A total of 4,073 tweets were posted, mostly from the UK, Spain, and France. Themes that have emerged from the discussion on Twitter include the types of food labeling, food industry, healthy vs. unhealthy foods in the context of food labeling, EU regulation, political conflicts, and science and education. Nutri-Score dominated the discussion on Twitter. General topics were perceived negatively by Twitter users with more positive sentiments toward the food industry, while negative sentiments were observed toward the discourse of political conflicts. The network analysis showed that a centralized communication was hardly existed between countries. Our results reveal that the discussion of FOPL on Twitter is limited to a very limited group of people, and it seems necessary to inform a wide range of consumers about existing and upcoming FOPL schemes. Educational programs should empower consumers to understand what a healthy diet is and how it relates to FOPL, regardless of the existing labeling system.

Association between Use of Nutrition Labels and Risk of Chronic Kidney Disease: The Korean National Health and Nutrition Examination Survey (KNHANES) 2008-2019

Nutrition labeling on food packages is increasingly found to promote healthier food choices associated with lower risk of chronic kidney disease (CKD). To examine associations between nutrition labels use and CKD risk, we conducted a nationally representative cross-sectional study of 32,080 adults from the 2008−2019 Korean National Health and Nutrition Examination Survey. Nutrition labels use was collected via self-reported questionnaires. Ascertainment and severity of CKD was determined by estimated glomerular filtration rate or proteinuria. In multivariable-adjusted (MV) logistic regression models, increasing awareness and use of nutrition labels was significantly associated with lower CKD risk (MV-adjusted OR “nutrition labels aware and use” group vs. “nutrition labels unaware” group [95% CIs]: 0.75 [0.59−0.95], Ptrend:0.03). This inverse association varied with CKD’s risk of progression, with 21% and 42% reduced risk observed for CKD subtypes with “moderate” and “high” risk of progression, respectively (all Ptrend ≤ 0.04). Furthermore, the nutrition labels use and CKD risk association significantly differed by age, with 35% reduced risk observed in the older group aged 49 years or older, but not in the younger group (Pinteraction < 0.001). Our results suggest increasing perception and use of nutrition labels may contribute to CKD prevention and its early asymptomatic progression, especially in older adults.

Traffic Light Diets for Childhood Obesity: Disambiguation of Terms and Critical Review of Application, Food Categorization, and Strength of Evidence

Traffic light labeling (TLL) of foods is a strategy often included in multicomponent behavioral interventions (MBIs) for childhood obesity. Traffic light labels categorize foods as "green" (no restrictions), "yellow" (moderation), and "red" (consume minimally). The body of research investigating the effects of TLL conflates the labeling itself with MBIs that include TLL as one component. For instance, the Academy of Nutrition and Dietetics' Evidence Analysis Library gave traffic light diets Grade I evidence for pediatric weight management. Yet, whether the term traffic light diet referenced TLL in isolation or as part of an MBI was ambiguous. Herein, we evaluate the evidence supporting TLL for childhood obesity as a stand-alone treatment and identify areas requiring further research. No articles from a PubMed search for TLL and weight-related outcomes tested TLL in isolation. One article was identified through reference lists that tested TLL mostly in isolation, which observed no significant differences between groups. TLL definitions and categorizations vary across studies and contexts, using average calories in categories of foods, energy density, or specific ingredients to determine labeling. Systematic reviews generally conclude TLL-based approaches affect food selection and consumption, but none studied obesity-related outcomes. We believe the evidence supports that: 1) there is a lack of standardization regarding TLL food classifications; 2) the term "traffic light diet" is inconsistently used to mean intensive lifestyle programs or TLL itself; and 3) there is insufficient evidence to understand the effects of TLL as an isolatable factor for childhood obesity. Importantly, limited evidence about TLL does not mean it is ineffective; TLL has been incorporated into successful childhood obesity intervention programs, but the unique causal contribution of TLL remains uncertain. Standardized definitions of traffic light labels for categorizing foods and trials with TLL alone are needed to test direct impacts of TLL on obesity-related outcomes.

Polish Consumers' Understanding of Different Front-of-Package Food Labels: A Randomized Experiment

Dietary practices are a key behavioral factor in chronic disease prevention; one strategy for improving such practices population-wise involves front-of-package labels (FoPL). This online randomized study, conducted in a quota-based sample of 1159 Polish adults (mean age = 40.9 ± 15.4 years), assessed the objective understanding of five FoPL: Health Star Rating, Multiple Traffic Lights, NutriScore, Reference Intakes (RI) and Warning Label. Objective understanding was evaluated by comparing results of two nutritional quality ranking tasks (without/with FoPL) using three food categories (breakfast cereals, cakes, pizza). Associations between FoPL exposure and objective understanding were assessed via multivariable ordinal logistic regression. Compared to RI and across food categories, significant improvement in objective understanding was seen for NutriScore (OR = 2.02; 95% CI: 1.41–2.91) and Warning Label (OR = 1.61; 95% CI: 1.12–2.32). In age-stratified analyses, significant improvement in objective understanding compared to RI emerged mainly among adults aged 18–30 years randomized to NutriScore (all food categories: OR = 3.88; 95% CI: 2.04–7.36; cakes: OR = 6.88; 95% CI: 3.05–15.51). Relative to RI, NutriScore was associated with some improvement in objective understanding of FoPL across and within food categories, especially among young adults. These findings contribute to the ongoing debate about an EU-wide FoPL model.

Evaluation of Nutri-Score in Relation to Dietary Guidelines and Food Reformulation in The Netherlands

An unhealthy dietary pattern is an important risk factor for non-communicable diseases. Front-of-Pack nutritional labels such as Nutri-Score can be used to improve food choices. In addition, products can be improved through reformulation. The current study investigates to what extent Nutri-Score aligns with the Dutch Health Council dietary guidelines and whether it can be used as an incentive for reformulation. Nutri-Score calculations were based on the Dutch Branded Food database (2018). The potential shift in Nutri-Score was calculated with product improvement scenarios. The Nutri-Score classification is in line with these dietary guidelines: increase the consumption of fruit and vegetables, pulses, and unsalted nuts. It is, however, less in line with the recommendations to limit (dairy) drinks with added sugar, reduce the consumption of red meat and replace refined cereal products with whole-grain products. The scenario analyses indicated that a reduction in sodium, saturated fat or sugars resulted in a more favourable Nutri-Score in a large variety of food groups. However, the percentage of products with an improved Nutri-Score varied greatly between the different food groups. Alterations to the algorithm may strengthen Nutri-Score in order to help consumers with their food choices.