Evidence on consumers' perceptions, understanding and uses of the Nutri-Score to improve communication about its update: a qualitative study with shopping observations in France

BACKGROUND

The Nutri-Score is a front-of-pack nutrition label widely used in several European countries to improve the overall quality of consumers' diets. In the view of the upcoming update of the Nutri-Score algorithm, this study evaluates consumers' perceptions, understanding and uses of this label as well as their expectations or criticisms and opinions regarding the algorithm update.

METHODS

Two complementary qualitative approaches were used in 2023. Six focus group discussions with a total of 51 participants as well as 20 individual shopping observations with real purchase conditions followed by in-depth interviews were conducted among French adults. The sessions were recorded, transcribed and then analysed using a thematic approach.

RESULTS

Participants were familiar with the Nutri-Score but used it for food purchasing in a secondary way due to other more important criteria such as price or habits. They were aware that the label aimed to help them choose healthier products and to protect consumers. However, the lack of awareness about some aspects of the label such as the entity responsible for it or the calculation method of the score created a sense of mistrust about the Nutri-Score. Nevertheless, consumers did not report hearing criticism about the label in the media. Finally, they considered the updating of the label to be relevant.

CONCLUSIONS

Participants had a rather positive image of the Nutri-Score and its forthcoming update. Notwithstanding, to improve consumers' trust in the label, this study recommends launching an information campaign to explain its calculation method and reassure them that the Nutri-Score is a government-endorsed scheme as part of the national public health nutrition policy.

Development and validity testing of the Canadian Food Scoring System (CFSS), a nutrient profile model based on the recommendations of Canada's Food Guide 2019

Canada's food guide (CFG) 2019 provides dietary guidance for all Canadians; however, there is no tool available to help Canadians easily determine how individual foods align with CFG. Therefore, the objectives of this study were (1) to develop a nutrient profile model, Canadian Food Scoring System (CFSS), to rank the healthfulness of individual foods according to the recommendations of CFG; and (2) to assess its validity. The CFSS was developed based on CFG, leveraging existing Canadian labelling regulations to set quantitative criteria for the CFG recommendations. The CFSS included three main steps: (1) classifying foods into the nutritious food categories and assigning points based on the alignment with the recommendations of CFG; (2) deducting points based on the levels of saturated fat, sugars, and sodium using thresholds from Canadian front-of-pack labelling regulations; and (3) calculating the final score from the first two steps to classify foods into one of five categories: "very poor," "poor," "fair," "good," or "excellent" choice. Convergent validity was assessed by examining the alignment of the CFSS with Health Canada's CFG-Food Classification System using a national food composition database and the Healthy Eating Food Index-2019 using nationally representative dietary intake survey data. The CFSS showed strong correlation with the CFG-Food Classification System (ρ = 0.782, p < 0.001) and moderate correlation with the Healthy Eating Food Index-2019 (r = 0.636, p < 0.001), indicating good convergent validity both at the food and dietary level. The newly developed CFSS can assess the alignment of individual foods with CFG, which can be used to help Canadians more easily make healthy food choices.

Canadian Dietary Intakes Assessed by Nutrient Profiling Models and Association with Mortality and Cardiovascular Disease

Purpose: Nutrient profiling (NP) ranks foods according to nutritional composition and underpins policies (e.g., front-of-package (FOP) labelling). This study aimed to evaluate Canadian adults' dietary intakes using proposed Canadian FOP "high-in" labelling thresholds and international NP models (i.e., Ofcom, FSANZ, and Nutri-Score) and examine the association between intakes using international NP models and all-cause mortality and cardiovascular disease (CVD).Methods: Intakes from the Canadian Community Health Survey-Nutrition (CCHS-Nutrition) 2004 and 2015 were given NP scores and assessed against FOP thresholds. CCHS-Nutrition 2004 was linked with death records (Canadian Vital Statistics Database, n = 6767) and CVD incidence and mortality (hospital Discharge Abstract Database, n = 6420) until December 2017.Results: Foods that would require FOP labels, should there be such regulation in Canada, contributed 38% of calories. Association between NP scores and mortality was significant for Ofcom, FSANZ, and Nutri-Score (hazard ratio (HR) in highest quintile (lowest quality): 1.73, 95%CI [1.20-2.49], 1.59[1.15-2.21], and 1.75[1.18-2.59], respectively), and for CVD incidence, among males (HR in highest quintile: 2.11[1.15-3.89], 1.74[1.07-2.84], and 2.29[1.24-4.24], respectively).Conclusions: Canadians had moderately healthy intakes. NP systems could discriminate between low and high dietary quality such that adults with the lowest diet quality were more likely to experience all-cause mortality and CVD events (for males).

The Nutri-Score nutrition label: Associations between the underlying nutritional profile of foods and lipoprotein particle subclass profiles in adults

BACKGROUND AND AIMS

Lipoprotein particle concentrations and size are associated with increased risk for atherosclerosis and premature cardiovascular disease. Certain dietary behaviours may be cardioprotective and public health strategies are needed to guide consumers' dietary choices and help prevent diet-related disease. The Food Standards Agency nutrient profiling system (FSAm-NPS) constitutes the basis of the five-colour front-of-pack Nutri-Score labelling system. No study has examined FSAm-NPS index associations with a wide range of lipoprotein particle subclasses.

METHODS

This was a cross-sectional study of 2006 middle-to older-aged men and women randomly selected from a large primary care centre. Individual participant FSAm-NPS dietary scores were derived from validated food frequency questionnaires. Lipoprotein particle subclass concentrations and size were determined using nuclear magnetic resonance spectroscopy. Multivariate-adjusted linear regression analyses were performed to examine FSAm-NPS relationships with lipoprotein particle subclasses.

RESULTS

In fully adjusted models which accounted for multiple testing, higher FSAm-NPS scores, indicating poorer dietary quality, were positively associated with intermediate-density lipoprotein (β = 0.096, p = 0.005) and small high-density lipoprotein (HDL) (β = 0.492, p = 0.006) concentrations, a lipoprotein insulin resistance score (β = 0.063, p = 0.02), reflecting greater lipoprotein-related insulin resistance, and inversely associated with HDL size (β = -0.030, p = 0.045).

CONCLUSIONS

A higher FSAm-NPS score is associated with a less favourable lipoprotein particle subclass profile in middle-to older-aged adults which may be a potential mechanism underlying reported health benefits of a healthy diet according to Nutri-Score rating.

Modelling Food Substitution Using the Ofcom Nutrient Profiling Model on Population Intakes from the Canadian Community Health Survey-Nutrition 2015

This study aimed to model how substituting foods consumed by Canadians for alternatives with more favourable nutrient profiling (NP) scores would impact dietary intakes. The Ofcom NP system, developed to help the UK Office of Communication differentiate foods that can be advertised to children, was applied to foods consumed by Canadians aged 2 years and older in the 2015 Canadian Community Health Survey (CCHS) (n = 19,447). Foods were substituted for similar options from the Euromonitor branded food composition database (Scenario 1) or from the primarily aggregated food profiles in the CCHS survey food composition database (Scenario 2) with either the most favourable (optimistic; 1A and 2A) or a more favourable Ofcom score (realistic; 1B and 2B). Mean intakes of Ofcom scores, calories, saturated fat, sugars, and sodium from these scenarios were compared to baseline. Only 2.9% of foods consumed had a similar Euromonitor option with a lower Ofcom score. Scenarios 1A, 1B, and 2A had lower Ofcom scores, calorie, sodium, saturated fat, and sugar intakes compared to baseline. Scenario 2B had lower levels of all outcome measures, except for an increase in calories compared to baseline. Selection of foods with more favourable NP scores has the potential to decrease the Canadian intake of nutrients of concern.

