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

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

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3173 (Published 16 September 2020) Cite this as: BMJ 2020;370:m3173

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  1. Mélanie Deschasaux, researcher12,
  2. Inge Huybrechts, scientist23,
  3. Chantal Julia, associate professor14,
  4. Serge Hercberg, professor124,
  5. Manon Egnell, doctoral student1,
  6. Bernard Srour, epidemiologist12,
  7. Emmanuelle Kesse-Guyot, senior researcher12,
  8. Paule Latino-Martel, senior researcher12,
  9. Carine Biessy, senior statistician3,
  10. Corinne Casagrande, senior statistician3,
  11. Neil Murphy, scientist23,
  12. Mazda Jenab, scientist23,
  13. Heather A Ward, researcher5,
  14. Elisabete Weiderpass, director3,
  15. Kim Overvad, professor7,
  16. Anne Tjønneland, research head89,
  17. Agnetha Linn Rostgaard-Hansen, doctoral student9,
  18. Marie-Christine Boutron-Ruault, team head1011,
  19. Francesca Romana Mancini, postdoctoral researcher1011,
  20. Yahya Mahamat-Saleh, doctoral student1011,
  21. Tilman Kühn, group head12,
  22. Verena Katzke, postdoctoral researcher12,
  23. Manuela M Bergmann, researcher1314,
  24. Matthias B Schulze, professor1314,
  25. Antonia Trichopoulou, professor15,
  26. Anna Karakatsani, associate professor1516,
  27. Eleni Peppa, nutritionist15,
  28. Giovanna Masala, medical epidemiologist17,
  29. Claudia Agnoli, scientist18,
  30. Maria Santucci De Magistris, nutritionist19,
  31. Rosario Tumino, senior pathologist20,
  32. Carlotta Sacerdote, medical epidemiologist21,
  33. Jolanda MA Boer, senior epidemiologist22,
  34. WM Monique Verschuren, professor2223,
  35. Yvonne T van der Schouw, professor23,
  36. Guri Skeie, professor6,
  37. Tonje Braaten, associate professor6,
  38. M Luisa Redondo, scientist24,
  39. Antonio Agudo, unit head25,
  40. Dafina Petrova, postdoctoral researcher262728,
  41. Sandra M Colorado-Yohar, postdoctoral researcher282930,
  42. Aurelio Barricarte, epidemiologist, head of service283132,
  43. Pilar Amiano, epidemiologist2833,
  44. Emily Sonestedt, associate professor34,
  45. Ulrika Ericson, associate professor34,
  46. Julia Otten, endocrinologist35,
  47. Björn Sundström, postdoctoral researcher35,
  48. Nicholas J Wareham, professor36,
  49. Nita G Forouhi, professor36,
  50. Paolo Vineis, professor37,
  51. Konstantinos K Tsilidis, senior lecturer3839,
  52. Anika Knuppel, nutritional epidemiologist40,
  53. Keren Papier, nutritional epidemiologist40,
  54. Pietro Ferrari, group head23,
  55. Elio Riboli, professor5,
  56. Marc J Gunter, section head23,
  57. Mathilde Touvier, team head12
  1. 1Sorbonne Paris Nord University, Inserm, Inrae, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Centre – University of Paris (CRESS), Bobigny, France
  2. 2French network for Nutrition And Cancer Research (NACRe network), France
  3. 3International Agency for Research on Cancer, World Health Organization, Lyon, France
  4. 4Department of Public Health, Hôpitaux Universitaires Paris Seine-Saint-Denis (AP-HP), Bobigny, France
  5. 5Faculty of Medicine, School of Public Health, Imperial College London, London, UK
  6. 6Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
  7. 7Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus C, Denmark
  8. 8Department of Public Health, University of Copenhagen, Copenhagen, Denmark
  9. 9Danish Cancer Society Research Centre, Diet, Genes and Environment, Copenhagen, Denmark
  10. 10CESP, INSERM U1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Paris, France
  11. 11Gustave Roussy, Villejuif, France
  12. 12Division of Cancer Epidemiology, German Cancer Research Centre (DKFZ), Heidelberg, Germany
  13. 13Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
  14. 14Institute of Nutrition Science, University of Potsdam, Nuthetal, Germany
  15. 15Hellenic Health Foundation, Athens, Greece
  16. 162nd Pulmonary Medicine Department, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Haidari, Greece
  17. 17Cancer Risk Factors and Life-Style Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
  18. 18Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
  19. 19AOU Federico II, Naples, Italy
  20. 20Cancer Registry and Histopathology Department, Provincial Health Authority ASP Ragusa, Italy
  21. 21Unit of Cancer Epidemiology, Città della Salute e della Scienza University-Hospital and Centre for Cancer Prevention (CPO), Turin, Italy
  22. 22National Institute for Public Health and the Environment, Bilthoven, Netherlands
  23. 23Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
  24. 24Public Health Directorate, Asturias, Spain
  25. 25Unit of Nutrition and Cancer, Cancer Epidemiology Research Program, Catalan Institute of Oncology - ICO, Group of Research on Nutrition and Cancer, Bellvitge Biomedical Research Institute - IDIBELL, L'Hospitalet of Llobregat, Barcelona, Spain
  26. 26Andalusian School of Public Health (EASP), Granada, Spain
  27. 27Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain
  28. 28CIBER of Epidemiology and Public Health (CIBERESP), Spain
  29. 29Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain
  30. 30Research Group on Demography and Health, National Faculty of Public Health, University of Antioquia, Medellín, Colombia
  31. 31Navarra Public Health Institute, Pamplona, Spain
  32. 32Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
  33. 33Public Health Division of Gipuzkoa, Biodonostia Health Research Institute, Ministry of Health of the Basque Government, San Sebastian, Spain
  34. 34Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
  35. 35Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
  36. 36MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
  37. 37MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
  38. 38Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
  39. 39Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
  40. 40Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
  1. Correspondence to: M Deschasaux m.deschasaux{at}eren.smbh.univ-paris13.fr
  • Accepted 3 August 2020

