Are foods 'healthy' or 'healthier'? Front-of-pack labelling and the concept of healthiness applied to foods

Mapping the evidence of novel plant-based foods: a systematic review of nutritional, health, and environmental impacts in high-income countries

CONTEXT

Shifting from current dietary patterns to diets rich in plant-based (PB) foods and lower in animal-based foods (ABFs) is generally regarded as a suitable strategy to improve nutritional health and reduce environmental impacts. Despite the recent growth in supply of and demand for novel plant-based foods (NPBFs), a comprehensive overview is lacking.

OBJECTIVES

This review provides a synthesis of available evidence, highlights challenges, and informs public health and environmental strategies for purposeful political decision-making by systematically searching, analyzing, and summarizing the available literature.

DATA SOURCES

Five peer-reviewed databases and grey literature sources were rigorously searched for publications.

DATA EXTRACTION

Study characteristics meeting the inclusion criteria regarding NPBF nutrient composition and health and environmental outcomes in high-income countries were extracted.

DATA ANALYSIS

Fifty-seven peer-reviewed and 36 grey literature sources were identified; these were published in 2016-2022. NPBFs typically have substantially lower environmental impacts than ABFs, but the nutritional contents are complex and vary considerably across brands, product type, and main primary ingredient. In the limited evidence on the health impacts, shifts from ABFs to PB meats were associated with positive health outcomes. However, results were mixed for PB drinks, with links to micronutrient deficiencies.

CONCLUSION

If carefully selected, certain NPBFs have the potential to be healthier and nutrient-rich alternatives to ABFs and typically have smaller environmental footprints. More disaggregated categorization of various types of NPBFs would be a helpful step in guiding consumers and key stakeholders to make informed decisions. To enable informed policymaking on the inclusion of NPBFs in dietary transitions as part of a wider net-zero and health strategy, future priorities should include nutritional food standards, labelling, and subdivisions or categorizations of NPBFs, as well as short- and long-term health studies evaluating dietary shifts from ABFs to NPBFs and standardized environmental impact assessments, ideally from independent funders.

Consistency of the Initial and Updated Version of the Nutri-Score with Food-Based Dietary Guidelines: A French Perspective

BACKGROUND

To help consumers to make healthier food choices, 7 European countries have implemented the front-of-pack nutrition label Nutri-Score. The algorithm was updated in 2022-2023 by the Nutri-Score European scientific committee, based on the current scientific knowledge.

OBJECTIVES

The aim of this study was to investigate the consistency of the newly internationally developed algorithm with the French food-based dietary guidelines (FBDG) and compare the respective performances of the initial and updated algorithm.

METHODS

Three complementary French food composition databases were used to access extensive coverage of the food supply in France (n = 46,752): the Oqali, OpenFoodFacts, and CIQUAL databases. Based on the French FBDG, a list of 41 criteria was defined by which the consistency between French FBDG and the Nutri-Score was assessed (eg, consumption of fresh vegetables is promoted in FBDG, thus the Nutri-Score should rate favorably such products).

RESULTS

Of all criteria, the initial algorithm met 63% (26/41) of them, whereas the revised algorithm met 85% (35/41) of them. Improvements achieved by the updated version of the Nutri-Score in alignment with the FBDG were particularly observed for high-fat products (ie, fatty fish, nuts, and seeds), sweet products (ie, ice creams and sweet spreads), salty products (ie, savory snacks and salted nuts), dairy beverages, and beverages with artificial sweeteners.

CONCLUSIONS

The Nutri-Score's updated nutrient profiling system appears to rate foods more consistently regarding the French dietary guidelines and improved the currently existing system. This work supports the implementation of the updated nutrient profiling system underlying Nutri-Score.

Recommender systems for sustainability: overview and research issues

Sustainability development goals (SDGs) are regarded as a universal call to action with the overall objectives of planet protection, ending of poverty, and ensuring peace and prosperity for all people. In order to achieve these objectives, different AI technologies play a major role. Specifically, recommender systems can provide support for organizations and individuals to achieve the defined goals. Recommender systems integrate AI technologies such as machine learning, explainable AI (XAI), case-based reasoning, and constraint solving in order to find and explain user-relevant alternatives from a potentially large set of options. In this article, we summarize the state of the art in applying recommender systems to support the achievement of sustainability development goals. In this context, we discuss open issues for future research.

Effect of a new graphically modified Nutri-Score on the objective understanding of foods' nutrient profile and ultraprocessing: a randomised controlled trial

Introduction

When considering health-related impacts of foods, nutrient profile and (ultra)processing are two complementary dimensions. The Nutri-Score informs on the nutrient profile dimension. Recently, mounting evidence linked ultraprocessed food consumption to various adverse health outcomes, independently of their nutrient profile. To inform consumers about each of these health-related dimensions of food, we tested, in a randomised controlled trial, if a graphically modified version 'Nutri-Score V.2.0', including a black 'ultraprocessed' banner, would improve the capacity of consumers to rank products according to their nutrient profile and to detect those ultra-processed, compared with a no-label situation.