What Is the Nutritional Quality of Pre-Packed Foods Marketed to Children in Food Stores? A Survey in Switzerland

Food marketing targeting children influences their choices and dietary habits, and mainly promotes food high in fat, sugar, and salt as well as ultra-processed food. The aim of this study was to assess the nutritional quality of food and beverages marketed to children over the age of 3 and available on the Swiss market. Products with at least one marketing technique targeting children on the packaging were selected from five food store chains. Three criteria to assess nutritional quality were used: (1) nutritional composition (using the Nutri-Score), (2) degree of processing (NOVA classification), and (3) compliance with the World Health Organization (WHO) Nutrient Profile Model (NPM). A total of 735 products were found and analyzed. The most common marketing techniques used were childish names/fonts (46.9%), special characters (39.6%), and children's drawings (31.3%). Most products had a Nutri-Score of D or E (58.0%) and were ultra-processed (91.8%). Only 10.2% of products displayed the Nutri-Score. The least processed products generally had a better Nutri-Score (p < 0.001). Most products (92.8%) did not meet the criteria of the WHO NPM. Products that met the WHO NPM criteria, organic products, and products with a nutritional claim generally had a better Nutri-Score and were less processed (ps < 0.05). Pre-packaged foods and beverages marketed to children in the Swiss market were mostly of poor nutritional quality. Public health measures should be adopted to improve the nutritional quality of foods marketed to children in Switzerland and restrict the marketing of unhealthy foods to children.

Less Favorable Nutri-Score Consumption Ratings Are Prospectively Associated with Abdominal Obesity in Older Adults

Nutri-Score is a front-of-package (FOP) labeling designed to assist consumers in selecting healthier options at the point of purchase and ultimately enhance their health. This study aims to evaluate the association between the Nutri-Score system and incident abdominal obesity (AO) in community-dwelling older adults. A prospective cohort of 628 individuals aged ≥ 60 were recruited in Spain between 2008-2010 and were reexamined between 2015-2017. Dietary intake was evaluated utilizing a validated computerized dietary history. Food was categorized based on the Nutri-Score system into five levels from A (green, representing the best quality) to E (red, representing the poorest quality). A five-color Nutri-Score dietary index (5-CNS DI) in g/day/kg was calculated for each participant. AO was determined by a waist circumference (WC) of ≥102 cm for men and ≥88 cm for women. Logistic regression models were adjusted for the main potential confounders. During a mean six-year follow-up, 184 incident cases of AO occurred. The odds ratio (OR) and 95% confidence interval (CI) for AO, when comparing the highest and lowest quartiles of the 5-CNS DI, were 2.45 (1.17-5.14), with a p-value for trend of 0.035. In sensitivity analyses, the OR was 2.59 (1.22-5.52, p-trend: 0.032) after adjustment for WC at baseline, and 1.75 (0.74-4.18, p-trend: 0.316) after adjustment for ultra-processed food consumption. In conclusion, less favorable food-consumption ratings in the Nutri-Score are associated with incident AO in the elderly. These findings support the use of this FOP system to potentially improve metabolic health.

Dietary indices underpinning front-of-pack nutrition labels and health outcomes: a systematic review and meta-analysis of prospective cohort studies

BACKGROUND

Nutrient profiling systems are increasingly used to characterize the healthfulness of foods for front-of-package (FOP) labeling, which have been proposed as an effective public health strategy to help people make healthier food choices.

OBJECTIVE

This study aimed to review available evidence from cohort studies that evaluated the association of dietary indices underpinning FOP nutrition labels with all-cause mortality and incidence of cardiovascular diseases (CVDs) or cancer.

METHODS

PubMed, Web of Science, and Scopus were systematically searched up to October 2023. We included articles if they were prospective cohort studies, if the exposure was any dietary index underpinning FOP nutrition labels [e.g., the modified Food Standard Agency-Nutrient Profiling System (FSAm-NPS) and the Health Star Rating System], and if outcomes were all-cause mortality or incidence of or mortality due to CVD and cancer. Random-effects models were used to calculate the pooled hazard ratios (HRs) and 95% CIs.

RESULTS

We identified 11 records (7 unique prospective studies), which were included in the systematic review. The meta-analysis comprised 8 studies analyzing the FSAm-NPS dietary index (DI) as exposure. The pooled HRs associated with a 2-unit increase in the FSAm-NPS DI of all-cause mortality, CVD, and cancer risk were 1.06 (95% confidence interval [CI]: 0.99, 1.13; I2: 80%), 1.08 (95% CI: 1.00, 1.18; I2: 70%), and 1.09 (95% CI: 1.00, 1.19; I2: 77%), respectively. The Chilean Warning Label score and the Health Star Rating systems were examined by 1 study each and were significantly associated with the outcomes.

CONCLUSIONS

DIs underpinning most common FOP nutrition labels and reflecting nutrient-poor diets show a tendency toward an increased incidence of CVD and cancer, but the observed effects are quite modest in magnitude. Further studies at the population level are needed to support the widely shared hypothesis that FOP labels, possibly in conjunction with other interventions, may contribute to reduce noncommunicable disease risk. This meta-analysis was registered at PROSPERO as CRD42021292625.

Diet quality and cardiovascular outcomes: A systematic review and meta-analysis of cohort studies

AIMS

To evaluate relationships between diet quality and cardiovascular outcomes.

METHODS

Six databases were searched for studies published between January 2007 and October 2021. Eligible studies included cohort studies that assessed the relationship between a priori diet quality and cardiovascular disease mortality and morbidity in adults. The Academy of Nutrition and Dietetics Checklist was used to assess the risk of bias. Study characteristics and outcomes were extracted from eligible studies using standardised processes. Data were summarised using risk ratios for cardiovascular disease incidence and mortality with difference compared for highest versus lowest diet quality synthesised in meta-analyses using a random effects model.

RESULTS

Of the 4780 studies identified, 159 studies (n = 6 272 676 adults) were included. Meta-analyses identified a significantly lower cardiovascular disease incidence (n = 42 studies, relative risk 0.83, 95% CI 0.82-0.84, p < 0.001) and mortality risk (n = 49 studies, relative risk 0.83, 95% CI 0.82-0.84, p < 0.001) among those with highest versus lowest diet quality. In sensitivity analyses of a high number of pooled studies (≥13 studies) the Mediterranean style diet patterns and adherence to the heart healthy diet guidelines were significantly associated with a risk reduction of 15% and 14% for cardiovascular disease incidence and 17% and 20% for cardiovascular disease mortality respectively (p < 0.05).

CONCLUSIONS

Higher diet quality is associated with lower incidence and risk of mortality for cardiovascular disease however, significant study heterogeneity was identified for these relationships.

Criterion validation of nutrient profiling systems: a systematic review and meta-analysis

BACKGROUND

Nutrient profiling systems (NPSs) use algorithms to evaluate the nutritional quality of foods and beverages. Criterion validation, which assesses the relationship between consuming foods rated as healthier by the NPS and objective measures of health, is essential to ensure the accuracy of NPSs.

OBJECTIVE

We examined and compared NPSs that have undergone criterion validity testing in relation to diet-related disease risk and risk markers.

METHODS

Academic databases were searched for prospective cohort and cross-sectional studies published before November, 2022. NPSs were eligible if they incorporated multiple nutrients or food components using an algorithm to determine an overall summary indicator (e.g., a score or rank) for individual foods. Studies were included if they assessed the criterion validity of an eligible NPS. Validation evidence was first summarized in narrative form by NPS, with random effects meta-analysis where ≥2 prospective cohort studies assessed the same NPS and outcomes.

RESULTS

Of 4519 publications identified, 29 describing 9 NPSs were included in the review. The Nutri-Score NPS was assessed as having substantial criterion validation evidence. Highest compared with lowest diet quality as defined by the Nutri-Score was associated with significantly lower risk of cardiovascular disease (hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.59, 0.93; n = 6), cancer (HR: 0.75; 95% CI: 0.59, 0.94; n = 5), all-cause mortality (HR: 0.74; 95% CI; 0.59, 0.91; n = 4) and change in body mass index (HR: 0.68; 95% CI: 0.50, 0.92; n = 3). The Food Standards Agency NPS, Health Star Rating, Nutrient Profiling Scoring Criterion, Food Compass, Overall Nutrition Quality Index, and the Nutrient-Rich Food Index were determined as having intermediate criterion validation evidence. Two other NPSs were determined as having limited criterion validation evidence.

CONCLUSIONS

We found limited criterion validation studies compared with the number of NPSs estimated to exist. Greater emphasis on conducting and reporting on criterion validation studies across varied contexts may improve the confidence in existing NPSs.

Less favourable food consumption ratings in the Five-Color Nutri-Score are associated with incident frailty in older adults

BACKGROUND

The Nutri-Score front-of-package labelling classifies food products according to their nutritional quality, so healthier food choices are easier when shopping. This study prospectively assesses the association of a diet rated according to the Nutri-Score system and incident frailty in community-dwelling older adults.