Abstract

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.

Footnotes

  • Contributors: MD, MT, SH, CJ, and IH conceived the study and defined the analytical strategy. MD, MT, and IH performed statistical analyses and provided preliminary interpretation of findings. MD and the writing group (IH, CJ, SH, ME, MJG, MT) drafted the manuscript. CB, CC, HAW, KO, ATj, ALR-H, M-CB-R, FRM, YM-S, TK, VK, MMB, MBS, ATr, AK, EP, GM, CA, MSDM, RT, CS, JMAB, WMMV, YTvdS, GS, TB, MLR, AA, DP, SMC-Y, AB, PA, ES, UE, JO, BSu, NJW, NGF, PV, KKT, AKn, KP, PF, ER, and MJG acquired the data and obtained funding to continue the study. All authors critically interpreted the results, revised the manuscript, provided relevant intellectual input, and read and approved the final manuscript. MD and MT had primary responsibility for the final content and are the guarantors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: This work was funded by a research grant from the French National Cancer Institute (INCa)-Cancéropôle Ile-de-France (convention No 2017-1-PL SHS-01-INSERM ADR 5-1, principal investigator: MT, co-principal investigator MD). MD was supported by a grant from the Fondation Recherche Médicale (ARF201809007046). The coordination of EPIC is financially supported by the European Commission (DG-SANCO) and the International Agency for Research on Cancer. The national cohorts are supported by the Danish Cancer Society (Denmark); Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle Générale de l’Education Nationale, and Institut National de la Santé et de la Recherche Médicale (Inserm), (France); Deutsche Krebshilfe, Deutsches Krebsforschungszentrum, and Federal Ministry of Education and Research (Germany); the Hellenic Health Foundation (Greece); Associazione Italiana per la Ricerca sul Cancro-AIRC-Italy and National Research Council (Italy); Dutch Ministry of Public Health, Welfare, and Sports, Netherlands Cancer Registry, LK Research Funds, Dutch Prevention Funds, Dutch ZON (Zorg Onderzoek Nederland), World Cancer Research Fund, and Statistics Netherlands (the Netherlands); Health Research Fund, Instituto de Salud Carlos III, regional governments of Andalucía, Asturias, Basque Country, Murcia, and Navarra, and the Catalan Institute of Oncology (Spain); Swedish Cancer Society, Swedish Scientific Council, and county councils of Skåne and Västerbotten (Sweden); Cancer Research UK (C864/A14136 to EPIC-Norfolk; C8221/A19170 to EPIC-Oxford), Medical Research Council (MR/N003284/1 and MC-UU_12015/1 to EPIC-Norfolk; MR/M012190/1 to EPIC-Oxford; UK). NJW and NGF acknowledge funding from the Medical Research Council Epidemiology Unit (MC_UU_12015/1 and MC_UU_12015/5) and National Institute for Health Research Biomedical Research Centre, Cambridge: Nutrition, Diet, and Lifestyle Research Theme (IS-BRC-1215-20014). AK and KP are supported by the Wellcome Trust, Our Planet, and Our Health (Livestock, Environment and People) (205212/Z/16/Z). The funders had no role in the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the French National Cancer Institute (INCa)-Cancéropôle Ile-de-France and the Fondation Recherche Médicale; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the local ethics committees and the internal review board of the International Agency for Research on Cancer.

  • Data sharing: Information on submitting an application for access to EPIC data or biospecimens is available at https://epic.iarc.fr/access/index.php.

  • The lead authors (the manuscript’s guarantors) affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: The results of this article will be disseminated as lay summaries to the public through different channels, including articles on the open web platform The Conversation (in English and French), press releases, social media accounts of our research team, International Agency for Research on Cancer newsletter, and communications through the French Nutrition and Cancer Research network (www.inra.fr/nacre).

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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