Chantal Julia, Manon Egnell, Pilar Galan, Morgane Fialon, Mathilde Touvier, Serge Hercberg
Sorbonne Paris Nord University, Inserm U1153, Inrae U1125, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center – University of Paris (CRESS), Bobigny, France
Public Health Department, Paris-Seine-Saint-Denis University Hospitals (AP-HP), Bobigny, France
Nutritional risk factors, and especially unhealthy diet, are considered as some of the main drivers of non-communicable diseases in Europe, including obesity, cardiovascular diseases, diabetes and some types of cancers. In order to tackle the growing burden of these chronic diseases, government-led strategies have been developed worldwide to improve the diet and the nutritional status of populations through the implementation of multifaceted nutritional policies. For several decades, Food-Based Dietary Guidelines (FBDG) have been disseminated in a large number of countries providing populations with guidance on optimal food groups’ consumption and dietary behaviors. More recently, Front-of-Pack nutrition Labels (FoPLs) have become prominent around the world and considered as effective tools to make consumers aware of the nutritional quality of foods. More specifically, interpretative FoPLs, providing an evaluation of the nutritional content of foods have been recommended by the World Health Organization.
Among the various interpretative schemes that have been developed, Nutri-Score was originally developed in France and has now also been officially adopted in Belgium, Spain, Germany, Switzerland, the Netherlands and Luxembourg. The Nutri-Score is a summary, graded, five colors-coded FoPL indicating the overall nutritional quality of foods according to a nutrient profiling system that takes into consideration both unfavourable food composition elements for which consumption should be limited (energy, total sugars, Saturated Fatty Acids – SFA, and sodium) and favourable elements for which consumption should be encouraged (fibres, protein, fruits, vegetables, legumes, nuts and olive, rapeseed and nuts oils).
Questions have been raised on whether Nutri-Score perfectly align with dietary guidelines. Even if alignment appears reasonable overall and may be improved on some specific points, 100 % alignment is unlikely to be possible as with any other systems. Indeed, FBDGs and FoPLs schemes represent expressions of two different kinds of nutritional information and the principles of development of each of them differ in a number of ways. To understand the respective role of FBDGs and FoPLs such as Nutri-Score as well as the complementarity and the synergy between these two public health tools, it is necessary to take into consideration the differences in their objectives and to discuss how they could be coordinated.
What are the objectives of food-based dietary guidelines ?
Food-based dietary guidelines provide the overarching framework for a healthy diet, which is the result of the consumption of a combination of foods, in both quantity and quality. FBDG provide consumers practical guidance about what is considered as a healthy diet giving general information about consumption of broadly defined food groups (fruits and vegetable, pulses, nuts, dairy products, meat, added fats, sugary products, …) in order to help consumers identifying what are the food groups for which consumption should be encouraged or limited. For some of these food groups, a recommended quantitative frequency of consumption is provided (e.g. at least 5 fruit and vegetables a day, fish twice a week, one handful a day of non-salted nuts), while qualitative advice may be given for others (such as limiting salt, sugar or fat, favour wholegrain cereals, and vegetal fats vs animal fats…). Finally, recent food-based dietary guidelines recommend unprocessed foods, promoting home-made meals.
What are the objectives of FoPL such as the Nutri-Score?
Nutri-Score FoPL has two main objectives: to encourage consumers to make healthier choices at the point of purchase and influence industry to reformulate their food products towards less salty, sugary or fatty products. To help consumer’s choices, Nutri-Score aims to provide information, in relative terms, allowing them, to compare easily the nutritional quality of food, which is a very important point to guide their choices at the time of purchase. Nutri-Score does not invent anything. It simply summarizes in a synthetic and easily understandable form the elements of nutritional composition that appear on the mandatory nutritional declaration on the back of the packaging.