METHODS

Cohort study with 1,875 individuals aged ≥60 recruited during 2008-2010 in Spain. At baseline, food consumption was assessed using a validated dietary history. Food was categorised into five Nutri-Score labels (A/green-best quality; B, C, D, E/red-worst quality) utilising an algorithm established in 2017 and currently in use. For each participant, a Five-Color Nutri-Score Dietary Index (5-CNS DI) in grams per day per kilogram was calculated. The 5-CNS DI sums up the grams per day of food consumed times their corresponding nutritional quality value (from A rated as 1 to E rated as 5) and divided by weight in kilograms. From baseline to December 2012, incident frailty was ascertained based on Fried's criteria. Statistical analyses were performed with logistic regression adjusted for main confounders.

RESULTS

After a mean follow-up of 3.5 years, 136 cases of frailty were identified. The multivariable-adjusted odds ratios (95% confidence interval) of incident frailty across increasing quartiles of the 5-CNS DI were 1, 1.51 (0.86-2.68), 1.56 (0.82-2.98) and 2.32 (1.12-4.79); P-trend = 0.033. The risk of frailty increased by 28% (3-58%) with a 10-unit increment in this dietary index. Similar results were found with the Nutri-Score algorithm modified in 2022.

CONCLUSIONS

consumption of a diet with less favourable Nutri-Score ratings doubles the risk of frailty among community-dwelling older adults.

Examining the diet quality of Canadian adults and the alignment of Canadian front-of-pack labelling regulations with other front-of-pack labelling systems and dietary guidelines

Introduction

Canada promulgated mandatory front-of-pack labelling (FOPL) regulations in 2022, requiring pre-packaged foods meeting and/or exceeding recommended thresholds for nutrients-of-concern (i.e., saturated fat, sodium, sugars) to display a "high-in" nutrition symbol. However, there is limited evidence on how Canadian FOPL (CAN-FOPL) regulations compare to other FOPL systems and dietary guidelines. Therefore, the objectives of the study were to examine the diet quality of Canadians using the CAN-FOPL dietary index system and its alignment with other FOPL systems and dietary guidelines.

Methods

Nationally representative dietary data from the 2015 Canadian Community Health Survey-Nutrition survey (n = 13,495) was assigned dietary index scores that underpin CAN-FOPL, Diabetes Canada Clinical Practice (DCCP) Guidelines, Nutri-score, Dietary Approaches to Stop Hypertension (DASH) and Canada's Food Guide (Healthy Eating Food Index-2019 [HEFI-2019]). Diet quality was examined by assessing linear trends of nutrient intakes across quintile groups of CAN-FOPL dietary index scores. The alignment of CAN-FOPL dietary index system compared with other dietary index systems, with HEFI as the reference standard, was examined using Pearson's correlations and к statistics.

Results

The mean [95% CI] dietary index scores (range: 0-100) for CAN-FOPL, DCCP, Nutri-score, DASH, and HEFI-2019 were 73.0 [72.8, 73.2], 64.2 [64.0, 64.3], 54.9 [54.7, 55.1], 51.7 [51.4, 51.9], and 54.3 [54.1, 54.6], respectively. Moving from the "least healthy" to the "most healthy" quintile in the CAN-FOPL dietary index system, intakes of protein, fiber, vitamin A, vitamin C, and potassium increased, while intakes of energy, saturated fat, total and free sugars, and sodium decreased. CAN-FOPL showed moderate association with DCCP (r = 0.545, p < 0.001), Nutri-score (r = 0.444, p < 0.001),  and HEFI-2019 (r = 0.401, p < 0.001), but poor association with DASH (r = 0.242, p < 0.001). Slight to fair agreement was seen between quintile combinations of CAN-FOPL and all dietary index scores (к = 0.05-0.38).

Discussion

Our findings show that CAN-FOPL rates the dietary quality of Canadian adults to be healthier than other systems. The disagreement between CAN-FOPL with other systems suggest a need to provide additional guidance to help Canadians select and consume 'healthier' options among foods that would not display a front-of-pack nutrition symbol.

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.

Nutri-Score: Its Benefits and Limitations in Children's Feeding

Reducing the burden of noncommunicable diseases (NCDs) is one of the top priorities of public health policies worldwide. One of the recognized means of achieving this objective is to improve the diet quality. The Nutri-Score (N-S) is a [five-color-A, B, C, D, E letters] front-of-pack labeling logo intended to help consumers quickly identify the healthier prepackaged foods within a food category. Available studies have shown that the N-S is an efficient tool to achieve this aim in terms of consumers' awareness, perception, understanding, and purchasing and that its use may help to reduce the prevalence of NCDs. The N-S is currently implemented on a voluntary basis in 7 European countries and a discussion is underway within the European Commission to achieve a harmonized mandatory label. However, no study on the putative impact of the N-S on children's dietary patterns and health is available. The N-S is not applicable to infants' and young children's formulas and to specific baby foods, the compositions of which are already laid down in European Union regulations. The N-S does not replace age-appropriate dietary guidelines. As children consume an increasing number of adult type and processed foods, the relevance of the N-S for children should be evaluated considering the children's high specific requirements, especially in younger children. This is especially necessary for fitting fat and iron requirements, whereas protein-rich foods should be better framed. Moreover, efforts should be made to inform on how to use the N-S and in education on healthy diets.

Mapping the nutritional value of diets across Europe according to the Nutri-Score front-of-pack label

Background

Front-of-pack labels, such as Nutri-Score, aim to offer clear information on the overall nutritional quality of foods and beverages to consumers, allowing them to make healthier food choices. Using the European Food Safety Authority (EFSA) Comprehensive European Food Consumption Database, the present study aims to map out European food consumption patterns by applying the Nutri-Score as a benchmark for nutritional value.

Methods

Country-specific food consumption data, collected by multiple 24-h dietary recalls or food records available from EFSA, were linked to the Dutch Food Composition Database (NEVO). Foods and beverages consumed by adolescents (10-17 years), adults (18-64 years), and the elderly (65-74 years) were graded following the modified Food Standard Agency Nutrient Profiling System (FSAm-NPS) and classified according to Nutri-Score grading, from A to E. Subsequently, a dietary index score (FSAm-NPS-DI) was calculated for each country-specific diet by age-groups and sex as an energy-weighted mean of the FSAm-NPS score of all foods and beverages consumed, with lower scores for a diet of greater overall nutritional quality.

Results

On average, the daily energy intake of adults across the European countries studied is distributed in 27.6% of A-, 12.9% of B-, 17% of C-, 30.0% of D-, and 12.5% of E-classified foods and beverages. This energy distribution, according to the Nutri-Score, corresponded to a median FSAm-NPS-DI score of 6.34 (interquartile range: 5.92, 7.19). For both adult males and females, Estonia reported the highest energy share from A-classified products, scoring the lowest on the FSAm-NPS-DI. On the other hand, Latvia reported the highest energy share from E-classified products, along with the highest FSAm-NPS-DI. Females and the elderly group reported, in general, a greater energy share from A- and a lower share from E-classified products, and had the lowest FSAm-NPS-DI scores. No sex-related difference was observed for adolescents whose share of energy was predominantly from A- and D-classified products, such as for adults and the elderly.

Conclusion

Our analyses leveraging the secondary use of country-specific databases on dietary intakes found considerable variation in the nutritional value of European diets, with an overall agreement across all countries on a modestly healthier dietary profile for the elderly and among females.

Consumer Reactions to Positive and Negative Front-of-Package Food Labels

INTRODUCTION

The National Academy of Medicine recommends that the U.S. adopt an interpretative front-of-package food labeling system, but uncertainty remains about how this system should be designed. This study examined reactions to front-of-package food labeling systems that use positive labels to identify healthier foods, negative labels to identify unhealthier foods, or both.

METHODS

In August 2021, U.S. adults (N=3,051) completed an online randomized experiment. Participants were randomly assigned to 1 of 4 labeling conditions: control (calorie), positive, negative, or both positive and negative labels. Labels were adapted from designs for a 'healthy' label drafted by the Food and Drug Administration and displayed on the front of product packaging. Participants selected products to purchase, identified healthier products, and reported reactions to the labels. Analyses, conducted in 2022, examined the healthfulness of participants' selections using the Ofcom Nutrient Profiling Model score (0-100, higher scores indicate being healthier).