Methods

21 159 participants included in the NutriNet-Santé web-cohort were randomly assigned to a control arm (no front-of-pack label) or an experimental arm (Nutri-Score 2.0) and were presented an online questionnaire with three sets of food products (cookies, breakfast cereals and ready-to-eat meals) to rank according to nutrient profile and to identify ultraprocessed foods. The primary outcome was objective understanding of nutrient profile and ultraprocessing, represented by a score of correct answers. Secondary outcomes were purchasing intentions and the healthiest-perceived product. Multinomial logistic regressions were performed.

Results

The Nutri-Score V.2.0 increased the objective understanding of both the nutrient profile dimension (OR highest vs lowest score category=29.0 (23.4-35.9), p<0.001) and the ultraprocessing dimension (OR=174.3 (151.4-200.5), p<0.001). Trends were similar for cookies, breakfast cereals and ready-to-eat meals. The Nutri-Score V.2.0 had a positive effect on purchasing intentions and on the products perceived as the healthiest.

Conclusion

This randomised controlled trial demonstrates the interest of a front-of-pack label combining the Nutri-Score (informing on the nutrient profile dimension) with an additional graphic mention, indicating when the food is ultraprocessed, compared with a no-label situation. Our results show that a combined label enabled participants to independently understand these two complementary dimensions of foods.

Trial registration number

NCT05610930.

Seeing the forest through the trees: the importance of the food matrix in diet quality and human health

Poor nutrition is linked to morbidity and mortality globally. The nutrition transition towards diets composed of high amounts of ultra-processed foods that are more refined, calorie-dense and nutrient poor, is considered a factor in the rise of diet-related metabolic diseases in low- and middle-income countries. Historically, nutrition strategies aimed at mitigating metabolic diseases linked to sub-optimal diets have targeted isolated nutrients, like fat; however, they overlook the complexity and importance of the whole food and food matrices, which can lead to unintended consequences, such as avoidance of nutrient-dense foods. Dairy foods, such as milk, cheese and yogurt are underconsumed, nutrient-dense foods that are often fall in the cross-hairs of reductionist nutrition strategies because of their contribution of calories, saturated fat, and sodium to the diet. This article highlights dairy foods as an example for exploring the complex matrices of food, nutrients, and other bioactive components that are associated with improved nutrient status and reduced risk of metabolic diseases, while considering a holistic approach to improving diet quality and human health. Statement of Significance Historically, nutrition strategies aimed at mitigating metabolic diseases linked to sub-optimal diets have targeted isolated nutrients, like fat; however, they overlook the complexity and importance of the whole food and food matrices, and can lead to unintended consequences. This article explores the complex matrices of nutrients and other bioactive components that are associated with improved nutrient status and reduced risk of metabolic diseases, and considers a holistic approach to improving diet quality and human health.

Comparison of Nutri-Score and Health Star Rating Nutrient Profiling Models Using Large Branded Foods Composition Database and Sales Data

Front-of-package nutrition labelling (FOPNL) is known as an effective tool that can encourage healthier food choices and food reformulation. A very interesting type of FOPNL is grading schemes. Our objective was to compare two market-implemented grading schemes-European Nutri-Score (NS) and Australian Health Star Rating (HSR), using large Slovenian branded foods database. NS and HSR were used for profiling 17,226 pre-packed foods and drinks, available in Slovenian food supply dataset (2020). Alignment between models was evaluated with agreement (% of agreement and Cohen's Kappa) and correlation (Spearman rho). The 12-month nationwide sales-data were used for sale-weighing, to address market-share differences. Study results indicated that both models have good discriminatory ability between products based on their nutritional composition. NS and HSR ranked 22% and 33% of Slovenian food supply as healthy, respectively. Agreement between NS and HSR was strong (70%, κ = 0.62) with a very strong correlation (rho = 0.87). Observed profiling models were most aligned within food categories Beverages and Bread and bakery products, while less aligned for Dairy and imitates and Edible oils and emulsions. Notable disagreements were particularly observed in subcategories of Cheese and processed cheeses (8%, κ = 0.01, rho = 0.38) and Cooking oils (27%, κ = 0.11, rho = 0.40). Further analysis showed that the main differences in Cooking oils were due to olive oil and walnut oil, which are favoured by NS and grapeseed, flaxseed and sunflower oil that are favoured by HSR. For Cheeses and cheese products, we observed that HSR graded products across the whole scale, with majority (63%) being classified as healthy (≥3.5 *), while NS mostly graded lower scores. Sale-weighting analyses showed that offer in the food supply does not always reflect the sales. Sale-weighting increased overall agreement between profiles from 70% to 81%, with notable differences between food categories. In conclusion, NS and HSR were shown as highly compliant FOPNLs with few divergences in some subcategories. Even these models do not always grade products equally high, very similar ranking trends were observed. However, the observed differences highlight the challenges of FOPNL ranking schemes, which are tailored to address somewhat different public health priorities in different countries. International harmonization can support further development of grading type nutrient profiling models for the use in FOPNL, and make those acceptable for more stake-holders, which will be crucial for their successful regulatory implementation.