The goal of Nutri-Score is to make possible for consumers to compare the nutritional quality of foods. However, this comparison between foods is only of interest, if it concerns foods the consumer needs to compare in real-life situations during purchases). Here again it should be remembered that the Nutri-Score allows for a comparison of the nutritional quality of:
1) foods belonging to the same category, for example in breakfast cereals, comparing mueslis vs chocolate cereals, vs chocolate and filled cereals; or in biscuits, comparing fruit cookies vs. chocolate cookies; or meat lasagna vs. salmon lasagna vs. spinach lasagna; or different pasta dishes; different types of pizzas; or different types of beverages (water, fruit juices, fruit drinks, sodas, etc),
2) the same food item proposed by different brands (e.g., comparing chocolate-filled cereal from one brand to its “equivalent” from another brand or chocolate cookies from different brands),
3) foods belonging to different categories provided that they are used or consumed in similar ways (and which are often close in supermarket shelves): yogurts vs dessert creams; breakfast cereals vs biscuits, bread or pastries…
Complementarity between FBDG and FoPL taking into consideration their respective specificies
FBDG aim to drive consumers toward a healthy diet. While we may identify a diet as healthy or unhealthy, by its association with various health outcomes, such as cancer, cardiovascular disease or type 2 diabetes, the same cannot be said for individual specific foods. Indeed, no food is detrimental or toxic per se, just as none is a universal panacea, and only their combination within diets may define healthy or unhealthy. However contrary to FBDG that refer to the overall diet, FoPLs rate specific foods. This contention is the main reason Nutri-Score does not classify foods as “healthy” or “unhealthy” in absolute terms. Such a purpose for a nutritional FoPL would even be questionable since absolute healthiness depends on the amount of food consumed and the frequency of its consumption, but also on the overall dietary balance of individuals (a nutritional balance is not achieved on the consumption of a single food item, nor on a meal or even on a day…). These complex concepts cannot be summarized by a nutritional label calculated for a specific product of a given brand…
Moreover, even for food groups that are recommended within FBDGs, a large variability in composition exists, even more so when considering the available range of industrial foods, e.g. fish may be purchased as raw, canned, smoked, patty, breaded, minced – all of them would fall under the definition of fish under FBDGs. For instance, salmon (or other fatty fish), depending on its form of sale may contain no salt (if it is fresh) or up to 3 to 4g of salt per 100g if it is smoked (corresponding to 1/2 to 2/3 of the daily recommended amount for salt). The Nutri-Score provides additional information: fresh salmon ranks A, canned salmon ranks B and smoked salmon D (Figure 1). This detail is particularly useful for consumers given that the recommendation “eat salmon, or herring or sardines” that may be disseminated in dietary-guidelines does not indicate the potential nutritional differences of various forms of the same food. Therefore, the Nutri-Score is truly complementary to the FBDG because it can help consumers adjusting the quantity and frequency of consumption of different types of salmon product in an easy way.
|0.1 g salt/100g 1,2 g salt/100g 3 g salt/100g|
Figure 1. The ranking of different types of fish with the Nutri-Score
Even for foods for which consumption should be limited according to dietary guidelines (e.g. crisps or sugary desserts or pizzas), there is a high variability in nutritional composition in terms of salt, saturated, fats, sugar or calories, fibers,… and often for products under the same name (Figure 2). So, even if the generic recommendation in FBDG is to limit the consumption of those products that are -for most of them – salted and/or sugary and/or fat, Nutri-Score may help consumers identifying products that present the least unfavourable composition.
Figure 2. Differences of nutritional quality between products from the same category
The Nutri-Score appears also of interest to compare similar product with the same name on packaging (e.g. “cheese pizza”, “chocolate biscuit,…) but presenting major differences in their nutritional quality depending on the brand (Figure 3). Even if consumption of pizza has to be limited overall, it is important to allow consumers to identify the brand with the best Nutri-Score. This aspect could notably encourage firms to reformulate their products.
Figure 3: Differences of nutritional quality between similar products
Once again, Nutri-Score does not assert that cheese pizzas (or even any kind of pizzas) are healthy, but it helps consumers that have decided to eat one, to choose the product with the less unfavourable composition (ranking better with Nutri-Score).
Another major point to take into consideration when raising the issue concerning the coordination between FoP nutrition labeling with FBDGs, is that general recommendations encourage the consumption of unprocessed or minimally processed foods in most of the European countries, promoting home-made meals. However, in the current European food environment, the amount of time spent cooking and the use of fresh raw foods to prepare meals – rather than mixing industrial ingredients – tends to decrease. The trends in food supply highlight industrially-produced convenient and ready-to-use ingredients and meals as a fast-growing market. Given these trends, Nutri-Score appears again as a complementary strategy to help consumers choosing foods available on the market with the least nutritionally unfavourable or better nutritional quality at the point of purchase, especially for populations who don’t cook meals from fresh products by lack of time, desire or financial resources will not cook meals from fresh products….
Yes, we all agree that the ideal is for consumers to make his own sandwich or tomato soup with fresh and good nutritional elements, but if for lack of time or desire or means they buy a prepared industrial sandwich or a canned soup, it is better that he chooses the products of higher nutritional quality, which is what the Nutri-Score is meant for!
Overall consistency between Nutri-Score and dietary guidelines and discriminating power of the Nutri-Score
The distribution of the score based on the Food Standard Agency Nutrient Profiling System modified by the French High Council for Public Health (FSAm-NSP), underpinning the computation of Nutri-Score has been studied in several food composition databases from food supply in Europe, and especially in 9 countries (France, Belgium, Spain, Germany, Switzerland, Italy, the UK, the Netherland, Sweden) (https://nutriscore.blog/2019/07/15/ability-of-the-front-of-pack-nutrition-label-nutri-score-to-discriminate-nutritional-quality-of-food-products-in-7-european-countries-spain-switzerland-belgium-italy-uk-the-netherlands-and-swede/).