RESULTS

Participants exposed to only positive labels, only negative labels, or both positive and negative labels had healthier selections than participants in the control arm (differences vs control=1.13 [2%], 2.34 [4%] vs 3.19 [5%], respectively; all p<0.01). The both-positive-and-negative-labels arm outperformed the only-negative-labels (p=0.03) and only-positive-labels (p<0.001) arms. The only-negative-labels arm outperformed the only-positive-labels arm (p=0.005). All the 3 interpretative labeling systems also led to improvements in the identification of healthier products and beneficial psychological reactions (e.g., attention, thinking about health effects; all p<0.05).

CONCLUSIONS

Front-of-package food labeling systems that use both positive and negative labels could encourage healthier purchases and improve understanding more than systems using only positive or only negative labels.

Validation of Food Compass with a healthy diet, cardiometabolic health, and mortality among U.S. adults, 1999-2018

The Food Compass is a nutrient profiling system (NPS) to characterize the healthfulness of diverse foods, beverages and meals. In a nationally representative cohort of 47,999 U.S. adults, we validated a person's individual Food Compass Score (i.FCS), ranging from 1 (least healthful) to 100 (most healthful) based on cumulative scores of items consumed, against: (a) the Healthy Eating Index (HEI) 2015; (b) clinical risk factors and health conditions; and (c) all-cause mortality. Nationally, the mean (SD) of i.FCS was 35.5 (10.9). i.FCS correlated highly with HEI-2015 (R = 0.81). After multivariable-adjustment, each one SD (10.9 point) higher i.FCS associated with more favorable BMI (-0.60 kg/m2 [-0.70,-0.51]), systolic blood pressure (-0.69 mmHg [-0.91,-0.48]), diastolic blood pressure (-0.49 mmHg [-0.66,-0.32]), LDL-C (-2.01 mg/dl [-2.63,-1.40]), HDL-C (1.65 mg/d [1.44,1.85]), HbA1c (-0.02% [-0.03,-0.01]), and fasting plasma glucose (-0.44 mg/dL [-0.74,-0.15]); lower prevalence of metabolic syndrome (OR = 0.85 [0.82,0.88]), CVD (0.92 [0.88,0.96]), cancer (0.95 [0.91,0.99]), and lung disease (0.92 [0.88,0.96]); and higher prevalence of optimal cardiometabolic health (1.24 [1.16,1.32]). i.FCS also associated with lower all-cause mortality (HR = 0.93 [0.89,0.96]). Findings were similar by age, sex, race/ethnicity, education, income, and BMI. These findings support validity of Food Compass as a tool to guide public health and private sector strategies to identify and encourage healthier eating.

Mortality prediction of the nutrient profile of the Chilean front-of-pack warning labels: Results from the Seguimiento Universidad de Navarra prospective cohort study

Background and aims

Front-of-Pack (FoP) nutrition labelling has been established as a policy, empowering consumers to choose healthy food options for preventing diet-related non-communicable diseases. This study aimed to evaluate the association between the nutrient profile underlying the Chilean warning label score and all-cause mortality and to conduct a calibration with the Nutri-Score in a large cohort of Spanish university graduates.

Materials and methods

This prospective cohort study analysed 20,666 participants (8,068 men and 12,598 women) with a mean (standard deviation) age of 38 years (±12.4) from the SUN cohort. Dietary food intake was assessed by a validated semi-quantitative food-frequency questionnaire at baseline and after 10 years of follow-up. The warning label score was calculated by considering the threshold of nutrients (sugar, saturated fat, and sodium) and energy density per 100 g/ml of product, as established by Chilean Legislation. Participants were classified according to quartiles of consumption of daily label score: Q1 (≤5.0), Q2 (>5.0–7.1), Q3 (>7.1–9.8), and Q4 (>9.8). Time-dependent, multivariable-adjusted Cox models were applied. To compare the performance of the warning label score and Nutri-Score to predict mortality, we used the Akaike information criterion (AIC) and Bayesian information criterion (BIC) methods.

Results

During a median of 12.2 years of follow-up, 467 deaths were identified. A higher score in the warning label values (lower nutritional quality) was associated with an increased risk of all-cause mortality [HR (95% CI) Q4 vs. Q1: 1.51 (1.07–2.13); p-trend = 0.010] and cancer mortality [HR (95% CI) Q4 vs. Q1: 1.91 (1.18–3.10); p-trend = 0.006]. However, no statistically significant association was found for cardiovascular mortality. Furthermore, the warning label score and Nutri-Score exhibited comparable AIC and BIC values, showing similar power of prediction for mortality.

Conclusion

A diet with a higher warning label score (>9.8 per day) was a good predictor of all cases and cancer mortality in a large Spanish cohort of university graduates. Also, the warning label score was capable to predict mortality as well as the Nutri-Score. Our findings support the validity of the warning label score as a FoP nutrition labelling policy since it can highlight less healthy food products.

The Nutri-Score algorithm: Evaluation of its validation process

The Nutri-Score front-of-pack label, which classifies the nutritional quality of products in one of 5 classes (A to E), is one of the main candidates for standardized front-of-pack labeling in the EU. The algorithm underpinning the Nutri-Score label is derived from the Food Standard Agency (FSA) nutrient profile model, originally a binary model developed to regulate the marketing of foods to children in the UK. This review describes the development and validation process of the Nutri-Score algorithm. While the Nutri-Score label is one of the most studied front-of-pack labels in the EU, its validity and applicability in the European context is still undetermined. For several European countries, content validity (i.e., ability to rank foods according to healthfulness) has been evaluated. Studies showed Nutri-Score's ability to classify foods across the board of the total food supply, but did not show the actual healthfulness of products within different classes. Convergent validity (i.e., ability to categorize products in a similar way as other systems such as dietary guidelines) was assessed with the French dietary guidelines; further adaptations of the Nutri-Score algorithm seem needed to ensure alignment with food-based dietary guidelines across the EU. Predictive validity (i.e., ability to predict disease risk when applied to population dietary data) could be re-assessed after adaptations are made to the algorithm. Currently, seven countries have implemented or aim to implement Nutri-Score. These countries appointed an international scientific committee to evaluate Nutri-Score, its underlying algorithm and its applicability in a European context. With this review, we hope to contribute to the scientific and political discussions with respect to nutrition labeling in the EU.

Associations between the Nutrient Profiling System Underlying the Nutri-Score Nutrition Label and Biomarkers of Chronic Low-Grade Inflammation: A Cross-Sectional Analysis of a Middle- to Older-Aged Population

Low-grade systemic inflammation is associated with a range of conditions. Diet may modulate inflammation and public health strategies are needed to guide consumers’ dietary choices and help prevent diet-related disease. The Food Standards Agency nutrient profiling system (FSAm-NPS) constitutes the basis of the five-colour front-of-pack Nutri-Score labelling system. No study to date has examined FSAm-NPS dietary index associations with biomarkers of inflammation. Therefore, our objective was to test relationships between the FSAm-NPS and a range of inflammatory biomarkers in a cross-sectional sample of 2006 men and women aged 46–73 years. Individual participant FSAm-NPS scores were derived from food frequency questionnaires. Pro-inflammatory cytokine, adipocytokine, acute-phase response protein, coagulation factor and white blood cell count concentrations were determined. Correlation and linear regression analyses were used to examine FSAm-NPS relationships with biomarker levels. In crude and adjusted analyses, higher FSAm-NPS scores, reflecting poorer nutritional quality, were consistently and positively associated with biomarkers. In fully adjusted models, significant associations with concentrations of complement component 3, c-reactive protein, interleukin 6, tumour necrosis factor alpha, resistin, white blood cell count, neutrophils, eosinophils and the neutrophil-to-lymphocyte ratio persisted. These results suggest that dietary quality, determined by Nutri-Score rating, is associated with inflammatory biomarkers related to health.

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.

