Elsevier

Clinical Nutrition

Volume 40, Issue 3, March 2021, Pages 1085-1094
Clinical Nutrition

Original article
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

https://doi.org/10.1016/j.clnu.2020.07.008Get rights and content

Summary

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.

Introduction

Globally, dietary risk factors are responsible for approximately 11 million deaths per year and 255 million DALYs (disability-adjusted life-years), which are attributable to preventable chronic diseases such as cardiovascular disease, cancer, and type 2 diabetes [1]. The continuously increasing availability and consumption of highly processed foods and beverages with low nutritional and high caloric content are key drivers of diet-related conditions [2].

Front-of-pack (FOP) nutrition labelling is one of the “best buy” policy measures that can be implemented in conjunction with educational campaigns to promote healthy eating and prevent diet-related chronic diseases [[3], [4], [5]]. FOP nutrition labels use nutrient profiling models to assess the nutritional quality of food products and display their healthiness in a simplified, visual form. Their purpose is to clarify nutritional information presented on-pack to help consumers make healthier food choices, and to encourage the industry to improve the nutritional composition of their products through reformulation [6].

The Nutri-Score FOP labelling scheme is a scientifically validated five-colour labelling system developed by independent French researchers [9]. It relies on a modified version of the British Food Standards Agency Nutrient Profiling System (FSAm-NPS) that was originally developed for the UK regulator for broadcast media to regulate television advertising to children [10,11]. The algorithm allocates an overall score to a given food/beverage according to its nutrient composition. Based on this overall score, Nutri-Score categorizes food products into five colours reflecting their nutritional quality [9]. Each colour is also associated with a letter from A (dark green) to E (dark orange) to make the labelling more accessible and understandable to consumers.

Several studies have shown that the underlying algorithm of the Nutri-Score is able to discriminate the nutritional quality of foods in a way that is mostly consistent with current nutritional recommendations [[12], [13], [14]]. Furthermore, the Nutri-Score format (i.e. interpretive, colour-coded summary nutrition rating system) has been found to be well perceived and better understood than other FOP nutrition labels such as the industry-preferred Reference Intakes label [15,16]. It has also been shown to be relatively useful in helping consumers to be aware of the nutritional quality of foods and improving the nutritional quality of both intentional and actual purchases [[17], [18], [19], [20]]. In addition, it has been suggested that FOP labels such as Nutri-Score have the potential to help decrease mortality from non-communicable diseases [21].

Previous prospective studies in the UK and France have reported that diets with a lower nutritional quality (based on the FSA-NPS) are associated with a higher risk of developing chronic diseases such as obesity, cardiovascular disease and cancer [[22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32]]. However, there have been no studies evaluating prospective associations between potential adoption of the Nutri-Score and mortality rate in the Spanish population. In this context, where olive oil is the major culinary fat, and particularly given the strong evidence supporting the beneficial effects of olive oil regardless of its energy and fat content [[33], [34], [35]], it also seems important to assess the effect of assigning olive oil the highest nutritional quality. Therefore, this study aims to evaluate the association between adherence to the FSAm-NPS Dietary Index (DI) and all-cause and cause-specific mortality in the Seguimiento Universidad de Navarra (SUN) prospective cohort study.

Section snippets

Study population: the SUN study

The SUN Study is a prospective, dynamic, multipurpose and permanently open cohort of Spanish university graduates investigating the impact of diet and lifestyle on non-communicable diseases. The design, objectives, and methods have been described elsewhere [36]. Briefly, since December 1999 graduates from the University of Navarra and other Spanish universities and professional are invited to participate. Information of participants is gathered through postal or web-based self-reported

Results

Among 20 503 participants (8016 men and 12 487 women; 38 ± 12 years [mean ± SD age at enrollment]), a total of 407 deaths during 223 574 persons-years of follow-up (median follow-up time: 10.9 years) were identified. Among 407 all-cause deaths, 208 deaths were attributed to cancer and 83 to CVD. The mean ± SD age at death among deceased participants was 66 ± 16 years, and the main cause of death was cancer (n = 208).

Age-and sex-adjusted baseline characteristics of participants according to

Discussion

In this prospective cohort study of Spanish middle-aged university graduates, a higher FSAm-NPS DI score (i.e. consuming food products with a lower nutritional quality) was associated with a higher rate of all-cause and cancer mortality. Every 2 additional points in the FSAm-NPS DI score were associated with a significant 19% higher rate of all-cause mortality and 24% higher rate of cancer mortality. There was no association with CVD mortality.

To our knowledge, this study represents the first

Funding

The SUN Project has received funding from the Spanish Government-Instituto de Salud Carlos III, and the European Regional Development Fund (RD 06/0045, PI13/00615, PI10/02658, PI10/02293, PI13/00615, PI14/01668, PI14/01798, PI14/01764, PI17/01795 and G03/140), the Navarra Regional Government (27/2011, 45/2011, 122/2014), and the University of Navarra. CGD was supported by a predoctoral contract for training in health research (PFIS) (FI18/00073) of the Instituto de Salud Carlos III. The funders

Acknowledgements

The authors thank very especially all participants in the SUN cohort for their long-standing and enthusiastic collaboration, other staff members of the SUN group, our advisors from Harvard TH Chan School of Public Health, and Matthias de Pauw for his help in the FSAm-NPS calculation for each food/beverage included in the FFQ.

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