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.

The Effect of a Future-Self Avatar Mobile Health Intervention (FutureMe) on Physical Activity and Food Purchases: Randomized Controlled Trial

BACKGROUND

Insufficient physical activity and unhealthy diets are contributing to the rise in noncommunicable diseases. Preventative mobile health (mHealth) interventions may help reverse this trend, but present bias might reduce their effectiveness. Future-self avatar interventions have resulted in behavior change in related fields, yet evidence of whether such interventions can change health behavior is lacking.

OBJECTIVE

We aimed to investigate the impact of a future-self avatar mHealth intervention on physical activity and food purchasing behavior and examine the feasibility of a novel automated nutrition tracking system. We also aimed to understand how this intervention impacts related attitudinal and motivational constructs.

METHODS

We conducted a 12-week parallel randomized controlled trial (RCT), followed by semistructured interviews. German-speaking smartphone users aged ≥18 years living in Switzerland and using at least one of the two leading Swiss grocery loyalty cards, were recruited for the trial. Data were collected from November 2020 to April 2021. The intervention group received the FutureMe intervention, a physical activity and food purchase tracking mobile phone app that uses a future-self avatar as the primary interface and provides participants with personalized food basket analysis and shopping tips. The control group received a conventional text- and graphic-based primary interface intervention. We pioneered a novel system to track nutrition by leveraging digital receipts from loyalty card data and analyzing food purchases in a fully automated way. Data were consolidated in 4-week intervals, and nonparametric tests were conducted to test for within- and between-group differences.

RESULTS

We recruited 167 participants, and 95 eligible participants were randomized into either the intervention (n=42) or control group (n=53). The median age was 44 years (IQR 19), and the gender ratio was balanced (female 52/95, 55%). Attrition was unexpectedly high with only 30 participants completing the intervention, negatively impacting the statistical power. The FutureMe intervention led to small statistically insignificant increases in physical activity (median +242 steps/day) and small insignificant improvements in the nutritional quality of food purchases (median -1.28 British Food Standards Agency Nutrient Profiling System Dietary Index points) at the end of the intervention. Intrinsic motivation significantly increased (P=.03) in the FutureMe group, but decreased in the control group. Outcome expectancy directionally increased in the FutureMe group, but decreased in the control group. Leveraging loyalty card data to track the nutritional quality of food purchases was found to be a feasible and accepted fully automated nutrition tracking system.

CONCLUSIONS

Preventative future-self avatar mHealth interventions promise to encourage improvements in physical activity and food purchasing behavior in healthy population groups. A full-powered RCT is needed to confirm this preliminary evidence and to investigate how future-self avatars might be modified to reduce attrition, overcome present bias, and promote sustainable behavior change.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04505124; https://clinicaltrials.gov/ct2/show/NCT04505124.

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.

"Even We Are Confused": A Thematic Analysis of Professionals' Perceptions of Processed Foods and Challenges for Communication

Processed foods are increasingly under the spotlight since the development of classification systems based on proxies for food processing. Published critical reviews and commentaries suggest different views among professional disciplines about the definition and classification of processed food. There is a need to further understand perspectives of professionals on the conceptualisation of processed food and the agreements and disagreements among experts, to encourage interdisciplinary dialogue and aid communication to the public. The aim of this research was to elicit views and understandings of professionals on processed food, their perceptions of lay people's perceptions of the same, and their perspectives on the challenges of communicating about processed foods to the public. The online discussion groups brought together a range of professionals (n = 27), covering the fields of nutrition, food technology, policy making, industry, and civil society, mixed in 5 heterogenous groups. Through thematic analysis the following themes relating to the conceptualisation of processed food and challenges for communication were identified: (1) Broad concepts that need differentiation; (2) Disagreements on scope and degree of processing; (3) The role of food processing within the food system: the challenges in framing risks and benefits; and (4) The challenge of different perspectives and interests for risk communication. Throughout the discussions blurred lines in the characterisation of processing, processed foods, and unhealthy foods were observed. Participants agreed that consensus is important, but difficult. Participants identified a need for further interdisciplinary dialogue, including public engagement, to break down the observed issues, and work towards a mutual understanding and develop clear communication messages.