Clinical Application of the Food Compass Score: Positive Association to Mediterranean Diet Score, Health Star Rating System and an Early Eating Pattern in University Students

Nutrient profiling systems (NPS) assist consumers in food choices. Several scores based on NPS have been proposed, but data on their clinical application are lacking. The food compass score (FCS) is a newly developed NPS per 100 kcal (from 1 “least healthy” to 100 “most healthy”). We examined the correlations of FCS with other indices, food groups, and meal patterns. A total of 346 students of the University of the Peloponnese (269 women and 77 men) participated. Dietary habits were evaluated with a food frequency questionnaire, and FCS, health star rating score (HSR), and MedDietScore were computed. Meal and snack frequency consumption was reported. Principal component analysis revealed three meal patterns: “early eater” (breakfast, morning snack and afternoon snack), “medium eater” (lunch and dinner), and “late eater” (bedtime snack). Pearson partial correlations between ranked variables were used to test the correlation coefficients between FCS, other scores, and meal patterns, after adjustment for age, sex, BMI, and underreporting. FCS was positively correlated to HSR (rho = 0.761, p ≤ 0.001) in a multi-adjusted analysis. In the highest tertile of MedDietScore FCS was also positively correlated to MedDietScore (rho = 0.379, p < 0.001). The FCS was positively correlated with juices, high-fat dairy, vegetables, legumes, fruits, and olive oil and negatively correlated with sodas, alcoholic drinks, red meat, refined grains, sweets, fats other than olive oil, fast foods, and coffee. In addition, it related positively to the “early eater” pattern (rho = 0.207, p < 0.001). The FCS was associated with other quality indices and better nutritional habits, such as being an early eater.

Front-of-pack (FOP) labelling systems to improve the quality of nutrition information to prevent obesity: NutrInform Battery vs Nutri-Score

Many systems for classifying food products to adequately predict lower all-cause morbidity and mortality have been proposed as front-of-pack (FOP) nutritional labels. Although the efforts and advances that these systems represent for public health must be appreciated, as scientists involved in nutrition research and belonging to diverse Italian nutrition scientific societies, we would like to draw stakeholders' attention to the fact that some FOP labels risk being not correctly informative to consumers' awareness of nutritional food quality. The European Commission has explicitly called for such a nutrition information system to be part of the European "strategy on nutrition, overweight and obesity-related issues" to "facilitate consumer understanding of the contribution or importance of the food to the energy and nutrient content of a diet". Some European countries have adopted the popular French proposal Nutri-Score. However, many critical limits and inadequacies have been identified in this system. As an alternative, we endorse a new enriched informative label-the NutrInform Battery-promoted by the Italian Ministry of Health and deeply studied by the Center for Study and Research on Obesity, Milan University. Therefore, the present position paper limits comparing these two FOP nutritional labels, focusing on the evidence suggesting that the NutrInform Battery can help consumers better than the Nutri-Score system to understand nutritional information, potentially improving dietary choices. LEVEL OF EVIDENCE: II. Evidence was obtained from well-designed controlled trials without randomization.

Are Front-of-Pack Labels a Health Policy Tool?

To stem the increasing incidence of non-communicable diseases (NCDs) and obesity, front-of-pack labels (FOPLs) have been developed since 1989. Whereas several countries have already adopted one voluntarily, the European Community wants to harmonize an FOPL system that will be mandatory for all member states. The purpose of this narrative review is to describe what could be achieved or not by FOPLs, and to discuss if there is enough evidence to establish whether such labels are effective in modifying purchasing behavior, in directing individual dietary patterns towards a healthy and sustainable diet, and in reformulating food products by the food industry. Non-directive FOPLs, which are still under study, appear to be informative and well-accepted by consumers even if they require a cognitive effort. Conversely, directive FOPLs are supported by several studies, but they are mostly conducted in simulated scenarios and/or performed as retrospective studies. Nevertheless, directive FOPLs are rated as an intuitive tool, and they have demonstrated a high capacity to help consumers rank food products as more or less healthy. In conclusion, directive and non-directive FOPLs convey different messages. No FOPL individually can be considered exhaustive in relation to all the objectives outlined in this narrative review, and therefore, the development of a model synthesizing both messages is advisable. Many questions remain open, such as the possibility of reformulating pre-packaged products, how to deal with traditional products, and the impact on the incidence of NCDs and obesity. In the light of the complexity of factors that condition consumption choices and health, none of the current FOPLs can be considered a health policy tool on its own. The possibility of development remains open, but as the state of the art, these tools do not seem to be able to achieve all the European Community goals together. We can speculate that they could meet these goals only if they are integrated into a multi-tiered, structured health policy intervention.

Development of the Choices 5-Level Criteria to Support Multiple Food System Actions

In 2008, the Choices International Foundation developed its logo criteria, identifying best-in-class food products. More advanced, global and graded nutrient profiling systems (NPSs) are needed to substantiate different national nutrition policies. The objective of this work was to extend Choices NPS to identify five levels of the healthiness of food products, so that the Choices NPS can also be used to support other nutrition policies, next to front-of-pack labelling. Based on the same principles as the previous logo criteria, four sets of threshold criteria were determined using a combination of compliance levels, calculated from a large international food group-specific database, the Choices logo criteria, and WHO-NPSs developed to restrict marketing to children. Validation consisted of a comparison with indicator foods from food-based dietary guidelines from various countries. Some thresholds were adjusted after the validation, e.g., because intermediate thresholds were too lenient. This resulted in a new international NPS that can be applied to different contexts and to support a variety of health policies, to prevent both undernutrition and obesity. It can efficiently evaluate mixed food products and represents a flexible tool, applicable in various settings and populations.

The Nutri-Score nutrition label

Nutri-Score is a front-of-pack nutrition label with summary graded colour-coding, which aims to inform consumers, in a simple and understandable way, of the overall nutritional value of foods, in order to help them to make healthier choices at the point of purchase and to encourage manufacturers to improve the nutritional quality of their products. It is based on a five-colour scale (from dark green to dark orange) associated with letters, from A to E, to optimize logo accessibility and understanding by the consumer. Nutri-Score does not merely characterize foods as "healthy" or "unhealthy". Rather, the graded logo provides semi-quantitative information, depending on the colour/ letter, of the relative overall nutritional composition of a food product compared to other similar products as to whether it is more or less favourable to health. Nutri-Score is the only proposed labelling scheme that adheres entirely to the concepts and processes that were published by the World Health Organisation (WHO) Europe concerning the validation studies that are required to select and evaluate a front-of-pack nutrition label. The aim of the present paper is to present the scientific basis for the design of the Nutri-Score and to summarize the various studies to validate its calculation method and its graphic format. We explore its effectiveness and superiority compared to other labelling schemes that have been implemented in other countries or supported by pressure groups. The necessity for objective, impartial consideration of how best to use Nutri-Score and avoid misunderstandings is highlighted.

Public health potential of guidelines-based dietary scores for non-communicable diseases mortality prevention: simulation study using the Preventable Risk Integrated ModEl (PRIME) model

OBJECTIVE

Dietary indexes measure the adherence of individuals to a set of nutritional recommendations. However, the health gains associated with adherence to various dietary indexes may vary. Our objective was to compare the magnitude of estimated avoided deaths by chronic diseases obtained by improving diet quality in the French population, measured by a variety of dietary indexes.

DESIGN

Simulation study based on observational data.

SETTING

Weighted data from a French population-based cohort study.

PARTICIPANTS

In participants from the NutriNet-Santé cohort, we computed dietary scores reflecting the adherence to various recommendations (Medi-Lite, Healthy Diet Indicator (HDI), Programme National Nutrition Santé/National Nutrition and Health Program - Guidelines Score, Diet Quality Index (DQI), Alternative Healthy Eating Index (AHEI) and the modified Food Standards Agency nutrient profiling system dietary index (FSAm-NPS DI)). Quintiles of the food groups' consumption and dietary intakes were used as input in a simulation model (Preventable Risk Integrated ModEl (PRIME)), yielding the number of delayed or avoided deaths in nutrition-related non-communicable diseases, comparing between very high or very low nutritional quality of the diet and medium nutritional quality.

RESULTS

A modification of dietary intakes from medium quality to very low quality (i.e. from the middle quintile to the quintile with the lowest nutritional quality) was associated with an increased number of deaths ranging from 3485 (95 % uncertainty interval (CI) 4002, 2987) for HDI and 3379 (95 % CI 3881, 2894) for FSAm-NPS DI to 838 (95 % CI 1163, 523) for Medi-Lite. Conversely, a modification of dietary intakes from medium quality to very high quality was associated with a decrease in the number of deaths ranging from 1995 (95 % CI 1676, 2299) for Probability of Adequate Nutrient intake diet, 1986 (95 % CI 1565, 2361) for DQI-International, 1931 (95 % CI 1499, 2316) for FSAm-NPS DI and 858 (95 % CI 499, 1205) for HDI.