The classification of the different food groups using the Nutri-Score displayed an overall consistency with nutritional recommendations (Figure 4): the majority of products containing mainly fruits and vegetables were classified as A or B, while a majority of sugary snacks were classified as D or E. This consistency was also displayed within food groups: in the starchy food group, legumes, pasta and rice were consistently better classified than breakfast cereals; in dairy, milk and yogurt were better classified than cheese. Composite dishes displayed a very large distribution, highlighting the variability of the products in this specific category. Finally, in beverages, while a majority of fruit juices were classified as C, soft drinks were classified as E, consistently with nutritional recommendations (only water is in A).
To help consumers being aware of the differences in nutritional quality of foods and to allow comparisons across foods, it is important that FoPLs have a good discriminating power with a sufficient number of categories in the Nutri-Score diplayed for each food group. The analysis showed that in all food markets of the studied countries, the variability in food composition was captured by the Nutri-Score: foods were classified in more than 3 categories of the Nutri-Score, both for food groups and for subgroups of foods.
Figure 4: Classification of the different food groups using the Nutri-Score
Requirement for a communication/education strategy to confirm the complementarity between FBDG and Nutri-Score
So, alignment of Nutri-Score with dietary guidelines appears globally consistent for a very large majority of foods present on the food market. Due to the high variability within both food categories to promote and food categories to limit, Nutri-Score provides a supplementary information to orient consumers toward foods with a better nutritional composition (with less unfavourable nutrients and /or more favorable elements). Even if there may be some misclassifications (which can be resolved by minor modification of the components in the algorithm), Nutri-Score appears as a complementary tool to FBDG. However it is necessary to accompany the dissemination of FBDG and the implementation of Nutri-Score on food packagings with communication material reminding the way both need to operate. Concretely for consumers: 1) it is recommended to follow the FBDG indicating which food groups should be promoted or limited to reach overall healthy dietary patterns, including a preference for minimally processed home-made foods, and then 2) for each food group, if pre-packed foods have to be selected, it is advised to use the Nutri-Score to choose those with better nutritional quality in the category or in the brand, and adapt the amount/frequency of consumption.
General nutritional recommendations are similar in all European countries (even if their dissemination strategies may differ). Besides, Nutri-Score cannot vary depending on the country (in particular in the EU where the free movement of goods forbids discrepancies in the single market). However, the communication and education strategies about how to use both FBDG and Nutri-Score should be adapted to the different cultural contexts taking into consideration the specificities of dietary habits. Communication and education on that point need to mobilize all the concerned actors: nutrition and public health institutions, nutritionists and dietitians, health professional, teachers, field actors,…
Nutri-Score (as all FOP Label) is not 100 % perfect. For instance, it does not take into account the presence of additives or pesticides. This is linked to the impossibility, given current scientific knowledge, of developing a synthetic indicator covering all the different health dimensions of foods. Indeed the level of evidence concerning the links with health differs greatly according the dimension considered. The accumulation of numerous epidemiological, clinical and experimental studies now provides a documented and robust level of evidence of health impact for several nutritional components (nutrients/foods). This is the case for salt, sugar, dietary fiber, etc., i.e. elements included in the Nutri-Score. For the other dimensions, in particular those referring to food additives, neoformed compounds or contaminants (pesticides, antibiotics, endocrine disruptors, etc.), while some hypotheses of their impact on health have been raised, levels of evidence are still limited (especially due to the lack of long-term human studies so far). Public health and nutritional research is actively working on these aspects and will bring additional elements in the coming years that could serve for optimization of the Nutri-Score in the future, once sufficient level of evidence have been reached. But for the moment, it is impossible to weight the relative contribution of each dimension of a food, to provide a synthetic score that would ideally be predictive of an overall health risk level. So as part of an effective public health nutrition policy, it is recommended to to choose foods with better Nutri-Scores, with no additives or the shortest list (information provided in the list of ingredients) and to prefer unprocessed/minimally processed foods and, if possible, organic foods (with a certifying logo).
Even if Nutri-Score will have to be improved and updated in the future based on scientific and public health argument, it is important to remember that its algorithm has been validated, demonstrating in several cohort studies that it is associated at the individual level with nutrition-related health outcomes (cancers, cardiovascular diseases, obesity, metabolic syndrome,…). This validation of the nutrient profiling system underpinning Nutri-Score and the demonstration of the efficiency of its graphic format on the nutritional quality of food purchases justify the implementation of Nutri-Score on food packaging in synergy with FBDG. This is important because, without information on the nutritional quality of foods, the consumer is at the mercy of marketing from certain food companies that use different strategies (heavily marketed products, advertisements, subtle evocations on packs…) to push the consumption of some products that should be limited. Moreover, the demand for healthier alternatives additionally drives the industry to meet it, flooding the market with industrially-produced heavily marketed foods with health and nutrition claims that consumers struggle to independently evaluate. Given these trends, Nutri-Score appears as a real help for consumers in choosing healthier foods at the point of purchase in complement to FBDG.