Pre-adolescent children's understanding of health and being healthy: a multidimensional perspective from the UK

Purpose

The authors applied a multidimensional conceptual lens that incorporated physical, emotional, social, intellectual and spiritual health dimensions to explore pre-adolescent children's understanding of health and what it means to be healthy.

Design/methodology/approach

Forty-six children aged 9–11 years old completed a short questionnaire about their understanding of health and what it means to be healthy. Data analysis was completed through a deductive analysis applying a multidimensional conceptual lens and an inductive thematic analysis of the content of children's responses to each question.

Findings

The analysis of children's understandings of health and being healthy both revealed five common themes: Being well, physically active, fit and healthy; Healthy eating and body composition; Physical activity examples; Physical activity characteristics; and Unsure or ambiguous. Across both questions the majority of responses reflected the physical dimension of health, with only a few references to the social and emotional dimensions. There was no evidence of the intellectual or spiritual dimensions of health in children's responses to either question.

Practical implications

The authors’ data suggest that the plateau in adolescent UK children's trajectory of understandings originates earlier in childhood, with children aged 9–11 showing a similarly limited understanding of health and being healthy as UK adolescents. Moreover, this focus on the physical dimension is narrower than previously considered as it is restricted to the movement category of this dimension only.

Originality/value

The authors’ findings have implications for the timing and focus of health education interventions for children.

Branded Foods Databases as a Tool to Support Nutrition Research and Monitoring of the Food Supply: Insights From the Slovenian Composition and Labeling Information System

Branded foods databases are becoming very valuable not only in nutrition research but also for clinical practice, policymakers, businesses, and general population. In contrast to generic foods, branded foods are marked by rapid changes in the food supply because of reformulations, the introduction of new foods, and the removal of existing ones from the market. Also, different branded foods are available in different countries. This not only complicates the compilation of branded foods datasets but also causes such datasets to become out of date quickly. In this review, we present different approaches to the compilation of branded foods datasets, describe the history and progress of building and updating such datasets in Slovenia, and present data to support nutrition research and monitoring of the food supply. Manufacturers are key sources of information for the compilation of branded foods databases, most commonly through food labels. In Slovenia, the branded food dataset is compiled using standard food monitoring studies conducted at all major retailers. Cross-sectional studies are conducted every few years, in which the food labels of all available branded foods are photographed. Studies are conducted using the Composition and Labeling Information System (CLAS) infrastructure, composed of a smartphone application for data collection and online data extraction and management tool. We reviewed various uses of branded foods datasets. Datasets can be used to assess the nutritional composition of food in the food supply (i.e., salt, sugar content), the use of specific ingredients, for example, food additives, for nutrient profiling, and assessment of marketing techniques on food labels. Such datasets are also valuable for other studies, for example, assessing nutrient intakes in dietary surveys. Additional approaches are also being tested to keep datasets updated between food monitoring studies. A promising approach is the exploitation of crowdsourcing through the mobile application VešKajJeš, which was launched in Slovenia to support consumers in making healthier dietary choices.

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.

Evaluation of the Ability of Nutri-Score to Discriminate the Nutritional Quality of Prepacked Foods Using a Sale-Weighting Approach

The implementation of mandatory front-of-pack nutrition labelling is currently being discussed in the European Union (EU). The Nutri-Score (NS) was developed in France to empower consumers to make informed and healthier food choices. Based on strong evidence of its efficacy in supporting healthy choices, it has already been implemented for voluntary use in some EU member states, making it relevant to developing a harmonised EU scheme. This study aimed to evaluate the NS’s discriminating ability on products available in the food supply and compare it with Slovenian national nutritional recommendations based on an adapted WHO Europe (WHOE) profile. The innovative approach of the study is that we used sale-weighting to address the public health importance of available foods, with consideration of market share. We profiled 15,822 products available in the Slovenian food supply in 2017. The NS had a high ability to discriminate food products based on nutritional composition. Products that are generally encouraged in dietary recommendations (fruits, vegetables, cereals) had, in most cases, better NS grades than less favourable products (confectionery, snack foods, added fats), which is also in line with the national nutrition policy programme. The discriminating ability of the model was also shown within food (sub)categories (e.g., plain and flavoured yoghurt). Sale-weighting showed that offerings do not always reflect sales. Major differences between offerings and sales were observed for beverages, dairy, fruits/vegetables, and edible oils/emulsions. Additionally, sale-weighted distribution tended towards less favourable nutritional composition, particularly in categories with overall smaller offerings of products with favourable composition. The NS showed moderate agreement with the WHOE profile (κ = 0.57); differences were particularly observed in flavoured yoghurts, juices, cooking oils, and cheeses. Modelling the operation of the NS with representative real-life food samples provided insight valuable for developing and implementing harmonised mandatory front-of-pack nutrition labelling in Europe.