CONCLUSIONS

Our results provide some insights as the potential impact of following various dietary guidelines to reduce mortality from nutrition-related diseases.

Five-color Nutri-Score labeling and mortality risk in a nationwide, population-based cohort in Spain: the Study on Nutrition and Cardiovascular Risk in Spain (ENRICA)

BACKGROUND

The 5-color Nutri-Score (5-CNS) front-of-package labeling system classifies products according to their nutritional quality, so healthier choices are easier when shopping.

OBJECTIVES

We examined the association between 5-CNS-based food consumption and long-term mortality in a Spanish, adult population.

METHODS

We recruited 12,054 individuals, representative of the Spanish population aged ≥18 years, in 2008-10 and followed up with them to 2017. Habitual food consumption was collected at baseline with a validated computerized dietary history, conducted by trained interviewers. Based on nutritional quality, foods consumed were categorized into 5 labels [A/Green (best quality), B, C, D, and E/Red (worst quality)] using an established algorithm. For each individual, a 5-CNS dietary index (DI) was calculated by summing up the amount of g/day from the foods consumed by their corresponding nutritional quality rate (e.g., A rated 1 and E rated 5) and dividing it by kg of weight. The associations between baseline 5-CNS DI and mortality were analyzed using multivariate-adjusted Cox models.

RESULTS

After a mean follow-up of 8.7 years, 514 deaths occurred (140 cardiovascular and 144 cancer deaths). The all-cause mortality HR for the highest versus the lowest quartile of baseline 5-CNS DI was 1.93 (95% CI, 1.34-2.79; P-trend, 0.001). The association was slightly higher for cardiovascular mortality and was similar for cancer. Those with the highest intake of foods labeled as D or E also had a higher all-cause mortality risk than those with the lowest intake (HR, 2.15; 95% CI, 1.56-2.97; P-trend < 0.001). Further, the isocaloric replacement of food products labeled as D or E with fresh foods decreases the risk of death.

CONCLUSIONS

The consumption of poor nutritional quality 5-CNS-labeled food products was associated with higher mortality in Spain. Pending further studies, these findings provide additional evidence to reinforce food policies on the use of this simple labeling tool at a country level.

International evidence for the effectiveness of the front-of-package nutrition label called Nutri-Score

OBJECTIVES

Front-of-package nutrition labels are intended to easily convey to consumers comprehensible information about the nutritional composition of pre-packaged food and are thus a tool in the combat against the growing prevalence of nutrition-related disorders, such as obesity, type 2 diabetes, cardiovascular disease, and some types of cancer. The objective of the present narrative review was first to describe Nutri-Score and then to synthesize some of the international scientific evidence for its effectiveness. Guided by scientific data and collective expertise, France formally adopted labelling of pre-packaged food with the 5-colour Nutri-Score label in October 2017 and that move was later followed by Belgium, Spain, Germany, Switzerland, the Netherlands, and Luxembourg.

METHODS

This article synthesizes evidence from several countries regarding the effectiveness of Nutri-Score and the associated individual-level diet quality index in terms of attitude/behaviour- and health-related outcomes. It also addresses criticism levied at the label.

RESULTS

The effectiveness of Nutri-Score has been demonstrated in terms of consumer ability to correctly classify food according to its nutritional quality, the nutritional quality of actual and intended food purchases, and portion size choices. In addition, consumption of foods that are less favourably rated on the Nutri-Score scale has been prospectively associated with chronic disease risk (cancer, cardiovascular disease, metabolic syndrome, etc.).

CONCLUSION

The adoption and implementation of a uniform front-of-package label such as the scientifically validated Nutri-Score on pre-packaged foods/beverages across Europe could be beneficial to consumers at the point of purchase and could help reduce the incidence of diet-related chronic diseases by means of improvement in diet quality.

Seventeen-Year Associations between Diet Quality Defined by the Health Star Rating and Mortality in Australians: The Australian Diabetes, Obesity and Lifestyle Study (AusDiab)

BACKGROUND

The Health Star Rating (HSR) is the government-endorsed front-of-pack labeling system in Australia and New Zealand.

OBJECTIVES

We aimed to examine prospective associations of a dietary index (DI) based on the HSR, as an indicator of overall diet quality, with all-cause and cardiovascular disease (CVD) mortality.

METHODS

We utilized data from the national population-based Australian Diabetes, Obesity and Lifestyle Study. The HSR-DI at baseline (1999-2000) was constructed by 1) calculation of the HSR points for individual foods in the baseline FFQ, and 2) calculation of the HSR-DI for each participant based on pooled HSR points across foods, weighted by the proportion of energy contributed by each food. Vital status was ascertained by linkage to the Australian National Death Index. Associations of HSR-DI with mortality risk were assessed by Cox proportional hazards regression.

RESULTS

Among 10,025 eligible participants [baseline age: 51.6 ± 14.3 y (mean ± standard deviation)] at entry, higher HSR-DI (healthier) was associated with higher consumption of healthy foods such as fruits, vegetables, and nuts, and lower consumption of discretionary foods such as processed meats and confectionery (P-trend < 0.001 for each). During a median follow-up of 16.9 y, 1682 deaths occurred with 507 CVD deaths. In multivariable models adjusted for demographic characteristics, lifestyle factors, and medical conditions, higher HSR-DI was associated with lower risk of all-cause mortality, with a hazard ratio (95% confidence interval) of 0.80 (0.69, 0.94; P-trend < 0.001) comparing the fifth with the first HSR-DI quintile. A corresponding inverse association was observed for CVD mortality (0.71; 0.54, 0.94; P-trend = 0.008).

CONCLUSIONS

Better diet quality as defined by the HSR-DI was associated with lower risk of all-cause and CVD mortality among Australian adults. Our findings support the use of the HSR nutrient profiling algorithm as a valid tool for guiding consumer food choices.

Association between nutritional profiles of foods underlying Nutri-Score front-of-pack labels and mortality: EPIC cohort study in 10 European countries

OBJECTIVE

To determine if the Food Standards Agency nutrient profiling system (FSAm-NPS), which grades the nutritional quality of food products and is used to derive the Nutri-Score front-of-packet label to guide consumers towards healthier food choices, is associated with mortality.

DESIGN

Population based cohort study.

SETTING

European Prospective Investigation into Cancer and Nutrition (EPIC) cohort from 23 centres in 10 European countries.

PARTICIPANTS

521 324 adults; at recruitment, country specific and validated dietary questionnaires were used to assess their usual dietary intakes. A FSAm-NPS score was calculated for each food item per 100 g content of energy, sugars, saturated fatty acids, sodium, fibre, and protein, and of fruit, vegetables, legumes, and nuts. The FSAm-NPS dietary index was calculated for each participant as an energy weighted mean of the FSAm-NPS score of all foods consumed. The higher the score the lower the overall nutritional quality of the diet.

MAIN OUTCOME MEASURE

Associations between the FSAm-NPS dietary index score and mortality, assessed using multivariable adjusted Cox proportional hazards regression models.

RESULTS

After exclusions, 501 594 adults (median follow-up 17.2 years, 8 162 730 person years) were included in the analyses. Those with a higher FSAm-NPS dietary index score (highest versus lowest fifth) showed an increased risk of all cause mortality (n=53 112 events from non-external causes; hazard ratio 1.07, 95% confidence interval 1.03 to 1.10, P<0.001 for trend) and mortality from cancer (1.08, 1.03 to 1.13, P<0.001 for trend) and diseases of the circulatory (1.04, 0.98 to 1.11, P=0.06 for trend), respiratory (1.39, 1.22 to 1.59, P<0.001), and digestive (1.22, 1.02 to 1.45, P=0.03 for trend) systems. The age standardised absolute rates for all cause mortality per 10 000 persons over 10 years were 760 (men=1237; women=563) for those in the highest fifth of the FSAm-NPS dietary index score and 661 (men=1008; women=518) for those in the lowest fifth.

CONCLUSIONS

In this large multinational European cohort, consuming foods with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher mortality for all causes and for cancer and diseases of the circulatory, respiratory, and digestive systems, supporting the relevance of FSAm-NPS to characterise healthier food choices in the context of public health policies (eg, the Nutri-Score) for European populations. This is important considering ongoing discussions about the potential implementation of a unique nutrition labelling system at the European Union level.

