Julia C1,2, Hercberg S1,2, Egnell M1, Galan P1, Jones A3, L’Abbé M4, Rayner M5
1 Equipe de Recherche en Epidémiologie Nutritionnelle (EREN), Centre de Recherche en Epidémiologie et Statistiques, U1153 Inserm, Inra, Cnam, Université Paris 13, F-93017 Bobigny, France.
2 Département de Santé Publique, Hôpital Avicenne (AP-HP), F-93017 Bobigny, France.
3 George Institute for Global Health, UNSW, Newtown, Australia
4 Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada.
5 Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
This week the Italian government issued a press release1 strongly criticizing an unpublished World Health Organization (WHO) report – the “WHO Guiding Principles and Framework Manual for Front-of-Pack Labelling for Promoting Healthy Diets”.
As its name suggests, the report provides advice to countries developing front-of-pack nutrition labelling (FOPL) policies to promote healthy diets. These simple, interpretive labels aim to make nutrition information easier to understand and use for consumers. They are part of the suite of measures recommended by WHO to prevent the growing global burden of non-communicable diseases. More than 30 government-supported FOPL are already operating worldwide using a variety of approaches. They include France’s voluntary Nutri-Score and Australia’s Health Star Rating, as well as mandatory ‘high in’ style warning labels now adopted in Chile, Peru and Israel.
On their face, the Italian Ambassador’s objections related to the use of nutrient profiling to evaluate the nutritional quality of foods, rejecting the concept as being politically motivated rather than rooted in science. His real motivations, however, were hinted in the findings he used in support: specifically a UK study that found one year after traffic-lights were introduced voluntarily there was “ a dramatic decrease in the sale of all the most typical Italian quality foods: a clear demonstration that systems based on nutrient profiles do not lead to healthier choices and penalize Italian traditional foods”.
While perhaps not surprising, these arguments are concerning for scientists and public health experts working in this field. Since concerns over nutrient profiling were raised a number of years ago, a significant body of scientific work has been developed to solidify the evidence-base underpinning its use in public health policy. A seminal article by Townsend et al. in 20112 (appropriately titled ‘Where is the science? What will it take to show that nutrient profiling systems work?’) provides a theoretical framework for scholars validating nutrient profiling systems to ensure they reflect not only the nutritional quality of foods, but also promote healthier diets. More importantly, the most robust form of validation available links the nutrient profile with health outcomes. This has now been investigated in numerous recent studies, particularly for the nutrient profiling system underpinning the Nutri-Score3. These studies have contributed significantly to WHO’s work in this area, and its recommendations to countries deciding to implement public health policies.
What is the Italian ambassador referring to when he speaks about the quality of typical Italian foods (we can suppose parmesan, prosciutto, salami, coppa, gorgonzola, olive oil, Parma ham… and may be Nutella)? The quality of foods could include a variety of dimensions, from the quality of individual ingredients, their cultural roots, their sensory properties, or their nutritional value to name a few. Nutrient profiling, by definition, only addresses one of these dimensions – namely nutrition – and does not aim at qualifying the all these other qualities. Nutrient profiling relies on decades of scientific studies on the associations between foods, nutrients and health, as well as dietary patterns that combine food choices and health. The nutritional quality of foods (and finally of the diet) is undoubtedly the main dimension to take into consideration from a public health viewpoint.
Though the nutritional quality of individual foods may not affect the overall balance of a person’s diet, depending on the amount and frequency of consumption – all foods may participate in a healthy diet – a higher consumption of less healthy foods is indeed associated with a less healthy diet overall, and in the end to a poorer health. This has been demonstrated by numerous epidemiological, clinical and biological studies during the last decades.
Food-based dietary guidelines are the first step in educating consumers on the appropriate frequency and amount of foods that correspond to a healthy diet. But alone, they are often insufficient to guide consumers through the vast array of foods present in the food supply. Consumers struggle to translate this guidance into their day-to-day dietary behaviour and to discriminate between products based on their relative healthfulness. Food policies based on nutrient profiling, such as front-of-pack labelling, aim to close this gap by building upon food-based dietary guidelines with tools to be used in stores.
While the use of nutrient profiling to qualify the nutritional quality of foods is only recent, tools to qualify the other dimensions of quality have long been present: protected designation of origin, traditional foods, organic label, etc.
So why this disregard for a new tool, that covers the major dimension of the quality of foods, one that pertains to health?
Perhaps because some of those foods judged ‘quality’ by other dimensions to not fare so well with these new measures of nutritional quality. Typical Italian processed meat (Prosciutto, Parma ham, Salami,…) and cheeses (parmesan, gorgonzola), similar to traditional equivalents in other countries are high in saturated fats, salt and energy. While they may be part of a healthy diet, they should not be overconsumed. Alerting consumers to the nutritional composition of traditional foods does not undermine their inclusion in a given food culture. Labelling their nutritional quality simply allows consumers to think about the frequency and amount of the food they consume.
As the full reasons provided by Italy suggest, industries behind these products are primarily motivated by profits, and determined to halt any action that may affect them. These concerns should not be used as argument against evidence-based policies to promote healthier diets.
Beyond the reasoning used by the Italian ambassador, perhaps more concerning is the timing of such a press release. An international meeting of Codex – a joint program of FAO and WHO that develops international food standards – is scheduled for next week in Ottawa. On the agenda is guidance on front-of-pack labelling. While the science now demonstrates that nutrient profiling is far from a matter of politics, action by the Italian government to criticize WHO’s work and garner support for its own Codex position is clearly a political move.
1. WHO – Press release on the draft document “WHO guiding principles and framework manual for front-of-pack labelling for promoting healthy diets”. (2019). (https://italiarappginevra.esteri.it/rappginevra/en/ambasciata/news/dall-ambasciata/oms-comunicato-stampa-sul-documento.html)
2. Townsend, M. S. Where is the science? What will it take to show that nutrient profiling systems work? Am. J. Clin. Nutr. 91, 1109S-1115S (2010).
3. Julia, C. & Hercberg, S. Development of a new front-of-pack nutrition label in France: the five-colour Nutri-Score. Public Health Panor. 3, 712–725 (2017).
Read also in The Conversation Front-of-pack nutrition labels: ‘The parmesan and prosciutto war’ https://theconversation.com/front-of-pack-nutrition-labels-the-parmesan-and-prosciutto-war-11696