Prospective associations of the original Food Standards Agency nutrient profiling system and three variants with weight gain, overweight and obesity risk: results from the French NutriNet-Santé cohort

Nutrient profiling systems (NPS) are used to classify foods according to their nutritional composition. However, investigating their prospective associations with health is key to their validation. The study investigated the associations of the original Food Standards Agency (FSA)-NPS and three variants (Food Standards Australia New Zealand Nutrient Profiling Scoring Criterion (NPSC), Health Star Rating NPS and the French High Council of Public Health NPS (HCSP-NPS)), with weight status. Individual dietary indices based on each NPS at the food level were computed to characterise the dietary quality of 71 403 French individuals from the NutriNet-Santé cohort. Associations of these indices with weight gain were assessed using mixed models and with overweight and obesity risks using Cox models. Participants with a higher dietary index (reflecting lower diet nutritional quality) were more likely to have a significant increase in BMI over time (β-coefficients positive) and an increased risk of overweight (hazard ratio (HR) T3 v. T1 = 1·27 (95 % CI 1·17, 1·37)) for the HCSP-Dietary Index, followed by the original FSA-Dietary Index (HR T3 v. T1 = 1·18 (95 % CI 1·09, 1·28)), the NPSC-Dietary Index (HR T3 v. T1 = 1·14 (95 % CI 1·06, 1·24)) and the Health Star Rating-Dietary Index (HR T3 v. T1 = 1·12 (95 % CI 1·04, 1·21)). Whilst differences were small, the HCSP-Dietary Index appeared to show significantly greater association with overweight risk. Overall, these results show the validity of NPS derived from the FSA-NPS, supporting their use in public policies for chronic disease prevention.

Association between the nutrient profile system underpinning the Nutri-Score front-of-pack nutrition label and mortality in the SUN project: A prospective cohort study

BACKGROUND & AIMS

Front-of-pack nutrition labelling is a key public health policy that can be adopted as part of a comprehensive set of measures to promote healthy diets. The Nutri-Score, a five-colour summary label based on a modified version of the British Food Standards Agency Nutrient Profiling System (FSAm-NPS), is being considered for implementation in several European countries including Spain. This study aimed to prospectively assess the association between the FSAm-NPS and mortality rate in a Spanish cohort of university graduates.

METHODS

Analyses included 20 503 participants (mean [SD] age: 38 [12] years) from the SUN cohort. Dietary intake was assessed at baseline and after 10-years of follow-up with a validated semi-quantitative food-frequency questionnaire. The FSAm-NPS was calculated for each food/beverage based on their amount of energy, saturated fat, sugar, sodium, fibre, protein, fruits, vegetables, legumes, nuts, rapeseed, walnut and olive oils per 100 g of product. The FSAm-NPS Dietary Index (DI) was computed as an energy-weighted mean of the FSAm-NPS scores of all foods and beverages consumed by each participant. Multivariable-adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality according to baseline and updated FSAm-NPS DI scores.

RESULTS

Over a median follow-up of 10.9 years, 407 participants died. A higher baseline FSAm-NPS DI score, reflecting consumption of foods with lower nutritional quality and hence less favourable Nutri-Score rating, was directly associated with all-cause mortality (HR _Q4 versus _Q1 = 1.82; 95% CI: 1.34 to 2.47; p-trend<0.001) and cancer mortality (HR: 2.44; 95% CI: 1.54 to 3.85; p-trend<0.001). No association was found for cardiovascular mortality.

CONCLUSIONS

The consumption of food products with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher rate of all-cause and cancer mortality in a large prospective cohort of Spanish, middle-aged university graduates. These findings further support the implementation of Nutri-Score in Euro-Mediterranean countries.

Evaluating Nutrient-Based Indices against Food- and Diet-Based Indices to Assess the Health Potential of Foods: How Does the Australian Health Star Rating System Perform after Five Years?

Nutrient-based indices are commonly used to assess the health potential of individual foods for nutrition policy actions. This study aimed to evaluate the nutrient profile-informed Australian Health Star Rating (HSR), against NOVA and an index informed by the Australian Dietary Guidelines (ADGs), to determine the extent of alignment. All products displaying an HSR label in the Australian marketplace between June 2014 and June 2019 were extracted from the Mintel Global New Product Database, and classified into one of four NOVA categories, and either as an ADG five food group (FFG) food or discretionary food. Of 4451 products analysed, 76.5% were ultra-processed (UP) and 43% were discretionary. The median HSR of non-UP foods (4) was significantly higher than UP foods (3.5) (p < 0.01), and the median HSR of FFG foods (4) was significantly higher than discretionary foods (2.5) (p < 0.01). However, 73% of UP foods, and 52.8% of discretionary foods displayed an HSR ≥ 2.5. Results indicate the currently implemented HSR system is inadvertently providing a ‘health halo’ for almost ¾ of UP foods and ½ of discretionary foods displaying an HSR. Future research should investigate whether the HSR scheme can be reformed to avoid misalignment with food-and diet-based indices.

[Nutri-Score and ultra-processing: two different, complementary, non-contradictory dimensions]

Introduction

The front-of-pack nutritional labeling system Nutri-Score is sometimes under attack because it classifies as A and B certain ultra-processed foods. In fact, this is not surprising given that nutritional quality (assessed by Nutri-Score) and ultra-processing (assessed by the NOVA classification) do not cover the same "health dimensions" in foods but rather different dimensions likely to affect health through specific mechanisms. Although they cover different and complementary dimensions, there is nevertheless an overall association between the degree of processing and nutritional quality of foods. But within the group of ultra-processed foods there are differences in the number, type and doses of additives, as well as differences in nutritional quality. Therefore Nutri-Score allows, within the category of ultra-processed foods (as for all categories of the NOVA classification), to differentiate the nutritional quality of foods, which is essential in terms of health impact. Indeed, regardless of the level of food processing, it has been shown that consuming foods that are better ranked on the Nutri-Score scale is associated with a health benefit and a lower risk of chronic diseases. This is important because, even if it is recommended to reduce the consumption of ultra-processed foods, for those who do not want to or cannot avoid consuming them, for those for whom cooking is difficult (for reasons of time, ease, taste, etc.), the choice of foods better ranked on the Nutri-Score scale has a positive impact on health. Nutri-Score and ultra-transformation must be considered two different and complementary dimensions.

The ineligibility of food products from across the EU for marketing to children according to two EU-level nutrient profile models

Background

A variety of nutrient profiling models have been developed to restrict food marketing to children. Previous assessments have shown substantial differences in terms of model strictness and agreement, but EU-wide data on how leading products in the various national markets perform against these health-minded nutrition criteria are unavailable.

Objective

To evaluate the nutritional composition of the pre-packaged food offer in selected categories sold at scale in the EU using criteria of two nutrient profile models intended to restrict food marketing to children.

Methods

The nutrient profile models of the private-sector EU Pledge and of the World Health Organization's Regional Office for Europe were applied to a commercial database with sales and nutritional information of 2691 pre-packaged products from five product categories (breakfast cereals, ready meals, processed meat, processed seafood, and yoghurts) and 20 EU countries. This study describes the criteria not met, the product ineligibility rates, and the distances to the various criteria thresholds.

Findings

Between 48% (EU Pledge) and 68% (WHO Europe) of the 2691 products analysed were found to be ineligible for marketing to children. The criteria thresholds most often not met were those for total sugars (in breakfast cereals, yoghurts), salt (in processed meat, processed seafood, ready meals), and fibre (in breakfast cereals). Total and saturated fat criteria also played a substantial role in rendering yoghurt products ineligible, and the energy criterion did so for ready meals.

Interpretation

A large number of food products selling at scale in the EU do not meet the criteria of two EU-level nutrient profile models intended to restrict food marketing to children. Given the considerable market share of many such products, they are likely to be consumed widely and in some cases regularly, including by children, even without being marketed to them. Nutrient profile models could serve as benchmarking tools for monitoring and evaluating food product reformulation efforts.

Association of the Dietary Index Underpinning the Nutri-Score Label with Oral Health: Preliminary Evidence from a Large, Population-Based Sample

The 2017 implementation in France of the front-of-package nutrition label known as ‘Nutri-Score’ was intended as a public health strategy to help individuals make healthier food choices at the point of purchase and thus help reduce chronic disease on the population level. Nutri-Score and the associated individual-level dietary index are based on the British Food Standards Agency Nutrient Profiling System (FSAm-NPS-DI). Prior research has shed light on the relation between the dietary index and various physical health outcomes, yet no studies have explored the link with oral health. We analyzed the cross-sectional association of the dietary index with oral health in a population-based sample of 33,231 adults from the French NutriNet-Santé cohort. Oral health (main dependent variable) was assessed in 2016 with the General Oral Health Assessment Index; FSAm-NPS-DI (main independent variable) was calculated using ≥3 non-consecutive 24-h dietary records, following established methodology; lower scores corresponded to better diet quality. Age-specific associations were explored via multivariable linear regression. Fully-adjusted models showed modest yet significant associations between the dietary index and oral health in younger (18–59 years) and older (60+ years) participants, with the strength of the model being more pronounced in the former compared with the latter age group (F value: 28.5 versus 6.3, both p < 0.0001). Higher diet quality was associated with a somewhat lower risk of oral health problems. Albeit preliminary, the findings support the relevance of dietary indices underpinning nutrition labels such as the Nutri-Score. Future research is needed to confirm the associations.

Association between an individual dietary index based on the British Food Standard Agency Nutrient Profiling System and asthma symptoms

The role of diet in asthma is still debated. In France, a front-of-pack (FOP) nutrition label based on a modified Food Standards Agency Nutrient Profiling System/High Council for Public Health (FSAm-NPS/HCSP) has recently been implemented to help consumers to make healthier food choices during purchase. At the individual level, the FSAm-NPS dietary index (DI) has been shown to reflect the nutritional quality of the diet. The aim of the present study was to investigate the association between the FSAm-NPS DI and the asthma symptom score. In total, 34 323 participants (25 823 women and 8500 men) from the NutriNet-Santé cohort were included. The overall nutritional quality of the diet was assessed using the FSAm-NPS DI. Increasing FSAm-NPS DI reflects decreasing overall diet quality. Asthma was defined by the asthma symptom score (sum of five questions). Negative binomial regression was used to evaluate the association between the FSA-NPS DI and the asthma symptom score. Overall, mean participant's age was 54 ± 14 years, and about 27 % reported at least one asthma symptom. We observed a significant positive association between less healthy diet, as expressed by higher FSAm-NPS DI, and the asthma symptom score. The adjusted OR were 1·27 (95 % CI 1·17, 1·38) among women and 1·31 (95 % CI 1·13, 1·53) among men. Unhealthy food choices, as reflected by a higher FSAm-NPS DI, were associated with greater asthma symptoms. These results reinforce the relevance of public health approach to orient consumers towards healthier food choices by using a clear and easy-to-understand FOP nutrition label based on the FSAm-NPS, such as the Nutri-Score.

Nutritional quality of food as represented by the FSAm-NPS nutrient profiling system underlying the Nutri-Score label and cancer risk in Europe: Results from the EPIC prospective cohort study

BACKGROUND

Helping consumers make healthier food choices is a key issue for the prevention of cancer and other diseases. In many countries, political authorities are considering the implementation of a simplified labelling system to reflect the nutritional quality of food products. The Nutri-Score, a five-colour nutrition label, is derived from the Nutrient Profiling System of the British Food Standards Agency (modified version) (FSAm-NPS). How the consumption of foods with high/low FSAm-NPS relates to cancer risk has been studied in national/regional cohorts but has not been characterized in diverse European populations.

METHODS AND FINDINGS

This prospective analysis included 471,495 adults from the European Prospective Investigation into Cancer and Nutrition (EPIC, 1992-2014, median follow-up: 15.3 y), among whom there were 49,794 incident cancer cases (main locations: breast, n = 12,063; prostate, n = 6,745; colon-rectum, n = 5,806). Usual food intakes were assessed with standardized country-specific diet assessment methods. The FSAm-NPS was calculated for each food/beverage using their 100-g content in energy, sugar, saturated fatty acid, sodium, fibres, proteins, and fruits/vegetables/legumes/nuts. The FSAm-NPS scores of all food items usually consumed by a participant were averaged to obtain the individual FSAm-NPS Dietary Index (DI) scores. Multi-adjusted Cox proportional hazards models were computed. A higher FSAm-NPS DI score, reflecting a lower nutritional quality of the food consumed, was associated with a higher risk of total cancer (HRQ5 versus Q1 = 1.07; 95% CI 1.03-1.10, P-trend < 0.001). Absolute cancer rates in those with high and low (quintiles 5 and 1) FSAm-NPS DI scores were 81.4 and 69.5 cases/10,000 person-years, respectively. Higher FSAm-NPS DI scores were specifically associated with higher risks of cancers of the colon-rectum, upper aerodigestive tract and stomach, lung for men, and liver and postmenopausal breast for women (all P < 0.05). The main study limitation is that it was based on an observational cohort using self-reported dietary data obtained through a single baseline food frequency questionnaire; thus, exposure misclassification and residual confounding cannot be ruled out.

CONCLUSIONS

In this large multinational European cohort, the consumption of food products with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher risk of cancer. This supports the relevance of the FSAm-NPS as underlying nutrient profiling system for front-of-pack nutrition labels, as well as for other public health nutritional measures.

Comparison of nutrient profiling models for assessing the nutritional quality of foods: a validation study

Nutrient profiling (NP) is a method for evaluating the healthfulness of foods. Although many NP models exist, most have not been validated. This study aimed to examine the content and construct/convergent validity of five models from different regions: Australia/New Zealand (FSANZ), France (Nutri-Score), Canada (HCST), Europe (EURO) and Americas (PAHO). Using data from the 2013 UofT Food Label Information Program (n15342 foods/beverages), construct/convergent validity was assessed by comparing the classifications of foods determined by each model to a previously validated model, which served as the reference (Ofcom). The parameters assessed included associations (Cochran-Armitage trend test), agreement (κ statistic) and discordant classifications (McNemar's test). Analyses were conducted across all foods and by food category. On the basis of the nutrients/components considered by each model, all models exhibited moderate content validity. Although positive associations were observed between each model and Ofcom (all P trend<0·001), agreement with Ofcom was 'near perfect' for FSANZ (κ=0·89) and Nutri-Score (κ=0·83), 'moderate' for EURO (κ=0·54) and 'fair' for PAHO (κ=0·28) and HCST (κ=0·26). There were discordant classifications with Ofcom for 5·3 % (FSANZ), 8·3 % (Nutri-Score), 22·0 % (EURO), 33·4 % (PAHO) and 37·0 % (HCST) of foods (all P<0·001). Construct/convergent validity was confirmed between FSANZ and Nutri-Score v. Ofcom, and to a lesser extent between EURO v. Ofcom. Numerous incongruencies with Ofcom were identified for HCST and PAHO, which highlights the importance of examining classifications across food categories, the level at which differences between models become apparent. These results may be informative for regulators seeking to adapt and validate existing models for use in country-specific applications.

Relations between the residential fast-food environment and the individual risk of cardiovascular diseases in The Netherlands: A nationwide follow-up study

Background

The food environment has been hypothesized to influence cardiovascular diseases such as hypertension and coronary heart disease. This study determines the relation between fast-food outlet density (FFD) and the individual risk for cardiovascular disease, among a nationwide Dutch sample.

Methods

After linkage of three national registers, a cohort of 2,472,004 adults (≥35 years), free from cardiovascular disease at January 1st 2009 and living at the same address for ≥15 years was constructed. Participants were followed for one year to determine incidence of cardiovascular disease, including coronary heart disease, stroke and heart failure. Street network-based buffers of 500 m, 1000 m and 3000 m around residential addresses were calculated, while FFD was determined using a retail outlet database. Logistic regression analyses were conducted. Models were stratified by degree of urbanization and adjusted for age, sex, ethnicity, marital status, comorbidity, neighbourhood-level income and population density.

Results

In urban areas, fully adjusted models indicated that the incidence of cardiovascular disease and coronary heart disease was significantly higher within 500 m buffers with one or more fast-food outlets as compared with areas with no fast-food outlets. An elevated FFD within 1000 m was associated with an significantly increased incidence of cardiovascular disease and coronary heart disease. Evidence was less pronounced for 3000 m buffers, or for stroke and heart-failure incidence.

Conclusions

Elevated FFD in the urban residential environment (≤1000 m) was related to an increased incidence of cardiovascular heart disease and coronary heart disease. To better understand how FFD is associated with cardiovascular disease, future studies should account for a wider range of lifestyle and environmental confounders than was achieved in this study.